Does a new Prime Minister signal change in health and social care? – with Rachel Wolf and Isabel Hardman Episode 24 of the Health Foundation podcast

Dr Jennifer Dixon: A new PM, a new government, a new health secretary. All facing a formidable array of challenges. And Prime Minister Truss saying the NHS is one of her top three priorities along with growing the economy and tackling the cost of energy and inflation. But what exactly do we know about Liz Truss? In the leadership hustings, she favours a small state, low taxes and high responsibility. She said she wants to put the NHS ‘on a firm footing’. And she's also singled out improving access to primary care, and of course, cutting management. Thérèse Coffey, her new secretary of state, has also said her priorities are ABCD. That is ambulances, backlog, care, and doctors and dentists. So how will this translate to the NHS to social care, to improving the UK's health? Will government really have the bandwidth before an election to address more than the day-to-day pressures? And we all know those are intense enough. Staff shortages, waiting lists, access to GPs, possible pay strikes, ambulance and emergency care, let alone her other two big priorities. And if a Truss government won a general election with a mandate to do more, what form would it take? Well, with me to discuss all of this, I'm delighted to welcome two experts on the political scene. Rachel Wolf, who leads the policy work at Public First, a policy and strategy consultancy. And she's on the board of The Centre for Policy Studies, a right wing think tank. Rachel co-authored the Conservative Party's Election Manifesto in 2019 and was policy advisor to the prime minister. And Isabel Hardman, who is a political journalist and the assistant editor of The Spectator. She probably needs no introduction as she features very often in The Spectator and on the excellent daily podcast, Coffee House Shots. She's the author of two books, Why We Get the Wrong Politicians and The Natural Health Service. And she's currently finishing a third on the NHS. And in fact, she joins us a little bit late in the podcast because she was very busy on the edits of this third book. Welcome both. I wonder if you just might tell us what you know about Liz Truss, particularly, what do you think her political ideology is? What do we know, Rachel?

Rachel Wolf: Yeah, I think there's been a lot of debate over the summer about whether Liz Truss believes the philosophy that she has kind of repeatedly set out during the leadership campaign or whether she was merely trying to appeal to the membership Conservative Party. And I think she unquestionably believes it. She has been more libertarian, more free market voice in cabinet for a number of years now. And I think has been genuinely impatient with what she sees as Treasury orthodoxy. So I think her ideology is exactly what she has described that said, and I think this is where it's going to be interesting and slightly unpredictable. She's also shown that she'll do what it takes to survive. So there were various things that she jettisoned very fast in the leadership campaign. The most obvious being regional pay bargaining, which obviously relevant for the health sector. But also, despite I think genuinely thinking that low taxes and low state intervention is the best way to pursue growth. She was willing to do a monumental universal energy package, which is, of course, a huge market intervention because she realized that if she didn't, it was over. So, what I think is going to be interesting to watch is when she's willing to take some degree of political pain for her convictions, because so far whenever it has gotten politically difficult, she's been happy to do whatever's necessary.

Dr Jennifer Dixon: When she was interviewed a few years ago by Nick Robinson. They say this was way before she had direct aspirations to be prime minister that were verbalised. She described herself as a big disruptor and a contrarian. Now you could say, that's just tough talk, but is that what you think she is?

Rachel Wolf: I think that's how she thinks of herself. And yeah, you've seen this even in the last week, she's decided to completely change how Downing Street is structured. Is that disruption to the public? No. But it's a signal that she wants to do things differently. I think she quite likes having a different opinion from the people around the room. It's been quite hard during the Cameron and Johnson era to be very free market and libertarian, and she has been and tried to be. So I think that's right. What I suppose, without wanting to be a broken record, it's easy to be a disruptor in a discussion. The thing about disruption is it causes temporary pain, all disruption, even if it's leading something positive, creates winners and losers. And there are always people who are attached to whatever the status quo is. So, you have to be willing to drive that through. And if she wants to disrupt, let's take planning reform, for example, which is obviously something she's going to want to do. You have to be willing to lose some politicians, some voters along the way.

