The year that was – 2023

Jennifer Dixon:

Welcome to the Health Foundation Podcast. In this festive episode, our last of the year, we're going to be looking back at the pick of the pod in 2023. Of course, it's been a bit of a year, as we all know. The NHS itself under pressure; the health of the population not improving as fast as we would like, and economic inactivity in the working-age population being a stubborn issue. 

But it's not all gloom. In the autumn, to some surprise, we saw the government ditch its nanny state objections to create a smoke-free generation by bold action on tobacco. And there've been breath-taking advances in technology, not least artificial intelligence. A reminder that innovation and indeed politics opens up some new possibilities and hope for the future.

We covered all this and more in the pod this year. So let's start with population health. As the Health Foundation published new work looking at trends in morbidity in England up to 2040, a whopping 9.1 million people, that's roughly 1 in 5 of the adult population, are projected to be living with major illness by 2040. Kevin Fenton and Jeanelle de Gruchy reflected on the implications.

Kevin Fenton:

We've gone through a period of significant economic instability and change, and we know that's having an impact on poverty, is having an impact. Therefore, on health. We're also dealing with increasing impacts of the climate, climate health impacts, climate change and the need for us to adapt and to mitigate those changes as we move forward. And as we've seen with the pandemic, we've seen the widening of many inequalities and the growing social and economic drivers of those inequalities. So in summary, yes, let's focus on the demographic change and understand how that's impacting health, but let's also begin to think about how it intersects with other wider determinants of health, both emerging and emergent, and then think about much more comprehensive approaches to tackling some of the issues.

Jeanelle de Gruchy:

I do think it's a live concern and certainly your analysis shows that we do need to pay attention to the working-age population. The figures I was looking at was an increase from 15% disability in 2010 to 23% now. And if you marry that with the trends in the older age population, I think really does focus the mind in terms of the economics of that. I think it does need to be addressed with a view to that longer term policies that will make a difference, and creating a bipartisan view of the fundamental things that everyone should agree on or could agree on to try and shift things. Again, if you take the issue around obesity, what we probably need to be doing are quite difficult politically. Having an ability to have agreement across multiple parties will really be quite important. I think there's more work we need to do to think about what do we do to address a lot of the economic inactivity from a health point of view.

Jennifer Dixon:

So if there's to be a big wave ahead of morbidity to 2040, mostly driven by the ageing of the population, let's also not forget health inequalities. The health gap between the richer and poorer parts of the country are stark and not closing. In January, I was joined by Alice Wiseman and Clare Bambra to discuss ill health in the north east of England, and what to do about it. Here's Alice Wiseman, Director of Public Health in Gateshead.

Alice Wiseman:

There is significant differences in overall health and wellbeing of people in the north when compared to the rest of England. If we look at differences in life expectancy, there can be as much as 12 year differences for men and around 10 for women. And during 2021, premature mortality was around three and a half times higher in the most deprived parts of the north east than the least deprived parts. So there are definitely not only differences with the rest of the country, but also differences within the north east as well. And the leading causes that we are seeing locally around premature death includes external causes such as poisoning and suicide. Those real issues around deaths of despair. And that's particularly relevant for men, but also big issues around cancer and cardiovascular disease and digestive issues and respiratory conditions.

Despite really good progress around smoking, for example, we've had a 47% reduction in smoking prevalence since 2005, we're still higher than the England average smoking. If I look at the hospital admissions and deaths as a result of alcohol misuse, we're still much higher than the rest of the countries. It kind of lends itself to think about the conditions that people are living in and some of the behaviours that people are adopting to manage those situations in terms of the impact of poverty and the impact of poverty linking to depression, then linking to maybe a higher level of health-harming behaviours. So there are some really significant challenges that we're seeing play out in the north east.

Jennifer Dixon:

And here's Clare Bambra, Professor of Public Health in Newcastle.

