Breaking down the Health Bill – with Clare Gerada and Nicholas Timmins

Hugh Alderwick:

The NHS in England is on a constant treadmill reform and restructuring. Despite saying they didn't want one, this government has embarked on their very own top down reorganisation of the NHS. And now there's a Health Bill that's been introduced into parliament to bring the legislation needed to finish the job. 

I'm Hugh Alderwick, Director of Policy and Research at the Health Foundation. And with me today to talk about the health bill and what it really means, I'm joined by Clare Gerada. She's a GP and crossbench peer in the House of Lords who will be scrutinising the government's legislation. And Nick Timmins, the peerless chronicler and analyst of the Welfare State and the NHS. Welcome both. 

So I want to talk about the bill, but first Wes Streeting, he's now resigned as health secretary after about 2 years in charge. So I'm wondering what's the verdict, Nick?

Nick Timmins:

Well, it'll be interesting how history judges him, won't it? I mean, in a sense, he's set off this massive reorganisation and not stuck around to see it through. So someone else is going to have to either implement his vision or modify his vision, one or the other. I mean, looking back, there will be critics of his time. So I think some people would say he was shadow health secretary for 2.5 years. And whilst nobody would want a new secretary state to come in like Lansley with an apparently perfectly cut plan to turn the world upside down, he came in with remarkably few visible priorities. He took Alan Milburn's advice. You could hear Alan Milburn from the 2000s in loads of the things that Wes Streeting was saying. And Milburn's bits of advice was, buy yourself time, have a 10-year plan.

So we have a 10-year plan. It took the better part of a year to produce it. Let's be fair, Milburn, when he got the money back in the 2000s produced his first 10-year plan in 4 months. In a sense, everybody knew what needed doing. I thought commissioning the Darzi review was a clever political move, possibly a necessary one. In a sense, it didn't tell people a great deal that wasn't known already, but it told it all in one place and very clearly and very loud. So that's to his credit. And then he's decided to abolish NHS England, which has a certain irony. Back in 2010, Andrew Lansley produced his white paper promising to liberate the NHS from political micromanagements and excess bureaucracy. And in 2025, Wes has he decided to liberate the NHS from that liberation by abolishing NHS England. We'll see how that plays out.

Hugh Alderwick:

Clare, what's your take on Streeting's legacy?

Clare Gerada:

I have high hopes for Wes Streeting. And I have to say this with a caveat because I think he's done his best, but I'm disappointed. He hasn't come up with the plans that we need. We don't really have a functioning workforce plan. I know we've got the 10-year plan, but we're sitting at the moment on the lowest proportion of funding for general practice in my professional lifetime, a time when 80% of all doctors and nurses are located in hospitals. A time where the patients that we serve have chronic comorbidities that don't require single episode care.

Now, Wes Streeting knows this, but yet I'm sitting in my practice, nothing has changed. We know that despite the promise of 3,000 new GPs, we have new GPs, but we don't have the funding to employ them. So about 1 in 5 are either underemployed or can't find employment. Wes came in just after the 75th anniversary of the NHS and I co-chaired with Chris Ham a 75th review of the NHS, which came up with exactly the same recommendations that the Darzi review came up, maybe different language. And the 10-year plan. I've been working now in the NHS for 40 years and I think this is the 50th plan and reorganisation that I've sat through. And to be honest, we talk about it in our partnership meetings about which bit of the system we've got now. We know it's going to go again in a few weeks' time when the new health minister beds down and decides that he wants something completely different.

Hugh Alderwick:

What I'm hearing is the 10-year plan when you read it has a lot of things that I guess you'd agree with about shifting care out of hospital primary care, but we knew it and why weren't you doing it?

Clare Gerada:

I wrote something in 2014 for NHS London, Commissioning Healthcare for London. And we talked about the big shifts. We talk about continuity of care, proactive care, in other words keep people healthy. We talked about access and we also talked about end of life, dying in a place of your choice. And we set standards against that. Nothing has changed. Where are the metrics for continuity of care in secondary care? Where are the metrics around get it right first time rather than shifting everything?

