Dame Ruth Carnall, Health Chat

“Dame Ruth Carnall has over 30 years’ experience in health care, including 20 years as a chief executive in acute hospitals, mental health, community services and health authorities. She spent seven years in charge of the NHS in London as Chief Executive of NHS London and now works providing strategic advice to leaders in health care.”

That’s what you will find if you google her, and read her bio on The King’s Fund Web Site.  As ever in the studied intimacy that is an in-depth 90 minutes chatting with Roy Lilley, he does unearth much more.

Dame Ruth Carnall

Roy Lilley’s first health chat guest was indeed the brave and innovative Ruth Carnall.  5 years later, she returned.  There had been many other guests in-between.  And I am sure there will be many a returner now that Ruth has paved the way – again.

I wasn’t able to be at The Kings Fund for the meeting, but caught up via NHS Managers You Tube channel which you can do yourself by clicking here.  It is worth the time.  The comments as live at the time on Twitter were summarised as “Common sense and a deep determination, from a normal human being telling it how it is – bold but modest”.  Go look, and join the 7000 who have done so already.

Let’s get back to the late 1970’s. There were very few female directors in any businesses at the time, and even fewer in her chosen specialism – finance – and even fewer in the Health Service. It does appear to have improved over the last 40 years, but maybe not at a startling pace.  First day back from Maternity leave, she discovered the Chief Exec had been removed, and she was to be acting Chief Exec from that day. Brought son to work, because they had a workplace nursery at the hospital.  Lots of discussion about why this wasn’t common practice still.  As Ruth said, it made money.  And with a predominantly female workforce in the health service, wouldn’t it make a lot of practical sense?  40 000 nursing vacancies should give us a feel that something simple but radical could help? Roy had one when he was a Chief Exec…it seems a non brainer to me?

Ruth started in London, trainee in finance department at Mary’s , then onto St Thomas’s. Even in 1979, when the accounts were still handwritten and ledger driven, Tommy’s already had Speciality Coding with clinician involvement.  It was paper driven, very labour intensive, but worked.  The culture shock was moving out to Hastings, which wasn’t quite at that level of sophistication.  Resigned from there because they wouldn’t allow a Chief Exec to be involved in a job share. Applied for a job in SE Thames which was a 2/3 day split job share.  Big positives are you get two for the price of one, with the best of two different approaches. Avoided London whilst kids were young, because of the commuting and longer hours expectation of networking and the like.  Roy did discuss this balancing act of work life and family and work with Ruth.  It was interesting that this often happens with a female in the chair at a health chat, and I have never witnessed that with a male interviewee.  Do I just need to get over it?  Like Ruth did with her opposition to a nanny when she had two small children, for fear of delegating the mothering part of her life? She realised it was her who had to get over it.  A leadership decision if ever there was one…we will come back to resilience tips later.

London beckoned after East Kent when the nanny offered to leave as the children could cope now they were over 12.  The big stuff in changing the way London acute health care worked happened now. Working with Lord Darzi, the evidence based changes centred on centralising genuinely acute care.  The Stroke initiative in London personifies the approach.  As Roy said, the thinking is based around starting with the patient and working backwards. Had a stroke? You used to be taken to one of 33 centres, who were generalists.  Now, there are 8 Hyper Acute Stroke Centres. Geographically optimised to minimise ambulance hold ups. Para medics trained to diagnose and take the patient straight to the specialist centres.  And outcomes are hugely improved.  The mapping caused the first hurdle as one of the best performing potential units was Tommy’s, and the leading Stroke consultant there was naturally not convinced.  Dr Tony Rudd though changed from that to becoming an advocate through evidence based argument.

That’s one example, and it is the special case (to me) that is London. It has been rolled out in some other metropolitan areas, like Manchester, Birmingham and other cities. But centralisation wouldn’t work in some parts of Devon.  Ruth gave the example of Barnstaple, where perhaps having a stroke centre would make specialisation excellence sense, but it wouldn’t geographically, because having a 65 minute ambulance journey would lead to worse outcomes.  Evidence based, horses for courses.

