Is the Ten-Year Health Plan the right plan for the NHS?

Matthew Taylor  

Hello and welcome to a special edition of Health on the Line. We're recording and releasing this episode the day after the publication of the government's much awaited and anticipated ten-year health plan. We at the Confed have been busy on the airwaves discussing what this means for our health leader members and their staff, producing briefings for them. All that's available on our website, so do check it out, really in detail briefing around that health service plan. 

But we've had a bit of time now to digest the key elements. And of course, they've been leaking out over the last ten days or so. So even if you haven't read every one of the 150 pages, you'll know quite a lot about the big ideas in this plan. The prime minister at the launch yesterday, which I attended in East London, said bluntly that it's a case of the NHS needing to reform or die. I think we all know which of those two outcomes we would prefer. 

So, to discuss the ten-year plan, what a great panel I've managed to bring together for this conversation less than 24 hours after the publication of the plan.  

Claire Fuller, GP, primary care medical director for NHS England. 

Sam Allen, chief executive of Northeast and North Cumbria ICB, of course the ICB that Jim Mackey hails from.  

And Bill Morgan, former Number 10 adviser.  

I asked them what they made of this plan. Claire, Sam, Bill, a very warm welcome. 

So Claire, let's start with you. It's really hard, I know, but in two minutes, give us your op-sum of the ten-year plan. 

Claire Fuller  

Well, two minutes. All right, Matthew, I'll do my best. So, ten-year plan at the heart of it is neighbourhood health and underpinning neighbourhood health is of course, primary care sustainability. But the other bits that are writ largely the plan are a relentless focus on patient voice and actually making sure that care is organised around patients’ needs rather than organisation need. You'll see that focus on technology and the way we can use technology in the future to increase clinicians' time to care and to improve things for the public and actually a real return to quality.  

So, one of the things I'm really excited about and pleased about in the plan is this return to the modern service frameworks and the commitment to start in with cardiovascular disease and with mental health and frailty and dementia.  

I think if you wanted real high-level themes and if you wanted the word cloud from it, I think you'd go with: neighbourhood, patients, patient voice, technology and quality. 

Matthew Taylor  

Really interesting and that point, which we'll come back to, about patient voice. I spoke to somebody who was closely involved in the plan a few days ago. And I said, what's the essence of it? And they said personalisation and democratisation, which is really interesting because that's not, don't think, where we started.  

Bill, what did you make of it when someone says to you, tell me about this ten-year plan. What do you pick out? 

Bill Morgan  

I think it did a good job for Labour, politically. I think after the week they've had, the government needed to give Labour MPs something to give them a spring in their step. And Labour MPs want to talk about improving the NHS and there's a lot of retail ideas in the plan. It's more of a list of ideas than a plan, I'd say, but politically, it gives Labour the space to talk about improving the NHS, which is sort of in their comfort zone and where they want to be. 

Matthew Taylor  

Really interesting because I spoke to someone from Keir's entourage, Keir Starmer's entourage, yesterday at the launch and he said to me, health is our happy place right now. 

Bill Morgan  

Yeah, well exactly. And I saw Wes in the chamber, I was watching his statement and he was just basking in the glow of his colleagues and after the week they've had and the aggro in the Labour party, it's sort of exactly what that party needs really. 

Matthew Taylor  

Thanks, Bill. We'll come back to bit of that later as well.  

Now, Sam, when I'm asked about the ten-year plan, one of the things I say is ICBs are dead, long live ICBs. ICBs, which a few weeks ago felt like they were and are under immense pressure in terms of reorganisation. But you read this plan, ICBs are absolutely central to it, aren't they? 

Sam Allen  

Yeah, they are really pivotal. I recall kind of back in sort of second week in March when the changes were announced to ICBs, my first take Matthew was that was an early signal for change for the whole system. And certainly, the conversations I was involved in was we're going to need to change and adapt, but everybody's going to need to change and adapt. The thing I really liked about the plan is the scale of ambition, but also the clarity for the case for change and why we need to do this.  

And I think the foundations of any plan, particularly getting the impetus for change to actually happen, is that absolute clarity on why we need to do this. I think for me personally, it feels like a real Bevan moment and certainly something we've all got to get our arms around and be part of implementing. 

Matthew Taylor  

Well, so Bill, let's take this forward. I mean, obviously, Claire, who's at the centre, involved in the plan, and Sam, who's leader out in the service and also has a national role, they've got skin in the game. You're an independent voice on this, so I want to get a dialogue going on around this. I want to ask you about the kind of implementation challenge here, but just before we get into that, Bill, reading the plan, is there anything in the plan which would have been inconceivable under a conservative government? I'm not asking you to judge its credibility, but in terms of the kind of politics of it, is there anything there you think, well, this could never have happened if Rishi Sunak was still Prime Minister? 

