Lord Markham CBE: NHS capital, innovation and economic regeneration

Matthew Taylor

Today, a first for Health On The Line. Although we hope it won't be a last. I'm delighted to welcome a member of the Department of Health's ministerial team. Lord Nick Mcarkham was appointed Parliamentary Under-Secretary of State at the Department of Health and Social Care just over a year ago on 22 September 2022.

Nick’s had extensive experience across the public, private and voluntary sectors. Amongst his many other roles previously, he was lead non-executive director of the Department of Work and Pensions and lead non-executive director at the Department of Housing and Local Government, and before that, Deputy Leader of Westminster Council. Nick's also founder of Safe Haven, a social enterprise charity that provides homes for the homeless in London, which he is able to do through an innovative funding model which effectively securitises housing benefit.

And then finally. Last but not least, Nick's also got extensive private sector experience of roles, including ITV strategy director, CFO at Laura Ashley and CEO of Top Up TV. But now and this is why I'm interested in speaking to Nick in particular, he’s Minister for the Lords in the Lords responsible for NHS capital, land and estates, data and technology and NHS finance and lots of other things as well.

But those are the issues I'm going to focus on. Welcome, Nick. Thanks for joining us.

Nick Markham

Thanks for having me.

Matthew Taylor

So I guess the first question is, what have you learned? I mean, you've been in the role for 13 months. What have you learned in the role? About the role, about the NHS? What's surprised you over the last year?

Nick Markham

Yeah, as you could see from my background, I'm not a politician by trade. So, you know, I've been doing various business stuff for the last 25, 30 years, you know, had obviously some links in terms of my non-executive roles, the departments you were mentioning. But it is an amazing thing where you go from being Joe Schmo off the street one day to literally the next day becoming a minister and in this context, in terms of being charge of capital programme, you've got a £12 billion spend a year, which is obviously a major, major money.

And so it is a steep learning curve, there's no other way to describe it. And I think first off, I'd often ask the questions from the perspective of, do you really need a decision on this now? Because I hate having to shoot from the hip. I'm very much data driven in terms of my business background and everything. 

And so making sure that we're making good decisions, especially around capital programmes, where you are talking about long-term decisions, if we don't have to make a decision immediately, let's get the proper data and analysis about it. 

And so then in terms of lessons learnt, I mean, the first thing again is that I think often the word ‘national’ in National Health Service is quite a misnomer in that I see a lot of very kind of individualised separate trusts. And so a lot of what we're trying to do is, particularly in capital states, is bring it into one coherent programme. 

I know that we're talk a lot more about the new hospital programme later on, but, you know, we had a system whereby every time we were building a hospital, we were designing a different hospital with a different approach.

You know, we got crazy numbers like, here trivia question for you: How many different types of doors do you think we have in in the NHS? I mean, the number is 27,000. I'm finding out maybe next time I'm on I’ll be able to let you know how many different types of loo seats we have.

Basically, what we have is a system of people developing things, you know, with best of intentions, instead of one uniform programme. And so what I'm trying to do in terms of the capital programme, in particular around the new hospital programme, is really just try and develop a process of standardisation that we use common parts, common designs. We're learning from best practice so that we can - just what you do in any business - really try and understand what works well and then roll it out as widely as possible.

Matthew Taylor

So the capital programme, the issues with the capital programme, there are a number of different sets of issues. One is obviously the quantum and as you would expect me to say - running the organisation, running the Confed - we wish there was a lot more money available given the size of the capital backlog in the health service.

Then there's a question of, well, who decides? How much is it centrally determined the capital programme and how much can be devolved, for example, to systems? And then there's the question that you've just focused on, which is, okay, we know the quantum, we know where the decisions are made, but nevertheless, how do we spend that?

How do we procure and spend that money effectively? What's the relationship between those issues? Because, of course, we tend to focus on the issue of the quantum, but you're focusing on the issue of how we get value for money. Do you think that if we did things much better, it could make a difference to the fact that there isn't as much money as any of us might wish there was?