Dr Jennifer Dixon: And what do we know about Thérèse Coffey? Does she have equally strong convictions or is she someone who is loyal and will follow?

Rachel Wolf: I should say I worked with Thérèse briefly at DWP, and she strikes me as one of the most nicest and most competent ministers that I've come across. It strikes me as someone who's focused on delivery more than she's focused on philosophy. I don't mean that she doesn't have principles. Everyone who becomes a conservator or a labor or a Liberal Democrat politician does it because they fundamentally ascribed to a basic view of the world. But what's to me set her apart, partly because she'd been a finance director in a previous life is she was interested in the detail of what departments did and how operationally much more than most ministers that I have met. And, of course, that's going to be interesting in health, know much more about health than I do, Jennifer, but A, health is enormous. We, obviously, the health department has much less executive control than it does in most other parts of government because NHS England role runs it. And because lots of different parts of the health system have control through the colleges or whatever that you don't otherwise have. And because you have a far greater core of experts, both officially and unofficially running the department. So I think it will be really interesting to see how it plays out. I also think that she has managed to attract a relatively very talented team. So, the fact that she's brought someone like Neil O'Brien in suggests that they do think this is an area which needs competence and ability, unsurprisingly.

Dr Jennifer Dixon: It's good that she's detailed. I mean, I think the time's described her as pragmatic and managerial as well as detailed, which is all good. She's got the health secretary job and deputy PM. So she's going to be very busy. But, in any case, given... I mean just thinking about the NHS now and social care, there's so much in the must do pragmatic entry, will they have the bandwidth to do much more than dealing with day-to-day crisis? Do you think?

Rachel Wolf: I think this is always the problem when you're health secretary, as far as I can tell, which is that the NHS always seems to be one step off a monumental crisis or in one. And it is such an enormous part of the public sector in expenditure terms and delivery terms compared to almost anything else that governments tend to try and do. The challenge it seems to me that the government has as a whole, is that by 2024, when the next election is most plausible going to be. They are going to have to have demonstrated some record of delivery, because they are got a lot of new voters who had not voted conservative ever before announced for permanent swing voters, who voted for change both during Brexit, but also in the 2019 election. And the manifesto, the kind of platform for any conservative government in 2024 has to be a version of, we started the job now, Truss has to finish it. So there needs to be a job they started. And health will unquestionably be a huge part of that because it was a huge part of what drove change in the first place. They wanted more money for the NHS. They wanted to see doctors. A lot of voters, however much you might dislike this. A lot of voters felt that it was too easy if you came to this country to use the NHS without contributing. A lot of that kind of fed people's perceptions. And obviously, at the moment, there's this massive backlog and people are very, very, very worried about it. So that's a very long way of saying, I think if they can deal with the day-to-day and do have some solution to the backlog, to freeing up beds, to GP appointments, perhaps to starting to redo these hospitals, that isn't itself a monumental achievement and has to be what they focus on.

Dr Jennifer Dixon: Liz Truss has said that she's ‘completely committed’ to existing spending promises on the NHS. And yet she's wanting to scrap or think she's agreed to scrap the National Insurance levy, which would've raised 12 billion a year for the NHS and social care. I mean, there's obviously a lot of investment needed immediately, not least and a workforce plan. Interestingly, the public 52% of the public support, the National Insurance levy for more investment and actually conservative voters in particular vote support that. And 71% of the public, we've just done these polling, think that more investment is needed on top of the levy. So, do you think she's going to follow through on these spending promises if she scraps the levy?

Rachel Wolf: I'd be astonished if any Conservative prime minister was willing to go into an election cutting spending to the NHS. It's not going to happen. So yes, she's obviously decided she wants borrowing to take strain of pretty much everything and her tax cuts are not being accompanied by traditional fiscal conservatism. They're being accompanied by greater borrowing. What I think may well be the case is that there is more public conversation about whether there is waste in the NHS about whether there are ways to reduce cost in the short-to-medium term. I could imagine there being much more focus on that, but I'd be astonished if headline numbers reduced.