Bill Morgan 

No, I think, reading the plan, there's some contradictory ideas in it. I think the challenge in implementation is going to be resolving those conflicts.  

There's a paragraph in the plan about how ICBs are going to become the strategic commissioners and procure services from a range of competing providers.  

And then there's another paragraph in the plan about how foundation trusts are going to become integrated health organisations and run all local services in the area.  

Those two visions are incompatible, in a way. You might end up with different approaches in different areas. And that's the way you sort of ride both horses. But they're two philosophical approaches to running the NHS fundamentally. And actually, both were sort of tried under the previous Conservative government.  

To answer your question, no, there's, there's not really stuff in there, which couldn't have appeared at any point in the last 14 years. And as you say, the challenges implementation. 

Matthew Taylor  

Well, look, this is going to be fun because I'm going to obviously turn to Sam because Sam is obviously running an ICB and also a part of the country where I would suspect we will see some acutes leading potentially in these integrated health organisations. So, Sam, I suspect that you don't agree with the bill that these things are completely incompatible. 

Sam Allen  

Yeah, spot on Matthew. Bill, I don't agree with you. I don't think they're incompatible. And I'll tell you why, because I think even when you look back at the history of the health service and you look at the size and the scale of the health service, you'll always have some parts that will have the capacity and the capability to go further. And we absolutely shouldn't limit anybody's horizon.  

So, I think fundamentally as a leader, part of my role is to support those parts of the system that can go further faster because that can only benefit patients and our communities and I think that's something we're keen to do.  

But I think also I've got a healthy dose of realism that not everybody will be ready to do that and therefore it will be a period of time. And I would say over the ten-year cycle particularly around the ambition to get everybody to foundation trust status in ten years, where we're going to be working at that Matthew and supporting those that need additional support to be able to have the capability to do that and I think that's part of our role as commissioners but equally part of our role as commissioners is supporting those that have got that capability to go further faster. 

Matthew Taylor  

Well, I think there was a certain frisson yesterday at Jim Mackie telling people that the first IHOs would be established next year. You said that this will take a while to work through. Do think Jim's maybe being a little bit optimistic about our capacity to do that? 

Sam Allen  

No, I don't think so. I think the plan says approved next year for implementation in 2027. I think that's perfectly realistic for a few systems to have aspects of their systems kind of progress to IHO status where there, as I said, is the capacity and capability to do that. And I am really confident here in the North East and North Cumbria, we absolutely have the capacity and capability in parts of our system to do that. 

I do think there will be other parts of the system that have had years of systemic underfunding structural deficit issues that will take slightly longer to address. It's not that there isn't the capability and the leadership, but we have, as we know, even if we look back when the foundation trust regime was first implemented, there are some parts of the country that would not achieve the kite mark of the foundation trust at the moment. And predominantly that's because of systemic structural underfunding issues.  

And equally, I've got some parts of those systems in my own system as well. And we need to put as much emphasis on addressing those, supporting those that can go further faster and become integrated health organisations.  

But I would also say I don't think it's the only way. And I know Claire, when you come on to talk about integrated neighbourhood health and GPs as the leaders, making sure that we support GPs and other forms of partnerships to deliver for patients, I think we've got to have that flexibility as well. 

Matthew Taylor  

So I will come to you now, Claire, and I would say that one of the things I welcomed about the plan, which is unusual actually, is the explicit commitment to different models in different places, to a diversity of ways of doing things.  

I think part of many of the mistakes we made in the past is trying to do the same thing in Cornwall as we do in East London or whatever. And it's interesting that what you're implying, Sam, is that there'll be different architectures, different models of integration, maybe different models of neighbourhood health leadership in different partsof your system, albeit a very large system.  

Claire, this question of doing things in different ways in different places, it links into, I guess, one of my areas where I can see a way forward, but I do worry still about how clear this is. And that's really around primary leadership, the capacity of primary, may be working with community, but to step up into the leadership opportunities that are provided in the plan. 

Tell me about that and tell me about what you think needs to be done pretty quickly in order to get primary to the table in the way they need to be there to grab these opportunities. 

Claire Fuller  

So general practice is ready. I would say general practice is probably more ready than the other rest of the family of primary care - when we talk about primary care as a leader, of course we mean across the whole family. But general practice in particular, this isn't the first time we've been talking about this. Again, this is one of those really good examples when policy is catching up with what's going on out in practice and the policy is behind the things that are actually going on at that. 