Clare Bambra:

We can see that particularly over the last decade or so, the life expectancy in the most deprived areas of the north east has fallen behind that in, for example, that the south east. We've also seen that, for example, we've covid deaths being higher in deprived areas in the north east than in equally deprived areas in the south east. So there's something particularly perhaps structural about the long-term nature of a deprivation in the north east. And I think what we can think about is that the general long-term trend is that within the 2000s, there was improvements in terms of closing the gap between deprived areas and more affluent areas, both in terms of infant mortality rates and also in terms of life expectancy and other indicators such as smoking, for example, as Alice mentioned. And then since around 2010, we begin to see the north east falling further behind on various indicators.

I think there's going to be a lot of factors in play, but my personal view is that we have to look at the impacts of austerity over the last decade in the north east. The economy of the north east is more dependent on transfers from government in terms of public services but also in terms of, for example, child tax credits as were, and things like that. So we've seen a big reduction in finances for the north east, both for particular families in deprived areas, but also for the public services which they have to access more, perhaps than more affluent people. So I think we're in this situation where for a decade we've borne the brunt of austerity. We had a worse experience of COVID, and I believe we're having a worse experience of the cost-of-living crisis as well.

Jennifer Dixon:

Yes, cost of living, debt, poverty, and in particular the poverty of single parents with children. But how does this type of stress actually impact on the body? In March, I was joined by Nish Chaturvedi and Michelle Kelly Irving to find out. Here's Michelle setting out how chronic stress causes the body's delicate biochemistry to get out of kilter and harm us.

Michelle Kelly-Irving:

The basic idea around allostatic load is when you're exposed repeatedly to stressors in your environment, and you're interpreting these as being stressful conditions and the brain is sort of telling many of these physiological systems to sort of get ready and respond to this stressful environment in order to act. And, of course, this is a survival mechanism. This has allowed us to cope with our environments and get out of stressful or bad situations. But of course, if that response remains at a higher level, it doesn't come down to the normal basal level or in fact after a while that basal level itself is altered upwards. Well, after a while, it takes its toll on the body, and I think that's where we can start talking about allostatic load.

Jennifer Dixon:

So disentangling, the effects of the many different stresses on us is tricky, but researchers are making progress, given lots more access to data computing power, and of course artificial intelligence. Here's Nish Chaturvedi.

Nish Chaturvedi:

We have major advances in data availability and its depth and our ability to capture data. So for example, remote testing and wearables allows us to capture stressors much more accurately than we ever used to with continuous readouts of the physiological stress response such as heart rate, blood pressure, glucose and associated health-related variables such as sleep patterns and exercise. And we are better able to capture the end phenotype. So for example, at the moment we've talked about health events like cardiovascular disease, diabetes and so on. But increasingly with non-invasive technology, with imaging, we can capture quite subtle changes in target organs. And a really good exemplar of this approach is the US ABCD study. And in America they've set up the study called the Adolescent Brain Cognitive Development study, recruiting children across the country age 9 to 10 and performing, every 2 years, structural and functional brain imaging.

They're capturing measures of early life stressors, behaviours, parenting approaches, social networks and measuring the very subtle impact that that has on brain structure and function and outcomes like cognition, mental health, cardiovascular measures, glucose and so on. So we can really get at what are the determinants of optimal brain structure and function, what are the determinants of optimal physiological stress responses, and what optimal determinants of psychological coping strategies in that very young age group? And AI approaches can then help us to understand the effects of these stresses within the context of the wider exposed zone. So we're not just taking stress by itself, we're seeing, and what else associated with that, which includes material deprivation on these complex interrelated biological mechanisms and their associations with multiple outcomes. And AI can help us detect patterns that hypothesis-driven research may well miss. So I think this is a really exciting time.

Jennifer Dixon:

So more stress and more people living with health care needs. All this at the same time as a financial squeeze on the NHS. We now know nearly 8 million people are waiting to access NHS elective surgery. And in that context, 2023 has seen rising numbers of people going private to get care faster. At the same time, the NHS itself is buying more care from private providers such as for hips, knees, and for eye surgery. Sarah Neville and Hettie O'Brien joined the pod to explore all this. Hettie told us why the shape of the private provider market matters. There's a shift in ownership of private providers with more private equity firms investing in the sector. Here's Hettie.