I think the best area, and you talked about Alan Milburn, I think that was actually an innovative plan that was then implemented that produced real changes, real different ways of working. So for example, we had the highest rate of unwanted teenage pregnancies in Europe, highest rate. What happened, we got together with all the key people that deal with unwanted teenage pregnancy, from schools to health to criminal justice, reduced it. We then developed a 10-year drug strategy. So those were the real changes that actually made a difference that are still making a difference today.

Hugh Alderwick:

I suppose one big difference with that era is the money.

Clare Gerada:

But you see-

Nick Timmins:

Yeah, but it wasn't just money.

Clare Gerada:

It wasn't just the money. There's less money needed when you do things. Look at frailty. Why don't we have dedicated accidents and emergency services for frailty? Why don't we have their own front door? We know that people who at the end of their life, I don't mean with cancer, I mean with frailty. We know they're in and out of hospital. Why aren't we redesigning the services, putting multidisciplinary teams around? And I'm sure somewhere in the NHS somebody is doing it, but it doesn't cost money to do that. It costs money to do what we're doing.

Hugh Alderwick:

The government would probably argue that their bill is trying to enable some of these shifts. So let's talk about the bill. So it does a few things. It brings powers back into the Department of Health and Social Care by scrapping NHS England. It tries to change how the system is managed locally and it introduces new powers to develop a single patient record. But before we get into that, maybe Nick, tell us where does the bill come from? Why do politicians think this thing, which is primarily about scrapping NHS England, why do they think it's needed?

Nick Timmins:

It was clear that the relationship between NHS England and the department had become somewhat dysfunctional. I don't think anyone would disagree with that. There was a degree of overlap in policy terms and PR terms and particularly over Steve Barclay’s time onwards there was a lot of friction between NHS England and those conservative health ministers.

So something needs to change and Wes has eventually, having repeatedly said he wouldn't do it and he decided to do is abolish NHS England. Well, he didn't need to do that. I mean, he is the secretary of state. Now NHS England is a statutory independent body, but the chair is appointed by the secretary of state. And if you really don't like what's going on, you change the chair. And if the chair doesn't think it's doing what the secretary of state wants, you change the non-executive directors and they fire the chief executive and you have a new chief executive and this takes you about 9 months, 10 months and you've changed the relationship and the way it works without going through all the palaver of legislation.

So clearly a degree of frustration set in, quite what the final trigger was that led him to say he would abolish it when he had mere 6 weeks before, said he wasn't going to do that. He said I could spend a hell of a lot of parliamentary time, a hell of a lot of taxpayers money, change two people across, changing emails with no benefit to the patient interest. Interesting phrase, but nonetheless. So I think frustration is the answer, but I'm not sure that the answer to frustration was necessarily to abolish NHS England. But that's what lies behind the bill.

Hugh Alderwick:

I suppose is there a longer run history here to do with the role of politicians in managing the NHS? NHS England itself was a quirk and experiment of running the NHS more at arm's length.

Nick Timmins:

The 80-year history of the NHS is that of an accordion in that endlessly the battle is to devolve power out to the periphery and then pull it back into the centre. And then secretaries of state discovered that doesn't work. I could quote you, Kenneth Clarke saying, ‘I'm devolving power out there.’ I can quote you Alan Milburn saying the same. Andrew Lansley, ‘I'm going to depoliticise the management of the NHS.’

Clare Gerada:

Liberating the NHS. Do you remember that?

Nick Timmins:

I mean, it just goes in and out like that. And the mere fact ministers keep saying that's what they're doing, their acknowledgement of the fact that there is a problem and the power keeps getting pulled to the centre. And I do think the bill is interesting. I mean, it's not a small bill, it's 400 clauses nearly.