I can take you to a number of absolutely brilliant examples of large at scale. What started as GP federations have actually evolved into what you can see will be the basis of a multi-neighbourhood provider and are able to work in partnership with the acute trust, with the community trust, with mental health trust.  

So, I think the other difference that we've got is although we're saying that there are different models, we're not in the land of a thousand flowers blooming.  

I think we're saying there are three. If you do bottom up, you've got three options: you can stay as you are; you can stay if you are a functioning GP practice that it's all going really well and your outcomes are great and your patient satisfaction is really high and you're happy with how you're working, you carry on and you stick with GMS because a partnership model where it works is as good as you're going to get anywhere.  

But in those parts of country either where the ambition is that you want to do something different you could come together as a group of practices or in I think about 10 per cent of PCNs are now single practices across that bit and actually say, you know, we want to do more, so we'll take on some more of the neighbourhood services. And then again, places like Sheffield, places like York, you've got Nimbus in York, you've got primary care Sheffield, where they've already got really good coverage, you can see they will want to take on more covering that bigger population working in partnership but also provide for those areas where the practices don't want to provide more and also support and provide GMS in those places where we can't get workforce. 

And that's what's so important. And it's to Sam's point that there are areas of the country where this is thriving, where you can absolutely see that people are going to fly and it's going to be brilliant. But there are other places where you still haven't got people to put the lights on.  

And what we've got to do is make sure that the populations, and it is the classic inverse care law, isn't it? It's the people that need the care most are actually the people where we haven't got the workforce. And by putting in place the multi-neighbourhood provider, that that provider has got to have the expertise and the understanding of how to run general practice, which is not easy. And some of our trusts have done this over the years, I think have found just how hard it can be. And that you need real general practice expertise in to run general practice. But we've got to be able to make sure we've got a consistent offer out to the whole country. But the vehicle may look slightly different, but it's definitely not a thousand flowers. 

Matthew Taylor  

Thanks for that. But Bill, you know of the role that you've played as an advisor, that it is an achievement to say to ministers, to say to the prime minister, look, it's not going to be the same everywhere,  much as politicians at the centre tend to want uniformity.  

But what do you see as being the kind of challenges as we go forward about this explicit commitment to allowing different models to exist - people live in one place, they don't necessarily need to know about the fact the system is different down the road. But what do you see as the political and governance challenges of having an NHS where different kinds of institutions are in control in different places, different models work in different places? 

Bill Morgan 

I think it's manageable politically so long as, I mean frankly politicians just want simplicity, so as long as I can tell a story of NHS improvement, they'll be happy The big risk for me is in legislating because it's fine to fudge, under the existing legislative framework say, and to say this will be an IHO here and this will be a ICB-led system here and we'll have these different models of primary care. 

As soon as you try and write that down in legislation, the parliamentary council will ask you who arranges healthcare services? Is it an IHO or is it an ICB? And if it's both, and you need to transition from an ICB to an IHO, what's the switch in legislation? What are the transitional provisions? And that's what imposes uniformity. And it's that legislative process. 

If I was in Number 10 now, I'd be thinking, let's just push that legislative process back. We don't need to go there yet. Let's just let the systems do their own thing and then work out how we do legislation later. But that's the risk. 

Matthew Taylor 

Which is of course what you did with ICBs. You basically set them up and then legislated for them having set them up. 

Bill Morgan 

Yeah, and of course, the 2022 Act constrains some of the things the way that ICBs were working because it kicked local authorities off ICBs because again, you have to write it down. So, you know, there are risks as soon as you write it down, and this is why this is why I try and steer away from it. 

Matthew Taylor  

Really powerful point.  

Sam, turning to the of, again, kind of the permissive nature of this plan. I mean, let's be honest. It has not necessarily been a strength of the NHS that leaders get together at a local level and agree how they're going to do things in a generous collaborative way based on the needs of the patient. I wish it was the case that it was always like that, but we all know that it isn't always like that.  

If it is important to the plan that we do develop a consensus locally about how to organise things, how can we get better at that than we have been in the past? 

Sam Allen  

So, if I may, Matthew, just going back just really briefly to the last point, because I don't think IHOs and ICBs, it's one or the other. IHOs will still need commissioning against the total population budget and ICBs will have a role there. So, I know the detail of this will become clearer as the new legislation gets drafted and we work through the practicalities of this, but I don't think it's either or. I think it's case that an IHO would have greater capabilities against the total population budget in order to deliver the outcomes that the ICB commissions from them. So, I don't think it's an either or.  

Just this point about leaders and convening and how we build trust. There's lots of huge opportunities in the plan. There's lots of things that need to be addressed, whether it's the structural staff, the funding flows, the infrastructure. One of the most fundamental things that doesn't get mentioned at all in the plan but will require a great deal of thought in terms of how we approach it, is how we continue to build trust and relationships. And actually we've done a lot on that over recent years. The slight danger is as we move to a more competitive landscape, that becomes slightly more challenging.  

