Ten-year plan: what must the NHS prioritise?

Matthew Taylor: 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 Sarah Woolnough, CEO of the King's Fund and Harry Quilter-Pinner, executive director at IPPR, about their hopes and perhaps fears for the NHS ten-year plan due this year and how we get to grips with that most slippery of challenges high NHS productivity.

And just to be clear listeners, this episode of Health on the Line is non-promotionally funded by GSK and developed in partnership with us at the NHS Confederation. 

Also at the end of the programme, we'll be joined by Simon Ashton, chief executive of Newham Hospital, for another Leader in Six, a series of quickfire questions designed to get us better acquainted with NHS leaders.

But first, I'm delighted to be joined by Hazel Cheeseman, chief executive of Action on Smoking and Health, known more commonly as ASH, the independent public health charity set up by the Royal College of Physicians to try and end the harm caused by tobacco. We're going to be talking about the government's tobacco and vapes bill currently making its way through parliament, and the wider goal of a smoke-free future for Britain.

Hazel, welcome to Health on the Line. 

Hazel Cheeseman: Thank you for having me. 

Matthew Taylor: So we all know in the health service about the harms of tobacco and concerns also about vaping and tackling those harms is a key goal for local health and care leaders. There's also a strong link here, of course, to health inequalities. We represent integrated care systems and reducing health inequalities is one of their core objectives.

In terms of reducing those harms and in so doing tackling elements of inequality, do you think that the proposed legislation goes far enough? 

Hazel Cheeseman: Well, the legislation is really world leading in terms of introducing this phased out sale of tobacco to the next generation. So it will introduce this measure, which no other country in the world has.

New Zealand had legislation that was repealed by an incoming right wing coalition, but we will be the first country in the world to bring this forward. And it will phase out the sale of tobacco to those who are born after the 1st of January 2009 and effectively put a kind of end date on when tobacco will be legally sold in this country, albeit sometime in the future.

So over the long term, this bill is absolutely something which will drive down inequalities. Of course, as you say, smoking is very highly associated with deprivation, disadvantaged; almost any group with high rates of disadvantage has high rates of smoking. But it does a bit less, I suppose, for those people who are currently smoking.

It will introduce some more regulatory measures around the retail setting, which might help; it will introduce new powers around smoke-free outdoor places, all of which might contribute to helping people reduce smoking. But on its own, it’s, probably unlikely to really end smoking or end inequalities in the near future.

And so, and that's something that's really important for the government to consider as it takes forward what's really important and powerful legislation, what else is it going to be doing, you know, through integrated care boards, through the NHS, through local government to help the 6 million people that currently smoke to quit.

And then there's the question of vaping and large parts of the legislation are about tightening the regulations that we have around vaping and other nicotine products really bringing our regulations in this space up to date. And that's a really comprehensive set of regulations, which will give the government or future-proofed powers, I suppose, across a whole suite of nicotine products to regulate the branding, point of sale displays, advertising, the design of products, the contents of products, which will ensure that we have really good control of the market.

And that's important because we've seen an increase in vaping among young people. And although vaping is much less harmful than smoking, it's not risk free. So, use among nonsmokers, use among young people is a source of concern. 

But what it doesn't do is it doesn't remove vapes from the market. It keeps them available. And that's also really important on that broad objective for reducing smoking and reducing inequalities. And because they are a really valuable tool for helping people quit smoking, particularly in populations with high levels of addiction and particular disadvantage. So it kind of strikes that balance between protecting children but also keeping products available for the smokers who need them to help them quit.

So I guess it's a bit of a mixed picture, I suppose, Matthew, in terms of it's going to do something, some really exciting things for the future. It's going to do some sort of more modest things in in the here and now around smoking, and it's going to future proof us around kind of nicotine and vaping products and ensure we have the kind of a kind of fit-for-purpose regulatory structure there.

Matthew Taylor: Yes, and enormous progress when you think about the, you know, campaigning you've, as an organization, had to do over the years and to get to this position. 