Andrew Lansley was brought up in this health chat, yet again. A lot of these initiatives were harder to do as Lansley thought all would be improved with having a market mentality. (I am sure the likes of North East coast railway and Carilion may make us decide differently in future?). Ruth and the team managed to get it through (but it is teeth grindingly difficult in the face of politics and the hoops to jump through to get anything past the anti change audits and form filling).  Memorable phrase from Roy: “We are at last scraping the final bits of Lansley reforms off our boots”.

Another fascinating section was Ruth’s top 10 tips for improving Resilience.  She wrote it originally 30 years before.  It was mentioned on Roy’s e newsletter, and had 2000 downloads.  Ruth found that a little depressing.  Why does it still resonate so much now? When will we move on? There is still prejudice in the workplace.  It is still hard to get the balance between job and kids sorted.  There is more pressure than ever.  What with Social and other media, and the loneliness at the top and  the lack of support.  20 % of chief execs in hospitals are currently interim appointments.  The most successful places have a long-term incumbent.

Another area? Merging Health and Social Care.  Roy has changed his mind, and thinks they have to remain separate, because one is free at the point of delivery, and one is means tested.  Ruth agreed with that, but thinks a merger has to happen, and we just need to think differently about the means testing. A debate for the future…

She was sensibly proud of the Stroke initiative.  And Leadership Development for Junior Doctors (some classroom, but main learning from being assigned to a mentor Chief Exec, and learning by osmosis).  This worked both ways, as you as a Chief Exec heard from the front line how your decisions affected outcomes, affected individual patients.

There was more…click here to go watch if you have the time.  I loved it. It really is a worthwile lesson in doing, not just talking about it.

Jane Cummings, Chief Nurse: Health Chat

Professor Jane Cummings is the Chief Nursing Officer for England and Executive Director at NHS England.  OK – that’s the NHS England web site piece – but what did she say to Roy Lilley in the NHS Health Chat at The Kings Fund?  read on for my personal take…

Ready to roll!

It’s always interesting to attend one of these Roy Lilley Health Chats. You do meet a lot of interesting folk, chatting before and after. I honed in on one of the post chat questioners, who asked the final killer question “55% of nurses don’t work in the NHS even though nearly all were trained by the NHS. They feel disenfranchised and don’t know who their leader is, even though, in England, it is you.”  What are you going to do about that, was the gist of the rest of the question. So I asked the questioner more. Who are they?


I’d assumed private, nursing homes, social care, and fringe stuff like tattoo parlours, school nurses and sports and stuff. But it also includes nurses in General Practice – because they are private businesses  and are employed by the practice itself.

Can you already see how complex this is?  Would you have thought that?

Jane wanted to be a nurse early on, when practicing bandaging on her long suffering brother. Lost the urge, but then regained as a teenager seeing what happened in such a positive way when her mum was in and out of hospital when Jane was a teenager.  A&E Sister at 24. Clinical Nurse Specialist at 27. This is where she honed the Art and Science of nursing – and started to manage people and process. Roy was asking about why move from the vocation to being a manager. I think she had proved how that question was irrelevant. And she also still did, and does a shift on occasions. Management by Walking About? Or Motivating Others By Doing It? MOBDI – my new acronym!  Getting your hands dirty is always going to both play well, and give you so much useful pulse level information. I love that.

After transitioning into General Management Jane then moved into the Department of Health. After her own personal trauma of losing her husband to Lymphoblastic Leukaemia, whilst working on the 4 hour max wait target, she wanted to get back into NHS work proper. Chief Nursing Officer for the North of England. Then this current place. She did indeed seem destined for it!

Having worked on trying to hit a target (98% of patients will be seen within 4 hours of arriving at A&E) Jane agreed with Roy that sometimes, “you can hit the target but miss the point”.

And after that, we traded numbers!