So I think it's important that all leaders have this overarching duty to the NHS and the outcomes and not simply to the sovereignty of their organisations or their IHOs. And I would like to see a conversation that's far more explicit about that in terms of the expectations on all leaders. 

Matthew Taylor  

Yeah, well, I absolutely agree.  

And Claire, straight to you on that question, I often share with people the fact that someone I know well has done a lot of work with health service leaders and speaks about them with admiration. But there's a but, and when I say what is the but? this person says, leaders are quicker than leaders in most other sectors that I've dealt with, she says, to blame other people. You know, there is a kind of willingness to say, well, of course we would be able to do that, but the acute is impossible. We'd be able to do that, but GPs won't work with us. We're able to do that, or the local authority...  

How do we get out of that mentality of reaching towards blame when we can't get our act together at a local level? 

Claire Fuller  

Yes, but we used to call it ‘othering’. When I was back in my old job in Surrey and it was one of those, you're not allowed to ever say anything, was somebody others, somebody others. Because there's always a person that wasn't in the room as well, isn't it? It was always the person that stops you doing it.  

And the way that and the way you reframe it is you just come back to this is about patient care and it's our responsibility to the population. And Sam spoke very clearly about the need for leadership. My real priorities around the clinical leadership. 

So, this change, particularly the neighbourhood health working, because it will involve how we do UEC different, how we'll do elective differently, let alone how we'll do prevention differently. But actually, that's a significant change in clinical practice. And this fundamentally will be about doctors working in different ways and leading teams in different ways and other health professionals as well coming together to make sure we get that right skill mix.  

One of the bits that I've talked about a lot over the last year or so really has been this primary secondary care divide. And unless we break that down, and the only way you break it down is by getting local leaders in a room together and actually going through all those grunty, really irritating bits that just kind of get in the way.  

It's the back to the basics bit that comes through in the plan. We can't go off and do all the fancy stuff. But actually, you're still really irritated because you can't get, because I'm dealing with 28 different forms and it keeps getting rejected or because nobody ever answers the phone in paediatrics, the paediatric secretary, nobody can ever get you. So you've got to put in place really local forums to deal with the basics. You've got to get your clinicians in a room together and be really clear what it is you are trying to fix.  

One of my colleagues, James Kent, who always talks about that we have the ‘James Kent scale of collaboration’. Level one is that you know you're meant to collaborate. Level two is that you know who you meant to collaborate with. Number three, and it goes up. And actually most people probably know who they're to collaborate with. 

They know it's a good idea and they've been in a room and they know how to talk to each other. But actually, it's not until you get on, you actually deliver services together that you change this and you do this. So the quicker people at a local level build those resources, get in rooms, also identify from looking at the data of the local population, what is the greatest need and fix it. That's how you unlock it. 

Matthew Taylor  

Yeah, in our work on that kind of interface, we sometimes talk about the three steps, which is irritation, integration, innovation. First of all, you've got to start pissing each other off [Claire Fuller: Yeah, it’s good]. Then you've got to start working together. And then new ideas will start to emerge as a consequence of that. But you have to go through those stages. No good trying to innovate when you're still annoying each other. 

Claire Fuller  

Exactly. 

Matthew Taylor  

Sam and Claire put this emphasis on relationships and trust and all of that but incentives also matter, Bill. How convinced are you by what the ten-year plan has said? And clearly, some of this stuff is now a bit more tentative, a bit more experimental than in earlier iterations. How convinced are you of the ten-year plan's attempt to shift the incentives in order to particularly to drive the leftward shift? 

Bill Morgan  

Yeah, I think I'd say relatively convinced. I think the foundation of financial incentives is financial stability in the system. And I think everything in the plan and actually, since Jim became chief exec about transparency of financial flows and rules-based system. And that that is a very coherent theme coming out in the ten-year plan as well. And it's so important to get to this system quite quickly if we're then going to create a world of financial incentives to move care around. Because financial incentives simply don't work if everyone's in deficit. And there's, you know, there's extraordinary buns flying around the system; just it kills everything.  

It won't surprise you to know I'm a fan of financial incentives. This is a similar theme to the original Lansley vision as well but it does need that foundation of financial stability to work. 

Matthew Taylor  

And Sam, the left would shift. We've been talking about it for decades and we actually achieved a rightward shift. I'm sure you would agree with Bill that it's very hard to do when people are in deficit. It's also hard to do when a system is at full capacity. What do you think is the key to unlocking this? Because the credibility of the plan relies upon the leftward shift starting to deliver a shift in productivity pretty quickly. Now there is evidence that if you do things in primary and community, you will save money, but the plan doesn't really work if we don't do that quickly and we don't reap those rewards pretty quickly. 