I want to talk a bit more in a moment about the role the health service can play in helping people who are addicted to smoking to give up. But before I do, how concerned are you, Hazel, about smoking becoming a kind of cultural issue, as it did in New Zealand, how worried are you that, I don't know, Elon Musk is going to start tweeting that the legislation is totalitarian and there needs to be a fight, populist fight back against it?

Let's not focus on Mr Musk, but you know what I'm talking about here. How concerned are you about this? 

Hazel Cheeseman: Yeah, absolutely. And I think you hit on something that's really important, Matthew, and it is the reason why, to some extent, you saw this roll back in New Zealand, that there was a coalition formed with a party of the right, and part of the coalition agreement was that the legislation be rolled back.

We've had a really strong tradition over many years. in the UK that tobacco is a non-party political issue, a cross-party issue. The All Party Parliamentary Group on Smoking is obviously truly a cross-party group. It has been led by the Conservative MP Bob Blackman for many years. And it was, of course, a conservative prime minister that introduced this legislation in the last parliament.

So, there are MPs, parliamentarians from across the house, from the Conservative benches, Labour benches, Liberal Democrats from the national parties too, a plurality of whom supported this legislation when it was before the previous parliament and voted for this legislation at second reading. So, I am confident that that coalition holds in the here and now, but we need to continue to ensure that politicians and voters of all parties continue to understand what the profound impact it's making has on individuals and on society to protect this legislation in the future.

But I think the fact that there is such strong public support for these measures does give us some protection. The polling that we've done shows that. Regardless of who you vote for, there's majority support for the measures in this bill and for other measures which the government isn't taking forward.

And the support for tobacco control measures, which has been high over time, as these measures get introduced, the public support them more strongly and support further measures as well. So I hope that the UK is in a position where the political consensus is sufficiently strong that we wouldn't see this becoming an issue where it's sort of dominated by some Twitter narrative or whatever that might be.

Matthew Taylor: Yes. I think it's, it's going to be important for us to remain vigilant in terms of how we make these arguments. I remember I was in Number 10 and was involved in the Cabinet argument about whether to institute the first, smoking ban in public spaces. And there was an argument from some Cabinet ministers that this would look like a middle class do-gooders taking away pleasures from working class people.

At that stage, the argument about passive smoking was very important, but I think it's also really important to always emphasise that most smokers say they wish they'd never started, and most smokers want to stop. Which takes me to my final question, which is, in terms of the role of public health, of the health service, our partners in local government, voluntary sector, what works best in terms of smoking cessation? What would you like to see us doing more of? 

Hazel Cheeseman: Well, there's a great deal happening. And if you go back to that those times when you were having those debates in Number 10. I mean, it was the, the Labour administration at the time that introduced this comprehensive white paper on smoking that brought forward the first smoking cessation clinics in the country, which were again, were world leading at the time and have continued to be world leading.

The way in which we support smokers to quit in this country, the mass media work that we've done over time. The approach that we've taken to illicit tobacco has been world leading as well as having these very strong regulatory measures passed through parliament. 

And so it's really about kind of sticking, sticking to the knitting, I suppose, for the NHS and local government. We've been rolling out these really exciting services embedded into NHS settings, in patient care and mental health services and in maternity settings, following from the, the NHS long term plan. And those are kind of. I'll not quite say embryonic, but they're still bedding down. Um, but we've seen some really early results from maternity settings, which has seen, you know, really historic drops in the rates of smoking in pregnancy since those services have been established, you know, some of the biggest drops we've ever seen in smoking in pregnancy. 

So we really can make a difference if we put these services in the right place and reach people at the right time. We really can accelerate smoking cessation in the population quite significantly. So we need to keep doing things like that and keep providing those services that we have in local government, which have recently been invested in by the previous government and by this government, doubled the investment into local authority stops making services. All of that will remain really important. 

But I do think that the passing of the legislation and building on the investment that we already have in local government in the NHS is a massive opportunity. The government have said they want to create a smoke free country. Well, now's the time to really kind of double down on that commitment to put that further investment into NHS services to make sure that every targeted lung health check comes with straightforward access into smoking cessation support; that we're putting more support into talking therapies where about a quarter of people are probably smoking; that we're reaching out into disadvantaged populations through social housing and through other kind of poverty-related allied services where we know smokers are likely to be overrepresented.

