The most challenging job in the country: being chief executive of the NHS – with Sir Alan Langlands Episode 12 of the Health Foundation podcast

28 September 2021

Sir Alan Langlands FRSE
Illustration of a hospital, a microphone and a chart showing an arrow going upwards.

Being chief executive of the NHS is one of the most challenging jobs in the country.

Since the role started in 1985 there have been nine postholders, with Amanda Pritchard taking over from Sir Simon Stevens this year. Like her predecessors she faces formidable challenges ahead: managing the pandemic’s impact, tackling waiting lists, boosting technology, managing a growing population of older people with multiple conditions and dealing with workforce shortages to name a few.

The role means being a leader and a national figure, working with the NHS itself as well as with government, the media and the wider health sector.

The bandwidth needed to do the job is huge. How is it doable?

Our Chief Executive Dr Jennifer Dixon discusses with Sir Alan Langlands, NHS chief executive number four, from 1994–2000. After leaving the NHS, Alan went onto a number of roles including Principal and Vice Chancellor of the University of Dundee, chief executive of the Higher Education Funding Council, Vice Chancellor of the University of Leeds and chair of the Health Foundation (2009–2017).

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Jennifer Dixon: What's the largest organisation in the UK? With a budget of £140bn in England alone, over 1 million staff seeing 1 million punters every 36 hours and Top of the Pops with the public over decades, and tellingly, the organisation that can strike fear and pride in equal measure among politicians. It is, of course, the National Health Service.

Being the chief executive of the NHS must be one of the most challenging jobs in the country. Since the role started in 1985, there have been nine postholders. In July there was a switch from number eight to number nine. That's from Simon Stevens to Amanda Pritchard. Ms Pritchard, like her predecessors, faces formidable issues ahead. To name a few: managing the pandemic's impact, tackling waiting lists, boosting technology, managing a growing population of frail, older and chronically ill people and finding more staff. All that as well as being a leader and national figure, and of course, dealing with government. The bandwidth needed to do this job is huge, let alone the physical and mental resilience. How is this job doable?

Well, today we're going to discuss this with, I'm delighted to say, one of the previous post-holders Sir Alan Langlands. Alan was in the role for six years from 1994 to 2000, spanning three years of Conservative government and three years of a Labour government. He was postholder number four, and at the tender age of 42. He was, I believe, the youngest of the nine ever to have held it. He was known as 'a manager's manager', and 'a formidably hard worker'. I know all this at first-hand as I was his policy advisor for the last two years of his tenure in the NHS. Alan was a career NHS manager. After leaving the NHS, he then went on to become principal of the University of Dundee, chief executive of the Higher Education Funding Council, and vice chancellor at the University of Leeds, among many other things, including chair of the Health Foundation. He officially retired in August 2020. Welcome, Alan.

Sir Alan Langlands: Well, thank you, Jennifer, for that introduction. Number four in the list of nine seems a very long time ago.

Jennifer Dixon: Indeed, but midway through so great perspective to have, thank you. So I thought what we'd do to kick off is just to give a little bit of your background in the NHS, if we might, how you got to be in the post?

Sir Alan Langlands: I guess I kind of grew up in the NHS in the period between 1974, when I was a national trainee in Scotland, 1974 and 1985. From there, I worked in Edinburgh at the Royal Infirmary, where I was in charge of maternity services in Edinburgh, but quite quickly, by 1980, I had moved to London. And I was first appointed to run the Middlesex Hospital, as it then was, and the community services in north west London. And then after that, quickly on the merger of the Middlesex and what was known at that time as University College Hospital, later becoming UCL hospitals, I was chief executive there until the mid 80s. And then along came the Griffith report, and reluctantly, because I think the emphasis was on a kind of hierarchy of hospitals and district health authorities at that time, rather reluctantly I applied to be the district general manager in Harrow Health Authority. I worked for a management consultancy firm only briefly. And then rather dramatically, and unfortunately, because a great friend, David Kenny, who was the regional general manager at North West Thames, was taken suddenly very ill. And I was imported from the consultancy to be the interim regional general manager and then became the substantive postholder. And then not too long after that, in 1993, I was invited into the Department of Health by Duncan Nichol, who was then the chief executive of the NHS Management Board, as I think it was called, to be deputy. So I was in the Department of Health from January 1993 and then appointed to the post of chief executive in April 94.