Wes says this is about the biggest evolution to power of the front line in the history of the NHS, right? Well, I'm prepared to take him at his word in that that is his intent. But if you look at the bill, the expansion notes lists 25 functions of things that NHS England now does and all but two of them move into the department. They become the secretary of state's direct responsibility from setting the budgets for ICBs to appointing FT governors, you name it. And there are some powers to devolve things to ICBs, but everything comes into the centre first and it's going to take a very strong willed the secretary of state to actually push that power back out.

Hugh Alderwick:

So not only does stuff come in, there's new broad sweeping powers to direct local decisions [inaudible 00:08:55] ICB.

Nick Timmins:

Absolutely.

Hugh Alderwick:

So it's a transfer in. Clare, what's your take on how we can limit the power of the secretary of state and what the bill does here?

Clare Gerada:

So I probably slightly disagree with Nick. Actually, I've always firmly believed that I know it's now, what, 140 billion pound budget?

Hugh Alderwick:

More like 200.

Nick Timmins:

200 billion.

Clare Gerada:

200 billion, gosh, it's gone up since I turned around. 200 billion pound budget, there has to be somebody who's accountable. And if I remember rightly, Andrew Lansley felt that it was sort of arm's length. They weren't accountable. Well, Andrew Lansley was still asked in parliament when things didn't happen. There's still question time to the ministers of health when things don't happen.

I am concerned because the inertia, as we know, that happens when you get big reorganisation is phenomenal. And in the end, patients suffer because things don't happen that should happen because there's so much inertia. I've been through so many, as Nick says, these push, pull, different systems that I just think he should have maybe just left it alone. He still had powers. I think the old system gave him more powers, but I think he should have focused on some of the things that are really urgent, like the reform of integrated care, which we've been talking about for years, looking at social care.

I remember just before the conservative government got in with Cameron and the coalition government, he gave a talk at the RCN when he talked about no more Alphabetti soup and it feels that everybody that comes in wants to do Alphabetti soup, wants to rearrange the deck chairs, wants to smash up everything that's gone before and start again.

And the only one that really didn't, and maybe Nick will tell me I'm wrong, was Jeremy Hunt. I don't think Jeremy did smash things up. He smashed things up in terms of accountability for quality and accountability for patient safety, because I think we were all far too complacent, but I don't think he smashed things up in terms of reorganisation.

Nick Timmins:

People say there was not a reorganisation between 2012, but actually there was a lot of evolution in that period. So you had Trust Development Authority and Monitor were merged into what was called NHS Improvement, which was merged into NHS England all non-legally in terms of practical day-to-day working before the 2022 Act actually did all that legally. But I think Clare's point is valid. It was evolutionary, not smashing things up.

Hugh Alderwick:

On the role of the secretary of state, Clare's got to be right that accountability's always going to rise up to ministers. It's right that they set direction. I think the question is how far should they reach into the day-to-day management of the system? And that's where I think there's concerns for this bill. If we accept government scrapping NHS England and they're not going to ditch that idea, where could there be some independence injected into the bill or into the way the NHS works?

Nick Timmins:

Well, one of the clauses in the bill widens the power to create special health authorities. Now these are wonderful beasts. They've been around for donkeys years. Shared Business Services is a special health authority, Blood and Transplant is a special health authority and ministry just create them through secondary legislation. I think this is a good thing, by the way.

Reading between the lines, I think that's been done because they realise that NHS Digital, which runs all the huge chunks of the IT of the NHS, the spine, hospital system, all sorts of things. The idea that you put that in the department just doesn't make sense. So I suspect that may go into a special health authority.

At the moment, he's got huge powers of appointment that's taken into this bill and we spent a long time, including in Alan Milburn's time, it was Alan Milburn who put a stop to ministers appointing everybody in the sort of then health authorities so that you tended to get this change of government, change of appointment. That's not healthy. You find good people do the job regardless of their politics, you know. And all that's coming back into the department, so maybe they'll find a mechanism to offshore that.

