Diagnosing the NHS: Myths, Root Causes, and Policy Solutions

[00:00:00]well thank you so much for joining this session I'm your chair Isabelle Hardman I'm the assistant editor of The Spectator but I've just finished writing a book on the history of the NHS and that's the reason I'm here today because Nigel has helped me navigate the NHS as soon as I announced that I was doing this book I was inundated by people who had theories about what was wrong with the Health Service Nigel's actually explained to me how it works and how it doesn't work and he's come up with this absolutely fantastic presentation um on its problems on the myths about it and I think on some of the solutions as well and after that we will be joined for discussion by Jill rotter whose senior research fellow at UK in a changing Europe and Stan Westlake who's the chief executive of the royal statistical society and then we will open up to the floor for questions so I will now unleash Nigel upon you okay strapping um so [Music] um this was inspired by a sort of whole host of people writing articles about the NHS and what its problems are and they all had a very similar sort of feel to them which is as a reasonably cursory analysis of the problem and then going straight to the solutions and many of the solutions if you've read in any of these are often not very good and maybe not don't even necessarily relate to the to the problem so I thought we'd probably ought to unpack things a little bit uh more and really understand what's going on underneath all of this so the Lancet commission really triggered this thought for me because they did they did quite a good job I thought of analyzing what's happening and uh what some of the problems that the NHS have and you'll be you'll be very familiar with with these the problems of poor patient engagement poor outcomes persistent inequalities uh sluggishness in the uptake of of innovation um low levels of equipment which we all know about and lower numbers of sync clinical staff that's good good diagnosis but it doesn't I still think it has a problem which is it isn't going deep enough into the root causes it's not doing the Toyota thing of asking why multiple times until you get to the uh to the real underlying course I thought we'd have a go at mapping all of the different hypotheses that people have got and go and see if we can go down levels to unpick them and see which ones we think might be right and then that might shed some light on well first of all give us a test to say when you've got a solution does it actually match the problem but it also might suggest some solutions to problems as well so let's uh see how we get on so I've got four domains to think about in in doing this first is one about sort of politics and and our overall governance the second is about management and culture the third is something about why does society and how that operates and the fourth is some something about the choices that we've made as a system over the years about the model the models of delivery the mods of funding whether whether we have social insurance or not for example so I'm going to explore each of these and see how they overlap and interact um and we'll we'll we'll start with those normal the normal starting point for people diagnosing the nhs's problems is we don't spend enough money um so if you want to reback that by the way what you do is you choose 2020s uh percentages of spending as a GDP because our GDP tanked um and we spent a huge amount on test and Trace and things so it distorts the figure so we won't do that but you normally you normally see it presented as GDP and on that basis we're sort of in the middle of the oecd pack the slight problem with this of course is we are substantially poorer than we have been in the past in fact one of the uh one of the things I used to say because it was funny was the reason I did quite a lot of work in places like Moldova and Kyrgyzstan is because I Was preparing for when the UK became a middle-income country and this this no longer seems terribly amusing um but um but what you see here is actually in terms of what we actually spent ahead because GTP is lower than many of the people that we tend to compare ourselves we actually are there is some truth in this hypothesis but um carrying on why are we spending so why are we spending less why do we make this Choice well one of the the common villains of the piece in this is the uh is the treasury um the treasury is the only Ministry of Finance in Europe I am told that doesn't have overall welfare of the population in as part of its mission statement uh it's Peter Smith from Imperial and not managed to find the original research he did he told me that personally I'm going to take his word for it but it sounds plausible I think they're using the I mean certainly I think there's big questions about whether the discount rate that they use gives us far too much focus on immediate expenditure control the management of fiscal space keeping basically keeping the lid on spending and doesn't really think anything like long term enough compared with other ministries of finance that we're used to and that starts to explain why we haven't solved social care because that requires a long-term bit of thinking it requires you not to say in 2008 or wherever it was like Nick Lake oh we don't need nuclear power because it won't we won't need if it won't be available for 12 years you need that long-term thinking to fix social care the work that Natasha has done definitely demonstrates you know that's what Germany and Japan did they thought long term we haven't done that and of course the other thing we don't do is we don't spend money on Workforce we don't invest in Workforce and we don't invest in capital and and on on Capital we're a real outlier see if we can get the thing yeah so this is capital spending as a potential GDP and remember our GDP is lower than you think it is so this is even worse than it looks and you can see the effective austerity there we're right the way at the bottom and then then we might wonder why we haven't built more than two hospitals in the last 10 years and while we're so short of MRI CT and other Diagnostics radiotherapy equipment and the like um so um big big impact of austerity there so that's a so why why the short-termism well there is something about um something about our politics and governance I think um Isabel has also written an excellent book um called why we get the wrong politicians uh which I commend you which has some clues in in uh in that um people may remember another really good book um called the blunders of our government um by King and crew which lists a whole series of problems that that we've had as a consequence of of uh of of of of uh of our overall political system but also the civil service so we they talk they point to things like in the in the political sphere uh ministerial turnover a degree of panic um which we've definitely not seen at all have we um in decision making a a over focus on Spin and a sort of a deficit in terms of cross-party discussion so a long list and uh Isabel has a shorter list in her book which really stands out very well around a lack of scrutiny a lack of oversight when we're not careful enough we're not we're not long-term we're not long-term enough I think one of the issues here is probably though there is there is some issues about this the the nature of the politics which she her book really brings through about why would you want to go into Politics the politics is is a difficult business but we're missing a bit of the equation here which does worry me and perhaps we'll hear from Jill about this later there's been a lot of anxiety about the uh General decay of the Civil Service really the the lack of subject matter knowledge uh within the Department of Health and Social care is a real concern if people have spoken to people who've got big policy area responsibility you find that they've had no previous experience in it at all they're very smart but they're generalists now paradoxically uh Luella Vaughn and I have been arguing for more special generalism in medicine and less specialism the civil service has gone almost exactly in the opposite direction and we you do it turns out need to know stuff uh to be able to make good policy so but it also seems to have lost I don't know whether it's a loss of confidence or credibility It's ability to shape policy to stop bad ideas um which of course they're often blamed for but it can be a really helpful intervention some of the most useful things I've done in other countries is tell people not to do things uh rather than advise them on what to do generally it's not to do ppps um so there's other good reasons for that so it's really kind of lost its role as a steward and custodian of the organizational memory possibly because we it was colonized by NHS managers who are all about delivery wrong about policy and then it was eviscerated because every time there was a shortage of money it was its Central budgets were raided and people it lost people who knew things and then in 2012 a whole bunch of people were transferred to to and it's England which disconnected the policy process further from from ministers and I think it was a bit deracinated de-experted in that process as well and then there's a sort of General competence question I mean we could do a very long list whether it's a chess and Trace PPE procurement managing the bmj piece this week on managing contracts with the private independent sector where large amounts of money seems to have been wasted making PFI deals um National program for I.T um so there's some real problems about the sort of the system of governance and the checks and balances that are that that are on it so that's the political realm one of the one of the issues with the NHS is it's very closely tied to politics in fact it's it's very noticeable I think I I can't really stand this statement up but I'm going to say it because I don't think anyone can contradict me I think it's the most centralized large health system in the developed world I don't know much about North Korea but um a bit of a blank in my knowledge but it but it's it seems to be very very centralized other NHS type systems such as Spain has some Spain runs on 17 autonomous communities the Scandinavian systems which NHS like have a mixture of regions counties municipalities Italy has Regional government the smaller NHS type systems are so small that they're the size of a of an ICB so you know they they can be relatively centralized so there's something about scale however that causes a problem and I think the the centralization plus scale and some of you will heard me say this before means that what you you may have economies of scale but they're dwarfed by the diseconomies of complexity you're too far from where the dis where where the action is you're conclude your your ideas do not get communicated terribly well you create space for some quite bad behavior in the middle of your system if you're not very careful um because you can't you can't have an eye on everything and and you you basically try and create one-size-fits-all Solutions which uh and a number of times I've heard senior policy makers