Nick Markham

Yes. So, the evidence of standardisation and again, the Department of Health won't be the first to do this - we've had a similar programme going in things like prisons, and if you can go for a standardisation approach, then you start to get 20 to 25 per cent savings, as you get the economies of scale going.

So again, just to give you an example, if you think about a patient room bedroom, normally if it's not standardised and it's a different design, you would need a plasterer, you’ll need a plumber, you will need an electrician, you need someone to do the gas and air, and you need someone to do the tiling. Whereas if you can have a standardised room effectively, you can construct that all offsite and just put it in as a module.

Much, much cheaper. Faster to build as well. So those are some of the things I'm talking about. Now, you're right, though, in terms of you've got to get the mix between allowing local systems to prioritise their capital spend - and where to put it - and where things are best done as part of the national programme. 

I'm definitely not saying that ‘one size fits all’ will always be the case. But it’s learning the difference between the two. As a good way to, one, get the most bang for your buck, as you say, but to actually make sure that, you know, when you are building things, you're getting constructors as quickly as possible because I freely accept two things: one, we are spending more money than ever on a capital programme - it's about 12 billion a year - but at the same time I'm very aware of just how much needs to be spent as well. 

And you know, the scale of the task that we're talking about because the state is massive and these are things that unfortunately take a number of years to resolve.

Matthew Taylor

Yes, absolutely. And what about the kind of the speed I mean, the other issue that people raise is just how long it takes to get capital schemes approved. Could standardisation, do you think, help with that?

Nick Markham

Yes, but also we've got our own approval process whereby, you know, that takes far too long. So, you know, it's one of these systems that probably over time is sensible say, you know, the trust might have their own sign up process, then the NHS has, and the Department of Health has, then the Treasury has. 

And you put those all on top of each other, and you know, as I've tried to look at about how long it takes to build a new hospital - typically 11 years from start to finish - and we’re easily spending about four years of those in approval processes.

So what I've tried to do - as an example - I found out that they have what's called a joint investment committee in Department of Health with the NHS, and that would meet, you know, 12 or 16 weeks before the decision came to me. So I said, well, look, yeah, I will quite happily sit on that joint investment committee. I value comments anyway that the rest of the team have on it all and hopefully the value my comments and we can take 12 to 16 weeks out of the timeline straight away and probably make better decisions.

The same for hopefully Cabinet Office and Treasury colleagues in terms of involving them or in that room together. So really trying to streamline that. But also - and this is particularly pertinent to the RAAC hospitals - we know that we've got to build those by 2030. We know we haven't got a choice. You know, we know that if they're not built by then, we're having to decommission hospitals.

So, especially the five new ones that come into this. If we take three or four years going through an approval process before we even start building, we're just not going to get there. So we have to streamline that process that does candidly take some people outside their comfort zone because sometimes you might be making decisions with less of the data there.

But what I'm trying to do in all of this, and I'd say to people all the time that you've got to weigh up the risks because you might be making decisions in the approval process with slightly less information. However, if we go on the status quo, these hospitals won't be delivered in time for 2030. So personally, I feel that there's a greater risk in terms of the approvals process and those delays now.

There's a greater risk of being late rather than streamline those decisions saying that we don't need to do so many outline business cases and strategic business cases, then final business cases. We can consolidate those so we get a much quicker approvals process.

Matthew Taylor

That all sounds really sensible and to be welcomed, but you've been in post for a year and the issues of the state of the NHS estate go back many, many years. But in the new hospital programme, particularly with the impact of RAAC, there are hospitals that thought they were going to get a rebuild, a new hospital, a significant investment and who are not going to have that now for much longer.

And you must have been around this estate, you must have seen the condition that some of these kind of hospitals are in? Ones that will not now be rebuilt. How aware do you think folk in Whitehall, in the Treasury, Number Ten, are of the kind of urgency for capital investment in the health service?

