Abolishing NHS England: a chat with outgoing chair Richard Meddings

Jennifer Dixon:

On 13 March, Secretary of State Wes Streeting made a surprise announcement in parliament: 'Today we abolishing the biggest quango in the world,' he said. He meant, of course, NHS England. 

Richard Meddings chaired NHS England's board for the last 3 years, having joined after a career in finance. What does he make of all of this? I'm pleased to say he's with us today to tell us. We recorded this 4 days after he stood down at the end of March. Welcome, Richard.

Let's start off with the announcement itself – the shock announcement of the abolition of NHS England. I mean, did you see that coming? Who knew?

Richard Meddings:

In fact, I think hardly any people knew and that was a heck of a week actually. We started with Monday with an announcement of a 50% headcount reduction for NHS England, and then on the Wednesday evening there was an announcement of a 50% expense reduction for the ICBs and then suddenly Thursday morning an announcement around the abolition of NHS England. Obviously that will take 18 months, 2 years to give effect to, but the announcement was on that Thursday morning. I think a handful of people knew at most and not even at the weekend that that was coming. We had anticipated probably that NHS England would be folded back into the department at some stage, but we did think actually likely to be a second term of the government decision or process and not so immediate. So it took us all by surprise.

Jennifer Dixon:

And was the 50% reduction NHS England on the Monday and the ICB on the Wednesday, were they also surprises or was it the shock abolition of the entity of NHS England?

Richard Meddings:

There was slightly more of a path and trail to those. Well, actually, not the ICB, but certainly to the NHS England, but only a matter of a very short runway before the announcement. The thing that I find very surprising about that, I don't want to come over negatively or be critical, and I do understand from a government or political perspective why it's important to think about bureaucracy and how to reduce bureaucracy, and it's part of a broader narrative around and that we see with government around call it the blob or the civil service bureaucracy. And I think what surprised me most actually is that of course NHS England today is very different from the NHS England when it first emerged in 2012 and that in 2022, as you know, we merged with an absorbed NHS Digital Health Education England, NHS X and had also already absorbed NHS Improvement.

So actually what was NHS England was then actually five entities in one, and that had aggregated to 24,000 people headcount, so big. But over the 2 years from July '22 to about September of '24, the important thing was that we'd cut 24,000 to 15,000. And by the way, that reduction had continued. So actually as I was leaving the role as chair, the actual headcount of NHS England had fallen further to 13,200 jobs in post. And yes, there will be bureaucracy, there's always bureaucracy, but actually Health Education England coordinates, liaises with, overseas all health education and training, initial and continuous. And in many ways more dramatic is that NHS Digital, now part of NHS England, runs almost 270 live systems connecting to 26,000 organisations and 44,000 IT systems in what's called the spine, the technology spine of the NHS. And that activity sits within NHS England.

So when you see a 50% headcount reduction announced as a big target, that's fine, it's really important to set big targets, but I do think we need an understanding of what actually are the functions of NHS England as it then was constituted. And so I think that 50% reduction is going to be a real test. Unless you're going to shift large parts of that functioning out into different organisations, but you can't imperil live learning of systems, the oversight of training and education, nevermind actually vaccination programmes, commercial medicine programmes, all the rest of the stuff that NHS sits at centre with a responsibility for overseeing.

Jennifer Dixon:

We'll get onto the role of the centre versus the local in a minute, but can I just go back to this announcement? It really was a shock for quite a lot of people, not just cutting the epoxy, which I think people can kind of understand, it's in the air, it's coming from all sorts of places, isn't it? But it's the shock of the sudden announcement of abolition felt to quite a lot of people disrespectful, brutal. And then of course the prime minister's speech talking about the checkers and the blockers and the biggest quango, blah blah blah. Is that just a pure political confection?

