NHS at 75: Is political leadership up to the challenge? – with Alan Milburn and Stephen Dorrell Episode 33 of the Health Foundation podcast

Dr Jennifer Dixon: 

For the NHS's 75th anniversary in July, this is the second of three podcasts on the challenges and opportunities of the service ahead and how best to respond to them. Last month, we set out the big challenges on the NHS from demographic change, a global workforce shortage, and low economic growth but also the huge opportunities from technology. One conclusion was the need for a long-term stable strategy to manage this challenging environment. Fittingly then, in today's podcast, we are going to be looking at political leadership and ask, is it up to the task of getting the NHS to its 100th? And if not, how could it improve? Well, with me to discuss all this, I'm very excited to welcome two experienced former secretaries of state for health, one Labour, Alan Milburn and one Conservative, Stephen Dorrell. Alan Milburn was a Labour Member of Parliament for Darlington for nearly 20 years to 2010. In Blair's government, he was Chief Secretary of the Treasury and then Secretary of State for Health until 2003. Since then, he's been chancellor of Lancaster University and he's also been described as the epitome of Blairite centrism and moderation. 

And Stephen Dorrell, who was Conservative MP for Loughborough and then Charnwood for over three decades, 2015. He held many senior roles in government under Margaret Thatcher and John Major, being Secretary of State for Health from July '95 until the general election of May '97. He also served four years as chairman of the House of Commons Health Select Committee. And then he stepped down from Parliament in 2015 in the general election and subsequently became a member of the Liberal Democrats. Welcome both. So I think maybe the first question is, before we get to the future, it's really your take on the situation in the NHS and how it's been gripped or not by the current political leadership, Alan. 

Alan Milburn: 

Well, look, this is the worst position I've seen the care system, and by that, I mean social care, as well as healthcare in 30 years around public policy. I mean it really is extremely tough. I mean people thought that going through COVID was the hard bit and obviously, it was extremely difficult, but in retrospect that was the easy bit compared with the pressures on the system now, where you've got endemic staff shortages, you've got a mental health crisis like the country's not seen before. We've got the exposure of health inequalities that COVID so dramatically highlighted, and you've obviously got the waiting list problem, the collapse of primary care and social care. 

So it's a pretty bad picture, but what compounds the felony is that there's no plan to deal with it. As far as I can see, there's no governing philosophy about how the system should actually operate, how it should be run if you like. And the biggest shortage in the NHS right now is the shortage of hope. And people that you talk to in the system are demoralised in a way that I've frankly never seen before. And so look, it's really bad and if it continues like this, the system will become unsustainable. And so the question really is, what we need to do to turn it round? 

Dr Jennifer Dixon: 

Stephen, is that your take on events and if that is how did we get here? 

Stephen Dorrell: 

Well, broadly yes, it is my take on events. The thing that Alan said that I most strongly agree with is that not only is this are the different stress points in different parts of the system, we are daily reminded of the basic truth that everything from the acute hospital sector through to social care and that indeed related public services. There's a tendency I think to think that health and social care are somehow something that's discreet from other forms of public service, social housing, other forms of local government support for communities. 

Actually, they're all of a piece. And the favourite provocation of mine is when a local authority cuts a library service, what it does is remove a meeting place, increase isolation, and that increases stress all the way through public services. Public services are a continuum, and the biggest mistake is to imagine that you can adjust spending in one level, cut spending, you avoid the euphemism and it doesn't have an impact somewhere else. And too often, the NHS and in particular, the acute hospital sector of the NHS is what picks up the pieces when other parts of public service are cut back. 

Dr Jennifer Dixon: 

And how much of this diagnosis is clocked in government? Is it a failure of understanding all of these factors and where the dots are joining and creating problems or is it that this is seen, it's just the kind of absence of ideas or will to acts is the issue? 