Nick Markham

I mean, it is difficult. Probably in the last year, I don’t know the exact number, I’ve probably visited 30 or 40 different hospitals just because it’s only when you get round and see a place, you really understand the nature of what you’re facing. And we know there are many, many examples where we need the work done and clearly we had to then certainly prioritise the RAAC hospitals.

And the Treasury – not unreasonably – were saying, well, that’s fine - to be fair to them and Cabinet Office and Number Ten, they got in a heartbeat that we had to prioritise the RAAC. So there was never any hesitation about putting them first. Their question always was, well, okay, then if you’re putting them first, clearly and others have got to be moved to the right.

And how are you going to manage that process? And that’s where I think one of the things which isn’t written about a lot, but I think is a very positive development is actually we’ve got agreement now of five-year capital cycles. So effectively we’ve got from 2030 to 2035 now, another five-year cycle from 2035 to 2040.

Another simple whereby those that had to be moved to the right in terms of us not being able to do it in this first phase to 2030 will come in the 2030 to 2035. And a general agreement, a bit like the Department for Transport has in terms of this idea, our capital planning cycles. This now is a long-term programme which I think is very welcome development.

At the same time, I do recognise exactly what you were just saying and that there was some hospital in some places that they were hoping that they might be part of that new hospital programme to 2030, which now might be moved out to 2030 to 2035 cycle. At which point that does mean that there’s some investment that needs to be done now in terms of some shorter-term work to make the very worst affected passable, and it comes back again to making sure we’re very strict in terms of our prioritisation, understanding the situation there.

I’ve said to all the teams in hospitals, understand exactly the nature what we’ve got here. Where there are critical risk items, make sure that we’re on top of them. Not an easy situation, this issue – built up over decades – but something which hopefully a systematic programme – bit by bit by bit over the years – we can really be seen to be getting on top of it.

Matthew Taylor

And those changes that you've described, that move to that kind of five-year cycle - we at the Confederation, we kind of acted with the department as the secretariat for the Hewitt review - and one of Hewitt's recommendations was a kind of review of the capital regime. So are there other changes which you're exploring which you think need to be made to the NHS’s capital programme? I’m particularly interested in - given your private sector background - is there more that we can do to encourage a more entrepreneurial approach from systems and trusts about how it is they use their assets to be able to…you know, I don't know whether it's disposal of land or whatever - ways in which they might be able to themselves be able to increase the investment they can make?

Nick Markham

Absolute. I mean, the one other part of my background, which you didn't put in the introduction is I used to be chair of London Continental Railways, which does all the regeneration rail stations. So we did King’s Cross years ago, we did the Stratford Olympics site. We've got a huge project now in Manchester Mayfield. And actually we made them into top ten enhance builder.

A very, very simple programme. You know, if you think of any of the train stations that we're all very familiar with; you take the car park around them, you build a multi-story on a third of the land, and you free up two thirds of land for housing. You can put between 100 and 150 homes on that piece. And desperately find land for house building. I'm very keen that we do something similar in the way we use our hospital estates.

We all know the challenges of recruiting staff and retaining staff, and housing can be a key help in that. Typically, you're asking people to move to a different part of the country, to take up work at hospital or even from overseas, being able to give them accommodation so they can get their feet under the table in their new job in a new place, I think is key in terms of recruitment and retention. 

And so what I've been working with our D LUC colleagues and housing associations - It's a very simple thing about where we do have space on a hospital estate, we say to the local housing association that we will offer you the land at a peppercorn rent in return for you building there and giving us a nomination agreement. So we can use it to put our key workers in.

If I use an example, let's say that the construction cost of a house is 100,000 and the land value is 50,000, and we're giving them a peppercorn rent on the land value. Then, they only need to get their return on the rent on the hundred thousand rather than the 150,000. So immediately that gives them a third discount - so to speak - on the on the rent that they need to charge. 

And the thing that's really valuable - going back, particularly about your question - is that then that capital that comes out of the housing associations’ capital limits, not the hospitals, and we've got Treasury signed up to the principle of that and we're actually doing a pilot programme at the moment in North Bristol to absolutely prove the case.