More nurses and midwives, to make sure that more doctors could actually do what they were employed for. But, still a huge shortfall 36000 to 40000. That is offset by 31 to 32000 bank and agency staff – some of whom may be local staff supplementing their austerity capped wage?

Retention was a big problem and not just in older staff. This occurs just as much in first year post graduation. So there are schemes designed to help such as mentoring preceptorships and more. There are many beacons of excellence – Sheffield was mentioned. (And many others…)

Flexibility seemed to be the key here. Some nurses loved the 12 hour shifts. Some really didn’t want that. Sheffield seemed to accommodate so well they had a waiting list of applicants! I have always believed in stealing ideas with pride. Forget not invented here….just nick it and use it. That’s what the FabNHS website is for…as well as looking locally. (Click to visit)

Technology will help. Jane herself had Skype and data upload interactions with her own doctors and nurses (sorry…can you imagine the Chief Nursing Officer making an appointment to see you? Oh heck!). And there will and should be much more of that.

Our protagonists did agree the non-rocket science answers, based around Compassionate Caring, were indeed simple to state.

  • workforce planning, with flexibility built in tune with staff needs
  • Being a good employer
  • Have great ideas like Retire and Return schemes
  • As well as mentoring for newly qualified
  • As well as apprenticeships for those nurses who prefer practical to straight academic I assume? (Already being successful, I am informed)
  • Patients are not the most important thing here. Staff are. Get the staff right, feeling good, doing the right thing, and the patients are cared for stupendously.

If we get the duty of care right for our workforce, we will serve our patients best.

Amen to that – thanks Jane and Roy.

All we have to do now is just do it…


Dido Harding, Health Chat

Baroness Harding

Dido Harding was different from almost all of the Roy Lilley guests I have witnessed over the last 4 years or so. If you have read any of my up sums of the events, you will see a theme of home grown talent, completely immersed in an often quite varied but mainly NHS job trajectory. Dido Harding had been at NHSI for a few months!  So, her back story is even more pertinent perhaps? And why has she jumped into the maelstrom that is the NHS…all her friends and colleagues suggested that she shouldn’t do it.


Dido Harding

All smiles, sponsors and all, before (and after!)


From a military family, born in Germany, brought up on a pig farm in Dorset. Granddad was a Desert Rat. Actually, a Field Marshall).  Here’s the first quote, this from Granddad, who she loved deeply (emotion and touchy feels stuff will figure highly in this report).
“You can’t be brave unless you are afraid”.
Granddad taught her that it’s ok to be afraid.
Catholic Convent in Dorset, followed by McKinsey (one of the big 6 consultancy firms then). They do suffer from a bad reputation, but Dido talked up the objective view from outside, the bought in skills that you may not have in your teams, and that ability to take a helicopter view of the leadership and culture in the organisation. She agreed with Roy that the consultants are as good as their clients. The problem is, I suppose, that if you knew exactly how to brief them specifically about the current set of problems that you are faced with, then you probably wouldn’t need them in the first place! In 25 years in business, she has used external consultants 10 times.  She was sponsored through her MBA at Harvard by McKinsey and also gained a scholarship. Quid pro quo meant returning to McKinsey afterwards. She felt too young at 22. Not enough real world experience. The MBA at the very least gave her grounding in pattern recognition. Which should stand her in good stead in her new NHS role.

A recurring theme surfaced in her career path. “I wanted to put my head on the chopping block”. The path went from Thomas Cook (squeezed by competitors because they only had travel agencies, and not planes and hotels), but “learnt the value of price”. Then at Tesco’s reporting to Sir Trevor Leahy, Chief Exec. No.2 to Sainsbury at the time, and a bit of a scared number two. Changed during her period there. Ruthless efficiency. Sometime at Woolworth as Commercial director – and realising she couldn’t answer the fundamental question as to “why was it there?”. Then potential being head hunted and moving to Sainsbury after being at Tesco? Her ex colleagues didn’t speak to her for some time! Sainsbury was nice, Tesco ruthlessly efficient. “You can be both”. Well said! She thought Tesco had its stumble because of the way it treated people.