Jennifer Dixon: For those of us who are living through that period, who remember it very well, it’s difficult for others who came later to think how hot that period was politically with respect to the reforms in the NHS, there was such an ideological divide wasn't there with the, as you said, the early 90s, 1991 Thatcherite reforms, Working for patients. So you came in, in 94, after they'd been introduced in 91. So things were pretty, pretty stressful, weren't they? Can you say a little bit about that?

Sir Alan Langlands: Well, they didn't seem too stressful at the time, strangely, because, you know, I had been there as the deputy and I had also been in the, kind of, heat of the changes in London's health services, and I’d been involved in that over a long period, both before being chief executive and afterwards. So the merger of some of the London teaching hospitals with each other, the merger of the related medical schools and the integration of the medical schools with the multi faculty colleges of the University of London was a very hot issue, but one that I had been involved in from the outset, and indeed, one that I continued to be involved with right through. And that was a hot issue. And for me, there was a huge prize to be achieved there. And on the one hand, we were dealing with that, whilst dealing with the kind of after-noise of setting up NHS trusts and, you know, stories about large pay settlements for chief executives, and all of that. So there was a lot going on

Jennifer Dixon: Yes, and there was of course GP fundholding as well, that was dividing general practices.

Sir Alan Langlands: Yes there was GP fundholding and a few people, a few GPs around the country who saw this as their great moment, their great play for power, and occupied a lot of attention and a lot of press. But in reality, behind the scenes, the more reluctant GPs were just getting on and trying to make things work in the time-honoured way. But I think, you know, probably at that time, about 26,000 GPs, probably 10 of them were making difficulty, making waves in the press about how powerful they were were and how weak everyone else was. But that didn't last for long.

Jennifer Dixon: So the early part of your first few years was, of course, the internal market, London, as you say. And I was just looking back over a timeline, and I was looking at Citizen’s Charter, well that was a bit earlier, Service with ambitions, the Primary Care Act, PFI, BSE in 1996. So quite a lot going on during John Major's sort of time. And then, of course, we had New Labour where you interestingly, and we'll talk about the politicians a bit later, had to switch horses, if you like, and sort of serve an incoming new government that was pretty green, wasn't it, after so many years out of power. And of course, there's a whole set of reforms there unleashed, which really underpinned the internal market. The other story, I suppose, which is just also worth remembering is the funding story. And I was looking, I think it was 1996/97 where there was actually a cut to the NHS just before Blair came in. Are you able to say anything about the funding environment at that time?

Sir Alan Langlands: Yeah, I mean, there were modest increases, but I think that really the trend towards big increases, and we're just seeing another one in the last week or so, really came later, probably just as I was leaving. I mean, we negotiated a lot of good stuff in relation to the settlement around 99 to 2000, in particular, and that's when it began to take off. But there were tough times before that. But of course that was driven by economics, it was driven by a government with a very small majority and unable to move. By 1996 the Major government, if you remember, had a majority of one.  So it was very difficult to function in that sort of environment. For your amusement, in terms of absolute numbers, when you introduced you said the health service was a £140bn organisation in England. At that time, it was a £48bn organisation, which seemed a lot at the time. But you know, that shows just the advance that was made in the first half of the 2000, 2010 period, and then the advances that have subsequently been made.

Jennifer Dixon: There was significant debate, wasn’t there, about the existence of the NHS and whether it could survive rationing, Mavis Skeet, remember these cases that kept… I remember watching on TV in your office once, cancelled cases, often on the back of the years of being squeezed. And it's difficult to remember that that the NHS itself at that point seemed under threat, the press was against it largely, quite a lot of the press anyway.

Sir Alan Langlands: The pressures were great. And I mean, right through that period, as I say until after 2000, that wasn't for the want of trying, but I think they were just boxed in on the economy. If you can remember, Labour were elected on the basis in 1997 that they were going to hold fast to the previous government spending plans. And they did. The pressures were very significant. And of course, the ultimate breakthrough was the famous Blair appearance in the Frost programme saying we're going to level up to the spending of other European countries. And that began a process that was followed through, I think, from 99 into the 2000s.