It's that kind of investment that we need now to maximize the opportunity of the phased out sale of tobacco and the other measures that this bill will come in. So, that's what we'll be saying in the spending review that now's the time to make good on this commitment and to build on really the tremendous infrastructure that we've put in place over the last two decades. 

Matthew Taylor: Well, Hazel, it's been a challenging start to 2025. So it's great to hear what is fundamentally a good news story in terms of the reduction of the prevalence of smoking in terms of this government acting and acting with cross party support and the effectiveness of health services.

So Hazel, thank you so much for joining me in Health on the Line. 

Hazel Cheeseman: Thank you for having me. 

Matthew Taylor: Now, I'm very pleased to welcome our next guests to the podcast. Sarah Woolnough, chief executive of the King's Fund, and Harry Quilter-Pinner, executive director at IPPR. 

Sarah, Harry, welcome to Health on the Line. 

Sarah Woolnough: Thank you. Great to be with you. 

Harry Quilter-Pinner: Delighted to be here.

Matthew Taylor: So Sarah, let's start with you. It's the beginning of another year. We're still, of course, in the thick of a very challenging winter for the NHS. But we're all trying to look up, look to the next ten years. 

To what extent do you think, since the beginning of this process, the ten-year plan being announced, which is pretty much immediately after the election, do you think we've become any clearer about what some of the kind of big solutions, the big directions of travel are going be? Or are we still stuck on Wes's three big shifts? 

Sarah Woolnough: Well, we've heard an awful lot at a high level about the three shifts and I think if we have become clearer as a community, as a system, hopefully as a country, it is to be more honest about where we find ourselves now, and to nail the point that we can't go on as we are. 

There were new life expectancy stats published shortly before Christmas. Life expectancy has stagnated over the past decade. It's got worse in some groups, you know, Darcy talked about a society in distress in terms of its health. So I think we have had a dose of real honesty about. where we find ourselves and how challenged our nation's health is, as well as our health and care system.

Are we closer to what are the big ticket bets that are going to unlock the change that I think we all agree we need? Not really. And I think the hope is pretty early on in this year, we get some more clarity. There will have to be a few bets made. How do we orientate our health system more towards prevention, earlier intervention, and what are we going to pick as the couple of big ticket exemplars of analogue to digital?

I am hoping we get more clarity pretty soon, Matthew. 

Matthew Taylor: So, Harry, just turning to you, you're obviously running IPPR, you're close to government. Your colleague, Chris Thomas, who I work with on the Health and Prosperity Commission, is in the Department, working at a strategic level. I'm sure you have insights.

Do you get a sense that things are starting to crystallize? There are certain kind of big bets, big shifts that are being pencilled in? 

Harry Quilter-Pinner: I think the only thing I would add to what Sarah said, in terms of what we've learned about the reform agenda that the government is pursuing was the government's plan for change reset.

And what I think that told us was that of all the things that the government have said they're going to prioritise in health, they've obviously talked about access, they've talked about the quality of care, they've talked about the experience of care, they've talked about health inequalities and healthy life expectancy. 

But that plan for change, that reset moment, they really shone a light on the access question and clearing the backlog. 

So I think we've learned that that is probably their top priority. I think obviously that's an incredibly important issue. People shouldn't be waiting that long for the care they need. But I have to say that priority made me a little bit nervous. And that's because I think if the system orientates entirely towards access and towards the backlog, it makes it potentially harder to achieve some of the longer-term shifts that we know we want. You know, better outcomes for cancer patients and in mental health, healthy life expectancy and health inequalities.

So I think the question now is, if that is the priority, and I understand politically why the government might want it to be the priority, how do we do that in a way that doesn't undermine those broader shifts that we might want the system to be pursuing. Because if we don't, I think what will happen is we will find ourselves in five years’ time in a situation again where health sectors have stood up and said, we want to do prevention, we want to do integration, we want to do population health, but then the activity and the effort in the system has pulled in a completely different direction.