But there I see an opportunity where we've seen loads of hospital estates where they have got space on them, where if we can work with the housing association to put homes for our key workers on them using their capital, not ours, then that's a great way to create a win-win situation. 

I think that's similar examples on putting solar panel on roofs or using LED lighting whereby the sorts of returns that you'll get there you can easily finance from the private sector. So again, I think if we were to put solar panels on all our roofs, it costs us about £300 million and we'd save roughly £50 million a year. 

So, you know, you're getting a 15 per cent plus type yield out of that, which again, candidly, with our limits, it might be hard to find 300 million out of our budget. But, you know you can finance that with those sorts of returns and create a win-win situation.

Matthew Taylor

You know, it's really interesting and I think many of our members will be very interested in the possibilities that exist there. And of course, ICSs, their fourth objective is around the NHS’s economic and social and environmental impact. So there's a kind of win-win there. Do you think, a more general point, do you think we underestimate the role that health investment has in economic regeneration?

We tend to think about there are bits of government that are around economic growth and there are bits of government that are about spending and health is in the latter category. But actually all sorts of ways health investment can contribute to the economy, can't it?

Nick Markham

Definitely. And I think there's a general understanding that we need to get upstream of the problems in terms of the prevention agenda. We know that hospitals often become almost a treatment place of the last resort, because people will go to A&E, and a lot of the time actually, they don’t need to be at A&E but they went there because they felt that they couldn't get a GP appointment, for instance, or they’re fit to be discharged, the 13 per cent or so, but they hadn’t been discharged because we're trying to find social care places.

So, it is as you say, a whole system programme and that's why we see the ICS review as so important and that does have, as you say, a much wider social and economic impact. You know, I've seen fantastic examples. I was in Red Hill GP surgery the other day where they look at their so-called frequent fliers who are spending the most time needing hospital treatment and saying what can they do in terms of prevention to try and avoid that happening and making a huge impact on that, which of course is better for them, best for their lifestyles, but as you say, better for the economy, because those people can be far more productive. 

In terms of a capital initiative, we've got now this mobile lung cancer screening programme whereby typically, unfortunately, something like 60 per cent or so of people go undetected with lung cancer until they’re at stage 4 historically. And unfortunately then it's often too late. 

With these mobile screening centres that are going into areas where you know that there's most need, we're now picking up something like two thirds at stage one and two, where you can treat it and you're fine. And obviously that's much better in terms of healthy outcomes. But that's also, of course, much better in terms of those people being able to return to the workforce and become productive members of the economy. 

So, you know that's where I see everything that you were working with Patricia on her review on how you can create whole system solutions. I completely agree with what we're trying to do there and it just has to be the direction of travel.

Matthew Taylor

Yeah, because it's interesting as a final question on capital net, but it's interesting, whenever we talk about capital - you and I have been guilty of this ourselves in this conversation - we tend to just talk about hospitals, but actually a huge proportion of our primary estate isn't fit for purpose. I know that colleagues in mental health feel that mental health often is quite low down the list and the mental health estate is very poor.

We want to move more investment into the community, into community settings , into health on the high street, for example. So, it is important is when we talk about capital that we're not just talking about hospitals and also that we avoid the danger that we do sink an enormous amount of money into hospitals. And that actually reinforces a model of care that we're trying to get away from.

Nick Markham

Absolutely right. We all know the old saying that it's the squeaky wheel that gets the oil. And that is a bit in terms of, you know, the hospitals, they are obviously the most visible manifestation of the health service. And so naturally, in terms of all of our attention and spend, that's often where it goes.

But it is those initiatives and either upstream or downstream. Again, when on my many hospital visits, I found that in one of the hospitals they just put in a physiotherapy space where they were then as a matter of general practice, giving all patients over a certain age, an hour or so physio a day, and in terms of their ability to then get home earlier and be fitter in there and needing less support, avoiding social care altogether, it just had a huge impact, absolutely massive.