Jennifer Dixon: Yes, with a period of plenty. And for listeners who know our podcasts, we did have a podcast on this, the most expensive breakfast in history, do we need another Wanless, which people might want to look at and also the publication. We'll put it in the show notes, it was written by Nick Timmins. With that context in mind, shall we move on to a bit more about the role itself? And what I thought I'd do, Alan, it's such a huge role isn't it, is just to take it in three chunks. So one bit is sort of managing inwards I've called it, which is in a sense your thoughts about managing the NHS itself, and its performance. Then the second is managing upwards, managing ministers, government, Treasury, and so on. And then managing outwards, dealing with all the other stakeholders that you have to deal with. Let's talk about managing inwards. It's hard to believe that the NHS did not have a chief executive before the mid 80s, which is quite interesting. This is a service that you came into a few years later, well, nine years later, as chief executive, that kind of wasn't used necessarily, or was getting used to a management structure. I guess the key question here is, what's your reflections on how you as chief executive could effectively influence the service to make progress on whatever it was that was the priority?

Sir Alan Langlands: Well, I think that the key issue for me, and for every chief executive probably in every other sort of organisation in the world, is to try and be visible to the organisation itself. Now doing that on the vast scale of the NHS is a difficult thing to do. But I did spend time on that. And it wasn't wasted time. You know, this wasn't cutting ribbons. This was kind of low key, undercover visits, listening to people on the front line, trying to influence them in a particular direction. People in the health service and the people who represented them, you know, the kind of network of royal colleges and the Royal College of Nursing, the BMA, the trade unions and a number of big charities, you know, Mind, Cancer Research UK, British Heart Foundation. They were all people who wanted to influence and shape things. So there was a lot of toing and froing, with people like that to try and kind of build a picture of what would be right for the future. I do think you mentioned what I think was the 1996 white paper on a service with ambition. I mean, I still think that was a really good bit of work. For the first time we were very clear about expressing for the modern day the purpose of the NHS, and the results that we were trying to achieve, the results of equity, efficiency, responsiveness, and became more and more confident explaining to people in the service, always going to be asking for more cash, explain the trade offs between these different things. So having policies that were built on the kind of results we were trying to achieve. And having strategies or approaches for delivering improvement around these results was the kind of thread that was running through what I was trying to do. But it wasn't easy. And it wasn't easy playing that out in a political arena. You know, at one point, I remember saying to Gordon Brown and Blair and Milburn, the trouble is, you all want different things, you want to give priority to different things. Brown wanted equity, because that's what he believes in heart and soul. Blair wanted a more responsive service that was clearly responding to the public demand. And Milburn, because he was responsible wanted an efficient but also an effective service where more attention was being given to health outcomes, but we were running a very tight ship in order to achieve positive outcomes. And these are perfectly legitimate roles for these three people. But reconciling them is difficult. And I remember in that particular meeting, saying to them, I could probably give you two out of three, but I'm not sure I can give you all three at the same time. So there's one part of the job that's dealing with that. And if you like, in a constructive way trying to speak truth to power. Then there's another part of the job that is engaging with the NHS front line, and with all the stakeholders that surround that, and all the different interests that are in play. And I think you've got to be visible in both directions, as it were, and kind of walk a bit of a tightrope, you know, was I there to deliver what the government wanted, or was I there to represent the interests of the NHS. This is pre-2012 so there was no real separation between the NHS executive and the government. The chain of accountability was very clear. And indeed, it's going to be clear, again, if you look at the new health and care bill that's making its way through the system at the moment. So balancing these two things, I think is the crucial part of the job.

Jennifer Dixon: Yes. And once you had consensus on what those priorities were, can you say a little bit more about delivery? And in particular, the management side of delivery? I mean, there's an age old question isn't there about how much central grip versus how much local autonomy. And in thinking back to when you were in post, there are clearly very strong regional health authorities where you had regional chiefs who would help to affect this across the country.