Richard Meddings:

I don't know what's behind it and I don't wholly agree about a language around is it brutal and so on. I mean, all these things, any such announcement is going to be difficult. And actually if I do step back from it, I don't think the structure of itself really does matter, the most important thing is that actually the provision of necessary central guidance of what is the centre responsible for remains consistent and that the service obviously to the patients and to the citizen is not disrupted by moving the deck chairs around at the centre. I mean, it will make a difference. It does mean that the direct responsibility for any of the decisions anywhere out to the system will come back directly into the politics. And that's the decision that's been made and that's fine.

My real challenge with it actually is it's actually that there are so many calls and so many demands for so many things in health. And if I'm a democratically elected politician, have the great privilege of being a minister in the Department of Health and I come in wanting to do good things, make a difference, you can't do everything. And so how will ministers and their advisors prioritise the thousands of things that potentially could be delivered to say, ‘Well, actually we've got to prioritise these things first or do these what we call enabling priorities first and that will allow us then to do that next and that next?’

Jennifer Dixon:

And this is also about the role of the minister and quite what they feel their role is, in the absence of any job description. Are they the chief executive of the NHS de facto, not, or are they in fact an elected minister who can set some guidance? And the more successful ones really do realise that they set the strategic direction but don't get involved in the operations.

Richard Meddings:

So I think the politics, I mean, it's really important and I do think Wes Streeting could be revolutionary as the Secretary of State of Health and the 10 Year Health Plan has a potential for painting a picture and giving us good direction and helping us to prioritise. But it's a hugely difficult job. And I think what the political area of responsibility is, as you said, it's to set the weather, it's to set the high level strategic direction, it's then to legislate primary and secondary and it's to allocate the money. And the money is a difficult debate between departments of government, particularly given the economic inheritance this government has. And then how that then gets deployed down through the system, and it's a huge system of course, the ecosystem at the NHS, I think it's very difficult for a minister, and particularly ministers who are often transitory, they change, I've had six secretaries of state in 3 years, so you do need this sort of solid organisational structure that says, well, these are the priorities we're aiming for, Minister. And we can make changes, but if you want to make those changes, this is the consequence.

Jennifer Dixon:

I'm interested in what Jeremy Hunt told us in one of our pieces of work with the Health Foundation, he said about his relationship with NHS England, ‘There was nothing I felt I couldn't do with the current arrangements.’ And he said that it was far more about the chemistry between the Secretary of State and ideally their understanding of their role and the chief executive at the time, which was obviously very good with Simon who was there at the time, but it didn't stop Jeremy Hunt from getting into very great detail on operational matters, the Monday morning stock take, which he did every morning, but generally he had three or four things he wanted to do largely concentrated on safety.

Richard Meddings:

Patient safety definitely.

Jennifer Dixon:

And that was it. So he had the experience over 7 years to understand that that was what he was doing. With such a rapid turnover, it's very, very difficult. Ministers come in without that kind of understanding, they don't actually know what their role is. So what is the role of NHS England to you, in a sense, educate us.

Richard Meddings:

I think Jeremy is right, and I think Wes I'm sure would say the same, there isn't anything he cannot do if he really wants to do it. But what he has to be able to win through is perhaps any single executive saying, actually, is there any funding for that or is it just a request? And if it's a request and there's no money, where do we take the money from to allocate to that? So it doesn't just do that, it's, and are you comfortable if we take the money away from this to do that? And/or it's, how can we have the management bandwidth not just in NHS England, but down through the system to do that additional priority you now want?

I think the system works well when there's real discipline, self-discipline of ministers and of the executive and they engage very openly with each other about, so what are the relatively few objectives that we agree we are absolutely pursuing? The NHS has about 130 objectives of which 110 are in statute regulation or legislation. That's just by miles too many different objectives. So what do you choose and agree with ministers are the key priorities that we must engage in? What are those few priorities we have to go for? And if we go for those first, then the others will follow sequentially, but we've got to put the enabling priorities in first. And they are things like the long-term workforce plan. They are the federated data platform, they're turbocharging the NHS app, they're doubling diagnostic centres' diagnostic capacity, they're rolling out virtual wards and then there's waiting lists and there's access predominantly to primary care and there's urgent emergency care.