Dr Jennifer Dixon: Although whether there's the inflation issue, isn't there eating away at existing spending?

Rachel Wolf: Yeah. And we also don't know right now what the inflation's going to be, right? Because a huge proportion, huge driver of inflation is energy. And we don't know really at the moment what that's going to look like in the next few months.

Dr Jennifer Dixon: Yes. I'm just going to pause there because Isabel's joined us. Hi, Isabel. Perhaps if I can ask you about what you know about Liz Truss in terms of her political ideology, what's her load style? What might that mean for us in health? Do you think?

Isabel Hardman: Yeah. So, Liz Truss is obviously very well known for changing her mind on lots of things. And I think that has been overplayed during the leadership campaign because she was once a Lib Dem and then changed her mind and was once anti-monarchy and so on. I think people think that she's somebody who doesn't have an underpinning ideology. And I think she does now. She's somebody who believes in a small state who believes in competition, who believes that public services can be more efficient. I think one of the ways of understanding how that then manifests itself in policy terms is not just looking at the Britannia Unchained book, which is now I think infamous. But also remembering that she comes from a think tank background. She was director at reform the think tank. And I think, to a certain extent, has spent some of the leadership contest and her preceding years slightly a think tank mode. And I mean, this is no insult to everyone else on this podcast, but not necessarily in a good way in that she has got quite used to the comfort of being able to think big blue-sky thoughts and have ideas without necessarily worrying about the pain of actually implementing them. And I we've certainly seen that when it comes to her utterances on the NHS, indeed. I don't think she has thought very deeply about the NHS during the leadership contest. The thing that really stood out to me was whenever she was asked at hustings about the health service. Her go-to answer was to say, "I think the NHS has too many middle managers." There were a number of things behind that. One is just, as everyone listening to this podcast, and on this podcast knows, there's no bogeyman like an NHS middle manager. You sort of guaranteed to please conservative members, probably the majority of doctors listening who think they could do it better, but also don't want to do it. And so on so, she was sort of ticking the boxes of the people in the audience. But the thing I found funniest about this was that she'd obviously spent the time running up to the leadership contest and certainly the contest itself. Dressing apparently accidentally just like Margaret Thatcher and trying to channel her as much as possible. But that makes me think again, that she doesn't have much for grasp with NHS policy because she would know who that Margaret Thatcher herself was a big fan of NHS managers. And that understanding of the background with the Griffiths report and how management came in the 1980s is clearly lacking. And then to bring that up to the present day, it did make me also wonder whether she'd noticed that the Health and Care Act had only just been enacted this year. And that really taking out an entire tier of NHS management now in the middle of a backlog when ICSs are still betting in and so on, might not be the best way of making a public service more efficient.

Dr Jennifer Dixon: Notwithstanding that the number of NHS manager really spend on management is lower than practically every other Western European nation. So, I mean, apart from easy knee-jerk responses, like cut waste, cut administration, cut regulation and red tape, et cetera, et cetera, et cetera, you mentioned competition, you mentioned the sort of Margaret Thatcher dress and so on. If you look at all the evidence on competition that was introduced from 1991 onwards, you see a pretty lackluster impact. You see a lot of spend, but you don't see much bang for the buck. What I'm trying to get at here is what's going to be her guiding light for bigger disruptive change if she can get round to that. And the competition and choice stuff, hasn't that boat just gone now? It's a bit retro, isn't it? It's Reaganite. I mean, is our approach to the state these days still defined by that? Are we really on for something like that, post-election?

Rachel Wolf: I mean, fundamentally, I don't think health is going to be where she concentrates her energy of reform. She wants health not to be a disaster, which is why she's put someone she trusts in terms of competence into it. But it's fairly obvious that her intellectual energy is going into other areas. It's trying to boost private sector investments, growth, competition from a general economy point of view. So I would be really surprised if much of her time, energy, and political positioning was on health reform. On the broader question, I don't think these ideas ever go away. I think they swing and roundabout and competition and choice will be one of the debates in public services probably forever.