Matthew Taylor: I'm going to go straight back to you, Sarah, on that. 

So I kind of get what Harry is saying, but I thought it was interesting reading the background briefing that went with Keir Starmer's speech. Because whilst the focus was on the elective waiting-list challenge, The ways in which they said they were going to go about that in the briefing materials was a shift away from simply pouring more money into the pockets of consultants and other acute staff members and opening up theatres more intensively.

They did talk about prevention. They did talk about more treatment outside hospital. I mean, 70/80 per cent of people on waiting lists are waiting for diagnostic and outpatient appointments. So one way in which you might square the circle that Harry's described is to go about the access challenge, that waiting list challenge in particular, in a different way, in a way that speaks to those shifts. It's what I sometimes refer to as split screen thinking, trying to do the stuff in the now screen in a way that aligns with the long-term direction. Am I being too Panglossian about that possibility? 

Sarah Woolnough: I mean, I'd love to see that come to pass. I mean, I think Harry has highlighted the major risk and it's interesting how people have been interpreting that relaunch. 

Clearly you get it politically. I think that the government has to show improvement on performance. And I think, reading between the lines, they are wise to seemingly roll back from earlier statements, which may have committed them to meet more constitutional standards quickly, or as many as possible within a first term, that would suck so much resource attention away from some other things shift-wise.

I get it politically. I hope it's an opportunity to try some of the shifts and try to implement some different thinking. I think there's a risk. We resort to how we did it last time and it becomes quite an acute measure and focus. 

But I've been around various conversations over the last few weeks where people are really talking about how do we use the marginal pound recognising as ever that money will guide quite a bit of this and financially things are really tight to do things differently. 

I know you do this, Matthew, but at Confed, you know, at the King's Fund, similarly, we're lucky enough to go and see some fantastic case studies in practice of where people are working in integrated neighbourhood teams.

They are trying to shift care closer to home. They are trying to think differently about how they measure and report on data, cut things differently. So I think you have painted an optimistic picture and one that I hope comes to pass. I think the government and the system needs to pretty quickly fill in some detail behind the high-level programme for government announcement in order that we don't default to trying to do it the way we did it last time and therefore reinforcing this acute is king, let's suck more money resource attention to an acute measure at the expense of prevention, care closer to home, meeting people where they are, delivering for them in their communities. 

Matthew Taylor: Yes, the idea that we might flunk this test again is kind of so depressing. So I understand the political imperatives around waiting lists, and I know that the focus groups that Labour or the government has been doing have shown that that's what the public thinks is the most important. And not surprisingly, so many millions of people are affected by those, those long waits. 

But Harry, you know, IPPI As I said was on the health and prosperity commission you focused on a different imperative and it felt to me as though progress had been made in getting people to understand that and that's what is now from called ‘the curve of doom’ that if we don't do something about what will happen if we carry on in the same way as we are at the moment to demand; if we don't do something about healthy life expectancy in particular, and of course, not just you've made this point, Chris Whitty has made this point, then it's not just the NHS that is in deep trouble, but the whole country is in deep trouble. Now that takes us into the kind of conversation about the mission.

I guess part of what one hoped was that even if this historic tendency for the NHS to start out with big ambitious plans and to end up pouring more money into acute, that might be balanced by this mission-driven approach that recognised the need for a much broader approach to health policy as a whole. But again, I hear mixed messages around missions. Where do you think we are on that, Harry? 

Harry Quilter-Pinner: I think it's an excellent point, and I agree with you, the optimism that I had at the start of the parliament was that in the documents that Labour published in opposition on health, they put healthy life expectancy and they had a health mission, not a healthcare mission, and there was healthcare within that, because healthcare is an important component of what allows us to drive better health, but it's far from the only thing.

And I agree with you that whilst my view has been and continues to be that mission-driven government could be more than a slogan; it could be a genuine innovation in how we do government that helps overcome some of the well-known challenges. In government, short termism, silos across different priorities, investment that gets dragged into the urgent and doesn't get invested into the kind of long term important priorities such as prevention.