Sir Alan Langlands: Well, it's too big to have a central grip on everything. There's no doubt about that. But if you just take the three priorities of time, which I would argue are probably should be still key priorities today, they were in relation to cancer care, coronary heart disease, and mental health, it's the three really crucial issues to get on top of there. There's so much of that policy level and maybe above kind of strategic or an investment level resource allocation level, you can dictate or influence I would prefer to say, from the centre, but a lot of the delivery and indeed a lot of the ideas have to come from the local people. I remember when we were thinking about the 50th anniversary of the NHS, you know, how much could we represent a kind of national thing and how much should we allow to be celebrated locally, and I think that's an important and fine balancing act. And I must say, I prefer the notion of handling these things in a devolved way, but working to some sort of central course of direction. I felt I was saying to people, I want you to go north, but it's okay if some of you go north west, north east, because that's the nature of these complex issues. But please, don't anyone go south, don't fail to deal with these issues. And that's a dilemma for people you know, I remember Blair saying, why can we get it right in Newcastle, but we can't get it right in Newquay, which I don't think was strictly true, but it was a nice kind of way of putting it. And the answer is the quality of local management, the quality of clinical care, the commitment of people in that part of the country, the history of resource allocation in that part of the country, and so on. And we're going to see this, aren't we, given the government's outpourings on levelling up, we're going to see this kind of north-south argument develop further in the health service in the coming years.

Jennifer Dixon: Yes. I mean, it seems to me, given the settlement just had, that there are two really screamingly clear imperatives. Obviously getting waiting lists down, waiting times, but the other one is to continue the progress in the long term plan, not least integrated care. On the waiting lists, unlike the examples you gave – cancer, CHD, mental health – this is a clinical issue, but it's also very much a managerial issue. And when you were chief executive, there was huge pressure then wasn't there on waiting lists as now. And there was some academics, Carol Propper, we know, described in one of her papers, targets and terror, that there was performance management used. There are obviously other levers as well, but when it's something so hot politically, like waiting lists, and actually this government has put all at stake on that it strikes me, it's political capital has been expended on the NHS, so delivery of the waiting list is a must to make an understatement. Where is the place – is there a place for targets and terror, if I can put it that way? Or very, very strong central performance management? Or do you think that really is old hat and there are other ways now?

Sir Alan Langlands: I think there's a place for targets but they have to be a small number of targets. Thanks to our friend, Nick Timmins, I famously got a big headline in the Financial Times that said, I can't remember the number at the time, but I think I was quoted as saying publicly if you like to the government, if you have 47 targets, you have no targets at all. And I remember being really kind of hauled over the coals for this. But actually, the person who came to my rescue wasn't even one of the health ministers. It was David Sainsbury, I think he was the science minister at the time, in a conversation that he and I happened to have with some of the senior politician, said he's quite right, you know, if you try and cover the waterfront you can only fail. So I think targets, but very focused targets, low in number, is a good thing. Performance management, which is not just about holding people to account for delivering, but it's about helping and supporting them deliver is important. I don't think there's any place for terror, I mean, what would that achieve in any organisation, particularly in this day and age? So that is not an approach that I would ever condone.

Jennifer Dixon: No. And if you do have a really hot priority, like waiting lists, and you do put the full force of, or full array of means of trying to deliver those, what do you think about some of the other what has been called levers to try to keep a wider set of objectives being progressed? Such as levers like incentives, regulation, public reporting of performance. How do you get the right blend of those, even if you're really focused in one particular area to get progress?

Sir Alan Langlands: Well, I think it's a hugely difficult balancing act. And again, it needs absolute clarity. If you try and mix an approach based on regulation with an approach based on choice with an approach based on very focused performance management, that's a very confusing way to tackle these things, I think. And it seems to me that the other significant thing is that with that sort of speak – if you like, policy speak, some of it ideologically based, if it's coming from any government – if you try and mix that policy speak with a serious discussion with the cancer specialists around the country or the cardiology and cardiac surgery community, you get into a mess. And that I think, is the other key thing, the process of of engaging thought leaders within these specialist medical or sometimes social areas is hugely important and gives credibility to the approach that's been developed and the approach has been implemented. Of course Labour did do a bit of this early on with the introduction of the so called czars. I think they thought that was, you know, get a tough clinician at the top laying down the law. But if you look at the way in which sensible, experienced able people, like Mike Richards on cancer, did that job helping and supporting the community to achieve progress and indeed, feeding off the community and arguing about resource allocation and supporting the development of policy nationally, that iteration, to me, is vital to progress.