say well we just need to think of it get the answer and then we can roll it out rolling out is fine if your intervention is simple if it's let's put all the stuff for putting in the central line in a box that's fine if it's let's completely redesign the front door of the hospital and then roll it out not so good I think so there's a real problem with centralization and complexity which which is an issue and with that a fairly punitive and and upward facing culture which will uh which we will return to but is frequently commented on and I think this is related to an interesting problem that doesn't come up a lot in the in the discussion so if you ask an economist what's the what's the issue about Healthcare they'll say well it's an unusual set of goods because you don't quite know what you buy you may think you've got something trivial and actually it's life-threatening is async there's asymmetrical information between the producer and the consumer there's a third party payer there's all of these economics things and it's true to an extent although there are other bits of business that are like that but I think the really interesting difference is one pointed to by um back in the 1950s by Isabel Menzies right who wrote about anxiety in organizations um and so what she says is Healthcare is different because it it's in fact it's probably unique in the extent to which it produces anxiety in its production and consumption right so you're confronted by uh rights of Passage intimations of mortality the opportunity to do harm while trying to do good um and and you're under great deal of pressure and scrutiny um and Healthcare systems are also for that reason and we'll talk about that in a minute not terribly uh forgiving and and this kind of this this I think resonates a lot so if you get unresolved anxiety you get lots of very Strange Behaviors now those might be a the ritual of a for a phone call four times a day while people who don't have anything to tell you useful hold court and you discuss the current emergency care center it's a ritual when you talk to people it very rarely solves any problems but it does create a it does create the illusion of control and the feeling that something might be being done and it of course shifts blame and and Gordon essinger's review uh I think picks up a number of these themes as well he talks about the the culture of checking burdensome regulation over hierarchical systems punitive approaches to mistakes bullying claim shifting which of course all of which are drivers are burnout by the way and I don't know those of you who've been around long enough will remember X number of reports which have said something very similar yeah and then she's not entirely unique in this um the Harvard academic Amy Edmondson talks about the idea of these problems in the U.S Hill system and she's looked at this concept of of psychological safety so the the I think the part of our hypothesis here is that we haven't got enough psychological safety which is the an environment in which it's okay to take risks um there's a shared understanding expressing opinions and ideas of welcome and that risk taking is okay and that if you get it wrong then you won't necessarily punished but it'll be an opportunity for Learning and she has a nice Matrix that let's see that looks at the interaction between being in a high accountability system and a psychologically safe system so if you've got high levels of accountability and you feel and high level psychological safety you can learn things can improve you can develop you you make a mistake you get up you you try again I think we would say that we've got far too many people in the high accountability low psychological safety zone um in our system we've also managed to get quite a lot of people into the apathy zone so neither of these are good I think you can agree um so so there's an interesting set of hypotheses that you don't normally hear there which is uh which is interesting and of course the poor old Secretary of State really is is caught in this as well you know basically you have a mediocre middle manager in charge of a position a situation they don't understand can't control um and uh for which they're going to be held brutally to account in public I mean it's not a job that if you put that in the job description yeah middle manager and you're going to be beaten up at regular intervals then I think recruitment might be difficult um so you get a lot of activity um again trying to find the uh the the some some sort of um uh feeling of control I think this is exacerbated by the fact that we haven't really got a change theory in the in the NHS have we um we have the ring Secretary State Rings up Chief Executives at regular intervals which is a change theory that this this current Secretary of State is apparently quite keen on and I think Jeremy Hunt was quite keen on apparently it was to learn but I always wonder whether the people on the receiving end of those phone calls felt that that was what was actually happening um or whether it was learning where do we send your p45 um that uh but but it did it certainly didn't feel it didn't fit it didn't feel like that so we've tried everything in the Box haven't we we had markets we've had Performance Management we've had for actually so it was a sort of an anxiety produced by not being not being in control as well and I I think this might explain the uh the resorts to highly frequent reorganization so not only are we the most centralized healthcare system in the development vote but I can absolutely confidently say we are the most reorganized uh uh and you can't read this it's a Gestalt this is a timeline since 1974 which shows every major reorganization people will remember a statistic I quoted previously which is um for quite a bit of this period if you were appointed to a newly established intermediate level organization and on that diagnosed with colon cancer you had more chance of surviving five years than the organization for which you were working um so the the uh the speed so the loss of organizational memory uh the disruption the loss of progress um is is is is a re is a real problem here and and the the emphasis on structure of course causes a problem I thought Steve later made a very interesting point about integration if we look at attempts to integrate across the four countries they'd largely not work and the reason they're not worked is they're focused on structure and you can't solve problems of relationships processes and culture by changing the structures it might be helpful it might be it might it might age but you don't pay attention to those things and you don't Focus particularly saying at the patient level you won't succeed and that's probably why you know most of the reorganizations we have in in sort of almost sort of dialectical Marxist type terms have contained the seeds of their of the future reorganization and I saw just the other day at Roy Lily saying oh we need 20 icbs 42 is too many I thought oh my God how how quick is that they've only been there since April last year so so a bit of an obsession of on reorganization which is highly disruptive the other thing I think if you have a very upward focused system um we end up with a lot of focus on leadership and I've become increasingly convinced that actually a lot of the problems that you read about and people complain about in the NHS are not due to poor clinical care they're due to bad management bad Administration and basic systems so we've so part of my one of my hypotheses here is we've under thought how you should do basic Administration and management this was triggered for me I did a Twitter thread on Primary Care in Spain and I got a lot of very interesting responses from GPS about scheduling system how you manage triage and the phone and the telephone front door and what it turns out is there is no agreement in the NHS on how to manage 500 million plus transactions we don't know how to do it or rather some people know how to do it and other people don't and aren't interested in learning that's or don't have to change management capability that's probably more likely because we keep asking people to do extraordinary things and then don't give them a chance to do it but I think this absence of of any investment in in management frequent reorganization and a failure to invest in digital to support the management systems and equipment and and buildings is one of the reasons why we have significant inefficiency left and you don't get that inefficiency out by salami slice changes you get it out by fundamentally redesigning your systems and processes we don't do that because we have short-term focus on balancing books now rather than investing for the future so that's a a a a nicely interlocking set of hypotheses a couple more in this domain um there's some very strange Behavior quite a lot of the problems we come across are about bad behavior at the front line um bad behavior by managers bad behaved by clinicians which isn't sufficiently dealt with back to Amy's graph not enough to explain everything one thing that is interesting although the international evidence of having clinicians and particularly doctors run your hospitals says they might do a little bit better than the professional managers I think there is a question about whether we've got our clinicians sufficiently engaged in quite a lot of how we organize and run things and and by clinicians I probably do mean doctors actually the nurses are quite engaged but I'd wonder probably General Lee clinicians as well actually anyway it's a hypothesis we're coming back to these um the juror is out on this one a bit but I think it's worth thinking about because it is an area again where we're different from other Healthcare Systems so that's um that's the management of culture domain now um possibly the problem is the population is letting us down the health services the Health Service is great it's just the people it's just the evidence of this is not that convincing I'm sorry to tell you um we're not we're not quite as healthy as we probably ought to be but it's not enough to explain the uh the issues um there are there are some questions about whether you know we do have very high level uh we do have some issues about health seeking Behavior anecdotally you know people it does seem to uptake of screening we have we also have a gatekeeping system so there is some issues about late presentation of cancers for example where there is there may be some issues about health seeking Behavior we you can't get uh International very good International comparisons about on health literacy that I've been able to find I asked GPT track GPT to see if it could found one and it made up a citation it gave me a citation to an article there was not the answer to my question and and but but even more bizarrely quoted percentage figures for health literacy which apparently came from this article but didn't it it made it up so there's a there's a lesson for us a bit of a lesson for us uh lesson for us there but so I don't think we know I think we do what we've probably got because of our large levels of income inequality is we probably got pockets of population who have very poor health