I don't think we've yet seen Labour in government innovate with the way the state works around this theme of mission-driven government to the extent that would be required to really turn it into something that galvanised different policy outcomes. 

For example, I would like to have seen and like, and this could still happen because we've got the spending review coming up, but I would like to have seen a set of metrics. I would like to see Rachel Reeves stand up at the budget and at the spending review and say we are going to measure all of our spending against a small set of outcome-focused metrics. Growth and living standards, great. Carbon emissions. But I would have liked to have seen healthy life expectancy in that list.

And I would like to have seen governments start to tool up its economists and its staff to quantitatively, as much as possible, quantitatively model big spending items against those things. I think that's perfectly possible to do. And that would have seen, in my view, or would see if this is indeed what they might do at the spending view, I hope so, that would see all departments be helped to account for their contribution to health.

And I would also like to see Rachel Reese stand up and say, we will give preference to spending bids that were jointly put together by departments towards those mission metrics. So for example I would like to see DWP and DHSC working together on how would we maximize our spending in this coming parliament to deal with economic inactivity, which is a massive problem.

DfE and DHSC do the same on children's health. There is infrastructure. So it's quite nerdy, but there's infrastructure in government to do that. There's something called the Shared Outcomes Fund, which is designed to encourage bids between departments. 

But unless the government stand up and say, this is going to receive preferable treatment, you're more likely to get your money as a department if you work together, plan together, and come forth with an ambitious proposal around these mission outcomes.

And I haven't seen that level of ambition to innovate in the state yet, if I'm honest. 

Matthew Taylor: In IPPR's work, you argued that different approaches to prevention and productivity could save the NHS about £200 billion while improving outcomes. You and I have spoken before about bits of preventative work where the benefits are indisputable, like vaccines, where every pound we invest in increasing the take up of vaccines has a kind of 14, 15 pound benefit to the public purse.

In terms of this area of prevention productivity, the lack of imagination that you're sensing from government, Harry, is it in the end, people just don't, in government, just don't really believe it. They don't really believe that there are ways, big and small, of investing money up front that genuinely will save money in the medium term.

Harry Quilter-Pinner: I think there's a lot going on and I don't have the full answer, but I would say there are a few common barriers. 

One is politics. I think politics draws you into the here and now, and it often draws you into some of the deliverables which are most visible to people, probably fundamentally not the ones that are most important to them. 

So the access question, access is really important to people. But I think if you went to most voters and said, you might have to wait a bit longer for this, but you're going to live longer in your life and you're going to have a longer healthy life expectancy. I think I know which trade off they'd take.

But that doesn't come up in focus groups and it doesn't always get rewarded if people, you know, politicians do the right thing. So there's kind of there's a political challenge that I think often gets in the way. 

I think there is then a bunch of things about the incentives and the structures in our system. So for example, if you talk about shifting care from acute to primary care and community care, the interest groups in the acute sector are just a lot more powerful than in community acute and certainly in social care and the organisations with the ability to kind of take on lots of resource sit in the acute sector, not in the primary care sector, usually, because we don't have primary care at scale everywhere. So there's a bunch of structural incentives and interests that I think weigh against it. 

And then I think you're alluding to a problem in the treasury in particular, which is, you know, departments always go to the treasury and say, we've got an invest save proposition. And the treasury always says, well, we don't really believe that's going to save any money. And I think there is some truth in that in that often what we're doing is making better use of resources not stripping out costs. So there's no direct saving, we're just getting a you know, higher productivity or better outcomes for the money that we are investing.

There's also some like unhealthy scepticism in there, which is that I think we need to do a lot more to add rigor to our argument for invest to save. For example, we've asked and said the treasury should ask someone to commission a review led by the treasury to rigorously define prevention spend across different departments and to then police that boundary so that they are confident that people aren't trying to slip things into the prevention category that actually isn't prevention. And then over time we could get a consensus to grow it. But I think unless that work is done by the treasury in my view, and unless it's done really rigorously, we'll never convince the Treasury that that investment is real and worth doing and that we're not just trying to pull the wool over their eyes and get them to fund stuff under the banner of prevention.