And so you've got those three large pieces, UEC electives and access, and then you've got a series of enabling investments. In the private sector, what you would do is you would say, I'm going to steadily invest behind that until it is completed. And often what happens with changing ministerial interests is actually you get a lot of bridges built halfway across the river, so you start and you don't complete and then the next initiative comes. And where it works really well I think is where there is a really helpful debate and tension between ministers and the executive about, so what is it we should deliver that makes the most difference and have we got it done yet? And what are our choices? And by the way, the minister is no doubt being lobbied hard by lots of other special interest groups or single issue groups, valid, but actually you can't accommodate all of them.

Jennifer Dixon:

So if we're saying that there needs to be more clarity and setting out some kind of compact between the Secretary of State, whoever it is, and top of the office NHS, both in what is delivered, what are the objectives, but also how you go on with each other to get the best, is the same argument true for the centre of the NHS and the local NHS? Then do you feel after 3 years in your post that you feel clearer about what the NHS centre should do versus the local? And given some of the howls of protests that have come up from the local NHS, not least in Patricia Hewitt's review, is there any further clarity that you would add here about what you think the centre and the local should do and how much autonomy the locals should have in what areas?

Richard Meddings:

So one of the reasons I took the role actually is I quite liked the structure that was emerging, which was the idea of, so the seven regions and then below that the ICBs working closely with the community and local authorities and voluntary sector relevant to the populations that they serve. There is a debate as to the number of ICBs, but it was a model I was very familiar with from being CFO of a big international global bank and how do we organise ourselves in a sort of hierarchy of decisioning and delegation? You have to devolve decisioning as far as you're able. And it struck me as a very good model.

I think where we got to with Patricia's very punchy review actually was in the end it got, I think, captured in a two-word phrase of earned autonomy. And so I think from the centre, the centre was very keen to see devolution, but actually it had to be earned. In other words, you had to demonstrate as an ICB that you were able and staffed effectively and you had the right partnerships to actually perform the role. Certainly some of the ICBs are doing an outstanding job actually, some of them are more pressured. And I think I've shared you before that as I was leaving about 19 of the 42 of the ICBs who are actually receiving very intense financial support and guidance.

Jennifer Dixon:

Yeah, that's a lot, isn't it? Nearly half.

Richard Meddings:

But that's partly though, we've got to step back and talk about the money, the NHS is under very significant financial and economic pressures. And so we go into this coming year, '25/'26 with a system overall to pursue a 4% productivity on a 1% net cost reduction, they're tough measures by any standards actually.

Jennifer Dixon:

Compared to other industries you've worked in, Richard, the NHS is a high-risk and clearly high political stakes industry. Given that the price to pay for disruption that doesn't go well is very, very high-

Richard Meddings:

Certainly higher.

Jennifer Dixon:

So you can see the level of caution that is in parts of the NHS. In fact, the NHS, if you had two sort of all different types of philosophy for change, one element would be faster iteration that people actually are safe with, the kind of Toyota model, the British Cycling Team model to shave off every man O second and you'll get your gold medal, but then there's this other pole which is to say, rip it up, it's disruptive, and do something bold, which you the infection coming across from the United States and possibly other-

Richard Meddings:

DOGE.

Jennifer Dixon:

DOGE, exactly, or the tech industry. You might say, Silicon Valley. Just do something just dramatically different and you get ahead, you move fast and you break things. But that second area does not sit comfortably with the culture that we've got in the NHS, which is more cautious and more of the first culture, and therefore the disruption can only mainly come from outside or it comes from a new politician.