Jennifer Dixon: So we talked a little bit about ministers, you obviously spanned four ministers: two Conservative, by my reckoning, and two Labour. So Virginia Bottomley and Stephen Dorrell for the Conservatives and Frank Dobson and Alan Milburn for New Labour. All very, very different characters. Can you just say something about how you were able to, I wouldn't say manage these politicians, but how do you interact with them to to get the best out of them?

Sir Alan Langlands: Well, you have to move quite quickly. Because I mean, if you think about 1997 and 2010, because of an election, the kind of sitting chief executive at that time, is dealing with more political change than normal, is not just kind of changing the pattern. So I counted up, you counted nine NHS chief executives. In that same time, that same time period from 1985, there were 16 different secretaries of state. I would argue, somehow we managed to get on reasonably well with all of them. They were different. Virginia Bottomley is pretty hands on, her Tory successor, Stephen Dorrell, was a bit more hands off, a bit more strategic, a bit more like the chairman of the board rather than the line manager. But Frank Dobson was very hands on, so if I were to say to you Frank Dobson was very like Virginia Bottomley, in that one respect I should add quickly, you might be surprised at that. I start from the basis that they're there to do a really difficult job. They're having to cope with parliament, and often that's very testing, with the Public Accounts Committee, or the Select Committees in the background. They're having to cope with government and often with party politics, and they're having to cope with their own constituency. So they've got a tough life. If you spoke to any of them, post their time at the Department of Health, they would say, it's the best job they ever had and they really believed in what they were doing. And that's not a bad starting point for our relationship between the executive system and the policy and political machine.

Jennifer Dixon: Our first podcast actually was with Jeremy Hunt, and it was on the subject of how to be a good health secretary. And one of the things he said was, the most important thing, is to just have two or three priorities then try and make progress on those. And so presumably, the job of the chief executive of the NHS is to try to make sure that ministers do have that focus, rather than 37 priorities. But assuming that they do get down to three or four, if I can put it frankly, how do you stop the secretary of state from micromanaging? Because if you think about it, as others have said, secretary of states often have never managed anything, they're now in charge of the biggest organisation in Britain, temptation to tinker must be quite high. What was your experience of that?

Sir Alan Langlands: Well, I don't think they were micromanaging to the extent that they would just go off and make decisions and kind of interfere with everything that's going on. I think they were micromanaging, maybe that's not the right phrase actually, by wanting to be across all of the issues and to want in their briefings and conversations a lot of detail. And you can see when a minister is under pressure about waiting lists, for example, they want to know in absolute detail what the issues are, and what the solutions might be. And they want a realistic timetable for pursuing the solutions.

Jennifer Dixon: Yes. I mean, there's certainly one issue with secretaries of state really wanting to be on the detail. But there's another one which is where in addition to that they do have pet theories as to what makes successful change faster. Whether It's one minister might say, you know, you have to have more financial incentives. Another one will say you have to have performance style meetings, another one will want targets, tough performance management, you know. Given that you're the chief of the NHS with all that management experience, how do you deal with that kind of situation?