Isabel Hardman: Yeah. I agree with Rachel on both of those points. Firstly, that I think for a lot of people on the right, their instinct with regards to competition in the NHS is a bit like a lot of people on the left with regards to communism in that they don't think it's ever been properly tried. There's just at some point going to be the ideal conditions where it's going to work. I think potentially some of them do accept that the ideal conditions, or at least they think that the ideal conditions would involve the NHS not existing as well at which point. Any sort of politician worth their salt starts to say, well, no one's going to thank us for that. And so, they end up going down again, a sort of pamphlet rabbit hole rather than anything more concrete. And then yeah, if you look at Thérèse Coffey, very close friend of Liz Truss's, someone obviously given the appointment that she made with Coffey is hugely trusted. She is also somebody who, in her previous brief at DWP, spent a lot of time. And I mean, it's remarkable that I have to say this, spent a lot of time trying to understand what was going on, which is not always the case with ministers, either in big delivery or reform departments. And I know that Thérèse Coffey was very uncomfortable with the way in which the Lansley reforms impacted on her local NHS. And was somebody who quite early on, even when conservative MPs were pretending that Lansley was, in some way, still a good thing and working and being implemented. She was being quite blunt in private meetings with the Cameron government at the time saying ‘This is a mess’. So she's someone who's prepared to look under the bonnet, which is always helpful with the NHS because you do end up in politics with people who, because they've been to a hospital, think they understand the entire workings of the health service. The same as with education policy, because I've been to school. I think I understand how academies work. It's very easy to fall into those traps. In a way, it's better when they go into a department that they just have never thought about before at all, like defence or DEFRA because it forces them to actually listen to people who do understand it rather than bring their preconceived ideas in. But I don't think Thérèse Coffey is one of those people, in fairness.

Dr Jennifer Dixon: You mentioned Isabel just then, 'They won't go down a pamphlet rabbit hole’. That's a good one because if I look at the pages... so just tell me I'm worrying too much. When I look at the pages, particularly the comment pieces, it has to be said in the Telegraph, The Times. And I have to say, Isabel, the Spectators' leader. There's a kind of uncertainly Centre for Policy Studies. Rachel, I know you're on the board of that and IEA. And the people are circling around the NHS. No ideas coming forwards, but a sort of attacks. You don't think that's a serious... that's just part of the warp and weft of political currency. It's not a serious potential outrider for a big attack on the system.

Isabel Hardman: No. I don't think it is. And I think having come to this podcast from doing my book edits and kept you all waiting for quite a while, because I forgot about the real world outside of my book. And to take us back to the '60s, which I was editing earlier this morning. You look at the row that Enoch Powell had with the IEA, the Institute of Economic Affairs, because they were absolutely furious that his stance on the NHS when he was minister of health was, well, the British people like it, so it's my job to get on and make sure it works. And the IEA was saying you've comforted our enemies. You are supposed to be with us in this march against this awful state health service. And I suspect it's a similar situation here where you've got think tanks, reformers, commentators or gust publications, such as my own pushing for change. And the government of the day saying, well, look, we have an NHS backlog that could kill us politically anyway, is now really the time to also scrap the health service. I mean, in terms of falling off voters, Christmas card lists, I think the Tories have got enough to worry about, anyway.

Dr Jennifer Dixon: That's a relief and you're presuming you agree with that, Rachel?

Rachel Wolf: Yeah. I mean the thing I always say to people from the left, when I do speeches and presentations, is you have to understand that the Conservative Party, above all else, really liked winning elections. And one of the first things you realize or are brought to realize when you work for the Conservative Party is you cannot win an election if the public think that you are going to cut or deeply damage the NHS. You cannot do it. So I think that it is very unlikely that she will put her other reform agenda at risk by creating a huge political row. But that doesn't mean there won't still be a battle of ideas between the right and the left on the NHS, because it is a huge part of our state. And I think a very large number of the thinkers on the right worry about its structure, its levels of expenditure, its performance that will keep happening. But I'd be astonished if it drove her big political choices.