Richard Meddings:

The basic problem I think, is that I don't disagree with the idea that the NHS is broken, particularly if you're waiting on a trolley for 12 hours, 15 hours or something, it will feel broken. But the narrative I prefer is actually it's being overwhelmed. And that is still a big problem, it's a different problem. So you say, well, where is it being overwhelmed? And you can say, well, there's access to primary care, and there were real pressures, but if I said that more than 1 in 7, the equivalent of one in seven of the population has an appointment in primary care every single week, then you come to acute hospitals. And what we see is we are overwhelmed in A&E and through hospitals.

Now, again, you know the stats as well as I do, in 2003, there were 144,000 acute beds, G&A beds. In 2010, that had fallen to 122,000, and today it's 98,000. So we've cut 46,000 beds in that 22 year period at the same time as the population has grown 15% and got older and sicker. So what we see actually imperils the reputation of the NHS, we see ambulances queuing to unload essentially into A&E or into the broader hospital. You go to an A&E or ED department, and many of the cubicles are simply occupied by often very old people, fragile, tissue paper thin, fragile people waiting to be admitted to hospital. And 25% of the population is over 65, it's 50% of admission, but it's 74% of bed occupancy.

So we have got to find a way to create capacity within the constrained capacity sitting in acute. Now, imagine a world if we could do that, what would the NHS then look like if the hospitals were running much more smoothly with discharge throughout into care or back home or into virtual wards, step up or step down care? And particularly focus on the frail and elderly to be able to do that, we could create the capacity we needed to take a lot of pressure of the system. And then what would come would be, I think, a much better realisation of innovations, we had amazing cancer vaccinations last year, liquid biopsies, cytosponges, genomics, and that gets lost in a world where actually we have too many people suffering harm, waiting to be admitted and then struggling to get discharged out of the system. So if you step back and said, what should we solve first that would make a massive difference? I think it would be that.

Jennifer Dixon:

Yes. I mean, the scientific developments come thick and fast, don't they? The ones you mentioned, but actually the service deliver side is much slower despite some experimentation. So I guess that's the task. The overwhelm point you make is a really good one because of the rapid acceleration of demographic change, particularly because of the baby boomers in the next 30 years.

Richard Meddings:

Yeah, if we assume that health demand grows at 3% a year, which is along an average that tends to be worked at, so go 10 years forward to the 10 Year Health Plan, 3% a year compounding is a 40% lift in demand for health. So how will that be met by the current capacity and the way we use it? So we have to think very, very differently, which is also why the prevention agenda is massively, massively important. Over 80% of health conditions that the NHS deals with are caused by exogenous factors, and you say whether it's air quality or poverty or diet, so sugars, fats, ultra processed foods, there's an argument about social media, there's a whole range of causes of real health.

And it goes to that 3% compounding point that gets to 40% greater demand, unless we are willing as a society and unless government is braver, and I realise it's very easy to sit here and say that, and politically quite difficult, I think unless we're willing to be much more interventionist around what we eat, how we're willing to regulate that, some of our behaviours, quality of housing, all of it, I think that continuous lifting in the ill health of the nation is going to even more-

Jennifer Dixon:

Compound into... Yeah.

Richard Meddings:

Overwhelm us. So I've called often for the, it's a terrible phase the nanny state, but actually I think we definitely need more. Why is cancer surging in our young people? Why is mental health surging in our young people? What is going on? And should we be looking to legislate more? If I was heading for the 1--year health plan, I would call for why do we have a mission, which is to make the UK the healthiest and fittest nation in Europe in the next 10 years? And by saying that isn't just asking the NHS to do more lung truck scans or fit tests for bowel cancer or more cancer checks and referral screening and scanning, it says, how do we as a whole society say, we are going to become the fittest and healthiest nation in Europe? And that brings in everything.

Jennifer Dixon:

And in fact, that is the idea behind the mission, isn't it? That the health mission should include something like this, not just the NHS, which as you say affects a small proportion of our health overall. And the question is the extent to which the government is prepared to exert itself to change the choice sets in which we all make decisions from foods to-

Richard Meddings:

Regulate ultra-processed foods.