MP husband, a 1 year old and pregnant, and suffering the usual balancing act that falls mainly into women’s laps. “I learnt a lot from the women around me on the staff who had children but had it much harder – either single parent, or very tight budgets and more”.  She is a soft skills stalwart and active practitioner.

“To be an effective leader, you have to be who you really are. You cannot do it if you are trying to be someone else”.

And didn’t that come to fruition when she had the the horrible experience of being Chief Exec of Talk Talk when they had the first major data breach in the UK. Web site ran slowly; Emergency call. Enacted the contingency plan; realised it was a real attack; sales team devastated because they couldn’t add orders! Then, anonymous e mail with attachment of customer data. I can’t imagine how that level of violation, followed by black mail threat, really felt. Loads of expertise, from GCHQ to BAe systems. “The breach could be a very few people, or 30 million e mail addresses”. Jeepers! Because they didn’t know what had been taken, they – mainly Dido Harding herself, I suspect – decided to tell the customers and to mainly be aware of people phoning and pretending to be Talk Talk. So, she did the people stuff again, first and foremost. Including looking after her own staff. They made mistakes, for sure. But protecting customers by warning them, and keeping staff in the loop through personal blogs (which she did 3 to 4 times a day instead of 1 per week), and then offering a free upgrade to all customers after the dust settled, which all served to save the business. After the crisis, the National Cyber Security centre was set up – “my little gift to the UK”. (The other was her team being involved in creating screw topped wine bottles. History will record which was felt the greatest achievement…). Talk Talk was better for the horrendous experience. They stopped being complacent, and turned to being a challenger for change.

Now? Well NHS Improvement and NHS England cannot become one organisation, legally. (However much Roy and others press for its logic). But they are having some joint cross Board appointments. They are learning to trust each other to get on with their part. To share things, so they only do something once. And to challenge the system. As well as making sure the Secretary of State doesn’t micro manage her.

One rejoinder to Roy Lilley, which I particularly enjoyed, was about looking forward not backwards. This raised a bit of a cheer.

She owns a horse, who is now 30, and cost £7000. But still Cool Dawn won the Cheltenham Gold Cup back in the day. She was an amateur jockey for 20 years too.

So, currently not hugely experienced in NHS, but diversely experienced as you have read. I think her lack of NHS tainting will actively be an asset. Coupled with a fearless practical intellect, and an overarching belief that getting the people parts right has to be first and foremost and the main driver of the way she leads, then NHSI, and the health service and social care as a whole, is in for an exciting time. Her level of humanity and engagement just shone through. Fabulous!

(If you wish to watch the Health Chat click here…)



Shirley Cramer, CBE


Roy and Shirley Cramer Jan 18

Yes, of course it’s water…Roy and Shirley settle in

I needed to look Shirley up after hearing her speak and before writing about her. Her NHS Health Chat at The Kings Fund in London, was so wide ranging that at the end I was confused about what she actually does…


Shirley Cramer, Public’s Health guru. Well, that’s how she came over! Luckily, her main job is Chief Exec of The Royal Society for Public Health, the oldest Public Health organisation in the world (161 years old).  And she gets involved in a lot of other things too – see later.
As ever, my views prevail here as the writer, but you can watch the podcasts (4 segments, easy to digest), to see if you agree with my take or not…click on the links below:

Section 1           Section 2           Section 3            Section 4

or the whole thing:  CLICK HERE

It is often the chatees (interviewee is the right word, but doesn’t fit Roy’s avuncular evisceration technique) – the chatees back story that informs why they have ended up in that chair right now. Shirley’s was more varied than normal.
17 year old girls from the unfashionable coast of West Cumbria don’t do their last year of school in Colombia in USA? Billeted with a family and schooled in a very different environment and style of schooling – she did a 7 page essay when everyone else did a paragraph or two, about a book – is a bit of a full on 24/7 learning experience. She just remembers it as a big adventure, but feeling homesick for first 3 months…