literacy uh and and not very helpful Health seeking behaviors um it's probably not enough to explain um uh everything that's going on but our income inequality is quite Stark and these data are a few a couple of years old and it's I doubt it's got better um this is Genie coefficient um well you see where we are on that so there we are that's um that's the population um so then we've got a now this is the favorite area of the um I've got throughout a column for Saturday um Brigade um and uh because they often got us they've often got a solution and they haven't necessarily defined the problem terribly well but they've got the solution so the first one you'll often hear is there's a lack of provided competition so um this is an interesting hypothesis I think there's there's probably some truth in this in terms of Diagnostics and um uh elective care the evidence there's a couple of studies looking at the impact of competition on Emergency Care they rely on making some quite bold assumptions about there being some sort of spillover effect you know so hospitals in competitive environments get their processes and systems and other things really slick so that their treatment of um endstemi and stemi are better than places that aren't and it's quite contested um it I I wouldn't bet the farm on that and I think the sort of the causal link between it relies on this spillover thing and I don't I think I think John the jury is largely out on that that one if if not come back and said not guilty basically yeah but so but I think I think it's quite plausible to say in terms of access if you're if your measure is access competition does seem to work if your measure is other things it may be less effective but but it's um but it's quite but I mean it's just worth pointing out the Diagnostics and alleged surgery are relatively small parts of what the NHS actually does so it does it won't explain poor cancer outcomes for example it won't explain um why our respiratory outcomes are not terribly good um it needed to explain why our diabetes outcomes are very good um so it's um it's interesting it but it's it I think it's in the category of sub hypothesis might be interesting interesting question because no one asked why have we got low levels of competition and it's because well I think it's our old friend the treasury actually which is uh We've we regards the spare capacity which you need to have to do competition as waste rather than something you can have to enable competition and that's because we've got state-owned providers and you know so in a competitive market you need to be relatively unsentimental about providers being able to get out of business and for them being spare capacity and people having problems that come with that but if your obsession is running everything at 98 and I think again I think I can quite probably safely say that we have the highest occupancy rate if not not the highest occupancy one of the highest Hospital occupancy rates in the oecd I also check to see I think it may be the highest it wouldn't at all surprise me um but so we regarded spec past is as bad as opposed to something that oils the wheels and makes flow work um and and this comes down to again now this is the real favorite explanation which I've short-handed as beverage not Bismarck so what this what I mean by that is in 1948 we took a decision to create a model with a tax-funded state-owned providers for the point of use larger was then entirely at the point of view as opposed to adopting the social insurance models that you find in the Netherlands Germany Austria and a number of other a number of other European countries and the the idea is that um through some processes not often very well explained social insurance gives you better results than NHS systems now the slight problem with that argument is actually quite a few NHS type systems do also perform very well so New Zealand Australia sort of nhse it's a bit it's a bit odd it's mixed um uh Spain very very long life expectancy quite a long wait um but does quite well on a number of comes on which on which we don't particularly amenable mortality it does well in fact although it does sometimes look at this data it's being northern European and English and speaking English seems to be a major prediction of mortality um but what's the magic ingredient it's not it's not really explained I mean Bismarck does give does does allow you better stakeholder voice I mean one of the problems of that of course is that just adopting Bismarck has a problem because we don't have the tradition of sort of multi-stakeholder governance of organizations where the trade unions employers local government and other bits of Civil Society come together to actually run things and organize things we have a highly centralized doing um sometimes the the argument is well it's pair competition but but actually most of the most of the social insurance schemes don't really have that much pair competition the Netherlands have a reasonably substantial amount but then but the payers are not activist payers there's no there doesn't seem to be any direct connection between what the payers are you know payers are doing and the outcomes that the Netherlands are getting the payers are not reorganizing Pathways so Cancer Care for children was re was was centralized and reorganized and the pathways redeveloped by the cancer surgeons not by the insurers they all just got together and said we're going to do all new Trek well and one other hospital because we can't persuade those we wait for them to retire so it was it wasn't standard at Healthcare compromise but they sorted it out it wasn't the payers right it was the clinicians back to my boxes on clinical leadership the clinicians went and did it so that's interesting so that not why would why would Bismarck be better well there is one thing but they don't tend to articulate this which is of course the the the beverage the system uh actually the Bismarck system puts the Ministry of Finance much more arm's length from decision making about investment and Healthcare so that may be the magic ingredient that Bismarck gives you but you've got to have all these other things to make Bismarck work and I have a strong suspicion that the advocates for social insurance don't really want Bismarck they want the system so in Germany you can opt out of the social insurance system but you'd largely get the same package as you would you get slightly quicker access um and you opt out if you have higher income you can opt out um I think that these people are not interested in even that I suspect they don't want a Bismarck system they want general pinochets which basically let the rich leave the poor behind um and that's what you would probably get if you unless you were very careful it would if to avoid that would rely on your government being really skilled at very complex policy change on the B scale so nothing that could possibly go wrong with uh with with that I feel that um so um perhaps that's the that perhaps that is the magic that one of the one of the ingredients because it does seem to speak to some of these things but you can't just go I mean there's one lesson I've learned over these you can't do policy pick and mix you can't you can't say I you know I'm going to have Swedish levels of social care and American levels of Taxation is the most extreme uh uh one that actually we aspire to it appears um and and you have to really think about how these institutions particularly in the social insurance countries are just embedded in a different culture and I you know the Dutch system is fantastic but I think you probably have to be Dutch all right there is a long tradition you know if you put based on hundreds of years of culture in which their system is embedded um one particular feature of Dutch medicine is it's much better at feedback if you've ever worked with Dutch people you'll understand what I mean about that um they're much better at feedback than we are there is much more of a culture of peer review and telling other people what you do what what what they've been doing and how good it is often you know as I've experienced somewhat brutally so um but you do get better I recommend working with Dutch people it's fantastic um but uh so um perhaps also in this area system of design um really good article we start to see some really Sarah Neville did really good article nft Camila cabadish who can often be relied on to be thoughtful was done done another one just just the other day which I think Maps out another sort of set of hypotheses is which is we've not really we're best about with the structures we haven't really done something much about the provider system it hasn't changed a great deal and she said oh well we haven't integrated it enough and it's uh we haven't integrated all the bits um primary and secondary and social care um and that's a that's a serious flaw in in in in what we've uh what we've been what we've been doing we've not and I missed it out on my map but it is just part of the short-termism we've not invested in prevention enough which also of course relates to that we've been very hospital-centric um uh and that that uh that means that we're stuck with levels of demand because we're not done prevention we not addressed some of these drivers of demand I think I think everything is she says is right um just a couple of observations of it very few countries have really fundamentally changed their delivery model um the post uh the post-soviet countries you had What's called the shamashka model um Estonia and Lithuania have done quite well um most of the rest of them are pretty Stark uh hungry as had made some changes so is Poland but it's taken years and most people don't change their delivery model that much it's interesting the the patterns that you you could you could go back 20 years and the models look very quite similar I mean under the surface there's all sorts of new technologies and things happening and and actually we look around Europe examples of really good integration are quite rare you really struggle to find uh um examples of the uh uh that of sort of structural level integration as opposed to uh sort of clinical pathway and uh and clinical network type in integration so I think she's she's got a good point but I don't think it's good enough as an explanation for what some of our problems are which is partly what she was she was offering I mean it's certainly true that we we haven't really delivered on any of the promises to shift work shift resources from hospitals to uh community and Primary Care have we I mean we're good at rhetoric we're probably less good at the uh the delivery so this is the map so far every time I talk to groups of people I get more um ideas to put on it but as you can see it's getting a bit full so I'm hoping that there won't be too many um or that you might have uh you might have ideas about how to how to modify it which are right well I think probably there's quite a lot of them have got quite a bit of Truth in them and what that means is if you if your solution only addresses one bit of the map it will not solve the problem um so that's a that's that's a bit of an issue um it it may also mean that some of the problems