Jennifer Dixon:

Just turning to the 10-year plan then, so that's one aspect, that's the sickness prevention you were talking about, Richard, but can I just press you a little bit further on what you'd like to see with respect to new service models that might help with the overwhelmed question?

Richard Meddings:

I would have at least three other chapters. One would go back to what I was talking about earlier about an offer for frail and elderly. Because if you think about the capacity constraint we have, I could build more capacity, but it takes money and it takes time. So you have to think about it as an industrial problem and say, if I can't build the capacity fast, how do I use it differently? So I would have a very major focus on a separate, more proactive approach to frail and elderly. And I think Chris Whitty has a phrase which actually is the majority of our people in hospital are in hospital receiving basic nursing care, not necessarily hospital treatment. So I would absolutely go on a proactive mission, proactive engagement with frail and elderly, with avoidable admission as a KPI for the providers, the hospitals, I'd have more virtual wards monitored technologically at home or in a home, I'd have geriatrician job plans where the geriatricians will be out in the community much more than they currently are, not just in the hospitals.

Jennifer Dixon:

And palliative care?

Richard Meddings:

And palliative care. So again, you would have a very different... But it's a focus though on an age group, which is most intensively using our constrained capacity and therefore putting pressure on the ability to deploy that capacity. And then in primary care you'd have nodal points with primary and instead of waiting for the elderly person to come in, you would proactively go out and ask them to come in at particular times and try and treat them all in one go.

And then my other two chapters, very quickly, one will be technology. And I do think one of my great disappointments in the 3 years has, and I've been complicit, we've raided the technology budget each year to make the numbers work. And in any event, the technology budget is wholly inadequate for what we ought to be spending. So I would have technology harder invested, but I'd then be careful that I wouldn't try and do too many things. So again, it's about prioritisation. And the other word for prioritisation is simply sequencing or queuing. So what do you do first? So I'd drive the NHS app, I'd drive electronic patient records harder, I'd drive FTP into more of the trusts, absolutely ambient documentation, but I'd do four or five or six things only for the first couple of years and see the difference that they made.

And then the third chapter actually would be about singing loudly the benefits of the innovation that are now being offered, because I think we are missing optimism. And when I talk to people, quite often, I do get people saying, ‘It's impossible to get a GP appointment,’ and then I say, ‘Is that your experience?’ ‘No, it's not my experience, but I hear that.’ But I also do know there are absolute deserts where it is very difficult and practices are overwhelmed. But we need more optimism in the discussion. And it is a remarkable machine, the NHS, and the brilliant academic medical scientists or Genomics England or the Genomics Medicine Service, the thought that we scan, as you know really well that last year we did 800,000 tests, whole genomic panel of single tests, and we now scan for 200 cancers and 7,000 rare diseases. It is remarkable. Remarkable.

Jennifer Dixon:

Yes, exactly. The last two days I've spent with Swiss and German health service people, they are both facing similar issues to us in terms of the supply and demand issues and also in a not quite zero growth economies, but low growth economies that they can't see an end to. So we're all facing the same issues, workforce shortages and so on. And it strikes me that in Western Europe we've got health systems which we're all playing the game of chess, but they've got their chess pieces in a different part of the chessboard because of their history and politics and all the rest of it. So looking forwards to the NHS is now, how old is it? 78? Something like that.

Richard Meddings:

Something like that, yeah.

Jennifer Dixon:

Will it reach 100 given its current trajectory?

Richard Meddings:

I'm really optimistic actually. I think the NHS does exist in 25 years’ time. And I think the innovation will come through. I think we will find different models of care which will be more proactive to the patient and will enable us to deal with what I call the capacity issues that we have. I think the models, people talk all the time about should we go to a different funding model, and I would say there are different funding models, the question is where you can get there from here. And I think it's very difficult. So the NHS costs currently about £3,200 per person. If you look at private health care, even if you could get private health care, if you start with significant conditions, I don't know what £3,200 actually buys you.