Dr Jennifer Dixon: Do you mean this side of the election? Or do you mean the other side as well?

Rachel Wolf: Well, the only way she could do it on the other side is if she promised it in the manifesto and that sort of thing gets noticed.

Dr Jennifer Dixon: So, what we're also saying then both of you, is that you think it's really just going to be a fixing pragmatic agenda to get ahead of some of the problems that are facing the public at the moment on the NHS?

Rachel Wolf: Yeah, that would be my assumption.

Dr Jennifer Dixon: You'd also mentioned that Thérèse Coffey is managerial and likes detail. You also said, and it's true, it takes years to get to grip with all of this. So, how is then just turning to Coffey for a minute, not Truss. How would you think she's going to approach this? If she's PM as well, deputy PM, she's going to have to trust or make a decision very quickly to trust the chief executive of the NHS England. Isn't she? Because there's no way she can get on enough detail to really in the time available before an election.

Isabel Hardman: She is. And I think the... I'm not going to claim any particular knowledge of the relationship between Thérèse Coffey and Amanda Pritchard, which I imagine is pretty early stages, anyway. But I think there had been a breakdown of trust in Simon Stevens from some areas. Not in the normal way that you have a breakdown of trust from politicians towards civil servants, people running big organizations, and within public services where it's sort of a competence thing. It was more that a lot of politicians felt that Simon Stevens was too good as a politician and was slightly out maneuvering. Which I always thought was funny because basically they were resenting him for being more gifted than they were, but there we go, that's politics.

Isabel Hardman: And so, they definitely see Amanda Pritchard as being, the words of one person I was talking to of the NHS. And I don't think they meant that necessarily in a particularly complimentary way. And that I think they just felt she was sort of an internal figure, who didn't have the kind of breadth of experience and ability to challenge in the way that Stevens did. I suspect that's unfairly disparaging of her. But that they certainly don't see her as a power base in the way that Simon Stevens that was, and I think liked to be seen as well.

Dr Jennifer Dixon: But how is Coffey going to get? I mean, Rachel, you work with her in DWP. How is she going to get on top of the detail to the extent to which she can prevail?

Rachel Wolf: I mean, I guess there are a few different questions in here. I suppose the first thing is deputy PM isn't much of a job unless you make it much of a job. It doesn't have to be an all absorbing or monumental task. And my guess is given the size the department she's running, almost all of her time will be spent being Secretary State for Health. Two, my guess is that she will try and deal with the head of NHS England operationally or the many ministers do. She will attempt to understand it from a financial and operational point of view, because that's how she's comfortable thinking. And that will be a different relationship. And I think she's possibly less likely to be trying to think Blue Sky Policy thoughts. But she will ask more detailed questions.

Rachel Wolf: The third thing I would say is, I think this has one of the best ministerial teams of any that Liz Truss has put in place. So I would've thought that someone like Neil O'Brien, for example, will be given a reasonable amount of runway to look at social care because they have tried to put in people who are capable of thinking or delivering into the department.

Dr Jennifer Dixon: I mean, just you mentioned social care then, let's just... we'll come back to the NHS, but it's not clear. It's very murky at the moment, quite what is going to be the overall approach to social care. Truss had said that she wants to see that 12 billion that was earmarked from the National Insurance rise to be diverted, to support social care. But she hasn't said how that will be funded. Have you got any particular insights on what you think their approach will be here?