Sam Allen  

Yeah, and look, we've all got a role in this. So I think the incentives are actually key here. So whether it's changing the financial flows around the urgent and emergency care pathway, which doesn't just reward attendances in the ED department, but also rewards preventative attendances in the ED department, in the right part of the system is going to be key.  

I think for us as commissioners setting ourselves realistic but ambitious goals of left shift in terms of where we place our resources and being really clear with parts of our system that actually they are going to have to address the reasons why perhaps aspects of their services cost more than others. They are going to have to address the productivity and not accept mediocrity and ensuring that we're using the data to drive the best possible outcomes for our patients and get the best value for the taxpayer. And I think this is a real wake up moment for everybody actually. 

So I think every part of the system needs to be examining what their role is in making that left shift and we've all got a role to play, Matthew. 

Matthew Taylor  

Claire, part of the achievement of the left shift is the willingness of primary to take on risk to a certain extent, to say, look, our funding is going to depend on us demonstrating we can reduce unnecessary A&E attendances, that we can reduce, you there's a bold commitment to reduce acute outpatient activity, for example. How ready is primary to take that kind of risk on? 

Claire Fuller 

So if you put it back into a clinical bit, primary care holds more risk from a clinical point of view than any other part of the system. And we're really used to handling risk and looking after people in really difficult situations.  

There is a very difference in the way the funding floats for particularly partners in general practice that actually it's your livelihood, isn't it? That makes it very different, which is why it's this move into neighbourhood providers and multi-neighbourhood providers and working in partnership with larger organisations I think will help general practice and primary care more broadly move into position to be able to share risk with bigger organisations.  

I think Sam's right again, the unblocking of the UEC tariff will be the bit that starts this and the move to the year of care payments. I think that of course there's an appetite to do things differently, you know, in general practice, if you make it really clear where the financial incentives are and the ability to reinvest savings to improve local patient care, then people will be willing to step up and do that. But it's got to be with the right protection for people's livelihoods.  

Matthew Taylor 

Last question for you, Bill, and then I'm going to ask you all one closing question, but specifically for you, Bill. This, course, is a tech-tastic plan. Some really big ambitions in that regard. And there's a certain irony, isn't there, that the plan on quite a few occasions talks about ambient voice technology as being an example of a kind of breakthrough technology that can change things. And this comes a few days after a long letter from NHS England saying to people that you mustn't carry on using the AI systems you're using because they don't meet information governance standards. 

What tip would you give to Wes, to Jim, to leaders about how we get this technology stuff right because we really, really haven't in the past? 

Bill Morgan  

Yeah, we haven't. I think the NHS app bit of a plan was great, politically, by the way. we're going to have my GP, my consultant, my spare - if you give that to MPs, they'll absolutely love it. And you're right, though, in terms of how on earth you deliver this, that's extremely difficult.  

We've been trying to get the app to dock into trust's e-booking systems for literally years. And it's still... you can view appointments on the app, but you can't change them, even now. So it's a long old slog to get there by 2028.  

I think in terms of the adoption of tech, where we get it wrong is it's got its foundations in the capital regime. What you need to do is design a capital regime where it makes sense for a frontline provider to adopt tech and use it effectively and invest in tech. But because the capital regime doesn't work especially well for tech, what we end up doing is procuring tech nationally and get we get a good price for it, but we procure it nationally and then tell frontline organisations to use it and they don't own the adoption of it. And I think that's a challenge which we have to overcome if we're going to really harness the benefits of all this fabulous AI and other tech which is coming. 

Matthew Taylor 

Yeah, I think that there's an implicit idea that I know some people argued for on the plan and doesn't quite make it in explicitly, but that's a kind of recognition that we will have a twin track health service. There will be a national digital offer, which is commissioned nationally and provided nationally and is universal in the same way as online banking might be. And then there is local services and the way that local services use technology. And I think it'll be interesting to see how that that evolves.  

So look, here's a kind of final question for you all. And it's a reflection of my own failure and inadequacy, because I had an argument with the ten-year plan team and a bit with Wes about something I wanted them to say more explicitly in the plan and wish they didn't. And indeed, spoke to Wes about this the other day. And at last plea, said, look, as you launch it, could you say this? And what I wanted him to say was how important patients and the public will be to the delivery of this plan, that patient attitudes, patient behaviours, patient expectations, the willingness of patients to do things differently are really critical. 