Sir Alan Langlands: Well, I think they are the government. You can deal with it by facing them down on particular issues. And certainly, as things were pre-2012 and the arrival of NHS England, and I don't actually think it changed that much in the meantime, you know, it's impossible for the Secretary of State to be too detached. It's impossible to have the principal leader of the NHS worrying about commission only and not worrying about everything else that's going on in the health service. I think the changes in the health and care bill while not terribly well presented in relation to the Secretary of State having more of a hand on things are not unexpected. Nor indeed is following the Lansley fragmentation, nor indeed is the idea of making things more coherent and having a greater kind of sense of partnership working across bits of the health service, geographical bits of the health service. So yeah, they can have their pet theories. Ultimately they are the boss and sometimes they get their own way. Where there are, and I have seen recently, by which I mean in the last 10-15 years, probably a change in the way in which some ministers treat civil servants so that, you know, that sort of speaking truth to power idea is just kind of dismissed as it were, you know, why should should I ask you? But where there's trust in that relationship, you can do that. And you can sometimes compromise, you give them what they want in terms of their particular political win. But you also know and they also know that this is going to be pursued in a kind of sensible, straightforward way within the service that will lead to a result. It's difficult, it's been very interesting for me to see the relationships between the NHS and the scientific community being exposed during, and their relationship with politicians being exposed, during the pandemic, and you can see the tensions. These differences exist. And they often lead to some pretty hard discussions in both directions. And you've just got to accommodate that and move on, you know, they've been elected by the people to represent them in Parliament and appointed by the prime minister to do this job. So you've really got to support them, but not at any price.

Jennifer Dixon: Can you say anything about when you think this post-holder does need to poke through as national leader publicly? Simon's profile, I mean, even though he's very well known, actually was not a high profile. And that's probably the smart thing, isn't it? Can you can you say a little bit about when you were in post how you thought about this?

Sir Alan Langlands: Simon's contributions were high profile compared to any of the other previous chief executives. Occasionally they were negative, you know, issues. Very often they were, you know, he was so skilled in bringing out the positive that they were often regarded as positive issues, or, you know, the head of the NHS taking, you know, what in anyone's world would be a kind of sensible, a common sense position. So that was, I think, brilliantly done and hadn't been done before. Most of his predecessors have been pilloried for doing things wrong, and never recognised for doing things right. So that kind of makes you slightly wary of what's going on. I don't mean to be unfair, but I mean, probably Simon was less visible on PPE and testing in the early stages of the pandemic than he was visible on the vaccine issue. So he played his cards extremely, extremely well. But behind the scenes, he would be dealing with both issues, and all of them were very difficult. And one or two of them were never going to succeed quickly enough to satisfy what politicians wanted and what the public demand legitimately was at the time.

Jennifer Dixon: And are you able to say then, going forwards from now, what kind of advice – I know you're reluctant to give advice to the new chief executive – but in terms of handling the national profile, is it a better thing do you think just to stay below the waterline most of the time and just deal with things that way?

Sir Alan Langlands: Well, I don't know Amanda well, but everything I've seen is positive. You know, she's got really kind of good, hard won experience. She's well respected within the NHS, and she is known to have a very strong, strong commitment to the health service. So I think she is a strong position to operate as she feels appropriate. I do think it's better to get on with it, rather than to face judgement from the media. I mean, the whole kind of thing is so unrelenting at the moment Always has been in the health service, but the arrival of social media, I mean I was there for the arrival of 24 hour news and that was unrelenting enough, because instead of our normal 12 hour cycle, from seven o'clock in the morning till seven o'clock in the evening, you're suddenly getting asked for quotes at two o'clock in the morning. So it's unrelenting, it's very demanding, and I think, carefully chosen moments, you know, if you speak slightly less in these roles I think you tend to get listened to more. I mean, I'm not a good person to ask, because as you know, I'd never liked that side of the job. I didn't like it because I thought it was no win. The 50th anniversary conference at Earl's Court with the prime minister and the whole cabinet sitting in front of me, quoting Bevan that if they step further down the privatisation road I think I would have to resign. To my surprise, that was the front page of the Guardian the next day. But I meant it, and it's what I believe. And I think I got away with it, because they knew it was what I believed. I would argue that despite all our weaknesses and idiosyncrasies, that the eight chief executives which have followed were all committed 100% to the NHS. So I, you know, the last seven have come from the NHS, it's very, very difficult for me to imagine someone coming from outside the health service, to really manage an organisation of that scale and complexity.

Jennifer Dixon: Is that because, it's presumably not because necessarily of a question about commitment, but much more about the complexity and the context in which the NHS has to deliver services?