Matthew Taylor: And Sarah, to what extent are we in the health service part of the problem in the sense that we make the argument all the time that investing in different ways upstream, in the community, in prevention, in addressing inequalities, that all of this will ultimately be a better use of money.

But yet, the evidence in practice of this is quite hard to get hold of. And I understand why. And the biggest individual problem is you've got people ladling water out of a bath, which is overflowing with both taps running. And it's very hard to prove that them ladling water out is making a difference, because in a sense it isn't making a difference because the bath is still overflowing. 

But do you think, Sarah, we are making strong enough arguments in the health service about the way in which different forms of investment, different forms of care really could help with financial sustainability?

Sarah Woolnough: Probably not. And I think you've highlighted the problem beautifully. I was out with a mental health charity a few weeks ago. They work in Surrey. They do brilliant things. They contract with the NHS. They try to ring fence about 25 per cent of their budget for prevention. They go into schools, they work with young people.

And we were having a conversation about evaluation, robustness of the evidence, how they can prove that they are truly preventing acute admissions. And well, on the one hand, the reality is, it is very difficult to prove it. And how far do you go down a road of trying to do that versus trying to get the best evidence you can, but trying to shift the narrative a bit, and I do think to Harry's point in your earlier conversation, we almost hold prevention to a higher standard at times in terms of needing to prove this invest to save and sometimes an unrealistic time frame.

I think if you shift the narrative a bit, you're honest that actually both care closer to home and a shift to prevention don't save you huge amounts of money, if at all in the shorter term. What they do is they bend the curve hopefully, longer term. They are also better for people and are good in themselves. And I suppose to give it a sort of human reflection, I've spent most of my career in health charities, delivering services to beneficiaries and of course if you can prevent disease or if you can prevent reoccurrence, if you can help keep people well after an initial cancer experience, or once you've got heart disease or chronic respiratory illness, if you can vaccinate, if you can sign posts to smoking cessation services, if you can keep people physically active, if you can keep them living at home, enjoying a better quality of life for longer without the need to go into hospital, they will report in their droves. You know, that's what they value. 

So I think we need to both try to shift this narrative a bit, which is the public don't really value or want prevention in the same way, or it's politically toxic, it's nanny state, we can't intervene in certain ways, but I think also have more realism about why we're doing it, the cost of it; it's not always cost saving. But the hope is it's how we have a sustainable health and care system for the future. And I would echo the double or triple wins across different parts of the state, across different government departments. 

Matthew Taylor: And how it is, one of the kind of conversations about how government has to change to support better outcomes and financial sustainability is mission government. But are there other ways in which more innovative government could help? And I want to give you a concrete example. 

I was speaking the other day to colleagues in social finance, and I've always been a kind of big champion of social investment methodologies. I've seen the boom and bust of enthusiasm for this kind of way of working, going back 25 years. But I hadn't realised that actually over the last couple of years, social finance working with I think primarily Macmillan has actually put together work in ten ICSs, and more join in next year, in which they've invested money to change the end of life pathway in ways which help patients. Seventy per cent of people at the end of life, or their carers, say that they had treatment they didn't want. So improve their experience, but also it saved enough money to be able to pay back the charity that had invested so that they can do more of this work.

Do you think we need more of that? I mean I’m thinking here of for example, you know medicines vaccination. Do we need to make the NHS more open so that if you've got a medicine or a bit of kit that you think could make a difference, you can go to a trust you can go to a system and say look, what we'll do is we'll put the money up front and we'll predict these outcomes in these savings and if they happen, we'll have a kind of payment-by-results way of working.

Do we need to do things like that to get out of this position we're in at the moment, which is all sorts of assertions about how doing things differently could save money, but not really a great deal of effort? 

Harry Quilter-Pinner: Yeah. I think what you're talking about there is certainly one example of a change that we would need in the system and would have a huge amount of benefit.