The story here, I think, is at the beginning of the ten-year plan process, they did some focus groups in which they said to people, do you think part of this is about you taking on more responsibility? And the people out them said, no, sod off. It's about you providing better services. I kind of get that, but I still think we ought to be engaging in all sorts of ways, from the public being willing to support difficult reconfiguration to using the app, whatever it might be. When I spoke to Wes about this the other day, he said, look, Matthew, if you want to make unpopular arguments to the public, you go for it, mate. So we will carry on saying that.  

Sam, how important do you think it is without, of course, wanting to contradict our Secretary of State that we have a message here to the public about their importance in achieving the transformation we ought to achieve over the next few years? 

Sam Allen  

I think it's really crucial, Matthew. I also have empathy, I guess, for the Secretary of State that perhaps saying that sort of thing nationally may run the risk of being viewed as the nanny state. And actually, one of the really exciting things about this plan is the devolution, the local decision making.  

So in part, I see that as our responsibility at local level. We know our populations, we can work with our voluntary sector organisations, all of our community partners, local politicians to be able to have that conversation, which is actually when we're looking at services and shape services in the future, this is what the evidence tells us. Actually, how can we co-produce aspects of this with our population, but also how do we have a conversation with them about what is all of our role in safeguarding and NHS free at the point of delivery for the future? And I think some of the announcements last week around Healthwatch, and I mean, we've got brilliant relationships with Healthwatch locally. They are really valued. 

But actually, if we're thinking about the future, we'll have some time now to work with them to think about how do we get a more representative voice. And we're starting to think about citizens assemblies. We need to have a different, transparent conversation with the public about the opportunities, the challenges, the choices that we need to make.  

I'm really conscious that every year as a council taxpayer, I get a bill that arrives on my doormat that tells me what the charges are, what they're for, if I've got a precept for social care. I think we need something similar on health, Matthew. We're spending in our system a billion pounds a year at the moment on medication. We've got huge wastage in medication. That's just one of many examples of how the public can work with us to better use the scarce resource that we've got to make the shifts that we need in this plan. So we have to have that conversation, but I think we do that locally. 

Matthew Taylor  

Yeah, and there's an intriguing paragraph in the plan. Of course, we're going to have mayors on ICBs as a quid pro quo for the abolition of ICPs. There's an intriguing paragraph that says we might, in the future, explore democratic accountability for ICBs. That's a very interesting to see how that develops as an argument. 

Sam Allen 

And I have no issue with that, Matthew. Our two elected mayors chair a cabinet, they've got programmes of work across skills development, transport, why not have one on health? And particularly when we know that health, the impacts around transport, employment, you know, these things are all interrelated. So I think the prospect of that actually is quite exciting. 

Matthew Taylor  

Yeah, I think that's fascinating that you take certain elements of the plan to their conclusion. You could see local government ultimately taking on the role of commissioning. And that's a fascinating thing.  

Claire, one of the things I talk about a lot is that we always talk about access to the health service, but a lot of the time we're over treating and mistreating people. That statistic that between a third and a half of people with long-term conditions aren't adhering to their treatment. That's not their fault, but it suggests that we're not quite getting the relationship right. That relationship is at the heart of general practice.  

Do you think we need to be a bit more explicit about needing a different kind of relationship with the public? 

Claire Fuller  

So I think this is really, it's complex, isn't it? So I completely understand why you're saying that you are, but I always worry about the most vulnerable because you go back sort of in covid and we say we're really busy, we're overwhelmed, come in, people stopped coming in to see us. So I think this is why, I think this is about really local conversations that are tailored to your local community to make sure that we don't exclude our most vulnerable.  

So particularly around things like you've to do everything on the app. Not everybody has got a smartphone. My parents, my dad is really tech savvy within IT before, back in the 60s and things. He will use his big computer, but he won't do it on his phone because he can't see it very clearly and can't necessarily access really. So it's making sure that locally for those people that do still want to access in different ways, that we make sure that services are available for them. 

I was in Frome recently and they have while people are waiting somebody that comes in a digital champion that makes sure it helps people load it onto their phone and make sure that they can gain access. So I do think there's local nuancing to the conversation and I think it's on us as leaders to make sure that the service is as accessible as possible and works in the way that works with the population.  

So it's always both, Matthew, isn't it? It's always both, but around the long-term conditions, but we need to make it easier for people. And for most people with one or two long-term conditions, they're fit and well and healthy. Actually we should try - so in UCL, in North Central London, they've been working with UCLP and actually been looking at how remotely you can improve your monitoring of long-term conditions.  

So, if any of us had hypertension, we might want to check our own blood pressure, book in for a blood test to get stuff checked. And as you might never need to see a GP or if everything is well and it's chugging over. So we just need to make it easier for people to manage health care in the way that works for them and keep them safe at the same time. But it isn't going to necessarily be book an appointment to see a GP once a year for every single different condition that you might have. 