Isabel Hardman: I don't. Other than that, there is fortunately, a Truss and her colleagues have not bought into the... you could use a number of different words, incorrect assertion on truth delusion that Boris Johnson, I think genuinely held that he had reformed social care. I mean, he said in his outgoing speech, we fixed social care, which just mad. And I think that is a great comfort because I think if you've got Truss saying, as she did that, she thinks the NHS needs more money. So she kindly needs more money then... And she's not going on about the needs. The way that which she soon act was for, I mean, she does talk about greater efficiencies. But I think she does recognize that to make a health service efficient, you can't ignore one of the big drivers of inefficiency, which is people being stuck in their hospitals. And when they're medically fit for discharge because there is no social care sector to pick them up. So I think they exist in the reality-based community on this, which I think is a good step.

Dr Jennifer Dixon: Does she support the cap? Which has got a lot of flak from particularly the right, hasn't it?

Isabel Hardman: I don't know. Rachel, do you know?

Rachel Wolf: I don't know. I don't know what her view is on social care financing, except that my guess is she'd be quite reluctant to have a massive reopening of it right now. She has very little time and limited bandwidth. And just coming back earlier to what I think we were both saying, I don't think this is her fundamental focus of reform. So my guess would be the focus will be things like how do we free up capacity, so we can move people out of hospital beds? What fixes can we put in place more than it will be a total revision of social care financing? The side of the election. I mean, I could be wrong, but given everything she said in all of high priorities, I'd be really surprised if she tried to reopen that.

Dr Jennifer Dixon: And going back to the NHS then, you think the intro will be highly pragmatic, a series of fixes that are things that are affecting the public the most, that will be influential certainly for the next election, in terms of how the public perceive they are managing the health service. And if that's the case, do you have anything to add other than the obvious things that will be in the intro, such as the workforce shortage there? Obviously, the long waits, the cancel waits, in particular the GP access. Anything else that you think that they might be looking at?

Isabel Hardman: Yeah. I think obviously on workforce, that's another example of them having to be pragmatic to the point of quite sort of embarrassing in that they're having to do more overseas recruitment, including from countries on the red list for staff shortages, which is not really a place where Britain should be. But there's this sort of acceptance that even if they train lots more doctors, that's not really going to solve anything before the next election.

Isabel Hardman: I think the other thing is that Truss will come under pressure from the right of her party to do things that incentivise the use of private healthcare by people who can afford it. Going back to the thing that Margaret Thatcher and Edwina Currie all talked about it being almost the duty of people who were better off in the 1980s to have health insurance and to opt out of the NHS. So that people who needed it could access it, which isn't how the NHS multiple was set up at all.

Isabel Hardman: But there have been back benches, who've made those proposals and given you've got this massive rise in people not taking out private health insurance actually, but paying up front. There may well be more pressure to give them some kind of tax incentive to do that. I don't think that that's something that politically they will want to go near, because again, you end up with the left jumping all over you on that. And you raise a greater question of, are you undermining the health service by stealth? Are you removing middle class consent for it? So on and so forth. But I think that's going to be an interesting political debate.

Dr Jennifer Dixon: Yeah. I think that could be quite incendiary as it was before. Although, the public are getting used to using private providers, so we did some work and found that in some parts of the country 75% of ophthalmic operations, elective operations are being done and funded by the NHS, but done in private providers, which is quite interesting. But it's another matter as you say about how it's then paid for and if it's privately funded.

Rachel Wolf: I don't know if they'll go near this, but just thinking about workforce. I could imagine that they would want to nudge further on what different people are allowed to do. So we obviously had pharmacies taking a huge role during COVID, but tend to take less of a role for injections, vaccinations. At other times, there's been a gradual increase of what pharmacies do. I could imagine them trying to nudge at that because what many of them will believe, which is that there are too many barriers to entry. There are too many qualification requirements that are sort of making the system more sclerotic than it needs to be. They won't want to address that head on. So they may address it through looking at increased permission for other people to do things.

Dr Jennifer Dixon: The big area to try to get to grips with is innovation and technology, isn't it? Particularly, labor saving and productivity enhancing that can help sustain the model in future and will even better offer good quality care. There isn't yet a sort of glimmer that's even been part of the debates or discussions yet, but surely that is the big, big area where the pandemic showed the NHS can move fast. The way it's set up means that we are perfectly capable more than any other probably health system to do mass testing of innovation because we've got single payer and all the information in one place. Do you think there's going to be a big push on that? I was looking at Robert Jenrick, William Prince, some of the other ministers' portfolios, they're not really hot on this area, but I wondered whether they might look onto that.

