Former Special Advisor to the Health Secretary

It's a really interesting question. As a new Secretary of State, you go to your department, and the tradition of Whitehall is that you get clapped into the department by all the staff. You get welcomed by the Permanent Secretary, the very senior civil servant, and they'll sit you down and start to talk you through the immediate issues. Often, when you take on the job, there'll be some decisions that need to be taken very, very quickly, and you'll want a briefing on the background, the options, and everything else.

Setting your own priorities is really important — but not everything is within your purview. There'll be priorities that the Prime Minister has that you'll be asked to deliver. If you look at the current Secretary of State, he's being asked to deliver 40 new hospitals, for example. That's a priority of the Prime Minister, which the Secretary of State then has to go and deliver. But the Secretary of State does have an ability to set his or her own priorities too.

When I was working for Matt Hancock at the department, Matt developed three priorities pretty quickly, speaking to the officials, people in the NHS, and outside advisers. The first was the technology agenda, which he's obviously personally passionate and committed to. The second was the prevention agenda — a long-term transformation of the system to be more preventative. And the third, which I think is the biggest challenge for the NHS — and your listeners in particular will know this — is workforce. How do we train and build a workforce for the future? It's been undervalued for a while, there are gaps in it, and it's a global challenge. Across the world, we are short of health and social care staff. How we start to plug that gap, and make these careers as enticing, attractive and well-remunerated as possible, is a huge issue.

Your ability to influence those priorities is interesting, because health is an unbelievably complicated system. It includes your own personal relationship with it, the way you conduct yourself, some of your family history — but then there's a whole system around the NHS, public health and social care, and the way it all interacts is very complex. So as the figurehead of the whole system, it can be quite difficult to drive through change. The key thing is that you've got to work with different partners, collaborate, and communicate really clearly to get things done. If you try to force things through, you'll get a lot of resistance. Being assertive but also working collaboratively and dynamically is really, really important.

One of my other reflections is this: if you don't have proactive priorities, in health you're always going to be reacting to issues in the system. It's such a large, multi-dimensional system that there's always going to be things coming up. So you've got to set a positive agenda as well as reacting to the challenges that inevitably pop up — and get that balance right. Setting them early, being really clear about what they are, and then collaborating with those different moving parts to push things forward: those are some of the reflections I have from working in the department.

I think it is about trying to find a healthy mix, and it's a very astute point. Changes you make in healthcare can take many, many years to come to fruition, but politicians need more instant results. There's a tension there in terms of where resource and official time is prioritised.

Take one example: there's a government commitment to improve healthy life expectancy by five years by 2035. We did a report at Policy Exchange on this, and we found that on the current trajectory we're going to miss that target by quite a substantial margin. That's 15 or so years away — that's three elections away. It's a great ambition, but a government is going to be looking much more at the next three, four, five years, particularly around COVID and access to services. While you're still in the trenches of the here and now, how do you also transform and build a system that can deliver on those longer-term ambitions? It's really difficult, and the short term inevitably does trump long-term policymaking.

One of the advantages of the very controversial Lansley reforms, which have widely been seen as very difficult, is —

Yes. The Lansley reforms were the 2012–2013 Health and Social Care Act, which sought to bring more competition into the NHS as a way to transform services. They've widely been seen as very difficult, and not the right answer to the question the system was facing. But one of the things they did was create an independent NHS board — NHS England, now NHS England and NHS Improvement — which sits to the side of day-to-day political control.

There's been a history at times of politicians trying to direct the system on an operational basis. This move was designed to avoid that — so you don't get short-term, headline-reaction policies where someone throws up a headline and a minister has to go in and get an initiative going to show that something's happening. That independence is really important. On the flip side, it's a lot of public money we spend on the NHS, so there needs to be new public accountability for it. There's a real tension between what you can get done as a minister and what should be left to the NHS to frankly get on with and deliver. It's a fascinating question of where decisions are taken and what the best model is.

There are inevitably crossovers with other sectors. It's on a similar plane to education, but I'd say more emotive and personal, and I think the pandemic has borne that out. In this country we have an NHS with very high levels of public satisfaction and a lot of buy-in across different political parties into how it's financed and managed. That emotive side creates an extra impetus.

I also think it's very complex as a set of systems. If you take the public health system, the NHS system and the social care system — the different structures, dynamics and levels of national, regional, local and even international — when you start to layer these things together it can get very difficult to work out where decisions are taken, where power lies, and how you deliver change. In a national system like this, that's always going to be a challenge. But on the emotive side and on the complexity, those are the two things that make health both fascinating and mean that the level of debate in it is inevitably more emotive.