are a bit beyond reach because they're deeply rooted in the uh their sort of political culture and the number of reports I've read over the years which said we need to change in the culture and we need we need politicians to agree that they're going to step back and that generally doesn't survive the next secretary of state let alone the next government so so that that seems a a bit of a problem many of these cultural and other behavioral problems are not are not bugs in the system they're features and therefore the solutions um it may need to be may need to be deeper I think it also suggests that the idea of some sort of big bad either quick fixes or Big Bangs are unlikely to solve your problems they may create new ones um but um which which leaves us perhaps with some um uh some perhaps uh rather less ambitious but but perhaps in the in the in the way that lots of small changes tend to produce very big changes over time perhaps um a bit more focus on some of the basic systems infrastructure supporting the workforce particularly Workforce well-being um creating change management resource to help the front line it's not very reasonable to expect you know practices to uh to absorb vast numbers of of new roles and do that all in their spare time without change management support for example if you think about the the recent changes uh to to pcns um more Improvement science more systems engineering it's all a bit slow and boring um but actually I don't know about you I've had enough excitement for the last couple of years and it might work um so I think I think we should however whatever we do and and in the rest of this conversation just make sure that whatever we are doing actually is based on a proper analysis of what the problems are rather than going straight to the solutions thank you yeah thank you thank you so much for that that was absolutely um fascinating and um breathtaking in in lots of senses and I just you've been so helpful to me in understanding the Health Service and one of the things that has really struck me about that presentation is the point that you made about the balance of funding and focus and attention and so on and on acute care as opposed to primary and preventive care and that we've never really managed to to shift that balance it it seems to me observing politicians that it's it's one of their fashionable things to talk about along with integration now they'll say you know we need to shift the balance along with we need to talk more about mental health but not necessarily fund it and all those sort of well-meaning things you hear politicians say repeatedly why is has that balance not been redressed and how might it be redressed I mean I suspect you may have the word treasury somewhere in your answer but is it is it all the treasury's fault the treasury part of it I mean part of the problem is that the uh the the the access targets and and are so Salient and so obvious and the direct coupling of the politicians to the NHS means that um they become quite a good stick to beat the politicians with so they feel a need to address them and I think I'm now important I mean there's a bit of a tendency sometimes it's just to think that waiting for elective surgery is somehow not that important but it is um but so they are right to focus on it but I think the the problem is to make that shift we would require to make would require us to make some long-term Investments because we'd have to put some of that capacity in first before we receive the results so you would you know um you create your bigger scaled Primary Care with proper community service General practices with proper community services and Physio and other things wrapped around them and it would take you it would take some years for that to trickle through into that into impacts on uh on demand at hospital we've also got a terrible tendency to frame everything in terms of reducing demands in hospital by the way as well as but but it would I think um have that effect but we're not I think we're not prepared to make that long-term punt um is the is the problem and how much should we again blame the public for that one of the things I've found whilst researching this book and indeed my first book and thanks for the plugs by the way they're available in all good bookshops is that they the public go absolutely bananas whenever a hospital that its own clinicians may say is killing people is um earmarked for closure and you sort of look at that not just in the London reorganization in the 90s but you know Enoch Powell for instance was talking about Hospital closures he had an MP who opposed the hospital closure and then the hospital his son then died in that hospital apparently the MP then changed his tune but but it does go back back to a sort of a local attachment to hospitals regardless of the good or bad actually they're doing in communities so how can you rebalance Healthcare when it might mean closing a much loved but possibly unnecessary or even dangerous local hospital I don't know I mean if you thought if we thought longer term we could have made that shift without having to close any hospitals because we could simply have differential rates of growth between the sectors it's just the hospitals of eating everyone's lunch largely so it but it would and you can therefore do that incrementally the other I mean part of the reason for doing incrementally is we learned in the 2000s with the Blair era if you suddenly dump a lot of money in the system it doesn't it won't it has trouble spending it well because you know and I'm always Becky Rosen is one of our senior fellows talks about the difficulty of absorbing new members and staff into her PCN and just the just how tricky that was just to take on a couple of extra roles so if you just suddenly throw all these people out the system it will get indigestion so you you need to you do kind of need to think about this over over a long long period a longer period of time I think and we're not the other thing actually Becky would also say is we've probably not been very good at actually explaining to the public this is how the system works this is how we're doing it and we're going to be making these shifts and the implications of this will be X Y and Z I think that's the other thing that we've been we've been fairly poor at um the NHS is very technocratic and the politicians talk in terms of big headlines and no one actually is saying to the patient to the patients in the public this is probably what it's going to mean I think okay I'm gonna bring in stone and Jill now they'll have their own picture points they want to respond on but just just to ask you to begin with about the treasury which is everyone's favorite monster um in this room are you um similarly scared of it or do you think it's just much on misunderstood and that we should learn to love it so I think the treasury has a lot of um full of wonderful people it's a very smart High performing institution but it has a lot of issues and this is probably no exception I suppose one of the things that I see in forming a lot of the problems that Nigel so expertly laid out is some of the things the treasury has recently done in terms of enabling basically under investment enabling Department of Health and Social care to flex the capital budget into the revenue budget over I don't know seven years pre-pandemic and you know the Nao show this was a nearly five billion pound under investment resulted from that now the treasury kind of the treasury's fingerprints are on the weapon in that case it was a treasury decision taken to allow dhsc specifically to do this but I think there's a case for saying well the treasury is just doing what is popular in this instance and I think something that we can see when we look at what the public think of investment in the NHS the energy the public are quite happy to see money prioritized to go to salaries particularly salaries on the front line and to be diverted away from things like maintenance budgets which we all know are important that seem a bit unglamorous and are probably less politically Salient people so treasury I think really has a has a big role to play in this um but they're not this the idea wasn't necessarily born with them I think it's a kind of they're they're messengers of a broader movement and another um favorite line of the public I think is is getting rid of managers and I think of all the many um interesting things that Liz trust suggested when she was campaigning to be a leader so she just said we just need to get rid of a layer of middle management I thought okay well that'll probably go as well as your plans for the economy on that so let's thank our lucky stars that that was only a sort of brief sabbatical in terms of her leadership Jill you said to me before this session that you were going to defend the treasury so brace yourselves uh thanks Isabel hi yeah well I assume that was why I was on the panel as the only person that the nuffield trust could find after an exhaustive Nationwide search who was prepared to come to this audience and basically blame the Health Service rather than uh rather than the treasury um I think I think interesting that it took Nigel 30 minutes to mention the word taxation and it's very very easy to blame everything on low levels of spending but the counterpart of low levels of spending is manageable levels of Taxation that command sufficient public consent and actually that's the very big constraint on this and actually if you look at within the envelope of public spending Health has done really rather well uh compared to everything else you might care about if you really care about health as opposed to the Health Service and I don't think we should ever Allied the two then you should be really quite worried about some of the things we were talking about in the first session there's a social care budget the Cinderella even though Jeremy Hunt suddenly said discovered social care in about 2018 added it to the title of the department but actually the budget's there in local government department and being ruthlessly squeezed over the last uh 13 years you should be fussed about education you should be fussed about children in care uh you should be very fussed about housing I remember when I was at the department for environment food and Rural Affairs writing to the Department of Health and asking if they were fussed at all about fuel poverty I wrote the deputy chief medical officer I got no response uh because the thing about this department for health is its largest department for the Health Service it's very very weak Department of Public Health that I think is one of Andrew lansley's you know sensible insights in his reforms I think lots of other things that were completely Bonkers but I think that was a good insight and I think actually if you see that as the big constraint then you start coming thinking where is the treasury coming from combine that uh uh one of the things I do in my spare time is work on brexit one of the big complaints of services business in brexit is why is everybody fussing about Goods when the UK is largely an 80 Services economy and services are the thing that we're really good at if you talk to any journalists