So yeah, I think trying to look across the system, where we can get upstream of the problem or use it problem downstream. That's got to be the way forward, as you say.

Matthew Taylor

I want to turn now to digital into technology. Your background as a business leader, entrepreneur, you've been a digital pioneer. So first of all, let's just start with your interpretation of why things are so difficult in the health service. 

I think almost everybody would agree that the pace of digital rollout has not been what we would want it to be. I guess the positive way to put it is that the cliche, the future is out there, but it's just very unevenly distributed in terms of good practice. Why do you think we are in the situation we're in?

Nick Markham

I think it seems a bit like the process I was talking about before, often about capital spend, where you get narrow in there of approval and decision making. And I think generally we've got ourselves into a situation whereby we're more and more risk averse generally about making decisions. I mean, it's the old saying, you know, nobody ever got sacked buying IBM and there's a lot of that where people just don't want to step out and run that risk and so you have all sorts of committees and consultants and processes and it becomes very, very unwieldy.

And we see a situation where we know we can do it, and quickly. Obviously, that happened a lot during covid, but you've got situations like Joe Harrison, who runs Milton Keynes Hospital. He's a real pioneer. He's really passionate about digital. And you go there and it's amazing, some of the things they've done there. 

Miles Scott in Maidstone, he's put in what I call a flight control system, which is looking at incoming ambulances and incoming demand. And you can see a projection. There's like a flight control system where you can see that they know every bed in the hospital and they can see they've got an incoming where those people are most likely to be ready to discharge. And then if they are ready to discharge them, they've got a process in place immediately which makes sure they've got their prescriptions ready, they got transport ready, they got porters ready to clean the bed and transport them and it's all there through marginal gains. I call it like the Team Sky cycling approach whereby it's just one or 2 per cent gains in every little bit of process, but you put them all together and they're significant. 

And so, as you say, there are those examples of those exemplars, but it's making sure that we can roll those out across the system. We've been trying to do that as really keeping support from the centre.

I think we've got some good examples of that. I think the electronic bed records and patient management that is coming in. Absolutely, as you say, I think it is taking too long, but it is getting there. The other thing I think, which will make a massive difference and a theme of a lot we're talking about is actually trying to put looking at the solutions at any individual local level.

We've got a series of big functionality enhancements to the app just coming up, which I think will make a huge difference. And when you think about how our lives could change in terms of banking and retail and media consumption with the use of apps, your ability to make your GP appointments or your pharmacy first point, if that's the better solution for the condition you've got, you know, being able to navigate to the right place in the first place, be reminded of that appointment on your calendar so you reduce the number of do-not-attends, be able to get your results on your phone and see your patient record so you can do your own type of research and really take control of your own health. 

In all of that, if you do need hospital treatment, being able to see what the waiting times are in a patient choice initiative so you can see where can I get my treatment done in the quickest and most efficiently. And putting that sort of information and that sort of power in the hands of the user - the patient in this case, I think that's how we could really use technology to make massive differences.

Matthew Taylor

You know, that's interesting. And obviously, once again, I'm not going to labour this point, but there is an issue about sustained investment. We have had kind of stop start investment in digital infrastructure as well. But some of the work we've done Nick - I’d be really interested in your perspective on this - has come up with what you might call, I don't know, the innovation tragedy or the innovation dilemma, and that’s this…and it doesn't just apply to digital, it applies to things like innovative medicines. And that is that in a sense, both our private sector partners and to an extent government - government officials and ministers - want things to happen at scale. And if they're really going to make a difference, they do need to happen at scale. And the economics demands action happens at scale.

But yet what we find when we look at what works on the ground again and again and again, is that the best solutions - the ones that have the most impact - are the ones that are designed very much around the particular local circumstances. Local population, clinical enthusiasm is absolutely critical to sometimes the reason that national programmes break down is that in the pilot you've got enthusiastic clinicians and then you roll it out to the clinicians who aren't so enthusiastic, they’ve got other priorities.