And there was a lot of talk about, well, we could do things differently after the pandemic. And I think a lot of that has disappeared and we've defaulted back to the system we were in before, to our detriment. I would like to see a lot more of that thinking come into the ten-year plan. And I think the thing that worries me about the ten-year plan is there are some tried and tested methods that were used in the new Labour era that absolutely have validity and they will work on the thing that you want them to achieve. So if you want to get waiting times down by making, creating a very singular target on access, chucking a load of money into, to those bits of the system, having quite harsh accountability and you will get waiting times down.

It's just that we also know what will happen. is that the other outcomes that we care about will get left to one side because staff won't be accountable, really accountable for them and they won't be seen as a priority. There'll be burnout and retention issues as people go, this isn't the system I want to work in and this isn't what I, you know, I came to serve patients and I'm spending my whole time not looking at the patient and going, what do they need? But looking upwards at the target that's been set to me from Whitehall. 

So, there are bits from the kind of new Labour era that we should absolutely pinch and we should build on and learn. So I'm not saying chuck the baby out with the bath water, but I am saying, part of the idea of what was called ‘new public management’, which was the kind of ethos and approach that underpinned new Labour's management of the NHS, was to take practices used by the private sector and apply them to the public sector. That was kind of part of the idea behind it. 

I think if we looked at the best private sector organisations today, they would talk a lot more about leadership. How do we cultivate really amazing leaders in our systems? They would talk a lot more about the culture that's created in those organisations, can we create – and Pat McFadden talks about this in his speech after the plan for change – a kind of test and learn culture a genuine culture of innovation where we limit risk adversity and we try and innovate instead, as well as things like targets and financial incentives, which have a place. We need those kind of things. 

They also talk about decentralisation. They talk about empowering the frontline to get on and deliver because they're the people that know best. Again, our NHS is wildly over-centralised. So, I would like these kind of things to be coming through in the ten-year plan because I think that's what will help us create a modern NHS that adopts the best new technology and innovation.

Matthew Taylor: Harry, that's brilliant. And actually, my last question was to say, what is the key thing above all else you're looking for in the ten-year plan? You've just answered that, Harry, so we'll end by turning the question to Sarah. 

Sarah, if there was just one big idea or one big different way of thinking about change that you could get into the ten-year plan, what would it be?

Sarah Woolnough: I'm going to say two. I know you pushed me on one. That's fine.  

Matthew Taylor: Harry had three. 

Sarah Woolnough: There is something about moving the money and the architecture and the incentives. We've published quite a lot on this recently. We published a report, Making Care Closer to Home a Reality, and we talked about despite 30 years cross-community, cross-system consensus on the need to move care closer to home, it hasn't significantly happened. If anything, you know, we've differentially invested further in acute settings. 

So why haven't we shifted care? And we talk about the system not being lined up and orientated behind that vision. And if you are serious about making these shifts do need to rewire the financial architecture. You do need to measure and prioritise the shifts. So, I feel very strongly we need a metric or two alongside 18 weeks that encapsulates pretty simply the shifts and that we can look in five years’ time and say, have we made progress? 

We need to think about the workforce and how we value generalists and how the status of working in the community and in prevention is at least equal to that of working in an acute setting, which it isn't at the moment. 

So you do have to line up behind your vision. So I would like to see the ten-year plan in a really concrete way, say, this is how we're going to rewire financially and from an incentive perspective. 

But the other point is for the ten-year plan to have impact and drive sort of success in any sense, it's got to drive a shift in how people experience the health and care system. Too often it's clunky, it's hard to navigate. People feel too much done to rather than kind of a partner in their health and care. In sharp contrast often to how we navigate so many other areas of our life, we say often we need to orient services around people and patients and citizens and we don't do that, but I don't know that we, we've quite defined what that means, you know, what does that mean in practice, particularly when people are living with one, two, three long-term conditions, but a prize and something I would love to see the plan make progress on is putting people at the heart, giving them more control over their health records, making it genuinely easier for them to navigate the health and care system and to get access to what matters most to them.

Matthew Taylor: Well, Sarah, Harry, we could have talked for hours and thank you both for your time. 