Stephen Dorrell: 

It is too easy to react to today's headline, whether it's any one of the issues that Alan mentioned, or you could mention a dozen others that are the headline story on the day. And both Alan and I have been familiar with the pressure that creates for a politician to react to the story rather than deal with the problem and other people in government who understand the fact that this is all joined up. Of course, there are others, highly intelligent people both within the government and of course, in the civil service that supports them. The challenge is creating the political space to do something more than reacting to the story. 

Dr Jennifer Dixon: 

And is that your assessment there, Alan? 

Alan Milburn: 

Well, look, this particular government looks doomed to defeat at the next general election. And so, of course, governments towards the end do run out of steam, but it's more than that in my view. The position that we're in is not just because of austerity or mismanagement or misplaced reforms. The truth is, and this is where you need such a searingly clear diagnosis of what the problem is, there are all those factors, but there is a series of other factors as well, which are deeply structural and long-term. And the truth is the care system is out of kilter with the world in which we now operate. There's a huge mismatch between supply and demand. Demography and disease have changed. The pressures on the system, obviously you've got on the supply side, massive shortage of staffing, 300,000 people short in health and social care. But more importantly, you've got a series of structures and incentives that, as Stephen was indicating earlier, put people in the wrong part of the system. 

We know that one in four people who are in hospital can be prevented from being there. One in five emergency admissions can potentially be prevented. But what happens is that the acute sector continues to suck more money away from primary and community services, when what the accent should be on is keeping people healthy and out of hospital. So the needs to be a fundamental diagnosis of what the issues are here and then solutions that are appropriate to that diagnosis. And that seems to me to be about how you move the system from a treatment bias towards a more prevention bias? How you get citizens engaged? How you get health and social care working together? That would be a step forward, of course, as two parts of the same system, but also how they work with others, both in the public and the private sectors to address these fundamental challenges. 

And that requires a long-term plan. And the truth is we haven't had a long-term plan for a very long time. So you've been in these boom and bust situations of austerity then about to spending, then it's turned off again. Capital has been cut back and because it's the easiest thing to do to switch from revenue to capital, and not surprisingly, the NHS is not where it should be on technology or productivity. And it's missing the opportunity. And this is the most important thing of what is a revolution that is taking place worldwide in healthcare as a result of genomic advances and advances in artificial intelligence and other technologies. So it needs a fundamental rethink. And I now no longer talk about reforming the system. I now talk about how you reinvented it. 'Cause what you need is an NHS 2.0 here to address these fundamental structural problems. 

Dr Jennifer Dixon: 

I mean, if there isn't the political space and just think back over the last couple of years or three or four years, how much has gone on that has taken everyone away from the long-term. But if there isn't political space for that, where should the space be? Which is a more technocratic sort of evidence-based diagnostic of what's going on. Where should that be in government or is it just a naive thought that perhaps the Cabinet Office should carve out some space? Do they need political cover to do that, or should they just be doing that anyway? 

Alan Milburn: 

It's entirely possible to create space and to create permission. I mean, if I think back 20 odd years, when I published the 10-year NHS plan in 2000, my biggest concern at the time was that... because there were some fundamental long-term changes that were needed and it was going to take time, the public wouldn't give you the gift because the system was crashing and burning. By the way, nothing compared with what it is today. But the truth is the public are a bit more grown up than the politicians sometimes. And they knew fine, well that it was going to take time to turn the waiting list problem around, et cetera, et cetera. So I think this is really about the art of political leadership because so much of political leadership is about, particularly when it comes to public service reform is about buying time and creating permission. 

And that's why I would say that I'm very pleased with what we're treating, and the Labour Party are now doing because they're talking about, but there's details to be filled in and all that. But they're talking about the notion of a 10-year plan for change. And that's absolutely right because the temptation is to be drawn into both the here and now, but more importantly into promising things that simply can't be delivered in the short-term because they require such long-term transformation. 