Isabel Hardman: Yeah. It's an interesting question, because obviously, the only person who's really talked about it from the political sides over the past few years is Matt Hancock. And he did sometimes get a little bit mocked because obviously, he had his own app and so on. But he did have more of a tech grasp than the average politician. And I was wondering, as you said that whether the way to do that would be to get a vote, like Ara Darzi, the government of all the talents under Gordon Brown, where you have somebody who understands it in a really practical way, what technology in the NHS means rather than... even Matt Hancock ended up sort getting excited about holograms and that kind of thing. Whereas just the impact of AI and robotic surgery and so on, on the NHS ability to move faster with its backlog to move faster with diagnostics and so on.If you've got a minister who is also a clinician like Ara Darzi was, pushing that reform agenda. That might be more powerful than, as you say, anyone on the current list in the department. But there's also the kind of, well, I don't know whether it is low hanging fruit given it's been so hard to pick. But the NHS trusts who are still paper based, aside from robots and that sort of thing, just that the fact that they're still using fax machines or indeed within those trusts. They've got computer systems that don't talk to each other and that you have to have nurses literally transcribing the details of a patient from one screen to another when they move from one part of an emergency department to another. We sort of laugh, but the amount of man hours that are lost just from somebody standing at a computer screen, typing things up in a kind of 1980s data entry kind of ways is another thing that could speed things up in the NHS just a bit I suspect.

Dr Jennifer Dixon: Yeah. I mean the other piston in the efficiency engine, as well as technology and innovation is, of course, good management because, as you know, Nick Bloom and other academics show it's actually management is more of an active ingredient to better productivity. And there was a glimmer of that wasn't there with a messenger report, which recently reported, I think earlier this year on state management in the NHS and how much it could be improved. So it'd be very interesting to know whether they'll go down those routes, on top of the immediate horror things like staff shortages. But then again, you have to change your narrative on management, don't you? And stop calling them a drag on the system.

Rachel Wolf: I just think you also have to remember that there's no time. The election is unbelievably close. This is a new ministerial team that has to get their head around the system that is dealing with fires everywhere. I think that they would be instinctively, incredibly sympathetic to the opportunity of tech and will feel why not? Why not? Is it still paper? Why have we not sorted this out yet? Unquestionably, but realistically, any serious reform is going to be promised and enacted during and after the next election, not before, because there is no time and there are other bigger priorities, both in health and across the government.

Dr Jennifer Dixon: We can just quickly just turn then to health. Previous government had clearly, it's a pledge to improve healthy life expectancy by five years by 2035 reduce inequalities. Sajid Javid when he was health secretary was planning and preparing a white paper on health disparities, how to reduce them. We know the drag on the economy of health. But yet, on the other hand, we see that Truss in the leadership campaign, so she was against the government stopping these BOGOFs, buy one get one free, or any new quote, nanny state levies on our healthy products. What prospects do you think there are at all before the next election of any more progress on the health agenda?

Rachel Wolf: I think if there's progress, the approach will be different. So I think there are not going to be sugar taxes. There are not going to be regulatory things put on the private sector. I could imagine them being more sympathetic to things like social prescribing environmental things, as in how can you create healthy environments for people. But again, because it takes a long time to show progress on those things. And because there are immediate massive problems and an election looming, my recommendation at least would be to people working on this is to focus on things that they can credibly promise in the next manifesto more than on big action now.

Dr Jennifer Dixon: Right. So, do you mean the short-term fixes?

Rachel Wolf: No. What I mean is that short-term fixes are going to dominate the next two years. So, things that are major inputs into preventative health, changing people's lifestyles, things that are long-term and difficult and multifaceted. You're much more likely to see progress, I think after an election than you are now.