Clare Gerada:

This is my concern. What I'm seeing on the ground is more and more fragmentation of the bits of the patient being hived off. So people are chomping away at the human body. They want to take, already we've got women's hubs, which sound a good idea, but then they take them away from, ‘Oh, by the way, doctor, as you bring your child in.’ It also takes resources away from primary care, which has precious little resource as it is.

And the reorganisation is, again, it's taking away some of the easy pickings and removing them and saying, ‘Well, we'll do that at PCN level.’ And it's further destabilising general practice and destabilising continuity of care. I've seen increasing patients opting out of the NHS, completely, people who can ill afford it. And I wonder whether we are actually thinking about what the patient's going to get out of all this as all these structures change.

Hugh Alderwick:

When you look at the narrative of the bill, it looks like government thinks this single patient record they want to introduce is the big thing that's the offer to patients here.

Clare Gerada:

It would be great to have your record in one place. But every time somebody says this, and they talk about Estonia and I was on the Times Commission, Estonia has got a tiny population and we already have the NHS app. I think an innovative solution, we should have digital surgeries for the public to be able to go and get help. Proper digital surgeries run by people who know about digital.

If I brought my smartphone out now, it's got my entire GP record on it, all my meds, all my allergies, and it's also got secondary care investigations that have been done and letters from secondary care. So of course we should strive for the hospital system to be able to. The hospital does need upgrading in its IT. I mean, the idea of most hospitals not even having an electronic medical record that sits and talks to each other. But I just think it sounds good, doesn't it? A single patient record when we already have one if you have a phone and if you've downloaded it. And as I said, a lot of people don't know how to download it.

Nick Timmins:

That does depend on whether the GP practice is prepared to let you have full access to your records, isn't it?.

Clare Gerada:

Yeah, I know it is, but that's-

Nick Timmins:

You may have that, but I don't.

Clare Gerada:

Remember that's a technical issue that got caught up because, and I don't want to get into politics, but by the fact that the general practitioners committing the BMA were having a ding-dong. I think in the future you will have full access to your medical record to the point, Nick, that we now with the patient co-write, because I know they're going to see what's going to be on their record, but I would say probably in the next 12 months, most people will have full access to their GP record, which has parts of their secondary care record. It doesn't have your operation notes. It would have your A&E records if you've got it.

Hugh Alderwick:

And I think the intention here is to join up the data from different places. I suppose what the bill doesn't have is a detail of what it would look like, how it would work as a GP.

Clare Gerada:

I would far rather have a doctor in the hospital not send me 300 bits of paper as they do to my practice every day, 300 bits of paper, of which 80% of them are tasks. I would far rather that doctor was able to directly access the patient record, my record and his or her record, do the work themselves, follow up their own blood tests. So if you say to me what would make a biggest impact for patients, it would be that if the hospital system was able to talk to my system, that would free me up more, that would mean their delays would be less because they wouldn't have to faff about having all their investigations followed up by different people.

Nick Timmins:

I think the interesting bit about the single patient record in the bill is it's very permissive powers. And every time we've tried to do this before, there's the huge privacy lobby says it's a terrible intrusion, it won't be safe, it won't be secure.

Clare Gerada:

The point you make, Nick, is right. I think we always get such antibodies about health data, yet as I keep saying to patients, you are being tracked every single inch of your life, every single minute that you use any app.

Hugh Alderwick:

Well, I think ultimately it's about trust in the system. Patients have to trust that their data's going to be used for the right purpose, but clinicians have to trust and GPs have to trust too. 

This is a question I wanted to ask both of you. We've got a bill that's got a lot in it from the role of the secretary of state to the role of patient voice data. Where do you think in the Lords this is going to get pushed back and where might there be compromise?

Nick Timmins:

Healthwatch. I mean he's abolishing Healthwatch. Shades of times past, Alan Milburn wanted to abolish community health councils and succeeded, but at the price of creating something else in its place. I suspect there'll be a battle over Healthwatch because at the moment it's saying there'll be a director for patient voice inside the department and the secretary of state will be responsible for patient voice and patient choice. I mean, whatever you think of Healthwatch, whether you think it's a highly effective organisation or not, it has a degree of arm's length freedom to criticise and this is all going to sit inside the department. So I think there'll be a battle over that.