Sir Alan Langlands: Well it's both. People can see if you're not committed, when you're out on the rounds with the community nurses on the Isle of Dogs, or, you know, sitting talking to the night staff in the surgical unit at Bradford Royal Infirmary, they know whether you believe in what they're doing. And if they do think that you believe in what they're doing, they want to do it better. And it seems to me that's such an important part of the job, much more important – what I'm saying is the inside is better, is more important than the outside – much more important than going to bed worrying about what you're going to say to the Today programme at seven o'clock the next morning.

Jennifer Dixon: So you've got the NHS to deal with. Big enough. You have the ministers, government, Treasury, money, all those wrangles, managing upwards. And then there's managing outwards with all the other stakeholders: the university sector, science, business, media international, as well as unions, professions, local government, many others, key private sector suppliers. So I think many people will be surprised at all of the range of stakeholders that you need to manage or at least be on top of.

Sir Alan Langlands: There was a huge network. I was involved pre the 97 election – just pre the 97 election I think, or just after, I can't remember, but it was around that time – in setting up what at that time was called the Commission for Health Improvement, now the Care Quality Commission and it's consumed a lot of other things along the way. And also NICE, which is a tremendous advert for something that's managed to sustain over a long period and do an important job, so the National Institute for Health and Care Excellence, and I did keep good working relationships with them. There are groups like the NHS Confederation and now the NHS Trust equivalent. The Royal Colleges were very tied into government at that time in a way that I'm not sure they are now. And of course the Royal Colleges have, at that time were spawning all sorts of additional groups, specialist ITU group, specialist emergency medicine group and it was important always to listen and to engage with them. The RCN and the BMA were always interesting collaborators because you know one half of the brain was focused on supporting the development and improvement of the health service and the other half of the brain was kind of trade union negotiations. The trade unions themselves, patient groups were on the rise at that time, and were actually physical things before the internet consumed that market, as it were. And then why if you had priorities, national and managerial priorities around mental health and cancer and coronary heart disease, why wouldn't you be engaging with Mind and Cancer Research UK, British Heart Foundation, the British Diabetic Association. So yeah, I spent a lot of time working on these relationships. And to your question of how do you set priorities, more time with those who are actively involved in pursuing the issues that we really wanted to tackle.

Jennifer Dixon: As a public sector organisation, dealing with the commercial sector is an art in itself, isn't it?

Sir Alan Langlands: I think the great example of our current time is they clearly got their act together with industry around, and indeed the scientific community, around vaccine development and the consequences of that in terms of production. So the work of the vaccine taskforce, which had its core in NHS England, has been a great success. So I would say, on the basis of that example, which is the one that's most visible, that maybe things have moved on, on that front than it has ever been,

Jennifer Dixon: You're known as a formidably hard worker Alan, all-nighters before Select Committees and so on. How do you stay resilient?

Sir Alan Langlands: I think, for such a tough, tough job, you have to believe it. So you, you know, the whole thing has to rest on a kind of values based approach, if you like. You have to build and rely on a good team of people around you. And whilst this job past and present might attract some attention, there's a huge kind of hinterland of often, of really kind of brilliant people behind the scenes who work equally hard and are equally committed. I do think you've got to have a very clear sense of priorities, or you get lost in the endless kind of detail and the endless demands. And you've just got to be able to explain why, you know, some things will get dealt with later. We haven't really touched on what I think is the biggest issue looking forward. And that is the question of workforce in terms of numbers, in terms of their education, development and motivation. That is going to be the biggest hurdle in the health service, achieving the recovery, the renewal and the future strategic development that you should be thinking about at the moment, and that is of a sufficient, well trained, motivated and committed workforce, and we're stretching that to the limit.

Jennifer Dixon: Supporting the workforce and addressing shortages has got to be the highest risk issue in the NHS right now and we'll be sure to return to it on these podcasts in the months ahead. But sadly we've got to leave it there for today, thank you Alan for giving us your time and your very rich insights on that very peculiar job of chief executive. And as ever, it's always a massive treat to talk to you. For links to key reading on the things we discussed today, as ever please find them in our show notes wherever you find this podcast. And next month, with COP26, we'll be doing a special podcast on climate change and health. Look forward to seeing you then.

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