Alan Milburn on the 10-Year Health Plan

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Jennifer Dixon:

So, last time on the pod we had Jeremy Hunt's take on the 10-year plan for the NHS, and this week we have Alan Milburn. Alan was the Secretary of State for Health in 1999 to 2003, under the Blair government, and his tenure saw the NHS Plan, but also record levels of investment in the National Health Service. Importantly, Alan also had a hand in writing and developing the current 10-year plan. So, what does Alan think? 

The current zeitgeist at the moment is reform or die, isn't it? And I remember this rhetoric from before, you'll remember last chance saloon, and 24 hours to save the NHS. And we've all seen the figures, the OBR and all the rest of it, and the fiscal squeeze, but it's a bit blood-curdling, isn't it? And it's not quite what Darzi said. And my worry is that if we amp up the ‘disasterisation’, then doesn't it just feed the old stuff swirling around in the Times, Telegraph and Spectator? The ‘end of the NHS’, ‘rip it up’ kind of stuff?

Alan Milburn:

No, I don't think that's the problem, the problem is that people haven't fully recognised that there are three things that are broken here. There's the operating model which is broken because you can't continue to run this gigantic system in the way that it's been run certainly over the last 15 or so years, which is a pretty centralised command and control system, with 20-odd thousand people sitting at the headquarters of the National Health Service. Seriously, that's the size of a town, we can't work like that, as we all know. When it was performing at its best, it was performing in a much more devolved and much more diverse operating model. 

The business model's broken because we can't just keep lobbing more and more money into the NHS at the expense of other public services. At least one estimate suggests that post the latest spending review we’re moving towards 50% of everyday expenditure being on the NHS, at a time when defence expenditure needs to rise, when social care expenditure needs to rise, when expenditure in infrastructure and so on needs to rise. So, the law of supply just isn't working anymore. Particularly if productivity isn't matching the increases in expenditure, and it isn't. We're in pretty anaemic economic growth, nobody is projecting that's going to turn around quickly. 

But the third and most important thing that's broken is the care model, and I guess what the 10-year plan tries to do is fundamentally change the care model to move from one that is frankly, over-dependent on acute-based care, which we know is both expensive and intervenes too late, to one which gives people greater independence, which enables us to intervene earlier, and which allows us to get upstream of disease and ill health, which is what the National Health Service at its inception was supposed to be about. Unfortunately, as you know, exhortations to change the care model haven't really worked, what you've got to do is you've got to change the system, the financial flows, you've got to change the architecture, and you've got to change I think the philosophy about what the care model is about. And the care model fundamentally should be about empowering the individual patient, citizen, to take greater control of their health. 

And I guess what's different this time round because people say, oh, we've heard all this before, is that now we have the tools in the box to be able to do that, through the genetics revolution and the data revolution. You've got to be candid with people about what is broken here, and you've got to be careful, of course, not to throw the baby out with the bathwater, because no one certainly in the government is saying that the fundamental principles of the National Health Service, the values set on which it's based, with care being made available according to need and not ability to pay, nobody is saying that that is wrong, and indeed it is more right and more relevant than ever, in a world where the genomics revolution is going to challenge more private insurance-based care systems.

Jennifer Dixon:

And in all the work for the 10-year plan, was there any plan B developed or mooted if progress didn't improve along certain lines in the next 5 years?

Alan Milburn:

No, I think this is an all-in plan, and it's right that it should be so. Not least because if we're candid about the last 15 or so years, what has been missing? Many things have, but two things I would say is clarity and direction, and hope for the future. And I hope what the plan provides is an answer to those two questions. So, I think it's clear in terms of the destination where we're trying to get to with this, and the reforms that are needed to make it happen, and I hope that it provides a sense of possibility and an island of optimism in what feels like a sea of pessimism sometimes about what it is possible for health care to do. I think what it is fair to say is that although it is a 10-year plan, in one sense it's a 3 plus 7 plan.