This is where you're very reliant on the excellent senior clinical leaders in the NHS and more widely in government — people like the Chief Medical Officer, who used to be Sally Davies and is now Chris Whitty, and the Chief Scientific Adviser, and the clinical leaders in the NHS. That clinical input is really important to policymaking. You get advice from a range of perspectives, but when you're given the health brief, making sure you're getting input from the clinical side as well as the traditional civil service side is really important.

I was reflecting on this before we came on. The NHS has gone through a transformation through these reforms, and I do worry a little that some of the clinical input isn't necessarily as strong afterwards as it was before. If you go back to the early 2000s and Lord Darzi's review of quality in the NHS, there was strong clinical input — we had full-time national clinical directors across a range of conditions. What we have now are part-time clinicians as clinical directors, which is important but different.

One of the things we should be looking at is how to make sure policy has enough strong clinical backing so that it translates into effective on-the-ground delivery. One example where I think it's working quite well is the technology agenda. NHSX, when it was set up, was really clear that it was going to build technology with both patients and staff at the forefront of engagement, making sure clinical leaders were actually inputting. So the technology wasn't presented to clinicians as "here's some new equipment, please use this" — it was a co-design experience. That's worked quite effectively over the last couple of years. But there's always more you could do, because ultimately clinicians are the people on the front line delivering it.

It's an interesting one. I don't think you need a medical background to be a good Health Secretary — just as I don't think you need to have been a teacher to be a good Education Secretary. What you do need is to get the advice in the right places, which means listening to a range of different voices when you're making your decisions. If you get that diversity of advice right, you'll make much better decisions.

It's also about the circumstances you find yourself in. Without going over that specific incident, which was obviously very difficult all around, I think the parameters of what was possible weren't set by the Health Secretary — they were set by the Treasury and the wider government, and it was the Secretary of State's job to implement that framework. You can argue he didn't go about it in the right way, and there are probably things Jeremy Hunt would say on reflection he should have done better. But sometimes, as a Secretary of State, it comes back to priority setting: you'd love to come up with a different answer, but the answer is set by those in more senior positions — particularly on economic questions around pay and conditions, where the powerful body is the Treasury.

The really important thing I learned was actually a very basic skill: listening. You have this amazing group of officials and an amazing knowledge base in the NHS, the department and the other arms and bodies — people whose day job is to look at specific areas and understand them in huge depth. As an adviser, you're having to cover a huge range of issues. I always described it as doing everything from fruit juice and high fat, sugar and salt foods, all the way through to how you finance long-term care for the elderly, and all the NHS stuff in between. It's a huge array of things.

You can't possibly, as one person, understand all of the insight, nuance and history behind each of these policies — but there will probably be someone in the department or the NHS who does. It's about finding that right person, giving them enough time, really tuning your brain into what they're saying, digesting that information, and then analysing what you should do about it and what the options are. So listening is a really important skill, and you pick it up quickly. I'm not the expert; these people are the experts. My job is to interpret the information and advise the minister on the best course of action. It's a basic skill, but a really important one.

The hardest thing follows on from that: it's the vast array of material you end up having to deal with. There are certain bits of the agenda you'd love to get into in more detail — because you have a personal interest, or your minister is particularly interested, or there's something topical you really want to dig into — but you just don't have the time to go all the way in. You're moving from discussion to discussion, meeting to meeting, issue to issue, having to jump quickly into something you're not a subject-matter expert on and then develop a decision-making process. That's probably the hardest piece of the job.

I was in the job before the pandemic. If you spoke to those in there now, I think it would be the sheer amount of work — the volume of decisions and pressures is just overwhelming. But it was a real privilege. I learned so much, met some amazing people, and we did some really interesting work: the NHS Long Term Plan was published, we published a prevention green paper and an interim workforce plan, we created NHSX. There's some really good stuff I can look back on. But it is that volume-versus-depth challenge. Now I'm out of it and working in the research space, I'm able to drop down a bit more into some of those areas, which is refreshing.

It's a really important question, and I think the pandemic has thrown it into sharp relief. The NHS needs to change — it needs to be constantly changing and updating itself so it can embrace the new treatments and models of care that deliver the best outcomes. But as soon as you start talking about changing the NHS, that sets off a load of antibodies, because it's an institution — it's a religion, something with huge amounts of public support. Go back to the Lansley reforms of 2012–2013: one reason they landed so badly was that they seemed so disruptive to something so sacred.