Dr Jennifer Dixon: Right. Thank you. And Isabel?

Isabel Hardman: Yeah. I don't really have much to add to what Rachel said other than that's, I think with a change of administration, you lose perhaps the appreciation that was developed during COVID of the need to tackle some of the health inequalities that drove higher infection rates in certain communities.

Dr Jennifer Dixon: If central government can't act, because it hasn't got the bandwidth and as time is short, as you say, Rachel, do you think that it will look to local government or be more permissive with local government to be able to do more? For example, local government can do quite a lot already on the health agenda.

Rachel Wolf: I think that's a really interesting question. And certainly, something that I think is a good area for people in the sector, if you call it sector about 34 different sectors, to push on because one of the few policy areas that was getting real traction before the leadership campaign and even during it was the evolution. And it is one of the few things that they can demonstrate in a couple of years that they've done that they've signed deals and they've devolved. So I think that's a very interesting area.

Dr Jennifer Dixon: Thank you. Isabel, any last word from you?

Isabel Hardman: I probably sound really cynical, and I'd love to read an analysis from somebody clever about when governments in the post-war era have actually trusted local authorities because I genuinely don't know. And obviously, one of the reasons the hospitals were nationalised was that Bevan didn't think that local authorities were in a position of strength to be able to administer them. And that got me thinking what stages have central government ever really thought. All local authorities are in a good state right now. I don't know, in sort of cynically, I always think, and this is probably because I've come from a housing background. That when central government talks about the power of local authorities, it's generally because they want to devolve and inverted commerce, a spending pot. Which actually in reality, turns out to be a much smaller amount of money than was being paid out by central government to a much larger number of spending areas, all of which should be priorities. But which the poor local authorities then have to do a Hunger Games with, and then get blamed for their bad funding decisions when they've got children's services competing against adult social care and so on. And the endless catastrophes that we've seen over the past few years just get repeated because you've got these devolved budgets that aren't big enough. And that's me being a bit cynical, but I am always now. Unless someone's in opposition, in which case, they can talk with real sincerity about how great local authorities are. Generally, when they're in government, I tend to think, what are they trying to cut and blame on someone else.

Rachel Wolf: Yes.

Dr Jennifer Dixon: Indeed. I think what I've heard from you both is that there may not be a coherent, overarching guiding star for fundamental big reform on the National Health Service. But, in any case, the current pressures will keep people focused in the next two years on pragmatic fixes. That Thérèse Coffey is somebody who is very detailed and managerial and pragmatic and will want to get on top of the detail and fix things for people. Social care there'll be some change, but we don't know what yet. And health there may be a mandate if the conservative went, won our next selection.

Dr Jennifer Dixon: So, thank you to our very incisive thinkers, Rachel Wolf and Isabel Hardman, all will be revealed as to the direction of the new government on health. Meantime, we await Isabel's new book on the NHS, so watch out for that. As ever, please refer to our show notes for links to relevant papers and articles we referred to in the discussion today. And next month, we'll be returning to health. Well, actually death. We'll be discussing what to do about death. I'll leave your mind to mull on that. Until then, stay well and see you next time.

• Rachel Wolf, Public First, A few thoughts on the Downing Street policy unit
• Rachel Wolf, Conservative Home, Truss’s in tray 3) Rachel Wolf: Levelling Up. There is no time for another new approach. The new Prime Minister must focus on delivery
• Isabel Hardman, The Spectator, Is Coffey good for health? Thérèse Coffey is expected to become Deputy Prime Minister and Health Secretary. What's the significance?
• Isabel Hardman, The Spectator, Can Liz Truss deliver, deliver, deliver?
• Hugh Alderwick, Health policy priorities for the next prime minister: Avoid zombie policies and invest in growing the workforce and reducing inequalities. BMJ MJ 2022;378:o1726
• The Health Foundation, Public perceptions of health and social care: what the new government should know
• The Health Foundation, Waiting for NHS hospital care: the role of the independent sector