Matthew Taylor 

So thanks, Claire.  

I'm going have a final word with you on this, Bill, looking at this through a political lens. What commercial organisations can achieve is that they can make decisions without the burdens of public accountability. A bank can say, we're going to close our branches, and you'll have to go online. And it's a bit controversial. But it's not career threatening in the way that a similar decision to close a hospital might be for a politician. 

How should politicians be talking to the public about this? It feels to me like ever since the failure of the big society from David Cameron, there's always been a nervousness about being explicit with the public about how they are part of the solution. But do you think the politicians should be articulating that more? 

Bill Morgan  

I think it's always tricky to get ministers to tell the public difficult things. You might wish it were otherwise, but it's quite tricky. I mean there are... 

Matthew Taylor  

You'd be one of the people saying to Wes, you should ignore that Matthew Taylor. 

Bill Morgan 

Well, I mean, it does lead you to certain things. So you may as well do the difficult things now, you know, because we're quite away from the election still. If you're going to crack through an FT pipeline, then start now with the really tricky ones, and then calm it all down ahead of the next election.  

What can really help politicians do difficult things in the NHS is clinical leadership. And I think the stuff in the plan, as Claire mentioned earlier about the modern service frameworks and the re-immigration of the National Quality Board, this to me creates scope for clinical leaders to make difficult arguments. And it reminds me of Mike Richards doing some tackling the number of prostatectomies in the 2000s, really difficult message about how services needed to close and he led it very well. So I think those are the kinds of arguments that need to be made by clinicians and hopefully not be undermined by politicians in the process. 

Matthew Taylor 

Well, I can see Sam and Claire both nodding their heads at that. So maybe you're right. Maybe it's not the message that's the issue, it's the messenger and what we ought to be using clinicians.  

Bill, Claire, Sam, thank you so much for joining us this morning. It's been an exciting week for the health service. The sun is shining. Have a lovely weekend. 

Well, thanks ever so much to my guests, Claire, Sam and Bill, for sharing their thoughts with you today. As I say, keep an eye on our website. We're going to be posting lots of opportunities for members to get involved in discussions around how we work to make this plan a reality. Because in the end, it is all about implementation. 

But that just leaves me to introduce our Leader in Six interviewee and that's Gubby Ayida, chief executive of Evelina London Women's and Children's Services, part of Guy's and St Thomas' NHS Foundation Trust. I strolled across the river last week to meet Gubby and members of her team. It was absolutely fascinating.  

So, here are your questions. The first one. What's the biggest challenge you're facing at the moment?  

Gubby Ayida 

Right, so I've been here about two years now, although I feel I've been here forever. I think I heard this phrase, ‘ambidextrous leadership’. And it's so resonated with me. It's about BAU and strategic. We have quite a lot of strategic projects that are consuming all my executive team. 

Then we've got all the BAU, the delivery, the quality, the waiting lists, financial sustainability, everything we're supposed to be doing on the tin to keep the hospital going. But we also have to do the strategic, the future here and now. So when my team say, well, what do you want us to do? This or that? Both. And we are learning: How do we do that? How do we delegate? How do we have people working at the top of their license? What is it only we can do? What is it that they can do? We are stretching our next layer down because you've got to take care of business and we know what the pressure of that is. 

But then we've got to say, our job is to, if we don't start five years now when we get there, and it's that. Ambidextrous.   

Matthew Taylor 

Well, I certainly recognise that as a leader. I'm sure other people as well. Tell me about a single improvement or innovation in your organisation that you're particularly excited by or proud of. 

Gubby Ayida 

I think there are quite a few, but I think the one that leaps out for me is how we are combining women's and children's being part of the clinical group and take and leveraging that. So it's all about that whole life course approach.  

And one of the things that we've got now is that in Lambeth and Southwark, which is our place, we have data on every baby born here and we've got the opportunity to follow them through. And really have data on them all the way through to adulthood. That is a game changer I think for us. The opportunities that will come out of that, the way we'll use that data to influence and target, especially with the whole inequalities thing. 

So I'm very excited about that. And of course, we've just moved to Epic. So it's the ability for Epic as an electronic patient record to link with primary care. I mean, that's the challenge in itself, but if we can actually do that, then we can actually start creating healthcare by need. Not just talking about it but really doing it. 

So I'm quite excited about that aspect.  

Matthew Taylor 

Yeah. Great. Of course, your new boss in a couple of months is going to be Amanda Pritchard, who did run the health service, which links to my next question, which is: if you were queen of the health service for a day, what's the one thing you do?  