Hettie O'Brien:

Private equity is quite an amorphous term in some ways because it can cover a lot of different types of investors. So that could be private equity funds or asset managers or even some pension funds that have developed their own in-house private investment arms. But I think from the perspective of understanding this in health care, it's probably most useful to see it as a sort of set of techniques that involve buying up companies and loading with debt and using probably higher amounts of leverage than you would otherwise expect. And I suppose because these funds have quite privileged access to finance and a willingness to use financial engineering in order to extract value for shareholders and investors, they can usually justify paying higher prices to acquire things like health care companies, meaning that they end up sometimes over-paying for those companies and loading those companies with debt in the process.

And I think there's something interesting about health care insofar as most funds are searching for businesses that have recurring revenues which generate cash, because cash can be used to pay down and service debt repayments. And health care is obviously attractive for that reason, but it's also one of the few sectors that are really growing quite a lot in quite a low returns landscape, and that's caused by a number of factors. So we have an ageing population, got people with growing number of chronic conditions, and we've also got medical advances, which mean that there is more types of treatment to spend money on.

So I think if you're an investor looking at this, you'd see that health care will be a quite sensible thing to invest in. There isn't much research that's been done on this in the UK, partly because it's a relatively recent phenomenon. So you're seeing them motivated more, I suppose, by waiting lists. So going into things like self-pay, kind of elective medical procedures, but then also because of those waiting lists, the government is saying we're going to open up our purse to the private sector. So I think we can probably see more of this in probably still quite a fragmented way, but I mean it's definitely a growing area of interest.

Jennifer Dixon:

So the aggressive drive for fast profit by private equity owners could compromise the quality of care. The jury may be out on these developments now, but they'll need watching closely, as Sarah Neville noted.

Sarah Neville:

The question I get is whether this growth in private equity involvement is going to prompt tougher regulatory action or is going to mean that a government, whether a conservative or labour is going to actually cast a sort of sharper eye on this. And I interviewed Wes Streeting a few months ago and he told me that an incoming Labour government would strip private equity run care homes of public sector contracts if they didn't meet certain quality and value-for-money standards. If private equity does become an ever bigger part of the health and care landscape, perhaps that that will increasingly attract the attention of the regulators and politicians.

Jennifer Dixon:

On the other hand, waiting for care must be hampering the health of the working-age population, which will affect the economy and productivity. And this in turn affects long-term living standards and reduces the spending available for the NHS. A link outlined powerfully by Jagjit Chadha.

Jagjit Chadha:

What's interesting you say about the connection between the economy and health, I would also draw another line from the health back to the economy in the sense in which if the NHS sneezes, the rest of the economy catches a flu. One thing we absolutely took away from terrible period of COVID and the shadow in which we still live is that there's not a trade-off between health and the economy. If you try and help people's health with lockdowns or some constraints on their mobility, that affects the economy in a negative manner. And there were lots of calculations about the trade-offs, but actually we now know very well that there's no longer run trade-off. The two snapped together very, very clearly. A healthy economy and a healthy population are things that move in lockstep with each other. And that is something we shouldn't allow to be forgotten as we emerge from COVID. And I would put that as the first principle on which you should guide policy planning both for the economy and in terms of health.

Jennifer Dixon:

Yep. Amen to all that. So with ill health growing and limp economic growth to power the NHS and social care, all eyes are turning to technology as a big hope for the future. Now, artificial intelligence has been a huge feature of 2023, particularly generative AI. The impact on care will be profound, as Axel Heitmueller explained.

Axel Heitmueller:

I would broadly agree that the two big areas are how it democratises knowledge and access to health care, whether it's in developed countries or developing countries, and also personalises health care. So the one-size-fits-all approach that we're mostly taking to treatment and care will probably become one that is much more tailored towards our individual needs that can pick us up where we are and that can give us individualised care plans and sort of interventions that we are only dreaming of now. I think I would add two other areas. Other industries have started with a mundane back office. The automation, the drive to be more efficient, health care hasn't started there and there's so much low hanging fruit. That's probably where a lot of other industries would've started, and my hope is that is developing or will be developing over the next few years more rapidly than it has. I suppose the other area is the whole drug development where AI actually has started to really make a big difference.

Jennifer Dixon:

Big questions then about the measures policymakers will need to take to manage the risks of AI and maximise the benefits. In the autumn, I spoke to Ashish Jha about how the US government is thinking about its role here.