Stephen Dorrell: 

I also think that there's an important point to be drawn out here. I don't think you can exempt the politicians from the requirement to create this space. Of course, NHS management and civil service support and so forth, can do some of it. And indeed, Simon Stevens did I think a tremendous job in creating a rather different narrative around integrated care from the one that he inherited from Andrew Lansley. So full marks for that. But you can't exonerate the politicians. And I think there's a real challenge here for politics, which is to move on from a culture which says public services are there to solve your problem, to create a space where we don't encourage dependency, where dependency isn't either necessary or actually what the individual citizen wants. 

And so it's a different narrative. It's using digital technology using integrated services so that we create supportive communities. There is such a thing as society, it's creating a supportive society with, of course, the public services that are required when they're required. But not, for example, as a simple way of expressing that over medicalizing or making things into medical problems, when actually if there were proper social support and proper communities, the demand wouldn't be there in the form that it currently is. 

Alan Milburn: 

I think the real thing that has changed since our day is that, of course, successive secretaries of state always aspired to move the system towards a more outcome focus, more preventative model and so on. But the truth is, in very many ways, we lack the tools to enable us to do so. Wind forward quarter of a century, and actually the tools exist today, and this is for me, this is why the mood of pessimism, which I really, of course, understand within the system. People need to reflect a bit about what's actually happening here because there are very strong grounds for optimism in the sense that the alliance, the synergy if you like, between the genetics revolution and the machine learning revolution can potentially create a very different type of system. One that's much less focused on diagnosed and treating illness rather than predicting and preventing it. 

Now I think if I were in office today, my number one priority, of course, you've got to deal with all the short-term things, but my number one priority in terms of the long-term agenda would be about how do you harness this revolution to change the fundamentals of the system to one that is much more citizen engaged, much more patient empowered, much more predictive, much more preventative. And that will require wholesale changes in how we train staff? How we procure infrastructure and how we deliver services? And I think there is... look, and if you've been in politics, believe me, you've got to be an optimist, right? But I'm very optimistic about it, precisely because you can see for the first time the ability to join the theory with the practise. And I'm really excited and inspired by that and I hope that a future government will because it can bring about meaningful change that is going to fundamentally change the way that we think about healthcare. 

Stephen Dorrell: 

I totally agree with that and that's why I think Jennifer's question, is this something that can be done without politics? The answer to that is an emphatic no, because there is a requirement to create a narrative around that type of citizen engagement, supportive community. Actually, the way you deal with waiting times outside A&E departments is not to buy more ambulances, it's to create healthier communities. And that's a much more positive, much more optimistic, but actually much more challenging narrative. 

Alan Milburn: 

And I think it's important that we remember that the fundamentals of politics here are really important. Most people, whether they're from the right, the left, the centre, they come into politics for good reasons, not bad. They come in to try to change things for the better as they see them. And what does change begin with? Change begins with an argument. Change begins with a proposition. Change begins with a debate. And what I would love to see is the political class engaging with the opportunities in health and social care as much as they engage with the challenges because there is a different vista here, but it is about constructing an argument. And look, the world is a crazy world. So political leadership now more than ever, it's about the job of explanation. It's about explaining where we are, but what could be? and that's really what we've got to look to the politicians to do. And, of course, you can have great leaders in the system or in the civil service, but that's the job of politics. 

Stephen Dorrell: 

Yeah. Can I just illustrate that with an anecdote, Jennifer, because I think Alan and I are on identical squares here. I went to a local authority conference a couple of, about a year ago I suppose, and was talking through the integrated care narrative and the supportive communities, all that very familiar territory and local authority leaders were explaining to me how difficult it was for them as people with budget pressures and so on, to engage with the health service because they saw the health service as somehow a foreign land and something where they were nervous about engagement. Actually, until there is that political engagement at both the local and the national level, then the kind of positive forward-looking narrative, we're talking about won't be created. It can't but just be a dialogue between front benches and the House of Commons. It has to engage political leadership at both national and local level. 