Went to uni after A levels. Applied Social Studies – 4 year course and come out as fully qualified Social Worker. 22 year old, in the Emergency team, even sectioning people in ambulances…

Married, husbands job goes to USA, so couldn’t work herself, as no permit. Masters in 13 months at private univ. Left in 86, and went voluntary, learnt about fund raising. East Side, NYC. Tough, I imagine…

Back in UK – involved in Muscular Dystrophy – already managing…

Back to New York City. (Tired yet?). Voluntary sector again. Learning Disability. Set up a Washington office. And was told to be bi-partisan, as she was issues based. Managed to befriend both sides, which stood them in good stead. Clinton 1 administration at the time. Worked. Televised Summit – “No child shall be left behind”.

A book fell out of this – still available – “Learning Disabilities – Lifelong Issues”. Click to see..

So why all this history? Everything that Roy Lilley and Shirley talked about afterwards was completely built on the foundations of that history. I’m not sure I have listened to anyone who has convinced me completely that they have learnt from every scrap of their experience. That’s what felt powerful tonight…

The Royal Society for Public Health is the oldest of its type in the world -as I said before. Abroad, it is talked of reverentially. Roy batted that back with the he rejoinder that Public Health had failed.

We did have a lot of talk about the reports they publish. Interesting, they are both fact based at the start, but also add in public opinion of those facts to find out if change is plausible and possible?

The discussion ranged wide – as wide as The Public’s Health remit is. Smoking? Tony Blair given plaudits for it. Sugar tax? £430 m – already taken, and has been allocated to schools specifically for fitness and outdoor kit. It’s probably only £20 000 per school, but it’s money they wouldn’t have and they can’t spend it on anything but sports stuff. Will it prevent childhood obesity? Maybe a step in the right direction?

There are pockets of excellence to copy. Portugal making possession of drugs for personal use legal. Crime and death rates have dropped. Scandinavia has the infrastructure (and smaller populations, I contend) to manage poverty well. There is also a positive attitude to ‘herd immunity’ everyone gets their kids immunised, to protect next door. We do it for our own.

There have been som excellent nudges in the right direction (report on high streets and poor areas having the worst range of shops).
I liked Shirley’s “evidence alone is never enough”. Her attitude also adds in public opinion. It gives the facts nudge worthiness…

I think though I tend to side with Roy.  Once we have the pointers from pressure groups such as RSPH, then Brits need legislation (Crash helmets; Smoking; Speed limits).  If you visit Scandinavia, you will note that (e.g.) the Danes don’t venture forth to cross a road until the little green man says so.  Brits ignore that, and get tutted at.  We are essentially a little bit rebellious, and don’t like to be told what to do.  But if it’s law, we do tend to do it right.  But we need to be pointed in the right direction first, and bodies like RSPH can do that very effectively.

Despite being in the widest job brief I can imagine, she also gets involved in other charities and groups. It seems she may not know the detail or the specifics, but that doesn’t matter – she has great people around her. And she is very good at leading and motivating a team. A vision person, I think.

Her one wish? Politicians to become more engaged and brave.

If that happens, maybe we could slowly move from a sickness based service to a Public’s Health service, with the NHS there for the fewer sick?

It’s a thought…

Alwen Williams Chief Exec Barts NHS Trust

Alwen Williams

Alwen Williams, CEO, Barts Trust.

The last NHS chat with young Roy Lilley of 2017. And what a fine send off the year had.

Alwen is patently well suited to her role, and has most definitely inspired me. She was calmness personified under the usual Lilley onslaught of contentious questioning. I especially enjoyed her almost complete blanking of “so what does a Chief executive actually do?”. Ignore impertinent questions! Not a bad start…