Ashish Jha:

AI has clearly come very quickly onto this national stage as a tool that we have to put our arms around. I mean, this has been long coming in terms of development. But over the last year we have seen massive gains in AI technologies that is going to have a profound impact on health care. And we really have not thought through how to maximise the benefits, how to manage the risks.

Jennifer Dixon:

And it seems everybody's at the similar point. Or at least if you think about the US as today, there's been a White House executive order. We've had the EU AI Act that is about to be passed; in the UK, a white paper on regulation, pro-innovation regulation. Can you just say a little bit about where you are in the US about policymaking to guide sensible AI development?

Ashish Jha:

Certainly the White House, other parts of the US government I think recognise that we need a strategy here, that leaving this a completely unto itself, letting the market drive it fully is not going to lead to optimal policy outcomes. There's some very complicated issues here. I mean, how do you regulate AI? What are other policy tools, accreditation, financial incentives? There are other ways of achieving optimal social outcomes. And I think what we're seeing is the US government get involved in that conversation, lay out some groundwork for safety and protecting people, but also starting to provide guidance to the marketplace. Because we know there's going to be a very large private investment in this area, and we want to make sure we guide that investment in ways that really improve health and wellbeing.

Jennifer Dixon:

So, we talked about the kind of principles that should guide sensible development. First among all of those was safety. And I think everyone would agree that these systems have to be safe in health care. But also we talked about access, about inclusion. We also talked about cost benefit. How active do you think a pro-innovation US federal government would be interested in going beyond safety and into some of these other areas that sound a bit like big government, don't they?

Ashish Jha:

I don't think you're going to have the federal government prescribe exact specifics of which tools can and cannot be used for what purposes. But I can imagine, for instance, Medicare, which is the largest air of health care in America, setting out some very specific pay for performance or other kinds of programmes that encourage certain types of health care services or health outcomes that can then drive AI investments in those areas. I can imagine the Federal Trade Commission being very involved in making sure that AI systems are competitive and that there is not a monopoly by one organisation. So you are, I think, going to see the government play a very specific role, not in shaping the entire market, but making sure that bad things don't happen, and also making sure that we're pushing towards better outcomes for patients and for people.

Jennifer Dixon:

So all very exciting and important, but let's not get ahead of ourselves. John Bell brought us back to reality.

John Bell:

The problem with the IT systems that we currently have in health care is that they were designed 20 years ago, and they're really clunky. And you don't need any AI, you just need a system that works. And we all spend all day every day on our phones getting all kinds of information quickly, efficiently communicating with each other, doing all that stuff. We've got a generation of now young people, everybody under the age of 40, has lived in that world. They then go and work in a hospital, they end up with a computer terminal that takes five minutes to boot up. It produces a green screen like we had 30 years ago.

I think nobody would have a problem about IT enablement of what you're doing. Because we've seen it in every other walk of life, and it just makes things faster, more efficient and slick. The problem is that we've invested in a set of systems that do exactly the opposite. And you are quite right, Jennifer, to point it out. Because when I talk to junior staff and medical students and young doctors, the thing that frustrates them most is that simple things will take 20 minutes on a terminal, where the quality of the processing and the quality of the tech function is terrible. So forget AI, just get a bit of tech that works in my view.

Jennifer Dixon:

So transformative tech is all well and good, but remember the basics. This needs capital investment, which the NHS is very short of. The basics also include good management to improve efficiency and productivity. And here's our very own Anita Charlesworth on this.

Anita Charlesworth:

We've tended to think about the quality of management within individual institutions, and clearly that matters hospitals and whatever it is. But actually we think an awful lot of the productivity gains that are available for the NHS going forward are about pathways, about running the system as a whole really well, earlier intervention, more prevention to reflect the fact that we've got multi-morbidity, treat people holistically rather than body parts with services that are able. To do that, fewer handoffs between them, which is often a point of inefficiency and poor quality. And that's why we're moving away from that quasi market model towards this system level with the integrated care systems. But these are organisations that are in their infancy and the task of management is very different. It's not so much a technocratic task, but much more of a relational task. Because this is about persuading lots of different organisations with different types of accountability.