it's because you can get pictures of lines of trucks at ports but you can't get pictures of damaged Services businesses because they've got dramatically reduced access to the EU single market and I think the analogy there is with the hospitals and the acute you know the pictures we have on our news of ambulances piling up failing to get in a e is not reflected in cuts to prevention budgets it's not even reflected in people failing to get GP appointments or having to wait for whatever and I think that's why politicians and I think this goes a bit to Isabel's uh points about wrong politicians the political pressure and the real pressure point at the time is current acute services and when the current acute Services need more everything else suffers and always like a sort of cool down list of where do you go one we all now post pandemics so we'd like a bit of redundancy in the system you know running really really hot why but why do you run hot because that means you're providing a bit more current service now at the cost of future capacity to respond and if that's you know what you're going to be held politically accountable for you will go there when the hospitals need more money where do you go you might squeeze primary care if you can you certainly squeeze down the prevention budget uh you go to Capital as Dion has been saying so I think it's a really interesting thing and a route is this point that Nigel made we want good levels of service we're not a very rich country compared to lots of people who have visibly Better Health Services than we do and we're really perceived and maybe wrongly uh maybe Julian McRae from engage Britain is going to tell us why this is wrong but it is perceived by politicians that we're incredibly unwilling to pay the taxes that are necessary to fund the services we want and that applies not just to health it applies against all those other things that you should be as every bit as fussed about as the health services you're really interested in the health of the country as opposed to just having a nicely well funded whatever swooped it round I thought one of the things that was fascinating Nigel said is we lack a theory of change now to me as a treasury official that would sound like okay so you asked me to write a big check to you with not much guarantee that it's going to turn into a concrete Improvement on the ground because you don't really know what you're going to do with it and therefore where I'm going to actually be able to see the benefits in the long run and I think one of the really interesting things if I was I'm going to shut up in a second but if I was flipping this round when you're in the treasury you know that every year every time you do a spending review the health secretary who as I say does very well in spending rounds compared to all his colleagues the health secretary comes in and says we need four percent to stand still for medical advance and aging population that was four percent was the cultural number Yanks ago I think it's still roughly the cultural number of how much the NHS needs you know I mean we've got an economy that's like growing by nothing so four percenters means you're buying and ever increasing sort of share of the state um so what does it take what would I be doing now to convince the treasury did why you put money somewhere else than into Frontline acute Services now uh in a few years you would be saying and the office of budget responsibility could show significantly reduce public spending pressure somewhere in the system so you'd be coming back to me and saying you know that four percent is now down to three and a half percent it's now down to three percent or look at these huge big savings that you're making over here or over here or look actually they're not coming through there let's reflect Andy haldane they're coming through and having a much more productive Workforce or whatever or whatever so where would I crystallize those benefits so if you want to make the business case for the significantly greater investment that you want um and I think we should probably treat prevention on all fours with um capital investment as a way of reducing long-term pressures on the system improving long-term outcomes how would you be making that convincing business case for spending the sort of money you want to have now with some sort of prospect that I am going to see it show up somewhere in the system because I think that's the convincing case you need to make to convince uh treasury to convince and to convince the politicians that this is a set of choices ultimately it's very easy to blame a bunch of civil service technocrats but they take their lead from the politicians and I think it's the political pressures that actually make hospitals the all-encompassing sort of you know gobble monster that they've become in the system I like the number of monsters that we've described uh so far well it's now time to open up to the floor as with the previous session there are microphones coming around yep just hands there in Union sets I've mentioned him um Julian McRae from engage Brickman thank you Jill the future funding of the NHS is the easiest conversation we'll do we'll take you about three four minutes um population is aging people are aware of that quite a few people are aware of people are living longer with chronic diseases they know we're going to as a society want to put more into Healthcare they are utterly attached to the principles of the NHS from 45 free at the point in use through taxation you'll get somebody who disagrees with that but they'll soon fall in line with the rest of the group and then it's a question of right what taxes are we going to raise and again it gets interesting at that point but this is not a big political problem so Julian where was the March demanding the retention of the Health and Social care Levy I think it was quite interesting that we didn't have a March demanding the removal of the Health and Social care Levy I thought the health research care Levy was a bad tax but a good principle so but I just want to say the I think it's really interesting if you start to trace through what does our public actually accept and extra taxation going into the health system is one of them what does it not accept that we wished it accepted and you've got to remember that they actually the public consent is around treatment not Health it wants a treatment system that's why it's really attached to hospitals um and then what is it that actually we can do that there is a huge Drive behind things like mental health and mental health not medicalized but in the community is something that people really really get how you do those Sports so I think it becomes really interesting when you start to not do the public as a demon that blocks things but think about where are they now but I think the interesting thing is can you convince the politicians that goes to Isabel's you know politicians that actually they can be comfortable with raising tax for health it'd be even better if you could convince them that National Insurance is incredibly bad tax and doesn't pay for the Health Service and they should raise the decent taxes like vat or income tax but anyway but I think it's really interesting because I think the political perception is that you can't raise taxes for it Stan can I can I come in there I think for me one of the most concerning things from a public perception point of view that gets transmitted to politicians is the unwillingness or hostility to invest in what I with my Economist hat would call intangible Capital but basically we've talked all day about integrated care about common Pathways about all these things I would see that as intangible Capital it's not a building but it's something that delivers a lasting benefit and we know that fundamentally the way you get that is you pay salaries to these terrible people who we call managers and this seems to be remarkably unpopular and politicians are kind of rightly aware of that so if you're in a world where people are very happy to spend more on the NHS as as you were saying Jill on on acute care but see intangible Investments see investing in the things that we know will make the effects of the system work better then that feels we there is a job of communication a job of persuasion to be done Nigel um lots to think about that yeah I think um I think Joe's point about the treasure is confidence in the NHS to deliver is a really interesting one I mean what where that well that tangibly translates into is large numbers of spreadsheets that need to be filled in um and uh and and an awful lot of boxing and whether or not that creates much change whether that's an effective surrogate for a change model is a is is an interesting it's an interesting point I think the problem the the unpopularity of management is a concept generally I don't know what the public think about Managers generally against them I I'm guessing um but um is a problem I mean but but in fact I mean we may have to change how we describe it but we do need to invest in change management capability and it might be that actually we're investing in people who are actually clinicians who have a management responsibility it might be how we're describing it we need to be needs to be thought about um but I'm I'm I think Kim Joe's given me some new things to put on the map around taxation so I just have to squeeze that in that's really really great points I think well between you first show me that map and this presentation I'm told it grew too big for PowerPoint so I don't know what that stage after this is galactic too big for PowerPoint is my new uh slogan right I've got lots of questions now um Sean at the front um I'm supposed to give descriptions so the Mike knows throwing a pink shirt um Sean Linton Health after the Sunday Times um I just interested in reflecting on this that talking about diagnosing the problems with the NHS is seems a bit of a national religion in itself a bit like the weather and helped Along by enterprising Health journalists who write about this stuff but how many articles I've read diagnosing the the problems with the NHS and what we should do to fix it and I just wanted to sort of ask the panel to reflect on maybe one of the things is we're not doing enough to focus on you know one area has nailed something and how we then get that spread across the country and there's far too much reinvention as opposed to thinking about how we practically help areas to deliver something that we know works and we're not talking about that enough either at this level My Level and political levels and I think I'll be over diagnosing the NHS rather and under treating it yeah just to add my thoughts on that I think one of the um one of the issues with the amount of ministerial turnover we have in our governments of all colors is that you get a new Minister who comes in and is delighted by the power they now have over I think it was um uh was it David Nicholson or um somebody else described it as the greatest train set in Europe and you get to move a bit to the track around and then say this was the Hancock line um or you know you have your sort of Mark on a bit of the Health Service and that's why you