The 22 March marked the first 100 days of the new Conservative government, led by Prime Minister Boris Johnson. Helen McKenna sat down with Michelle Mitchell OBE, Chief Executive of Cancer Research UK, Alex Thomas, a programme director at the Institute for Government, and Paul Corrigan CBE, former special adviser to two Secretaries of State for Health, and a former policy adviser to Tony Blair during his time as Prime Minister. Together, they explore what these first few months can tell us about the government’s intentions for health and care, as well as how – in this new political environment – organisations can influence and affect change.
- Health and care: the first 100 days of the new government
- What’s your problem, social care? The eight key areas for reform
- What are health inequalities?
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HM: Helen McKenna
MM: Michelle Mitchell
AT: Alex Thomas
PC: Paul Corrigan
HM: Hello, I’m Helen McKenna and I’m a Senior Fellow here at the Kings Fund. The episode you’re about to hear was recorded on 10 March and focuses on the first 100 days in office. Although the 10 March was only a couple of weeks ago, our world has changed a lot since we recorded the episode. Covid-19 has developed rapidly affecting us all but particularly impacting on our health and care systems and the incredible people who work in them. Over the coming weeks and months, we will be thinking about how we can use future episodes of the podcast to focus on the impact of this virus and to shine a light on how people working in health and care are dealing with these extraordinary times. In the meantime, we hope you find this discussion interesting, whether you’re listening during the outbreak or indeed once things have returned to normal. As always thank you for listening and from all of us here atThe King’s Fund, please stay at home, it helps to save lives and obviously we hope you stay well.
Hello and welcome to The King’s Fund Podcast where we talk about the big issues and ideas in health and care. I’m Helen McKenna, I’m a Senior Fellow here at the Fund and I’m your host for this episode. Given everything that’s going on in the world right now, the general election might feel like a distant memory. However, it is only three months since the country went to the ballot box and elected a conservative government with an 80-seat majority in parliament, led by Prime Minister Boris Johnson. At the time of recording this episode we are approaching 100 days of the new Conservative majority government, so it seems like the perfect opportunity to take stock of what we’ve seen from the government so far and what it signals in terms of their intentions for health and care policy. And to help me do this, I’m delighted to welcome three fantastic guests, all of whom have extensive knowledge of working in or with different governments. So, I’m joined by Michelle Mitchell, Paul Corrigan and Alex Thomas. So, Michelle, I’ll start with you. Can you tell our listeners who you are and what you do?
MM: I’m Michelle Mitchell and I have the absolute privilege and honour of being the Chief Executive of Cancer Research UK, the world’s largest independent funder of cancer research.
HM: Brilliant, thank you and Paul?
PC: Paul Corrigan, Special Advisor to Alan Millburn and John Reed and Tony Blair between 2001 and 2007.
HM: Thank you very much and Alex?
AT: I’m Alex Thomas, I’m a Programme Director at the Institute for Government which is a think tank that focuses on making government work better. I’m about seven weeks in, so before that I was a Civil Servant in various places including the Cabinet Office, briefly the Department of Health and the Department for the Environment, Food and Rural Affairs.
HM: Brilliant, so between us a huge amount of knowledge around this table. So, on 22 March the new government will have been in power for 100 days. So far, the government’s been pretty busy in relation to health and care. Clearly a lot of that time has been overseeing the UK’s response to Coronavirus or Covid-19, but they’ve also been busy trying to deliver some of their manifesto pledges. We’re also recording this the day before the budget when we should get a clearer sense of the government’s priorities and policy agenda but Alex if I could come to you first, what’s your take on what these first few months tell us about the new government’s intentions in relation to health and care?
AT: So, I think in general terms, actually it feels quite early and it’s a little bit too soon to know. One of the things that has really struck me about the first 100 days of this government is how there’s been quite a lot of sound and fury, there have been a few blog posts, there has been quite a lot of media briefing but actually the set piece events that really tell us the detail about what the government’s likely to do have been relatively few and far between but one of the things that has really struck me is how it’s quite hard to get your arms around what this government are really going to prioritise. They will care about long term infrastructure; they will care about tackling the wicked issues and they’ve got the opportunity to do that. Within that, trading off investing political capital in social care versus levelling up infrastructure in the north of England, I think we don’t really quite know. So, I’m still trying to get my head around exactly what this government is going to prioritise.