So private sector providers in social care, local government, local businesses, all those NHS organisations, GPs and all the independent contractors, to work together and to work in a different way and to move resources around. And I think one of the issues, when you start to look at this, is very few people don't think that that is the right direction of travel. But actually as is so often in the parallels with wider economy, UK management in the 1960s, et cetera, was seen as not as good on average as many comparative countries. And we invested much less in management training. We were so amateur about management and we've put the ICSs in.

There's really very little support to ICSs around the leadership and management challenge and how different that is and where that comes. And then you think the other big opportunity, going forward, is to move to system and then to design a new system that has technology at its heart and is really fit for the 21st century, rather than the 20th. But where is the real, again, support offer to people and the advice and guidance and infrastructure for improvement around how you properly embrace technology? And in that regard, the NHS is just a microcosm of some of the problems and our economy as a whole.

Jennifer Dixon:

Yes, indeed support. But just where are the patients in this tech revolution? Here's Navina Evans.

Navina Evans:

So I think primary care is doing a big piece of work in this space. Because a lot of scrutiny about face-to-face appointments... And quite a lot of people want face to face, but quite a lot of other people don't want face to face. The health care system isn't catching up with how people want to live or isn't keeping up rather, whereas retail and leisure, they're doing it all the time. They're keeping up with their customers and what their customers want. Whereas we are like, oh God, this patient's really demanding and being really difficult. Well no, we're the customers, so I'm talking about myself as a patient. So that's something I think for us in terms of the leadership community in health and care sector about keeping up with what our service users expect and need and have a right to.

Jennifer Dixon:

And Penny Pereira agreed.

Penny Pereira:

I think one of the lessons here is that actually we maybe introduce technologies very quickly. We particularly did that a lot during the pandemic. We saw them have quick uptake. I think it would be really disastrous for policy leaders and managerial leaders to present that as job done or think that you can simply scale from there. Because actually what we're saying is that we do now need to go back around the loop and make sure that we're doing the detailed work that understands, okay, which patients in which scenario will this be the right thing?

Jennifer Dixon:

So technology, yes. But it's used has to be designed with patients from the start and by skilled up competent managers and clinicians who are supported to make the change. Simple, isn't it? So one issue that particularly reared its head this year was the challenges that women experience working in health and care, not least in surgery. In March, to mark International Women's Day, I was joined by a panel of three generations of leading female doctors. In this clip, we'll hear from Gabby Matthews, Nikki Khanani and Jane Dacre.

Gabrielle Mathews:

I don't think, to me that means that we've made any change on the position of women in medicine just because more women are coming into it doesn't mean that more... And the data says aren't taking up leadership positions or I guess have the space in their career to do what they want. I think to me, the measure of success is if you ask a woman in medicine what they're passionate about and what they'd like to pursue and they're able to do it, then I think we can say that we've been successful. And I don't think we're anywhere near that and we're nowhere near where I think I'd like to be in terms of equality and leadership positions and in research funding distribution.

Jennifer Dixon:

Nikki, do you agree with that?

Nikita Kanani:

I remember my mum applying for medical school, bravely as a migrant to this country in the '70s, and not getting in. And I love the fact that so many women are joining the profession. And I think for our patients, for our communities, having that breadth of diversity across all protected characteristics is hugely important. But as Gabby says, there's more to do and there's some very fantastic role models in and around our health service who will help us do that.

Jennifer Dixon:

And Jane, what's your perspective sort of later on in your career?

Jane Dacre:

I think it's an awful lot better than it used to be. And so I think that's quite an important point to note that we have come a long way. But I think that the structures of the NHS were set up for the 1950s male and they haven't changed enough. And the gender pay gap, the fact that it's so wide, wider than any of the other elements of the public sector suggests that we're not reaching equality in the way that maybe we should be. And I think affects decision-making in the NHS.

Jennifer Dixon:

Progress then, but slow going. And in the meantime, many women still having to pull themselves out of shape to adapt to a male environment, or be blocked or worse. It's the 21st century folks, and we're still facing far too much of this rubbish. So looking ahead, 2024 will almost certainly be an election year. In October, I was joined by seasoned commentators, Rachel Wolf and Stephen Bush on what we can expect. Here's Rachel.