In other words, over the next 3 to 4 years, you've got to really deliver the stuff that needs to be delivered, in terms of the basic fundamentals of what patients need and care about, access to primary care, access to A&E, shorter waiting lists, and so on. And the 3 years has also got to see the foundations being laid for the longer term transformation, both digitally, genomically, in terms of the workforce, in terms of the architecture of the system, and then the further 7 years probably post the next general election, really about driving those reforms even further and faster.

Jennifer Dixon:

You mentioned optimism, but I can't leave this podcast without asking you about the decision that was made in March, the chainsaw decision about NHS England and Department of Health. And sure everyone understands this needs to be leaned up, this needs to be not duplicative and all that, but it's the way that it was done has really demotivated a lot of people. So, can you say anything about why that decision was just suddenly made in a way that now has probably demotivated some key assets in the system?

Alan Milburn:

This always happens, Jennifer, you've been around this course a million times, and so do I. Change is not pain free. Nobody but nobody that I hear anywhere across the system is saying that it is currently sustainable. In fact, that's one of the big changes I would say from when I was Secretary of State to when Wes is Secretary of State, 25 years later there's a consensus that something has got to give this time, and that is right. And when you just take a big step back and look at it, it's faintly absurd the number of people who sit in the centre.

Jennifer Dixon:

I think even though people quite understand the need to cut back, it just seemed a menacing thing to do.

Alan Milburn:

I don't think it's menacing at all, I think it is absolutely consistent with the operating model, whereas the government wants to see, which is one that is much more delegated, much more devolved, much more diverse, which is much less room from the centre. And in order to do that, I'm afraid the centre just has to be smaller. If you remember there was a one-word slogan for the election campaign, it was called ‘change’, and that's what all the government is doing is enacting the promise that it made to the electorate, and it's getting on with change. We're already a year into the government, and so it needs to be delivering not just tangible changes that people can see, but as fundamentally, the structural and reform changes that hopefully will make the system sustainable for a longer term.

Jennifer Dixon:

Let's go on to the bulk of the 10-year plan. The big point that everyone's been making is the delivery plan, and some of the enablers still need to be built, don't they? Like the financial physiology, incentives in the system and so on. So, on that delivery side, given the realism of the money, what you think the next step is? Is it really the three-seven as you say, you do the must-dos now, but see what you can possibly do within the financial envelope for executing this vision?

Alan Milburn:

Well, I think what three plus seven isn't is deliver the hell out of the as-is, and then post the next general election, get on with the reforms so to speak, that just isn't going to work because deliver the as-is, you're going to have to do the reforms. So, not [inaudible 00:08:08] because as you say, the fiscal position for the government and for the country is obviously an extremely difficult one, and yes, the NHS is a sort of net winner, of course, alongside defence, but nobody's pretending that there's a huge bonanza here, particularly when you take pay pressures and staffing pressures into account. So, we've got to drive much harder on what we get out for what is being put in, and that's obviously an uncomfortable message, and the good thing is there's a lot to go at.

And I think the neighbourhood health piece is of course an extremely important piece, and that's partially about infrastructure, it's partially about ways of working integrated teams, it's partially about what you incentivise, we need to move the financial incentives from driving more activity into hospital to driving more activity out of hospital, and keeping people healthy and at home, and in the community. But I think a lot of the prize in terms of a more value-based approach to NHS finances is going to come through digitalisation, and is going to come in time through the prediction and prevention revolution that we're in the foothills of.

So, if you take an area like outpatients, we're spending 25 billion quid a year on outpatients, it's a pretty sub-optimum system, where it's full of duplication and necessary attendance as people who don't show up at all, and the modelling that is being done for the plan suggests that a goodly proportion of that can simply be taken out, people can be sort of dealt with either through the NHS app or through neighbourhood health care, which is just more efficient, and frankly more convenient for the individual.

Jennifer Dixon:

On the neighbourhood health idea and prevention, there's a whole lot that can be done in healthcare outside of hospitals. What slightly worries me is that if there's a lot of autonomy in the system to develop this, which you want, you say you want, you don't want a one-size-fits-all, quite a few places might kind of go off into the blue yonder on the wider side, at a time when the NHS just really has to hunker down and do what it needs to do first. And just before I left to come here today, I just had a look at what Kaiser Permanente offers in this space, and it does offer preventive care, which looks very health care-like, vaccinations and stopping smoking and all that kind of stuff. On the wider sort of determinants population health stuff, it does a bit, but it's quite circumscribed. So, do you think there should be some stronger guide as to what this means?