have this sort of Perpetual Motion and certainly have over the past few decades because you have that perpetual motion in ministers and then a political system that's geared towards rewarding ministers for doing new things rather than actually trying to make them work or indeed I mean Ken Clark said that after he presented on the internal Market Margaret Thatcher sort of leaned back and so that was it you know we've done it now they hadn't even implemented a single change but actually because it had landed politically it was fine that was it job done and I think that is a real problem within our system I'll come to you Nigel on that yeah I've so I pose uh one of the implications of this map is that the scope for intervention is actually quite limited um and and we've probably therefore ought to focus much more attention on fixing some of the things we can fix rather than worrying about whether we should have social insurance or or co-payment or some of the other zombies um that regularly get resurrected so you know I I take from from all of this much more focused so get get Primary Care sorted out much more um sort out some of these administrative and management change management uh bits of the process get the digital thing sorted so that we can actually get some of our administrative systems working and bits and systems which kind of but it's all terribly boring really I mean it seems to me we rather like radical you know I remember particularly during the play area there's a lot of focus on well it's not radical enough it's the biggest criticism you could have of a policy well I actually think the radical things are not the problem here the problem is getting there's some basic things that we need to get right some things that need stabilizing and sorting out um when we've got a platform that's really working we might then think about it being radical but I just don't think that we're in a situation and the other thing we to do is I'm afraid he's much much more focused I don't know how how many targets a pcn's got I mean um how many things are there in a long-term plan I mean it's not it's a list not a plan isn't it let's be honest um so I think there's a bit of there's something here about actually focusing down getting some of the much more focus on some of the basics um uh I think it's there's quite a bit of this links together at an interesting point in the system which is never really talked about which is and again very unpopular Group which is Frontline supervision middle management um and if one of the things you're really interested in which is one of the things we need to fix very quickly is sort of Staff welfare and burnouts that group is key for that they're key for they they are the sort of one of the problems we we've had and Allison theory is really good on this but but the the adoption there's a bit of a risk that into delayering the the supervision management level and replacing quite a lot of your staff with people who do tasks rather than have pattern recognition uh expect you can see the whole picture uh you lose we lose quite a lot of this ability to to learn as a system so fixing fixing some of these really basic Frontline things we could get on with it might not need that much money it might mean clearing away a bit of the undergrowth to allow attention to be dedicated to it so you know the pcns might do smaller number of things and do them really well or we you know we might fix the appointment system or you know um my two friends who are recently treated at a central lung Hospital both of whom fail to get their phone calls about their example the results of their prostate biopsies um twice two weeks running getting that stuff right impacts on an awful lot of people very very quickly and then buys you some credit to allow you to then say look we actually we have fixed some of this stuff and you know your few fewer people in your surgery you've had their haven't had their their cancer treatment organized well or can't get a GP appointment or can't see it then you know get actually some of those basic things right um and move on from that would be my is what I take from the map actually [Music] um but Jill I suppose the the response of civil servants a lot of the time to a new ministry is what on Earth are they going to do now um and I just wonder whether you see that that constant turnover of ideas and of reforms as being something that can never be the system can ever be coaxed away from or whether it's just politics I think if you get ministerial turnover but remember we had a very long-serving health section in the shape of Jeremy Hunt who was told he wasn't allowed to do anything fairness yeah I mean because the previous one made such a mess but he was there for really quite uh quite a quite a decent time which is very exceptional I think it's it's almost inevitable that even within the same government a new secretary state wants to make their Mark in their thing and one of the things that I thought was really interesting about Nigel's comment about Margaret Thatcher is there is a real danger that politicians uh are convinced that the announcement means sort of instantaneous implementation you can move on to the next thing well actually it takes the system ages to digest and see that through I thought Nigel made some really interesting comments about the Civil Service and with uh ducking even more but I am having to leave at lunchtime so I didn't say this um uh I remember shortly after the sort of landsly reforms were introduced I went and did a thing at the Department of Health on policy making and I was just struck having only relatively recently enough government by just how disempowered to challenge ministers the officials in the Department of Health seemed uh can I commend an incredibly brilliant paper about why we get the wrong civil servants by me no it's called Uh ministerial Civil Service relations a time for a reset um which is about the need to put more distance between civil servants and ministers um to give the Civil Service more responsibilities to challenge but also more exposure for their advice which a number of uh former civil servants have all suggested to actually put a bigger premium on knowing what you're talking about because if you put your advice out and then uh you know the very well-equipped health Think Tank world will be all over you like the play if you don't know what you're talking about um I think it would be quite a good Improvement in that and actually act as a bit of a bull work against if you like Whimsical ministerial all sort of decision making of this is the thing I am going to do and put my put my name on um so I think there are some real problems that we could address that I think you know one of the things that was quite good about the coalition government was its ministerials relative ministerial stability by having that sort of lock-in um but yeah since then since 2016 ministerial instability which was always a problem has gone to completely absurdist levels and there are some brilliant Institute for government diagrams administerial turnover which will show you you know a sort of almost a competition for being able to overtake the turnover rate of your predecessors so it's a real real problem when we give politicians so much say on the Health Service that's always been a constant battle when I was doing Health yogs ago in number 10 I was Health advisor and when Virginia bottomly was Secretary of State which dates me very very very badly looks at Stephen Doral there um and she kept on we kept on trying to tell her that she should not respond to Media comments on sort of things that were very clearly managerial issues in individual hospitals rather than systemic failures But ultimately she just couldn't resist being drawn in there were questions the house and things like that and we've never resolved that question of you know what's the right boundary of ministerial versus manager you know NHS leadership accountability I came across a lot of your memos from that time at the national oh my god oh no don't tell me that as well various people writing in the margin saying yes we should stop her and that sort of thing what do you make of that point I suppose just reflecting on that and reflecting on actually Sean's question a lot of this does feel like it comes back to Nigel's little box about beverage versus Bismarck to the extent that we collectively as Citizens not as NHS experts if we if we as a citizenship have generally terrible views about how to manage the NHS terrible instincts about how to manage the NHS if there are things that are emotionally Salient to us that aren't helpful for managing it well if we put incentives on our policy missions to deliver change quickly in a way that isn't consistent with how you manage your organization successfully then I suppose that does direct you back to you know should we have a system that gives us that much power you know if you're Odysseus and the sirens keep ubering you off maybe you should tie yourself to the Mast obviously the problem that we have is the current setup of the system is very popular as well but it does suggest that if you're trying to see where the origins are in Nigel's Labyrinth that a lot of the roads seem to lead back to that one I do think journalists like me have got a lot to answer for on this because the way we measure ministerial efficacy is very warped it's often based on what a spinner in number 10 will tell us and that is you know how often have they been on the Today program for instance rather than anything to do with their implementation and also more basically than that whether they're fun over lunch the number of people who I've seen written up as very effective Minister and I know that's because they'll share a bottle of red over lunch and you know this bet has no bearing on what officials in the department will say about them is is quite troubling and although they have pudding then I will put them up my rankings right we'll take a question from sort of that part of the room uh there's a man there with glasses yeah he's looking behind himself so you you know everybody thank you thank you so yeah comment from Manning glasses sorry I saw it John Appleby nutfield trust so thanks Nigel is great I have seen some of that before and it's I think it's uh it's a really it's a tour de force I just I was going to say uh more a comment than a question but I think I can people see people think oh no but they're very very brief and it's more around the international sort of comparison stuff very much strut Nigel about the um the well-established systems tend not to change you know you look around Europe you know you need something like the fall of the former Soviet Union to see some big changes in healthcare and uh I could turn that into a question just by asking why or why do we think that the systems generally don't change um my other point was um that in my experience all countries at some level fret about their own Health Care System we shouldn't think that we are unique in this and it's it's hard to sort of have an almost out of body experience and put yourself in France in Germany in Italy in Spain or wherever um my my first experience of that was when some