Gubby Ayida 

If I was queen for a day, I would ensure that there is sufficient allocation for leadership and leadership training. 

I cannot tell you because that's what's going to really make the difference and, in fact, I sort of think paradoxically, you almost want to put your crack team in the most challenged areas because if anybody can do it, they can, rather than moving them to the ivory towers where it's great and you're in a place where you're being inspired. 

But if we are looking at healthcare as a whole, the continuum, and it's not about geographical location. Leadership is what is going to be able to transform the way we work. And I don't think we do enough of that.  

Matthew Taylor 

I completely agree with you. We do quite a lot of leadership development at the Confed and I think people see as money being spent on bureaucracy, but it's not, it's absolutely critical.  

So I completely agree with you on that. Which takes me to my next question, which is, tell me about a leader you particularly admire. It might be someone you've worked with, it might be, you know, someone globally, but just a leader that's inspired you.  

Gubby Ayida 

I'll come closer to home and I'll probably actually say Lesley Watts at Chelsea Westminster, which is where I was a divisional medical director. And then she moved me across to be an interim because in another trust that she was sort of overseeing. And Lesley, for me, just, I don’t know how she found time in the day to do walkabouts. And do everything else you do, not just for the hospital or for the region. Then nationally and it's how to lead and still have that popup on ward.  

I want to aspire to do that because in my head I want to be a visible leader and back to that, but in my day I can't because if I get to the ward, I can't get back in time for a meeting. 

So I loved that about her and I loved the fact that she is so plain speaking. She calls it as it is. If you say you can do something, she goes, you want to do it? Do it. But don't come back and say... so the challenge is then on you to do it. So I think there are lots of global, but always for me it's related to where you are now. 

Matthew Taylor 

Gubby you obviously work incredibly hard here, doing your ambidextrous leadership as best you can, but tell us something about yourself that's nothing to do with your job.  

Gubby Ayida 

Oh gosh. You know, for us as leaders, you have this double life and I'm immediately uncomfortable. It's like, oh no, this is the face I bring into the NHS. 

I've got an amazing Akita, you know, dog. Big, elegant dog. And yeah, it's so... I would say...  

Matthew Taylor 

Dog walking’s good for the soul. 

Gubby Ayida 

Dog walking is good for the soul. It's where I get my best thoughts. It's either I dream them or when I'm going on a ball, so that for me is very therapeutic. Even holidays now, because life is so busy, I can't do anything when I'm not working. For me, the luxury is time that's my own. You know, I wish I could say I've got these amazing hobbies. I go to the theatre, but actually what I crave now is just like silence and my own companionship.  

Matthew Taylor 

And final question, share with us something that you've read, something that you've watched. It could be anything. Someone said White Lotus, someone said something else. Anything you've watched, read, listened to that you've enjoyed, you recommend to other people?  

Gubby Ayida 

In fact, this is very recent. I watched a private screening of a short film called 22 Plus One, and it was a dramatisation of a black pregnant woman, married to a white guy, and it was really her experience through her pregnancy. 

It is the most powerful film I've ever seen. And how I actually got to be at the first screening was, this was a story that happened to one of my previous patients who wrote a book and I helped her with the medical accuracy of it. But she was white and she's in the media and she's a journalist, and she started researching this and then saw how her story was superimposed in a black woman, so she got an actress to do that. They collaborated.  

This film was so powerful that I thought everybody in my maternity... ...you know about all the inequalities... everybody in my maternity unit needs to see the film. So well done. And myself and the director of midwifery, we were going to bring film to our maternity service. And then I thought, no, actually I'm going to show this to everybody involved with maternity. So the national chief midwife, the chief nurse, the clinical director, nationally, regionally, chief nurse, regionally, clinical director. We got CEO of our ICB. So we gathered all of these people last night for the first NHS private screaming. 

And you know how that moment, about five minutes before it starts and you go, what if they just have the same reaction as I did? And honestly, the reaction and the conversation we had afterwards was probably one of the richest, because if we had to have a hashtag, it was instead of awareness and knowledge and data is to convert it into action and move the dial on black maternal inequalities, but beautifully done, thought provoking, and literally just so much authenticity in the room. 

And I couldn't have timed it better because of course this is the week that Wes Streeting has just made the announcement and has called out inequalities from a race point in maternity.  

Matthew Taylor 

Brilliant. And do you know when the rest of us will be able to see this?  

Gubby Ayida 

Very soon. Because I have challenged our leaders, our decision makers, our influencers there, that if you feel like me, which they've all said, then this is what everybody has to see. 

Matthew Taylor 

Oh, we'll look out for it on general release. Gubby, thank you so much.