HM: Okay and Paul, is it the same for you, you think it’s too soon to tell or…?
PC: I think it will be clearer in a few weeks perhaps months. I think there is something quite interesting in that a lot of the fire and fury that’s come out of the government is about disruption and that is I think quite real that they believe that they have a better chance of bringing about a lot of change if they change the way in which things have been done. However, that’s not the case with the NHS. So, there’s a bracket about disruption. So, you’re allowed to disrupt A, B, C and D but not the NHS. I think the noises from inside both Number 10 and the DH is take our targets seriously because we pledged to do them and we probably will and so I think we’ll see a target driven set of changes in the NHS and that may lead to quite a bit of change. I think the rest, we have to wait and see but I think for me, this twin approach to change I think is very interesting.
HM: Yes, and Michelle, do you agree with that, more broadly we’re seeing a kind of disruptive element to this government, but the NHS is going to be protected from that somehow?
MM: I would just draw us back to the general election to enable us to paint a picture of where we think the priorities may be. So when you look at the work that’s been conducted by Murray on the public concerns about the health and care system, the government responded with some pretty meaty manifesto commitments, not least 50,000 new nurses, 6000 doctors, 6000 primary care professionals and has talked about a funding settlement for health in pretty serious ways. We’ve also got the rhetoric of Boris Johnson the Prime Minister talking about the NHS as being one of the most beautiful and brilliant things about Britain and we would agree with that but we would all agree that there needs to be significant improvement and resources and funding to ensure we meet some of the big ambitions in the long term plan and that had yet to be seen. So where I do agree is the budget and the spending review are going to be pretty important in ensuring that the money and resources are there to ensure we have, not only the right workforce but diagnostic funding and capital funding to ensure we meet a very ambitious agenda.
HM: So, I wanted to spend a bit of time thinking about how you influence a government with this size of majority. The last time we had a government of this scale in parliament was under the last labour government or an earlier Labour government. Alex can I come to you first? What difference does it make for a government to have a healthy majority in terms of how policy is developed and implemented?
AT: The key for me on this is, it shapes where the kind of locus of debate is. So, for the last few years with a minority government, the focus of debate has been on parliament and quite a kind of exposed, public row that is being played out with one, two, three, four MPs being really influential. In the coalition government it was about the kind of balancing within the government. So actually, if you could influence one part of the government, in the policy formation stage, then that was quite effective. Once the coalition had agreed a position it was then very hard to change it unless you had a proper row as we saw with the Lansley reforms. In this circumstance, I think the focus of debate is inside the Conservative party. So, we’re seeing the rows that have happened so far are things that touch Conservative MPs’ hotspots. So, if you can get 40 Conservative backbenchers on your side then you’re talking but more prosaically and in more general terms it will be the special advisors in individual departments. The department of Health, in Number 10, the Ministers and the political layer and also as ever, the Civil Servants, the officials, not necessarily the very top ones but the ones who are working on your particular policy that will help frame the debate for their political masters. So, in this environment it’s that kind of, slightly more closed, slightly more difficult to get into.
HM: So, it’s quite a lot harder therefore for organisations like ours, like The King’s Fund and Michelle’s Cancer Research UK, to have influence or is there a point…? AT: If you’ve got the relationships then it’s easier and also of course, if you’ve got the relationships and you influence the individual in government then it’s easier for them to transact and to get done the thing that you’ve agreed that is the right thing to do.
HM: But it’s all about relationships.
AT: It’s relationships, it’s more kind of closed, it’s more behind the scenes, of course there’s still the public shaping and influencing but I would say you’re less likely to achieve the outcomes that you want through a big public back and forth and more likely to do it through behind the scenes influencing. A government with a majority, some issues then become a test of machismo and so it’s harder for a government with a majority then to back down because in every U-turn is a degrading of the government’s political power and political capital.