of you may remember who published in 2000 a ranking of all Health Care Systems in the world all I can't remember the number 190 or something France came number one I think the UK came somewhere like 18th and in 2000 I was at a health Economist conference in Paris and all the French Health economists saying don't believe that we're terrible we we really treat our elderly and mental health patients badly and so on so just to bear that in mind that this fretting about uh what we're doing how well we're doing and so on is a shared a fretting um the other thing was just a quick comment about UK tax takes which I seem to remember are some of the lowest in Europe and have been for some time have we reached our sort of maximum level of tax resistance um we could be spending two or three percent more tax take and that would provide a considerable amount of money for health care and other things thanks we'll go along for them I I find this fascinating this question of International comparisons and certainly in my world of doing science and technology policy we see exactly the same thing so we often beat ourselves up in the UK that we're not very good at turning University Research into benefits we look at Germany and see these wonderful institutions they have called fraunhofer institutes which transfer Tech from universities to businesses and when I was working in government on this um we agonized over how we measured the effectiveness of our own institutions that did this and we would put into all sorts of metrics we grill the people who ran it it was very very kind of uh angsty and one day I thought to ask the person who ran the farnhofer Gasol shaft in Germany about what metrics they used and it turns out they didn't use any metrics at all they just thought this was a self-evidently good thing it was an effective organization so they kept on funding it and I suppose there's one interesting Dynamic there which is when you're in a when when something is working well audit culture things like that fall away and success breed success when you start to agonize about something then your effects to make it worse or better can be counterproductive but uh that wouldn't doesn't surprise me at all to hear we see some of those things in international Health comparisons too Joe so I think busted by a tax change John as you can see um yeah we are a relatively low tax country um compared to a lot of our European counterparts certainly um so I think this is where the sort of conversation that Julian initiated is really really interesting do we find and you know it's where some of the conversation about hypothecation goes as well is the NHS so special uh that we're prepared to pay you know as dedicated tax for that and that's why I thought the Health and Social care Levy though misconceived as a tax was a really interesting way of potentially increasing results also why I um sort of probably less dismissive of social insurance than others because if there's a sort of non-tax way that doesn't have uh politicians to have to account for putting up my taxes to increase the funding available then that made de-politicize that to some extent be quite helpful and I don't know whether that's you know so Nigel had it as cutting out the Ministry of Finance but it may just be be a different way of doing it I was just in Australia for a quite a bit of time which is great uh they're fast you know not fussed about their funding their first about how staff shortages it's why they've got some very aggressive advertising can I recommend the advert for going to Western Australia strategically placed for anyone going to work at guys hospital um which has a picture of people on a paddle board in Winter and Western Australia then offers them jobs in their health system and they're very very fast that they can't get people to go and work in rural areas so even you know systems that do seem quite stable have their problems that every slightly wants to fuss about health and you've got to sell newspapers and it's a thing that you know basically sells you know Health Service working okay I mean I think there's a really interesting way going to what Sean says about where are there interesting successes one of the things I've asked one or two people around us you know we hear a lot about Manchester having integrated you know extended Health and Social care responsibilities but I can't remember seeing anything about whether that's any good doing anything interesting new different uh maybe quite a lot of you know and can tell me it's wonderful but I don't know I mean it seems like quite an interesting model if you believe in a more sort of default system um but yeah but I haven't read anything about it as a casual reader maybe it's too good a story to you tell or maybe it's just like the same as everywhere else off to Manchester now so um Israel changed from a NHS type system to something a bit it still looks a lot like an NHS system but it is run by hmos um it's actually one of the more Integrated Systems around um Greece changed from a social insurance system something a bit more like an NHS system but it's very Greek and quite unique um uh the chamashko countries um Belarus Russia have not really changed their health system really at all that's probably true to the Central Asian Republic's largely not much different the baltics have done better so but it's path dependency is the answer John it just like what we the decisions you've taken in the past constrain the ones that you can take now um and and you've got a set of professionals training in a particular way a public use to using it so so people introduce Primary Care into a number of these countries but people still go straight to the the so-called narrow specialists in hospitals similar experience has been happening in in India and just the points on Jones I think the the social insurance countries have reduced the influence of the Ministry of Health beneficial Finance but only reduced it it's still there because actually increasingly social insurance countries are funding their health systems through tax um because there are a few people paying tax and there's more people consuming it so you know it's basically the retires and children and the unemployed are all paid for by the taxpayer um so um the ministry of finances is still in there so the attitude and approach of your Ministry of Finance also still matters um but that you're right there is an opportunity to have I mean the other thing that social insurance just worth pointing out is social insurance basically is a deduction from your payroll uh from your paycheck uh and a deduction from your employer and an employer's contribution sounds a lot like a tax to me um who determines it is the question yeah and that's that is the point yeah okay another question lady there in the blue dress thank you uh Jane Townsend chief executive of the Home Care Association really interesting Nigel very comprehensive I wonder whether all Western nations are struggling with these issues because we have a fundamental error in our concept of Health we think it's to do with physical malfunction of parts of the body that can be fixed by pills and surgery rather than recognizing that we are complex organisms whose thoughts and feelings and relationships and levels of stress have a fundamental impact on our health arguably more than any hospital beds and this leads us to the fallacy that Healthcare is some Health outcomes is something to do with health care rather than to the social determinants of Health where other people have alluded to so how do we turn that round you can say let's take a couple more we have to think about that one actually with the seminar this afternoon yeah it is a great it's a really good point um and I think um I mean or we want both don't we we want the system that can fix people who are who are immediately sick and we want change most of what you're describing is of course completely off my map altogether near the new map yeah I need a new map yeah I'm going to need a bigger sorry I mean it's employment it's about education it's a housing it's about a number of other bits of social policy that we don't do terribly well as a country either um you know and I I and and I think um you know our attitudes to fixing fixing our problems of inequality about dealing with with with the poor about providing proper education I mean we these are all problems again of long-term investment and infrastructure and that is on my map it's just that that I need a three-dimensional map so yeah but I would agree I would agree with much of what you just said and I think that's that's that's true in in many other that's true in most other countries but I think some of them have better developed uh Jill will probably be able to comment on that but you know if we look at Finland or or Norway or swint I mean Norway or it's obviously got so much money um but um but but certainly other Scandinavian countries countries with more of an ethos Association solidarity and you know the who motto of leaving no one behind having a little bit more meaning in those countries than it seems to do here Jill this really ties into the letters that that you were writing to the Department of Health for fuel poverty and so on and I suppose one of the things that we see a lot of at the moment is poor quality of say social housing where people are already quite vulnerable then put into Flats full of mold I mean there's I know quite a lot of people I think the who talks in about health in all policies and I think one of the things one of the things that's really interesting in Whitehall um and it may be different in the devolved governments where industry is much closer is my perception has always been this is probably very unfair and I look forward to former Department of Health officials taking me apart about this later um is the Department of Health focuses very much downwards on managing the NHS and the politics of the NHS and whatever that's very much where the real focus is and it's a quite weak cross-white Hall player and influencer as far as I can see so on quite a lot of these wider issues we identify in the department of environment where I was then working we identified the Department of Health as a natural Ally on a lot of issues like sort of air quality fuel poverty and things like that but we couldn't get any couldn't get any response out of them it's really interesting what the uh what research Department of Health funds one of the really interesting things I always thought about nice guidance on public health interventions was where there's not much evidence for this but it's so cheap compared to most of the sort of interventions you could make and the potential returns are so big that like God's sake just do it um but you know the NHS research project I think Sally Davis used to have a feather about 97 of it's looking at sort of treatments and medicines all of which sort of end up costing as opposed to those other sort of wider interventions so I think it's really interesting questions to ask about the Department of Health and it's sort of wider wider Public Health role we've now lost Public Health England I don't know whether the UK Health security you know we had that