37 years in NHS. Barts trust will be her last job, she said. Lived in East London all her life; honoured to be involved in making the most important local employer better.  Been through all the “reforms” from Griffiths, to Lansley, to Austerity. After languages at uni, decided it wasn’t for her.  Looked for management training scheme, and found the NHS one suited. Been in operational management for a lot of her time in the NHS.  Her first contentious statement. Which I totally agreed with, (as did Roy…Christmas love-in?), was when she said most of the reforms only created change at the margin.  So all that messing about, like getting rid of RHAs, competitive tendering, FPC becoming FHSAs morphing into PCTs then CCGs , with a soupçon of fund holding…only had effects at the margins.  And I bet 5% of the budget went on management consultants fees to try to explain to everyone what was going on! It doesn’t really work…

In NE London and The City, she was there when 7 PCTs were amalgamated, and she was the overarching boss. Sorry, accountable officer. It was a bit easier to be strategic, when at least the NHS boundaries were co-terminus with the local authorities…

“Having an Internal Market is not the panacea for service improvement”. Alwen quietly kept hitting us between the eyes like that. I guess her teams know this already.  Not a quiet assassin. Just a highly committed people person.

Roy asked her more about what she did and how she did it.  Deep seated core values just flooded out. Here’s a flavour:

  • They have 200 leaders in their trust. These can be Chief Execs or Porters. All equally important.
  • The leaders need to define the needs of the organisation, then make that happen.
  • There has to be continuity of purpose, and everyone needs to know it, live it and share it
  • “I make sure I have great people around me” It is simple isn’t it?  Simple to say, but hard to keep doing…
  • You need to pay attention to what staff are saying, and act on it
  • If you espouse Safe and Compassionate as your core reason for being, you have to recognise it, do it, support it, laud it, praise it and kick out those who can’t or won’t do it! (I added the past bit. always is too polite to say that!)
  • You have to nurture and develop people. Not command and control. No Ivory Tower.
  • Everyone is respected. There is no hierarchy espoused. Everyone is as important as each other.
  • Leaders set the direction

In the end, it was all about engaging the staff.  Operational imperatives emphasised this, for me. Like the following:

  • Make joint appointments so that the prestige St Barts post also had sessions in difficult to recruit parts in their area.
  • Whistle blowing – encouraged and protected ( and I assume vindictive claims equally stamped on?)
  • Have a great Occupational Development team, to make sure the big conversations happen.
  • Move away from Agency cover to home grown Bank cover. (Please, steal this idea, everyone…)
  • Huddles – for specific communication purposes. Like, Safety: or Cyber Attack coordination (which she says she never wants to live through again…which is very understandable.)
  • Take your services to the people…don’t make them travel miles to you if they are ill, infirm or very worried.

16000 staff and  2.2 million people covered in the area. It feels big.  It feels very accountable.

It feels in good hands. Calm and effective.

Gives you a bit of confidence, and a lot of pride, yet again, in the standard of leadership we witness within the NHS. I’m smiling whilst writing.  There’s no need to grieve for our NHS yet.

If you missed the chat, you can view it by clicking here

Ed Smith, NHSI

Just stepped down as Chair of NHSI – after a positive marriage guidance role betwixt Monitor and NHS Trust Development Authority.  And ex captain of the Titanic (no relation – but hey, we always get someone who asks about re-arranging deck chairs when Ed is on stage…he has the decency to smile still…).

Health Chat 51 (I only know it’s the 51st because the last one was the 50th.)

Did we get anywhere near finding the answers to Health Care in the UK? Well maybe not? We expected more from this health chat more than others? Just because he has left his role? Well, a lot of people had arrived in the hope…I think

I just loved some of the themes. I do find it difficult to keep up with Ed’s train of consciousness. So maybe I haven’t noted everything!  But I hope you get the overview. Biased by Phil, of course. If you want to see the whole, to make your own view, see here.

The great thing about all the people Ed encountered in his time was simply summarised. “Desperately committed”. And they were exhausted, in the main. And had never been thanked. Just so many great people. Daft. It didn’t help that we have had to endure the Lansley legacy. Reforms that were specifically not only left out of the 2010 Tory manifesto, but we were told there would be no change whatsoever in the NHS, as too much re-organisation had been frosted on it already.  You can always tell when a politician is lying, because you can see their lips move…

How would Ed fix the NHS?  Three phases, he started with. He and Roy Lilley kept going off at tangents (Roy said and interrupted more than Humphrys, so I got a bit lost. I think, like all of us, he got a little excited…and his respect shone through).