MM: Every charity, not least Cancer Research UK’s job is to use the evidence base it has, to tell the story of where we are today and use the brilliant brains that we have to come up with solutions about how to make it better. So of course, we are non-political we work across all of the political parties but also across the health system as well. So I would add a couple of points, one I think a majority government makes legislation on health more likely, this government is particularly interested in science and innovation as a route for delivering transformational change and impact for people as well as changing the NHS and so we as charities need to, where we can, speak with one voice, so we have co-ordinated more recently 25 cancer charities to speak to government about its priorities, really being clear on what’s important. Using evidence continuously and solutions to the problems that are facing us. But I would add a second point, the government is of course, incredibly important but so too is the NHS, NHS England, NHS Improvement, an arm’s length body with significant degrees of autonomy and independence so we continually have to work at a national level and many things happen at a regional and local level as well. So charities need to focus on describing, with evidence, the problem, what are the solutions they see and working at every level within government and the health system to ensure that a range of ambitious changes, for us, improvement in cancer survival are met because the levers for change are diffuse in the health system and what we’ve seen over many governments is saying from what you want the change to be, doesn’t necessarily always deliver that change to time and to target.
PC: The thing I’d like to add to what’s been said is that people who’ve spent their lives in policy don’t understand the euphoria of having a majority, it’s 32 years since the Tories have had a large majority and therefore people are sitting in government with an experience of being supported by the public to do things which is quite stunning as an experience. I just remember myself in 2001, 13.5 million people voted for these things and so you took them seriously and you took that mandate morally pretty seriously. And so, I had, between 2001 and 2003, lots of policy people coming in to see me, especially The King’s Fund, coming in and saying…
HM: What about Cancer Research UK?
PC: They probably would have been there as well, saying that maximum waiting times are not an issue, it’s the wrong issue, and I had 13.5 million people saying it was the right issue. So, this was not a healthy debate between politics and policy. When a couple of years in, it started to happen, a lot of people then came in and said, “How do we help you?” And that seems to me to be the clever bit of influencing, is looking at what the government wants to do and thinking, “How do we help you?” Because the helping bit is helping a large number of the electorate to get what they wanted. It’s not just a political party, this is in a sense what democracy is all about. There are other things, but actually it seems to me, going in and saying, “These are the issues that really matter to the British people and how do we help you do them?” Is something which special advisors…
HM: And make things work?
PC: Yes, and make things work as the electorate want them to work and I think there’s a genuine unity there between what outside policy makers want, what charities want, what the electorate want and what ministers want and you can then get some really important traction. Those of us who’ve been involved in health reform for some time can help this government hit these targets by bringing the notion of reform earlier into their discussion. So 50 million increase in GP surgery appointments, for those of us who’ve been trying to reform primary care for the last few years, we know how to do that and we know around the country there are real life examples where the appointments have been transformed my tech, by pharmacists, by a whole range of people that are not GPs and so it’s possible to get them to that and also in my interest to bring about some reform in primary care. So, I think we have got real things about change which we can help the government with.
AT: This might sound strange given what we’ve been through as a country over the last few years and particularly the last nine months or so but on health and more broadly on social policy, I don’t get the sense this government is particularly ideological. Yes, of course they’ve preferred to push one button or pull one lever, but I suspect they will be most interested in what works.
AT: And that comes to the one don’t and the one do that I would throw in is, the don’t is, don’t assume malign motives, and the do is, it doesn’t have to be one solution but set something out that is easily forwardable on from one powerful special advisor to a permanent secretary or a secretary of state saying, “Here’s a thing, do this.” And that’s the way to get influence I think is to package up a proposition that the government can look at and go, “Actually that makes sense and that is going to help us achieve what our objectives are, let’s get on and do it.”