Clare Gerada:

I agree. I think there will be concern about abolition of a Healthwatch. I think there'll be concern about what it means about having the patient voice in the heart of the Department of Health. I think there will be issues around data, but I think there will also be what's not there. So I've already heard lots of peers wanting to piggyback amendments onto the bill for issues that they want to see changed around a primary care standard, for example, about workload, about workforce. So I don't know how this bill is going to pass by March actually.

Nick Timmins:

There are some good things that aren't in the bill. It's a good thing they're not in the bill. So the white paper produces a renewed fascination with foundation trusts, new style foundation trusts, and already it's quite... Clearly the department's already struggling to work out quite what a new style foundation trust is, but there's nothing in the bill that creates a new style foundation trust. So that's a good absence.

Hugh Alderwick:

Well, there's quite a lot in the 10-year plan that's not in the bill. Integrated health organisations.

Nick Timmins:

Exactly. It is good that that is not in the bill because it means you can actually work out what you should do without that as you go along and you're not constrained by stupid bits of legislation. For example, the white paper that says integrated health organisations will only happen when a top-performing foundation trust is given the ability to run one. Well, that's a really stupid constraint because top performing foundation trusts can become poor-performing foundation trusts and that's happened in the past. The bill doesn't do that. The bill doesn't also try and legislate what neighbourhood health should look like. So that's all good.

Hugh Alderwick:

But what the bill does do is it changes the rules around some parts of the local management of the NHS, which I think do a couple of things. One, make a sharper divide between commissioners and providers again by changing who's on an ICB and back to the hope that strategic commissioning or world-class commissioning or just some better version of the commissioning system will help improve the system. And another is it in some ways just reduces the focus on systems working together to manage finances, for instance. Do we really think that another round of commissioning that we've tried since 1991 is going to be the answer to improving the system?

Clare Gerada:

No. I remember all the discussions in the late '90s about what is commissioning. And the best advance I ever had was buying something. It's just buying and planning. And we make this big thing about commissioning as if it's some complex, I mean it is because it's health care, but it's no different from a grocer working out what he needs to put in his shop and working out what his population is and what the data is. But I think I've got concerns about how commissioning is going to work out.

Hugh Alderwick:

And you followed the various versions of integrated care systems over the last decade and this seems to change the way they're operating away from being a system leader to being a commissioner.

Nick Timmins:

Yes. I mean, the 10-year plan faces in two different directions at the same time, doesn't it? It continues to talk about integrated care and the need to integrate care, but at the same time, it puts more emphasis on competition and choice been stronger in the past getting a bit of a revival. There used to be something called the system control total for an ICB/ICS, right? Which meant that the whole system had to balance overall, even if there were bits that were losing money or in deficit in between, and they've removed that.

Now, it wasn't a terribly powerful tool, but it did mean that the commissioners could say to the big teaching hospital, ‘You're part of this. You've got to help balance the system.’ So the signals it's sending is just look after your own organisation. We want integrated care, but actually incentives are, you will look after your own organisation, number one, number two, number three, as opposed to, of course you've got to look after your organisation, but we need to work out ways we can change the way the system works that may cause a bit of a financial problem for you for a while as we adjust things.

Hugh Alderwick:

And the big challenges facing the population are to do with managing multimorbidity, addressing social determinants of health. They're things that you need to work together on, aren't they?

Clare Gerada:

The NHS is so slow in shifting some things. So let's take type 2 diabetes. What we're going to see is that type 2 diabetes is going to plummet in prevalence because of the new drugs. It's already reducing. Certainly patients are taking control of their health. Those that can afford, I'm not saying people should paying for it privately, others are going through GP services. I spoke to somebody today who's reduced her weight by 45 kilos. People are taking joy in tracking their weight on their app. They're taking joy in adjusting their dose and talking to their health care provider.