But the other problem is for government that actually the economic inheritance they've got is truly difficult. How do you shift? But also if it is right, I think, that 54% of our society, or adult society, either pay no tax or see more in benefits than they pay in tax, then what, we're now going to ask them to suddenly pay £1,000 or £2,000 for health? How do you do that? How do you do that?

And the insurers of course, let's go to the insurance model, but the insurers, it's a bit like the independent sector, the independent sector providing health care is a really important partner. And I do think some of the arguments sometimes that the NHS is against the independent sector, simply untrue, I've never seen that, large parts of the NHS are in any event private businesses, but we use them for about 8% of our health care. But it's also true that the independent sector doesn't want to do much what the NHS has to do. They don't want to run A&E or ED and they don't really want to run long run complex conditions, which can be expensive. So we do know that they go in particular areas and they're very welcome and they provide great service in those areas, but there are areas where they know they can make a margin and they can make a sufficient return. Again, for the NHS-

Jennifer Dixon:

I mean, in terms to answer my own question, just will it survive and alternative models, just to say we've funded and just published a report with the OECD to look at performance in health systems of different archetypes, the Bismarckian, the private, the Nordic, the nationalised system, and the answer is that no one system outperforms the other one if you take away the money and investment, and that the variation in performance within each model type is greater than across it. So the answer is don't try and think the grass is greener, just work with what you've got and try and make it better.

Richard Meddings:

Sit and improve.

Jennifer Dixon:

Exactly. I think the optimistic point is to look at the assets that we've got here and how we have unusual, unique assets that we could corral in the face of quite fierce headwinds that other systems, I mentioned Germany and Switzerland, just simply don't have that capacity, for example, to have coherence across their system. So we have a lot of positives that we're not using so much, some of which we are, data, concerted system, the ability to change strategically. But the weaker point is that we have this top and change political system that can get in the way of quite significant longer term development.

Richard Meddings:

Which is why a long-run government is very difficult, making some public priority choices and then steadily investing behind those will, I think, make a real difference. One of the things I was stunned to see when I came in was the fact that we've had a cap on medical training of doctors, which was 7,000 in 4 years imposed by treasury. And I think I'm a bit glib here, I understand why they did it, but they prefer to buy in doctors trained at the cost of another government than pay for the training ourselves. Now, the NHS is remarkable, and I think it's one of the standout features of what makes this country really good. If I was thinking about UK's soft power and I look at the quality of our education and the quality of the training we give to our medics, wouldn't it be a great world where actually, we did say, you know what? Why don't we train enough of our doctors to export our doctors-

Jennifer Dixon:

Indeed, indeed.

Richard Meddings:

Around the world. All the countries, as you said referencing Switzerland and Germany, everyone's facing the same problem. So actually wouldn't it be brilliant to be as real source of really good medical experience, and not just doctors, but nurses and other skilled professionals?

Jennifer Dixon:

And the final question probably is that if we do have an unparalleled set of assets that we mobilise in the face of these headwinds that are not going to go away for some time, are they, in order to sustain what is effectively a social model based on social democratic values, if the way of doing that is to muster those assets as intelligently as possible, there has to be a better bridge, doesn't there, between the NHS itself and the politicians who are setting the objectives here? So maybe circling back from where we started, given all your experience in the last 3 years of working in the political system, how do you think that relationship can be strengthened so that there is less swerve, there's less short-termism?