sort of move into the Department of Health I don't know whether that's changed the Outlook but it's really really interesting one of my first encounters Department of Health was when they would do it was when I was in the treasury and they were doing it the health in the nation white paper Youngs ago and they just were so disempowered about asking for anything and I was in and then I moved into number 10. then for God's sake almost for a bit more from other government departments but actually it's really interesting in the treasury just asked for a bit more from other government departments because yeah we had loads of clout they perceived themselves as having very little clout when we agreed in the treasury to give them a commitment to maintain tobacco tax duties and alcohol duties in real terms we persuaded ministers do on the grounds you might as well do it we're going to probably keep the taxes up anyway we might as well claim a bit of Public Health credentials for it by allowing them they just couldn't believe they couldn't believe that the treasury allowed them to say something about tax in their white paper I mean it's really quite sweet how needy they were very very distressing if you care about population health I suppose if we're talking about social determinants of Health I feel I should put in a plug for my enthusiasm the absolute macro level one which is economic growth I mean I I I'm very swayed by my friend Tom forth who I think is one of the sort of the most eloquent spokespeople for the economy of the North of England who will make the point that when you look at places we think of as deprived and left behind they're often very low inequality they're just poor they just don't they have very low local gva or GDP and um actually investing in that if we're thinking let's look at the big picture is really important obviously it increases the tax take for any given tax rate and there is a challenge because the more money we have to spend on acute care the less we're spending on transport links energy skills policy r d all of that stuff that is so lacking in many parts of the UK another kind of right at the front in the patterned dress so I feel like I'm sort of offering a kind of Vogue commentary as well as a tearing role for the fashion critique Catherine Catherine so if this chat is about diagnosing the NHS what's the prognosis for this soon to be 75 year old I did wonder when I started writing this book whether it be a complete history of the NHS from start to finish given the way things have been going um Nigel is it going to be here in another 75 years well that's quite a long time period okay um that's cheering yeah I mean yeah I mean it's in trouble but as John was saying it's people tend not to change their systems um uh we've had some big bang changes they're very hard to predict um they're often triggered by uh sort of events you wouldn't think would normally trigger a change you know um Tim is often written and you know maybe maybe Skeets and all of those uh Jennifer's here and all those other sort of instance um I I can't I think it'd be very hard to envisage a major shift to a new system I think a much more likely scenario is is pointed out by what's been happening in dentistry which is a sort of General drift away from the NHS there's people you know as the practitioners and the patients decide that actually maybe it's easy if I pay for it myself and and and and it gets sort of under so everyone's worried about you know the the sort of on Twitter you can I would inundated by people saying oh this is about Tory privatization right you've that there's been a 20-year 25-year history of privatizing Dentistry um there's a there's a we've privatized long-term care so we have a precedent here and the worry would be that you see next thing you see is general practice and let surgery going the same way um and leaving a very patchy service in which if you happen to live in a poor area you're going to get a very poor service that that's my optimistic scenario we talk about that over drinks I mean the the key determinant here is is the macro economic picture I mean I think that's the and that's that's that's not looking great right um the other worry is the workforce um you know and our under investment and I mean John's point about not not being sort of exceptional and it just is a bit guilty of exceptionalism you know but actually lots of other countries have got burnout problems um it's just I think ours are slightly are probably a bit worse but they're not you know not probably on a different level but everyone's got that problem but we don't seem to be terribly good at dealing with this at the moment and we need to deal with that or so there's a sort of General decline rather than cataclysmic implosion is the is the is the real risk unless we do something we do something about it yeah Joe are you any more optimistic um well optimism implies that I basically want the NHS to continue and since I'm much more NHS skeptical than 99.99999 of the British population um I'm not sure that you know I'm I think someone said you know what you really wanted sort of decent decent treatment so what I want to know is that if something goes wrong with me I'll be able to access reasonable treatments uh at you know acceptable resource costs to me that I can do so from a personal point of view um yeah go outside the system but anyway of course how General Peter Shay sold his reforms um so yeah you've got a final salary pension so you're fine um the rest of you too bad yeah so yeah so so I don't know as a system staggering on I think the system needs to take a long hard look at itself um I think it needs to sort out Workforce I think it needs to look at the way it organizes internally in terms of where it treats its staff um my niece who hopefully is not watching is a what I think you'd call Tommy Turner Junior doctor I think there's I cannot understand how we manage to take so many very enthusiastic students to 18 and hack them off so relentlessly by the time they're in their mid-20s by treating them you know really quite appallingly in what seems to be like a ritual slightly sadistic initiation test of training so I think there's some quite interesting things you might want to do there about you know making it sort of you know Workforce training model fit for the 21st century I think it's really quite interesting um some of the closed shops and divisions of labor within the Health Service of who can do what I was very struck on my I don't have very many associations with the NHS but I had to I went because I broke my hand I went after three weeks within two minutes an incredibly efficient radiographer told me I'd broken my hand uh five hours later I was given an appointment for the fractures Clinic after I'd been through accident emergency and Urgent Care in the hospital that wasted my time it exposed me to quite a lot of covert risk I don't know why my radiographer could not have just said you've broken your hand I'll give you a fractures Clinic appointment on Monday which is what they ended up doing I do not understand those intermediate stages one iota at St Mary's Hospital Paddington if anyone's from there um so I think there's sort of quite a lot of internal things about empowering people to make sensible decisions about what's the future look like yeah so I think you know I think there is a big internal look that needs to be had to say actually with all this massive public resource we have we're all talking about how little there is but there is an awful lot of resource in this how are we really going to use it to have something that we like working in or please be working are proud We work in and offers something where most of us feel we're doing a good job for the people who want to use us and if they can answer those questions then I think it's got quite a good future because there's a huge amount of public buy-in to it and if it can't then it probably doesn't deserve to survive soon well I wrote an Empire managed to keep going a thousand years after the fall of Rome so I would imagine so Christianity has been going two things exactly a brand with the salience with the emotional Resonance of the NHS I would imagine will exist for the foreseeable future in some form I guess the interesting thing to come back to to Jill's point is how can the system change and how can it respond to some of the problems that we've talked about while protecting this sort of sequel this really important emotional response to that voters care about that politicians care about the optimistic story is that that emotional salience gives us the power to change things the better because people want to keep it going people are committed people are willing to put in more money for example towards levees or willing to accept changes that's a positive story the pessimistic story I suppose is that the the the beauty the value of the intangible asset that is the NHS brand stops US changing things makes it harder to to put in place the the incremental reforms that Nigel was talking about that get you through that that that that Labyrinth and I guess those are the two to me the two Pathways the badly good well I'm starting to get a gentle rumbling of stomachs which means that lunchtime is upon us and I'm just going to let Nigel close possibly just with a reflection on how much bigger his diagram needs to be um but on just on your closing thoughts on what you've heard and yeah so we need to expand the diagram to think about tax that's certainly true and we I think we need to there's a whole chunk of Public Health and what is health bit that's missing from the map in its current in its current form that we we we ought we ought to Break It We ought to bring in I think I'm I'm still left feeling that that the the discipline that this way of thinking about the system brings you is to to think more forensically about individual changes and things that we could make a difference with now and to avoid the idea that that's out there there's some magic thing like charging or social insurance or you know whatever that will fix your problem and and the the the as a as when I finished the answer is methodical it's probably quite slow probably quite boring evidence-based and will require a lot of hard work and in while we're doing that we need to pay some attention to as Joe said stabilizing that dealing with the issue about staff welfare and how people are treated uh sorting out some of our basic systems um and making making the place a great place to work and be treated in while we then think about some big changes and there's some of lots you know people used to say a lot think a lot about you know the people quote the cycling team and everything and say you know lots of small changes you know which is how animals of old eyes and wings there's a controversial Theory but um but how did you get to fly but you know by by small incremental change not by suddenly jumping off a cliff boring that we're very much in favor of the board thank you so much Nigel thank you Jill thank you Stan thank you for your questions I believe there is lunch I have no idea where it is so somebody who knows will show you but thank you very much for joining us thank you