So, do you have a kind of insight into how we manage this kind of innovation paradox that on the one hand we need to scale things up and on the other hand they've got to be designed to fit local circumstances?

Nick Markham

No, you're absolutely right. And I think actually of all that we’ve talked about that is one of the toughest things I've seen. The old joke goes that, you know, the NHS has got more pilots than British Airways. But it's taking those pilots and scaling up is the challenge. And we see local hospitals, right down to clinician level who are quite fiercely independent. And that's where you have the problem in terms of the adoption. 

I think there are things that we're trying to do far more in the centre. I'm exaggerating slightly to make a point, but it's been the case in the past whereby for one place where we've helped get that innovation going and it really works in one place.

And then we say we've proven the case, and then they say, well, great, how do I expand this? And we say, well, here's a telephone directory of 200 trusts. Good luck. Again, I'm exaggerating slightly to make a point. But effectively what we're trying to do now is actually put in place much more of a central buying set up whereby we are able to roll those products out according to that.

And it's very interesting. I was actually in Boston just last week to try and absolutely learn some of the lessons that we see because obviously Boston, we've got a fantastic ecosystem of the Harvards and the MITs of the world. And then in top hospitals in terms of mass generals, and the Boston Children's Hospital and the entrepreneurial flair and venture capital. They really try and foster innovation and then scale it out and then roll it out from there, and what we can learn from that.

And a lot of that, I think we are very good - as you say - at the innovation. I think we can do well to foster some of those partnerships between the clinicians and the hospitals and teaching hospitals and sometimes the local venture capital partners. But actually the scale out and adoption across the system is the real challenge.

And we've got some good examples we're starting to get now where we've got things such as the AI delivery platform where you've got things like brainomics, which is really improving stroke treatment. And we're getting platforms where we can effectively roll those out across the board. 

So there are bits we’ve been doing there. But I would say of everything we've talked about, that's the one now that I'm really trying to focus on to improve because that is quite a challenge.

Matthew Taylor

Yeah, we're in conversation with a leading university and will bring other universities to the table and also commercial partners to think about whether we can create a kind of capacity between our members, academia, commercial sector to think about this rollout challenge and how we can help to spread innovation more effectively. So maybe that's a future conversation for us.

Nick Markham

Yes, love that.

Matthew Taylor

Couple of kind of final questions. I know we’ve got to be careful because of the commercial sensitivities here, but tell me what your hopes are for the national federated data platform. How do you think that's going to turn the dial?

Nick Markham

And again, I don't know if you've seen - I'm sure you probably have - some of the things that Chelsea and Westminster in particular have been doing in this space. And whenever they show it to me, in some ways the great news is it's so simple, the slightly frustrating thing is it's so simple. Why haven't even done this before?

In terms of, you know, they show me what they do and say, well, these are all patients here and this is what this person is suffering from and this is what we're going to do and we're going to book them in to this lot and we're going to immediately have the follow up action and the appointments get fixed and the communication goes out. And this is how we get keep track of it all. And now we're going to book them into the theatre, and this is how we get utilisation. 

And, you know, you just see it and it's just well, that’s great. But this is, you know, pretty darn simple. But then they talk about what happened before, where they had spreadsheets and bits of paper, and you could just see how these things got lost.

So at the basic level, I'm just amazed by the simplicity of just having all the information in one place and just the ability to make sure that people are captured. You knew exactly what needed to be done. As I say, you book your appointments from there, and it gets followed right the way through. 

And Chelsea in Westminster were able to talk about how they'd increased utilisation of their theatres by 20, 30 per cent. How they actually found that as they went through this process, they cleaned up a lot of the database where they saw that actually there were duplications or people that didn’t need treatment anymore.

So I think that can really make a massive difference on the whole waiting lists for electives. And then you've got other examples of other hospitals that have used it to really get a quicker discharge out. And so really reduce the so-called bed blocking from it all. 