Richard Meddings:

The political world works to different measures of success, often more short-term, often driven by announceable profile, appearance of real momentum activity, and it's an intensive rhythm of desire for announcements. And you go to the private sector, far less need for that. There's a continuous narrative, but of course a smaller bridge of key priorities, which is what the private sector companies would talk to. So I hope that, well, I've said a couple of times, I have high hopes that the 10 Year Health Plan as a conception might do it. If it allows us to say, these are the relatively few things that we are now going to campaign on politically and we'll get the NHS to deliver, and I don't mind whether it's the NHS merged within the department or not, but actually we get operational executive skilled buy-in in terms of these are the priority deliveries that we're going to go for in this order, then I think that gives us an ability to work more closely together. If we end up in continuous tension with the desire for much more announcements and so on, and continuous swerve-

Jennifer Dixon:

Which seems inevitable. I mean, the Secretary of State-

Richard Meddings:

Well, unless the 10 Year Health Plan allows us to say, we're going to get here and we're going to do the three shifts and under the three shifts, these are the things we're doing, these are our priority choices to get to that. So that's why I would have an offer for frail and elderly because it isn't actually what you would write in the sunny vision of what we look like in 10 years’ time, but it is the absolutely necessary first enabling step to free up our resources, including our financial resources because those hospital beds are our most financially expensive absorptive cost units within the system. So we can free those up, we have more financial flexibility. So it's not necessarily what you'd write as that's the vision, but is the first enabling step you must do to be able to get to that vision, I think.

So I think you can do it, but I think that's where the 10 Year Health Plan has an ability to be seminal. It could be revolutionary if the 10 Year Health Plan actually acts as that, dampener is the wrong word, but it controls the frequency of change of, ‘Let's do this, let's do that, let's do this,’ and say, ‘No, we're going to do these things first to give ourselves a chance to bring order and better performance.’

Jennifer Dixon:

That sounds very sensible and very rational, but of course you have a cycle of five ministers and secretaries of state in 2 or 3 years. Some of them are very sensible and some of them are really quite wild.

Richard Meddings:

But they're all passionate. But the question I think have we got now and with a government with a sizeable majority and a long run in office, can we then say, ‘Okay, these are the things we are going to focus on,’? It's a really difficult task.

Jennifer Dixon:

Yeah, and to keep them to stick to the knitting. And thank you, Richard. I mean, is there anything that you wanted to say?

Richard Meddings:

You've been very cogent in all your work as a health foundation around the causes of demand lift. And some of the areas and the rates of growth in demand for health services are utterly remarkable and we've got to find a way to engage in that. I was shocked about just the capacity constraint that we operate within, under-invested, terrible estate, technology budgets rated. We've got to just be much more thoughtful. Hopefully the 10-year health plan will allow us to be much more thoughtful about that. I've talked a bit about innovation.

The thing that's missed, and this is why I go to this, today the NHS is providing absolute record levels of health care, record levels of health care. And the increases in provision, so one I often use is last year we did 3.2 million cancer referrals and cancer checks, and if I went back 8 or 9 years, it was 1.3 million. So we are checking more people today for cancer testing their symptoms, and therefore we're finding more people who have cancer as we do those checks. But the volume of service being provided today by the NHS is at record levels.

One of the great privileges of this role actually, and the humbling of this role is just seeing that front line in action, engaged with us when we're at our most often distressed, anxious, and you see the front line in action. And they're not just the front line, all the people, the support staff, and then the management are doing their best to provide this health service for the nation in spite of actually years of under-investment in capacity and so on.

And you see the front line today in action and I said it was humbling and it is, and we have to pay real thanks to them. So to the primary care GPs, they carry huge risk for the system. They hold the risk and they're doing 380 million appointments in the year, in 2019 less than 320 million, so more than 60 million more than 4 or 5 years ago. And I could recite, and I won't, more stats just about that level of provision, but it's mainly the passion and the commitment and the service that you see whenever you go out. Ambulance night shifts, I often say you see them non-judgmentally looking after people in distress and it's humbling to see it.

Jennifer Dixon:

So we must leave it there. Many thanks to Richard for all of his insights and of course for all of his work for NHS England over the last 3 years. We wish him very well in his new phase. Join us next month when we are going to be discussing work benefits and health and teasing out what is going on in this space. Until then, many thanks as ever to my colleague Sean and Leo at the Health Foundation, to Paddy and team at Malt. And it's goodbye from me, Jennifer Dixon.