Immediate need? Emergency level of funding. If there is a Flu epidemic (it’s overdue, and is already happening in Australia) we are up that creek without a paddle. And the biggest problem? If 10 % of staff are laid low, when we have unfilled vacancies everywhere (which is why everyone is knackered and deserve even more thanks. Just remember, these are the guys who run towards the shit hitting the fan.). So the emergency money has to fund temps. Tough. But please, get someone to negotiate this well? And if someone takes the rise, stop them being used anywhere in the NHS. Or let’s simplify stuff? If most agency nurses (for example) are NHS staff, pay them sensible overtime. It’s a lot cheaper and safer from a continuity point of view…

Second? We do need to invest money, Keynsian style, to bring down waiting lists.  OK, you do need fiscal responsibility. I do think a lot of the Brown Blair money was wasted. Setting the target as spending up to the GDP average of the EC doesn’t mean you get value for money.  We need to get back to basics, I think. Ward level budgets, real time spend on dashboards on every ward (like they do in every manufacturing company I work with, who are successful). And a sister in charge of that budget,moraines and incentivised. (Sorry. Last 5 lines were my views…back to Ed and Roy…)

There’s a maintenance backlog as well as a workforce challenge.  The estate will not be fit for purpose if we don’t fix stuff and just let it decay.

Thirdly? A need for investment in transformation. Luckily, although ere is legislation to back the Lansley reforms, the people on the ground ignore it, and just get on with doing things properly. This will need 3 to 4 billion per year over 3 to 4 years.

There is no one magic bullet…no one size fits all. There are different needs in different communities.  There are different patients with different levels of confidence in their own input into their healthcare in all parts of the kingdom.  We really need to change the mentality.

How? Ask the citizens? That’s Ed’s view (- although there was some concern that Brexit result shows what happens if you ask…). But if we start with free to use at the point of care? My view is there will still need to be rationing, and we still have to think health improvement as well as sickness fixing.  We still have to make digital work for us, and keep it simple. Maybe we all have to hold our digital record, if we want to, on a phone or a memory stick or on a personal cloud?

Primary Care is just another provider, Ed said.  But we maybe need to change the way we think about how we fund the patient interaction across the whole of health and social care? Pay for inputs by the General Practice, not an annual fee per patient. (Sorry guys – I think we either have GPs as fully small business or we have all of them salaried. This in-between level just confuses funding.)

What is the plan? He talked about when he started at NHSI, that their main aim was jet to keep the lights on.  Have we moved on? It doesn’t feel like.  Workforce planning would be OK for unskilled jobs? But most of our NHS and Social Care gaps have a 5 year lead time to fill them.  That was one of Ed’s regrets, not adds sing that earlier.  Along with not convincing politicians of the need for collaboration. On the plus side? Very proud of working with the Grim Reaper (Jim Mackey).  And to be trusted by the people he worked with.

He talked with passion about about being involved in a good, positive regulator. And of a blended ‘bricks and clicks’ style of healthcare provision, tailored to each citizens need – which will vary by citizen of course, depending on each situation they are in.  He often described what he was saying as ” romanticised “. It maybe was.  I call it passion.

He did show that passion at the end, expressing his view that Roy should Keep Going. He loved him, for representing the citizen in those e letters we all read.  And I agree.

We may have lost him from the NHS at the moment.  Ed Smiths legacy though is that he hasn’t really left. His ripples keep expanding.



Health Chat 50

“So, what is a Health Economist doing in a place like is?”.  Being chatted to by Roy Lilley of course, at The Kings Fund in London, at one of the NHS managers.net. This was a landmark occasion – the 50th Health Chat. I was there for the first, and the majority in-between. And always, always have been uplifted and learnt something.