Alan Milburn: 

And let me give you one more reason for optimism, which is that the crisis in my view is, and I know it's an overused word, but I genuinely think in this case it is true, it is so bad. It is on such a scale that simply tinkering around the edges with the system and providing a bit more money here if you can, a bit more investment there, a few doctors, a few nurses and so on and so forth. It isn't going to change the fundamentals. The fundamentals are that you've got a system that was invented in the mid-20th century from mid-20th century challenges, and you've got to transform that into a system that is fit for purpose so that it can move with confidence from a 75th anniversary to a 100th anniversary. And that is going to require quite fundamental change. So nature abhors a vacuum and so does politics. And what I actually believe is going to happen is that the political class in one way share or form, is going to have to step into this space because the alternative is that the system simply becomes unsustainable. 

Dr Jennifer Dixon: 

This sounds like strong, stable, intelligent political leadership is needed. And as we know, past history, yourselves accepted have been littered with slightly random secretaries of state, if I can put it that way. 

Stephen Dorrell: 

I don't know why you exempt us. It's very generous...

Dr Jennifer Dixon: 

And you just have to read the IFG report on how to be a Secretary of State. You see the ramshackle way in which people are hired and then sort of left alone and they don't know how to do the job, et cetera, et cetera, you know all that. So if this really does require a 10-year strategy, or at least stability and at least clocking the diagnosis, how are we going to move forwards from this rather random sort of set of leaders? 

Alan Milburn: 

I think you've got to be a bit careful because that's a bit of a council of despair to be perfectly honest, that they're all crap, they're all haphazard and I just don't buy it because politics has achieved amazing things. If you think about the welfare state at the creation of the NHS modernization programmes that you've seen in the past and so on and so forth. 

Dr Jennifer Dixon: 

But there's a lot of chop and change, isn't there a lot of distractions. 

Alan Milburn: 

But that's not going to change. I mean, to be honest, that's just part of... unfortunately the- 

Dr Jennifer Dixon: 

The warp and weft. 

Alan Milburn: 

Yeah, that's just how it is sort of thing. The question is, how do you create? And this is where I think the burning platform in an odd way helps you. It is so bad that there's got to be a strategic and long-term view taken about what's needed. And I think one of the curses of modern politics has become this awful sort of short term as a move from one issue to the next without any sort of focus for the medium or long-term. And the truth is, if you look at the challenges that the country faces, well beyond the care system, whether that's the net zero transition, how we get energy security? How we deal with the challenges of an infrastructure in a new world? How you harness technology more broadly? They're simply not amenable to short-term fixers. 

Dr Jennifer Dixon: 

No. But then how do you protect against the risk of short-term as secretaries of state who appear? Is there something that could be more binding, I don't know, coming from central government that can somehow put some parameters or guardrails around Secretary of State. 

Alan Milburn: 

Let me give you one idea which is sort of in that space. One idea would be that, look, one of the things that's really bedevilled, the ability of the care system to plan for the medium to long-term has been this awful annualised system of financing the NHS and social care. And I think we've got to move away from that. And there needs to be, in my view, an agreed over transparent long-term funding settlement for the system or a period of parliamentary term that gives the NHS and people in social care, the opportunity to plan the transformation that I believe is necessary. Now, people will always say it's never enough money, but if you get line of sight, it does give you the opportunity to plan. That's the first thing. 

The second thing is, I think it's really very important that people within the system make it more possible for the politicians to behave in the way that they would like them to be. And this is not a criticism of people because I understand what it's like when everybody's back is to the wall, but people have got to find a way to get the heads up and they've got to find a way, in my view, to stop defending the system as is and think about the possibility of what it could be and make the arguments for change because there's one thing that politics and politicians respond to. It's a market. 

Stephen Dorrell: 

Jennifer, the question you ask about how do you create this kind of long-term narrative that various different ways, we're talking about all through this conversation, I don't think you can do that through institutions. I think that it comes back to the point Alan and I, I think agree about, which is that it's political leadership. And the point I wanted to make was that chopping and changing the health secretary, that the health secretary is only responsible for part of this broad system of public services. And actually, it is about a political narrative that binds a government as a whole, just as the same way I agree with what Alan was saying about the net zero challenge. If a government as a whole doesn't embrace the challenge, then we won't deliver. And if the government as a whole is committed to it, then actually chopping and changing the personalities of different secretaries of state a relatively secondary. 