Alan Milburn:

I think here, although the distinction between primary and secondary prevention obviously isn't an absolutist one, the wider social determinants of ill health, poor housing, poor jobs, poor people, and all of that, and frankly, that broadly is outside the remit of the National Health Service, said one exception, which is the NHS tends to be, well, is the biggest employer in the country, particularly in more disadvantaged communities, which obviously bear the brunt of health inequalities. So, I think there is something that the NHS needs to think more about in the primary prevention space, as an anchor institution, and what it does to help address those issues, local employment for people, getting people out of economic inactivity and into work. But I think the general message in the plan is, focus where you have locus, and the locus is around secondary prevention.

That's where we've really got to up the game, and in my view, I think you're right, we'll need to be clear what the framework looks like. The new tool in the box, the thing I'm really excited about in the plan is this genomics population health service, where eventually we will move to genetic testing at birth, and we will move to co-creating with families, how you deal with risk factors that are identified, and we know it's not an exact science and so on, but it just opens up an entirely different vista for what health care can look like. So, we do move away from, if you like, the diagnose and treat model, towards the predict and prevent model. Which is something that everybody's always talked about, what we now have is the collision of genomic science and data analytics, which is actually going to allow us to do it, both at the individual level, precision medicine, and at the population level, population health management, this is where I think we want the neighbourhood health service to really, really focus.

Jennifer Dixon:

Isn't there also another area on this risk prediction side, where people like me, well and healthy and low risk can go off with the fairies about what our risk prediction is, and start creating demands on the system? So, you've created a whole load of people who are well with risk on their heads, that they're now worried. So, isn't that another area where we've really got to patrol the boundaries or else, to be able to protect more basic care?

Alan Milburn:

What we've got to do is make sure, to this guardrails point that you raise, that not only is it clear what the centre wants from the neighbourhood health service, and from Foundation Trusts, and so on and so forth, but we've also got to set up the architecture and the financial flows in such a way that it incentivises those behaviours. And that's why I think the advent of this IHO model, underpinned by a very different set of financial reward and recognition mechanisms, is going to be so critically important. Look, the thing I learnt more than anything else, in terms of the NHS and getting it pointed in the right direction, is money talks, and I don't quantum, what it is that you are recognising and rewarding. So, this is a big, big change that needs to be made to make sure that we are keeping people healthy and out of hospital, and that organisations are incentivised to do so.

Jennifer Dixon:

I was just rereading your essay, Alan, that you did with Nick Timmins for us, in our book, and you were very clear of the distinction between the political engagement and reform to develop the system architecture, including regulation, financial flows, all the things you mentioned. Looking at then the reform side, the architecture, when I looked at this, having been around the houses rather too many times, it seemed as if there was a bit of a mishmash in there. On the one hand, as you say, there's integrated health organisations and on the other hand there was a more statist kind of total place type of vibe going on in it, in neighbourhood health care and so on, and I just wondered whether you can have a architecture that has bits of both in it, or is that really just a recipe for one bit pulling one way, and another another?

Alan Milburn:

All too often we have this rather binary debate, don't we, between, it's got to be collaboration or it's got to be competition. And most big ecosystems, whether in health or in other walks of life, they have a combination of both, and you need both. So, the plan is very clear, isn't it? About one really big change, which is that we've got to stop viewing the health care system in this country as being about a single institution that we happen to call the National Health Service, and instead see it as being an ecosystem of very different providers, from telecos, techcos, of course private sector providers, at the margins, the public sector, and that's what it is. And the role of the centre by the way, back to that sort of thorny question, has got to be both to manage and convene that ecosystem rather than to direct or run a single institution. And I think that is the genius of the modern world, we have so many tools available to us if we're prepared to leverage them.