And at the same time they're getting better. So type 2 diabetes, which is responsible now for 11% of the NHS budget, I think will start to reduce. Just like TB reduced when I first started medicine. How soon will it be for the system to start acknowledging that and reduce services in diabetes and start reframing those as care of multiple morbidity or care of frailty? I think 20 years, 30 years.

So these are the things that if I was a new secretary of state for health, or if I was really energised in a leadership role, that you start to have to get the players together to say, ‘This is going to happen. So how are we going to change the way that we design and work services together and bring those players in?’

Hugh Alderwick:

Well, Clare, I think you've hit on a very important point, which is improving and redesigning services is how you improve the system over time and the bill is about structures, organograms, responsibilities.

Clare Gerada:

It's structures.

Hugh Alderwick:

Do we think that's going to have an impact on the way care is delivered?

Clare Gerada:

Our local innovators are bringing GPs with their local secondary care providers who are empowered through loop finances that are able to do this. But no, it's about structure. So I would have actually started by saying any health bill, what are the big ticket issues? Which is what Darzi did to a certain extent with his three shifts, but to start looking at some of the real issues that are going on, type 2 diabetes, reducing frailty, dementia, enormously increasing social care issues and start to say, how can we address these big ticket issues rather than let's look at the building, smash the building to bits and then hope that the building that we've just smashed to bits will address these issues.

Hugh Alderwick:

I suppose the argument government would make is their vision for neighbourhood health services is the root in here. What's the development in your area? How do you see neighbourhood health panning out as a policy area?

Clare Gerada:

You have to understand it's on top of about five other changes that we've had over the last 5 to 6 years. So what we do is we take a deep breath in. We have different people that we have to engage with. We've got different rules, we've got different bits of money that come here and there and everywhere. We have to engage with lots more people.

So my feeling is that the system becomes so slow to change unless you start to say, ‘How can we control the money and make sure that we empower people at local level to shift these big resources?’ Involving everybody, which is what ICBs are meant to do, but ICBs we know are not involved in primary community care to the level that they should. So they're rebuilding secondary care structures really.

Hugh Alderwick:

So when you stand back from the detail of the bill, what is the logic that the government has now for how the NHS improves at different points in time? It's been competition and choice, it's been collaboration.

Nick Timmins:

The degree to which these things have a lasting impact on service varies. But you can say genuinely that from working for patients in 1991, Ken Clarke's original purchaser-provider split with some bumps on the road all the way through to Lansley, it was kind of choice and competition that will drive an improvement in services. Since 2010, 2012 changes, it's been integrated care, which has run all the way through to now as the predominant narrative, which has been replaced by the 10-year plan, which already you said faces in two directions.

Now, of course, these things are not entirely the only driving force. So there has been a desire to better integrate care ever since the 1974 Act and during this long period from working for patients all the way through, there was an undertow of trying to integrate services better. The one thing you have learned over the years is that it's very, very difficult to do.

Clare Gerada:

And you've got to really then start to go back down to the details. So for example, the people that have done integrated care best at ground level are actually psychiatrists. So psychiatrists since really the dismantling of big asylums have had to do integrated care because they've had to integrate it into the community with social care.

But if you look at something like children, why are we not, for example, moving paediatricians out into the community working alongside us, which was a policy direction, I think it was 2009. Now, some people do do it, but it's a lot of effort in terms of getting the resource out, getting the regulatory framework out. So integrated care is this word that's used, but when it comes down to the ground, if you use examples and start to shift things round and actually say that is integrated care to say, how can we actually do it on the ground? I would love to develop proper integrated care around frailty, pulling together all the different strands that currently one frail person will have as they go in and out of hospital and engage with the social care system.