Dr Jennifer Dixon: 

Yes, that's true. I mean in a sense the green agendas has got the net zero target and there's international pressure. Do you think we need some kind of target for the health and social care system then to bind people into a sort of target for the future? 

Stephen Dorrell: 

Well, it's much less pronounced, but there is, of course, a UN development target associated with Universal Health Care, which you could make a bit more of. I think, actually, when the prime minister and the chancellor start talking about health outcomes, about communities, when the prime minister doesn't appear as certainly John Major, I think would plead guilty to doing in my day, and frankly, Tony Blair did in Alan's day as well. They pitch up when there's a good headline story, but how often do they actually make speeches about the kind of issues we are talking about? In truth, neither of them did he on a sustained basis. If Universal Health Care, the delivery of improved health outcomes, doing all the stuff that we're talking about is to be a core objective of a government. It has to be articulated from the top. 

Alan Milburn: 

I think there's a lot in that, Stephen, I think a big focus, perhaps the primary focus for governments going forward in the future, it's got to be about exactly the word that you used, which is about outcomes. And so the big challenge is how do we improve healthy life expectancy in this country? And that requires, of course, the NHS and social care, but it requires a wholesale effort on the part of communities, institutions, both public and private. And it requires the whole of government to cooperate. So just in the way that you see the beginnings of net zero or being a galvanising objective for the whole of government. I'd like to see the idea of healthy life expectancy and its improvement being a galvanising objective for government and much should be reflected in machinery of government changes. And it would be good for example, to see the prime minister chairing a Cabinet committee that deals with that and the treasury represented by the chancellor and the Cabinet, not just represented by the Secretary of State because then it becomes this objective. It becomes the property of every government department rather than just one. 

Dr Jennifer Dixon: 

Just in terms of the major ingredients of reform ahead, you've mentioned some of them, technology, citizen engagement, integrated care, better working between local authorities and the NHS. Are those the main headlines? Are there others? 

Alan Milburn: 

Well, I think those are some of the principle ingredients. There's a lot more to be honest, because I mean certainly my learning from being Secretary of State is that you walk into that office and you assume if you pull a big lever then something will happen. And what you find very quickly is that very little happens. And what you need is to create an invent if you like, a multiplicity of levers. So those are some of them, but there's a real question about how you get money working in the system to reward the right behaviours because not just about the level of money, it's how it's used as well as the level of it. It's about some important structures. Have we got the structures, right? I'm not advocating a wholesale Lansley style reorganisation of the NHS, but the truth is we are right now, we've got a spaghetti soup of organisations that is deeply confusing to most people working within the system. But there there's always got to be a galvanising principle. 

The galvanising principle has really got to be, how do we harness the big benefits that technology is going to bring to produce a very different type of healthcare system? And the thing that I like about this is that it provides the opportunity not just for engagement with the politicians, but it also engagement with civil society, the private sector technology companies and others who all are interested in this space and have something to contribute. So you've got the making of a national mission for change here. 

Stephen Dorrell: 

The national mission, it has to be a government objective. You have to have the education secretary talking about child health. You have to have the housing secretary talking about the impact of housing on health. If health is delegated to the health secretary, then we missed the point completely. This is about creating healthier, happier lives using all the instruments that are available to government. And it isn't about government just micromanaging public services. It's about a government creating a policy context across the public sector, the private sector, the third sector as well, where the government is judged by its ability to deliver better health outcomes for citizens, whether it's through hospitals or houses or libraries or schools or whatever. 

Dr Jennifer Dixon: 

Clearly the next election's going to be very fraught, isn't it? And it may not be clean either way, meaning a majority. If we are in a hung arrangement, how confident are you that we could make progress on this? 