So the NHS is a fascinating case study in how to do continuous change. It's through dialogue, collaboration, and utilising innovation and investment that you keep a national system like this in place — because there'll always be different types of need and new technologies coming on stream. You've got to do the change, but it's far better to take people with you and do it in increments than to try to turn it upside down overnight.

That sense that it's a religion, a sacred thing, does make the change conversation much more challenging — whether you're introducing new technologies or redesigning services. And the dialogue-and-collaboration approach isn't necessarily fast, which comes back to the short-term versus long-term question. Say your objective is improving cancer outcomes for UK patients: you can slice that cake in a number of ways — diagnosis, treatment, specialist centres, awareness campaigns. One of the challenges is that you've got a lot of different things going on, but the connectivity and joining-up isn't always there. So the NHS is a brilliant and amazing thing, but trying to change it is fiendishly difficult.

Probably that it's done in an ivory tower with very little consultation or engagement. I take that point to some extent, but I don't think it's quite fair, because there were many examples in government where we did do consultative exercises, held roundtables, and got people in. The challenge is frankly logistics: how do you take very busy frontline staff out of a workforce that's already under-resourced and get them to help support a policy development process? And how do you do engagement from the centre to the local level — have a proper dialogue, line of sight, and an engagement strategy that gets you the feedback you really need?

The NHS also has a real history of doing lots of pilots. It tries things out, but then has a real problem with scale, because something might work in Manchester or Cornwall, but if it's "not invented here", we're not going to do it. This national system is not a series of small villages — it is a national system, and that scale challenge is a real problem. So the misconception would be that there isn't that dialogue and engagement. I'd say there is — it could definitely be better — but one of the fundamental challenges is that logistical one.

Come and talk to us at Future Health, and join us on this journey at the research centre — we're genuinely looking to bring people from different backgrounds and specialisms together to crack some really complex and interesting challenges. We'll be putting out more materials, literature and publications over the coming weeks and months, so that's not a bad place to start.

There are also a number of very esteemed and well-respected organisations in the space — the King's Fund, the Nuffield Trust, the Health Foundation. They're really good, with very evidence-based approaches, and you can get quickly into particular topics of interest. They cover the full spectrum: the public health and prevention agenda, that NHS structural piece, and the really important issues around social care. I should also give a shout-out to Policy Exchange, where I'm a senior fellow in health policy — that's the think tank world I operate in. We've put out reports in the last 12 months on the impact of COVID on health policy, and a recent one on public health. So there are a few options there, but do come and talk to us at Future Health.

Reading is definitely the best way in. There are lots of events too — again, it comes back to how many hours there are in the week. The King's Fund has a great "introduction to the NHS" resource, and they host fairly regular introductory half-day sessions, which are also quite good for networking. That's a good place to start, particularly if you're trying to get your head around the alphabet soup of acronyms the NHS has. But reading, for me, is always my superpower for getting into this stuff.

I personally ask a lot of "why" questions. It comes back to that point about evidence and historical context. Asking the obvious question could give you a piece of information that's actually really important. So: listening, which I learned a lot about in the department, and asking lots of why questions.

And then there's determination — keeping going. It's a very exciting and interesting space, healthcare policy, but it can be frustrating and slow. If you're determined, focused, and you work hard, you can see change through, but it often takes years. If you've been working in social care reform, you might have done 30 years and not seen much change — and as depressing as that is, even introducing a new technology to the NHS is going to take you three or four years to go through the process. So determination, focus, and getting up off the canvas when things aren't going great is other advice I'd give.

A couple of things I've read recently. One is somewhat depressing but very good — it's long, but it's probably the bible of the welfare state: The Five Giants by Nicholas Timmins. It covers the creation of the welfare state after the Second World War, all the way through to pretty much today — it finishes around the Coalition government. It's a fascinating take on politics and policy, and how these massive systems and institutions we know today got established after the war. People have been comparing the recovery from COVID to the period after the Second World War, so it's a very timely thing to read.

The other is Pale Rider by Laura Spinney, about the Spanish flu outbreak of 1918. What's interesting is that the Spanish flu was a very different pandemic to COVID, but they had three significant waves — and we're talking in what I'd describe as a fairly difficult moment for our health system, in the third wave, with the vaccines now rolling out. Hopefully brighter times are ahead. On pandemic preparedness and response, you can see how, post-COVID, there's going to have to be new policy, new structures and new systems — public health is moving on, and we're going to see a new national institute created. There's loads of policy there in terms of where it's going to go.