Nick Timmins:

I mean, I suspect what it comes down to is how you control budgets of financial flows in the end. And if you look at the places that do integrated care best like Kaiser or Northwestern in the States, they run the whole show. They employ the GPs, the hospitals, it's all one organisation and we just don't have that. And of course, that's what in theory integrated health organisations will become here, except that there's no discussion in the 10-year plan about how you need to change the financial flows to make that possible to happen. And I would perfectly well argue that you could run it with a powerful bunch of group practices taking the budget of the hospital and doing it that way around, but you kind of want one budget and one set of flows, but you would have to rewrite a lot of contracts to do that.

Clare Gerada:

But it can be done. Do you remember fundholding? It actually requires putting out proper tenders, proper joint working across the system to say, ‘We want to deliver X, Y, and Z,’ and then you hold a budget, which you can do. I do take issue about Kaiser deploying a few GPs. We are the highly skilled parts of the system and actually the way that integrated services work best is by co-locating some folk, having shared budgets, banning letters, all of these things and start to say, ‘We want to make this journey best for the patient. Now, how can we do that?’

Hugh Alderwick:

Yeah, Clare, when you look at the policy on integrated health organisations, the conclusion you could come to is that actually it's going to be big hospitals that are going to be the leaders for this.

Clare Gerada:

Of course it is. I mean, they'll just develop hospitals again. And if I was in charge and I was completely in charge, I would abolish outpatients. Why do you need outpatients? Now you'll say for follow up, but there are different ways of doing follow up. I wouldn't quite, because some things do need. I would start to set a metric around continuity of care for hospitals. So if you've gone in for something small, it's a week, but something catastrophic it might be for a year that you have to provide a way of delivering continuity.

And I would also take some of the big areas that I've already talked about like frailty and to say, right, how can we now redesign the system? I'd also make every single hospital doctor, irrespective of their endpoint, work in primary community care, not as a junior or not as a, you know... somewhere along their specialty training so that we start to work closely together.

I would start giving every GP an honorary contract with a hospital so we can start having a better flow into the hospital, start using that resource, seeing our patients on the ward if we need to, doing joint meetings. These simple things would start to shift, but at the moment we don't have it.

Hugh Alderwick:

So Streeting's gone and we've got a new health secretary, James Murray, we've got the bill, we've got a 10-year plan. What advice would you give to the new health secretary?

Clare Gerada:

Keep the patient at the centre. And think of the three different sorts of patient. The acute patient that wants to see somebody now, which is a different sort of patient to the one that might be your grandma that's in and out of hospital that needs a wraparound team and continuity. And then the third sort of patient is the one that we want to stop getting an illness in the first place to try and reduce what's now a 17-year gap between developing ill health and diet and think of those three different groups and then read what's gone before because the answer is blowing in the wind, it's there.

Nick Timmins:

The single issue that matters to patients most is waiting times always. They're much more worried about waiting times than they are about quality of care, paradoxically, but you should just focus on the two or three things that you really think matter in the waiting times thing and get on with it and do your very best about it. You probably do need to decide exactly how you're going to manage the NHS at the centre because that still isn't clear. Are we going to have executive in the department, going back to the pre-2010 days, or are we going back to the mid-2000s when one person's the permanent secretary of the department and the same person is the chief executive of the NHS? It's not a success, so you should avoid that. And they need to demonstrate that they have actually produced a significant improvement in patient experience and patient waiting times and focus on that.

Hugh Alderwick:

Good place to end. Thank you both for your time.

I really enjoyed the conversation with Nick and Clare. I took away three big things. The first, will this make any difference for patients and the public? I think they were both sceptical. Second link to that is the time and energy and resources that go into these big restructures. Given the big challenges facing the health of the nation, it's hard to justify these top-down reorganisations of the health system, even if there's some positive changes hidden in there.

And last, I think this is going to be a real fight in the Lords. We got a hint today of some of the big things that will be part of the discussion, scrapping Healthwatch, but also data, digital infrastructure, and whether Lords have confidence in their proposals being put forward on the single patient record. Next month, a normal service will resume with Jennifer Dixon back hosting. Meantime, thanks as ever to Sean and Leo at the Health Foundation and Paddy and his team at Malt.