Sarah Woolnough and Harry Quilter-Pinner: Thank you. 

Matthew Taylor: And finally, it's time for another Leader in Six, this time with Newham Hospital's chief exec Simon Ashton. 

Simon, what's the most pressing issue for you right now? 

Simon Ashton: Two things. One is managing non-elective flows through the hospital and keeping our emergency department safe for the winter.

And the second is managing safety and finances through the winter. 

Matthew Taylor: Challenging.

What is the area of improvement or innovation in your hospital that you're most excited about? 

Simon Ashton: It actually is in the system. So it's actually integrated neighbourhood teams, so part of my leadership role as hospital chief exec is to also co-lead the health and care partnership in Newham, and we've largely got consensus now among partners within the health care partnership that the neighbourhood model is the way in which we want to construct our population health management approach for the borough.

I think it's really exciting because it's an opportunity to do something really different and really help local people live the best quality of life possible, which I think our borough deserves. I think it's super exciting that we can have an opportunity to influence that rather than as a hospital, purely beyond the receiving end of people in health or mental health crisis.

Matthew Taylor: Great.

Tell us something about yourself that's interesting and nothing to do with your job. 

Simon Ashton: I guess the probably most interesting is I ran my first half marathon with my son Joe, who's 20, and we did it for Sam's Charity, which is a neonatal bereavement support charity. He kept trying to speed up and I kept saying, slow down, I need to run at a certain pace. He was struggling more than me in the last five kilometers. So yeah, it was really great to do together. Really lovely. 

Matthew Taylor: Dare I ask the time? 

Simon Ashton: You can, but remember, it's my first one. It was two hours 27. Next year I'll be better. 

Matthew Taylor: If you were king of the NHS for a day, what's the one reform you'd introduce?

Simon Ashton: I would have some sort of way of making/helping organisations change their mindset about integration and integrated working for the benefit of patients along patient pathways. 

I would wave my magic wand as the king of the NHS and I would move everybody into integrated neighbourhood teams, integrated approach to healthcare, move the barriers and silos within health and social care, and within that would be reform of primary care and help primary care be the best version of itself with values aligned to the NHS.

Matthew Taylor: Who is the health service or other leader you most admire and why? 

Simon Ashton: My last line manager. My last boss, Olwen Williams. So I've been at Barts Health for 23 years. I came to Barts Health as a physiotherapist. I've been working in the NHS for 28 years. I worked at Whipps Cross. I saw Barts Health form as part of a merged organisation. Barts Health then struggled in its first couple of years and went into quality and financial special measures. And then Olwen took over the reins of Barts Health in 2015. 

And I really saw the difference in how a leader can have an impact across a massive organisation through her own personal style and values. And I think she single handedly changed the organisational culture across a multi-site organisation, circa 20, 000 people through working in a very specific sort of way, which was incredibly values based. I saw that you can be super effective and enjoy your job through having really great values and all wing was just a perfect role model for that.

Matthew Taylor: Brilliant. And then finally, I know you're very busy, but you must have some time to watch TV, listen to podcasts, read books, what can you recommend to everyone else? 

Simon Ashton: And I'm just finishing reading a Simon Sinek book, Leaders Eat Last. Which is absolutely fascinating. If you're a leader, you've got to read it.

And I'm now telling people that I work with to read this book because it just explains why values-based leadership works and why there's a scientific approach to values-based leadership that has a certain impact on people and makes people behave in a certain way. And it is absolutely the right way to lead. I'm a real believer in this approach. It's a brilliant, brilliant book. Fascinating to read. 

And then a podcast, again, quite factual, but a guy called Peter Attia, who talks a lot about healthy aging and how to age well and how to look after yourself as you age and the scientific benefits of things like running, strength training, yoga, and pilates; he's got loads of different podcasts.

Matthew Taylor: Great recommendation. Thank you, Simon. 

Well, I'm afraid that's all we've got time for on this edition of Health on the Line. We'll be back with our next episode very soon. But in the meantime, please do follow us and leave us a rating or review wherever you get your podcasts. It really does make a difference.

Thank you and goodbye.