So what I see most of all is that - and this is what I see you very much as the job of the centre - is that we provide the platforms. So we provide this federated data platform from which clinicians and hospitals will develop the innovation. And so that discharge, more of that talking about that was about - I think it was Stoke Hospital, apologies if I've got that wrong - but that was developed by one of the local hospitals using that platform data, as I say, Chelsea and Westminster ready forged forward from that.

So it's giving that platform; common data from which people will then be able to develop the services. And this is where amongst all that challenges that we know we have, where I see, you know, the real grounds for optimism. Again, when I was in Boston just last week, they were saying, look, you don't realise the power that you have in terms of your data.

There was one company that had raised 250 million to invest in using 9 million hospital records of just a single health system. And, you know, just the possibilities. They said that you've got 50 million patient records and not just secondary care, but primary care as well. And you can link them all together through the NHS number. 

Yes, it will be messy linking them all together, we're not saying it's easy in terms of cleaning up the data, but they were saying think of dementia, our problem about dementia is that we are really shooting in the dark in terms of cures. When we know what we're going after like we did with covid, we were able to target something very, very quickly. The trouble about dementia is we don't really know what the cause is.

But when you think about your data and that it’s longitudinal, you know, you can take people who are suffering from dementia when they’re you know, 75, 80 and look back at their GP records when they're in their 50s and 60s and see; are there linkages? Throw all that at AI and they will come up with patterns that we just haven't seen.

To see, are there some early warning signs that we can then really set our researchers going after? So to me our whole data platforms that's exciting in terms of just a) the basic management of patients, navigating them through the health system, but b) just being able to use them to really pioneer new areas of research and development.

Matthew Taylor

Nick, we're really grateful to you for giving so much time to us. And I'm just going to ask you one final question before I let you go back to your ministerial duties - you've talked a lot about a kind of incremental agile approach to change and I always think that that there are two things we have to do together which involve different kinds of ways of thinking.

One is that we need to try to think like a whole system because our health system is complex and interrelated. And if you try to achieve change in one part, you need to think what the ramifications are across the whole system. 

So you need to reimagine the system, but then you need to adopt - exactly as you've said - this very kind of entrepreneurial, agile approach to change because the world is unpredictable, change is unpredictable. 

But just in that, if I was to say to you, just give me one or two thoughts about the health service of I don't know, that might be there in, say, 15, 20 years, what do you think are the things that are most fundamentally going to change about health over the next generation?

Nick Markham

So I really think it will be the use of - first it being people using the app to navigate their whole approach and taking control of their health and again, being able to show, because the data exists, they will be able to look at my background, look at my DNA background, look at my patient records, look at my lifestyle factors, you know, how much I'm drinking, whether I'm smoking, what I'm eating, and be able to start to prescribe my own individualised screening programme and course of action. 

Now, a lot of time people won’t take that up, and that's their choice. But a lot of the time, you give those people the pointers, and I think you would just see, I think we're seeing a shift away from a health system which, you know, 40, 50 years ago was very much the doctor knows best, and when there was something wrong, you would turn up at the doctor. You were told what treatment you need for cure. And off you went. To actually very much a much more active management of our own health, where we know more about our own bodies and our health, backed up by having the technology to kind of support us in that.

And we're taking a much more active participation in our health in terms of prevention, early diagnosis and treatment. And armed with that I think that will fundamentally change the way that health is set up to support around it rather than being based around hospitals and treatment, very much around the care of the whole patient.

I think that's the journey that we're going on. And that's where I have to say, as a minister, sometimes some very, very hard moments, and yet this is by far the hardest thing I've done in my life, where it really is difficult in terms of all the challenges you're trying to face. When you see those kind of, this sunny upland, so to speak, that sort of healthcare for the future is  the sort of thing that gets me out of bed in the morning.

And I hope that we look back in 15, 20 years and say that the investments we're putting now into the app and the digital platform and technology as well as a new hospital programme, I hope that we're really setting the foundations down for what will be that future.

Matthew Taylor

Well, it's great to end on a hopeful note. So, Nick, thanks for the work that you do as a health minister and thank so much for joining us on Health On The Line.