Jennifer Dixon:

That's quite a sophisticated architecture that's going to be needed, and that takes time, and there's a sort of outline of it in the 10-year plan, and presumably more to be filled in, but that-

Alan Milburn:

That's why it’s a 10-year plan, it is what it says on the tin. You're right, there's both a capability and a capacity question, it's a very, very fair question, and one of the tragedies I think over the last decade, is a lot of the pipeline of talent, particularly at that sort of mid-tier level, I'd say, regional, sub-regional has been wiped out. Because all of that architecture was taken out, then Simon found a way of surreptitiously putting it back in. So, we've got to rebuild quite a lot of capabilities and capacity, and we know that the analytical capability, for example, on the commissioning side is nowhere near where it should be.

Some are doing it well, some parts of the country are doing it well, some ICBs have really begun to get to grips with this, but the majority are in absolute the foothills. So, this is going to be a muscle that is going to have to be built over time, and I guess without taking too much solace in a decade-long transformation, that is the beauty of having a 10-year runway, that you can afford to say, actually, there are some things that are going to take time to build, we know where we want to get to, and it will evolve over time.

Jennifer Dixon:

Given that speed is needed, and given that hope is needed, can something work fast that shows you hope and optimism, what you said in your essay, it's quite colourful language, ‘If politicians got out of the way, F-all would happen,’ you said. So, in true Milburn style, are you also planning to have demo sites, where there are vanguard areas, I don't know, that are the most mature sites, where all the conditions are right to really push some of this forwards, to at least show that it is possible? I didn't see that in the 168 pages, but I might have missed it.

Alan Milburn:

I think so. I think as with all of these things, look, this is a gigantic sort of ecosystem, isn't it? Just the NHS, never mind the broader health ecosystem. It employs 1.6 million people, and its budget is the size of Portugal, so it's a country. And so, some things you're going to want to make universal, as quickly as possible, so the NHS app would be a case in point, let's build out the functionality in such a way year by year that that's available everywhere. And then, there are going to be parts of the country, and we've touched on IHOs, IHOs in the first instance are not going to be everywhere, there're going to be a few places where we think the performance and the people in terms of leadership are there to be able to manage a whole population health system. So, of course, that's going to be a few places.

Neighbourhood health, we want to make sure is rolled out across the whole country, but as you'll read from the plan, one of the very strong emphases is about ensuring that areas of advantage, where the health inequalities are most acute, become priorities, these areas become priorities for the new infrastructure that needs to be established. And I think on social equity grounds that is the right thing to do.

Jennifer Dixon:

So, I guess that's my last question, which is approaching the next election, there has to be some kind of convincing narrative, particularly if enough change hasn't happened, hopefully it has. The ground is warm, right? The public want that NHS, at least at the moment. Would that be the pitch, do you think?

Alan Milburn:

What we can't do is go into the next election, government couldn't go into the next election, saying, you trusted us, we've delivered, everything's fine, that is just not going to be the position. But I think on the core deliverables so to speak, we have to deliver on the waiting list, it's absurd that you've got 7 million people sitting there, many of them in pain, in distress, and it's a real erosion of confidence. You can track the confidence graph, and the waiting list graph, and the correlation is absolute, so of course, we've got to deliver on that. We've got to get the madness of the 8am scramble to get to see a GP, not in every part of the country, but in many parts of the country, we've got to get that ended.

So, on the basic things that people see, often people, Jennifer, are judging both the performance of public services, including the NHS, and the overall state of the country, not whether it's a perfect position, but whether it's moving in the right direction or the wrong direction. And I think people concluded at the last general election that the NHS and the country was moving on the wrong direction, by the time the next election, the conclusion has got to be that it's moving in the right direction, both the NHS and for the country as a whole.

Jennifer Dixon:

Thank you so much to Alan for those insights. Do join us next time, and don't forget to subscribe to the podcast for more in future. And if you've got time also, please do give us a rating, which will really help as well. Meantime, thank you very much to my colleagues, Sean and Leo at the Health Foundation, to Paddy and his team at Malt Productions, and it's goodbye from me, Jennifer Dixon.