Rachel Wolf:

I think this is going to be a policy-light election in general, and it's going to be more about failures of record versus ability to make the sums add up, than it is going to be about radically different visions about what you would do with public services. We're obviously in a relatively low economic growth, relatively high taxation and spending scenario by British standards at the moment. And both parties are very nervous about making big promises, because they don't want to say that they're going to substantively raise taxes to fund them. I think you are going to be in a situation where people talk less about the NHS than you might expect, given there was a poll that came out about a week ago that when you ask people what they're most disappointed by, in terms of the government's record over the last decade, health comes higher than the economy.

Health is a thing that people feel the government has most failed. I don't think health reform is a big part of how the conservatives are thinking right now. I'm not seeing huge numbers of ideas emerging, and I think there is very little appetite to do health reform. Lansley cast a long shadow, and people are very hesitant about health reform in the Conservative party. I think there's sort of excitement about bits and pieces like technology, but without a huge amount of specificity underneath it. I think the interesting thing is all the incentive is still to push for more headline staff numbers. More nurses, more doctors, more training places. And that's on both sides. There seems to be very little evidence that that's the big constraint in the health service right now.

Jennifer Dixon:

And Stephen brought some fascinating texture on how a Starmer Labour government might shape health policy.

Stephen Bush:

Well, this is the fascinating thing, right? Because essentially all of, with the exception of the Ministry of Defence and of course the Climate Change Department where Miller Band is, all of the spending departments and all of the delivery departments on the Labour side now have a Blairite, or at the very least Blairish politician in them. They will still have quite blurry ideas about how to reform the public services. But you can feel that they have this anxiety that they go, okay, well, I know that that's not Keir Starmer's original political trajectory. Am I here because I've been loyal, I've done a lot of media, when he was trying to modernise the party and tackle the problem of anti-semitism in Labour ranks. Is it then he's just had to attack more to the right than he would like? And ultimately, I think that's a question that's only going to be answered when they get into office.

You can see in terms of the stuff Wes Streeting was talking about publicly, and some of the stuff he talks about privately, what does effectively look like a return to a kind of Patricia Hewitt like approach. Eroding more of the powers of GPs, returning to some would say Labour's traditional hostility to small GP practices in particular, focusing on that type of NHS reform. And of course focusing on anti-smoking measures of the kind that Patricia Hewitt drove through with a great deal of internal resistance. But whether or not that's where they actually land in office is the big known unknown. Because Keir Starmer is still is a bit of a black box for essentially everyone not called Keir Starmer.

Jennifer Dixon:

So potentially a general election devoid of detail on health and care and a new government whose public service agenda is a big unknown. We've been here before, haven't we? But to close, let's turn to a discussion we had with seasoned politicians, Alan Milburn and Stephen Dorrell, both former Secretaries of State for Health, who know all about the challenges of crafting a policy agenda in the face of challenging headwinds. They both look forwards and set out what the future might hold.

Alan Milburn:

I think a big focus, perhaps the primary focus for governments going forward in the future has 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 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. A 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.

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.

Jennifer Dixon:

Ah yes. And these themes we're going to be covering on the podcast in the covering months. But let's end the year with some cheer, perhaps a glimmer of optimism for the NHS from Alan Milburn.

Alan Milburn:

And let me give you one more reason for optimism. Which is that the crisis, in my view is, 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 for 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, shape, or form, is going to have to step into this space. Because the alternative is that the system simply becomes unsustainable.

Jennifer Dixon:

So that's the wrap for 2023. We look forward to returning in January when we are going to be looking again at the health of the working-age population. Because with more jobs now than people available, with 2.6 million people who are economically inactive due to ill health, what solutions are there? We hope you'll join us then. As always, thanks for listening. The links to all the pods we've mentioned here are in the show notes as usual. So for now, thank you to all the guests who've joined us throughout the year, to colleagues at the Health Foundation who support the pod, to Paddy and his team at Malt Productions for expert support and great fun, and best wishes from me for the festive season and from all of us also at the Health Foundation.