Stephen Dorrell: 

Alan's views on this probably won't have changed a huge amount since he was first elected. Mine have changed fundamentally in that I started as a conservative, I'm now a Liberal Democrat, and I actually think that part of the problem in the discontinuity of public policy is the laboratory, the assumption not just on the part of the parties, but a lot of the political class that the only alternative to a Tory government is the Labour government. And I argued throughout my time in the House of Commons for one, the first pastor post. I actually am strongly in favour now, changed my mind on that completely of a more proportional system that allows shifts in the opinion of the electorate to be reflected more accurately in the House of Commons. I think that would create a significantly more stable environment for policymaking around this issue among many others. 

Alan Milburn: 

Look, I think there's a lot in electoral reform. I'm a supporter have of it. I have been for a very long time. So that makes a lot of sense. In terms of the potential for a home parliament. I mean look, time will tell, but the truth is whatever the results of the next election throw up, the fundamentals are not going to change. The fundamentals are you've got a system in wholesale crisis and that's simply outdated. As I say, I really do believe it's drinking in the Last Chance Saloon here. I'm worried about what happens after the election, not so much because of whether, I think it's almost inconceivable that the Tories can win a majority, but it's possible that they can deny Labour a majority. I'm concerned about that because it makes things much less clear. But I'm also concerned about what happens to the politics of the Conservative Party post the election. And I think it seems to me to be pretty clear there's going to be a massive move to the right. 

And I think for the first time that could well threaten the political consensus that has been achieved in this country, which is that the National Health Service funded from general taxation based upon a very important principle around need and not ability to pay. I think that consensus could be under threat. 

Dr Jennifer Dixon: 

But just to finish on a positive note, you generally seem to be quite excited about the possibilities of harnessing technology as being the biggest hope. Is that true, Alan? 

Alan Milburn: 

Yes, very much. So I think that technology provides, I think the opportunity to do what many in the health field have always wanted to do, which is to move from a system that's just about providing a safety net of treatment and instead opens up the possibility of a more proactive system that is about identifying illness before it arises and then dealing with it. And so I think this is the big opportunity, and it's very interesting when I look at what the Labour Party and Wes Streeting are saying nowadays, that seems to be very much at the core of what they're thinking about as a big mission for government. And if that's the case, that's pretty welcome. 

Dr Jennifer Dixon: 

The question is, can we do it fast enough? So that is the big question on the table, isn't it? And can we harness AI as fast as more effectively than we have to date, in fact. So last word, Stephen, on all of this, the future, are you optimistic? 

Stephen Dorrell: 

I am optimistic and I agree with what Alan said about the importance of technology allowing us to do things we've talked about often enough and fail to deliver. I think what we have to understand, technology by itself won't do it. The challenge is to ensure that technology supports a different pattern of behaviour so that we don't just wait until people are ill and treat them so that the NHS is not simply a rationing system for access to care. It's part of a network of public services designed to support healthy living. And that's a completely different thought process from the one we've been used to. 

Dr Jennifer Dixon: 

So sadly, we've got to leave it there. Fantastic insights. Thank you so much to Alan and Stephen for the sober analysis. For those of you interested in the politics and the role of the Secretary of State, I really highly recommend a book that we published a few years ago called Glaziers and Window Breakers, written by Nick Timmins, formerly of The Financial Times, published by The Health Foundation. You can see it on our website, and we'll put a link into the show note. And next month in our final episode, focusing on the NHS at 75, we're going to be looking forward in a bit more detailed to how to adapt the service to this wave of new technologies and treatments coming our way. So look forward to that next month. Join us then. Thank you for listening. Thanks to Kate and Leo here at the Foundation, to Paddy and Louise at Malt Productions. And it's goodbye from me, Jennifer Dixon. Until next month. 

• Institute for Government (2019) Becoming secretary of state  
• The Health Foundation (2020) Glaziers and window breakers: former health secretaries in their own words 
• The Health Foundation (2021) The most expensive breakfast in history