Roy & Anita Charlesowrth

Anita Charlesworth with Roy Lilley

The willing interviewee was Anita Charlesworth, Director of Research and Economics at the Health Foundation.  She is also Honorary Professor in the College of Social Sciences at the Health Service Management Centre at The University of Birmingham

Interesting Roy alluded to the first ever interviewee, Dame Ruth Carnall. He linked the fact that the 50th interviewee was another woman in a senior NHS role.  As Anita pointed out, the fact remains we are still less at than 3% of senior positions held by females.

She did hanker after going back to berate her Careers Advice teacher.  There are more possibilities  than becoming a nurse or a teacher (with nothing against those prospects, but she is right, there is more that is possible).  It just that no one told you that back then…

Gosh, it was a free ranging discussion.  We started with how and why Health Economics was her calling.  As ever, serendipity and an influential inspirational boss were the enzymes. It was the Masters in Health Economics at York that got her started.) (all the degrees, even chemistry and physics, used to be BAs at York.  I play am still rather upset that all economics degrees are BAs and MAs.  Why can’t it be a science?)

But what do Health Economists do?  Anita’s Masters dissertation gives you some idea of the questions they try to answer.  “Should every woman be screened for Breast Cancer?”  The attempt is to have science and numbers answer those sorts of question, not passion or opinion.  I suppose that sums up the raison d’etre, really?

Let’s get some of the quotes:

“We often focus on what you can measure”  (Sadly, what gets measured gets done – even if it is only measured because it is easy to do so…)

“Show me the evidence”

“If you were good, anywhere in the senior civil service, Treasury stole you”

I got the feeling that no one is leading the NHS.  No one is looking at the whole piece – old style DHSS.  Health and Social Care together.  Surely my cynical alarm can’t think the government might have sectioned off social care and community services to save money and screw up local authority budgets (so they get blamed rather than the government)? And maybe, hyper-cynically, to make the NHS wither on the vine?

I did want answers from Anita.  I wanted my cynicism to be assuaged.  I got a list of priorities, that were evidence based.

What were her priority concerns? (I liked them).

  1. New government 2015 decisions were worse than 2010 coalition.
  2. Austerity is proven not to be a good way to fix funding shortfalls
  3. We might need Keynes mentality, not Cameron / Osborne austerity continuation
  4. Investing in people’s health is worthwhile – Public Health, not Sickness is cheaper, but needs investment
  5. Tax funded health service, free at the point of use, is sustainable
  6. The model is fundamentally right
  7. Anita worried about the next few years – especially the potential for staff leaving who just throw in the towel, because they are undervalued and not engaged
  8. We might need to invest first before we gain….sorry, we need to do this, not might.
  9. It’s not worth doing investment in one specific area which might give a positive sound-bite…like more consultants…if they have no nurses to support their work. No one thinks of the whole piece

There are amazing and effective new models of care out there, and need to be out there:

  1. Sam Everington from Tower Hamlets (a previous interviewee, and very enlightening), where 93% of first contacts in NHS happen in GP land, for only 11% of the budget. It is a bargain.  And works. (Click here for more)
  2. Primary Care Home works well in areas it is being trialed (see NHS England summary here)
  3. Buurtzorg could easily be adapted to our UK funding model, and nurses would love it, and so would patients and their families. Let’s not forget that.  And suddenly, we don’t have as much delay in transfer of care.    And powerfully. (See founder Jos de Blok presentation to Kings Fund

OK everyone – you may have noticed at health chat 50 I have been more self-opinionated than normal.  But the whole NHS and Social Care arena feels like it is under attack, and that attack is not going away.  And that is not for the want of all the totally committed people who keep it rocking and rolling.  The staff.  The poor overworked and under resourced stalwarts, who get abused from all sides, and hopefully never read The Daily Mail.  Let the good people and their managers and leaders get on with it – they can keep it going.  Let’s just get the politicians out of the way. Except to sign the cheques.  And maybe agree and set some boundaries.

(Thanks to Roy Lilley – and here’s to number 100!)

(If you want to see the whole interview – it is available here )