HM: Brilliant, so quite a lot of really helpful tips I think and obviously following the election result there’s been lots of talk about the red wool turning blue, lots of focus on the need to level up particular areas and address regional inequalities. Paul, when it comes to health and care, how do you think this is likely to shape the government’s agenda? PC: I think it will, I think it’s a serious agenda, I think the new MPs will make sure it’s a serious agenda and I think there are two really important areas where they’ve got to get change going very quickly. First and where I think all of us outside of government can help. The first is around health inequalities in the left behind areas which are truly shocking. I know a lot of these places in the north east and the difference between Bishop Auckland, Blythe and the rest of the country is enormous. I think we know from other areas how to intervene in areas of high health inequality and to start to change life expectancy and health and I think we need to start talking about what those lessons were and how to influence these locations. I think it will need very specific interventions so we around this table know some things to do and we then need to work with the government. So that’s the first thing. The second thing is the nature of health policy and what we do with our hospitals and how we organise our hospitals had added to the experience of being left behind. So, we have, and I think quite correctly, moved specialisms into specialist units. And that means Bishop Auckland Hospital in Bishop Auckland and Shotley Bridge Hospital in Consett, have as far as the public been concerned, been downsized and that actually it becomes a less important institution because you a person I know in Bishop Auckland with cancer goes to South Tees and has nothing to do with Bishop Auckland. Now changing that isn’t easy because actually the decisions that have been made around healthcare have been important decisions around healthcare, however in Bishop Auckland there are at the moment, more people using the hospital even though they’re not doing specialist activity, then there were when it was opened. So, we’ve given the impression to the people of Bishop Auckland that the hospital is less important when actually in human terms it is more important and that’s because of the way in which we talk about health policy. So, specialism matters, long term conditions don’t and actually in Bishop Auckland there are tens of thousands of people who need it. So we need to recognise that the health service of the present and the future is going to be working in all areas and that those areas are just as important as Newcastle General or as South Tees Hospital and I think that’s very doable but at the moment, the public perception following on from health policy, is that the small institutions don’t matter.
HM: Yes, and of course there’s always the role of anchor institutions in these areas and the role that hospitals can play in that sense.
MM: What we’ve seen in the government quite bold and as an ex-civil servant you may say brave on some issues. What we want to see is bravery and boldness on prevention and smoking is the single most important driver of health inequalities accounting for about half the difference in life expectancy between the richest and the poorest. We have a budget coming up imminently. I would really like to see the government loosen its reigns on funding for local government because of course that’s been one of the hardest areas hit. It is a way to ensure some of those essential services are put in place at a local level, including smoking cessation and also to be bolder in policy making and explore ideas, like the polluter pays and taxing the tobacco companies, if we are going to address some of the big health inequalities that exist and also see a much more radical shift around prevention more broadly. The same goes with obesity, the second largest risk factor impact on cancer.
AT: I agree the government is serious about this, two quick thoughts on it. One is the sorts of issues that Michelle and Paul were just talking about are the work of decades and more. I think this government will have an eye to the long term, but they will need some short-term political sweeties as well. So it comes back to where we started this conversation, not just the recruiting of the staff and things but what are the wins that you can make in the next two or three years on this to give you the political cover to do the ten, twenty year interventions? The second thought which slightly relates to that, prompted by Michelle talking about local authorities is, I have a feeling that, assuming the spending taps are going to come on at least in some areas in the government after ten years of austerity, the government is actually going to find it quite hard to spend money efficiently and to get it out of the door. So, shuffle ready schemes or …
MM: Oven baked.
AT: Oven baked schemes, microwave ready etc will be things that go down very well but also there’s something incumbent on the government to give local authorities the support, to give the usual delivery mechanisms that they would use the support to spend this money well l and not to either waste it or just have it sitting in bank accounts in Whitehall. I don’t quite know what the answer is to that but there’s something about being able to make effective interventions there.
MM: When you look at the hundred days of many governments from around the world, I think there’s a message that comes through quite strongly is, do be bold and do be brave, and you would have great descriptions of it yourself but time moves on quickly, things can get more complicated in time. You have a unique opportunity in your first year to lay out a radical and reforming agenda on a whole range of fronts, including not only the support of the long term plan here but much more radical steps around prevention and not be shy and reserved about that.
HM: And particularly an opportunity with the size of majority.
PC: I think in five years you can get some good numbers around health inequality change. The health of people is so bad, no neglected that in five years up until 2006, we bent the curve on life expectancy in ten local authorities and that comes back to working with local authorities because actually you can identify the people in their fifties and actually intervene and surround them with care and actually keep them alive for another 20 years and that’s pretty important to them and pretty important to changing the numbers. So, from five years you can do things. We start in these areas from people being unnecessarily sick for quite a long period of time.
HM: And that could make a tangible difference to people’s lives as they come to voting at the next election. So elsewhere we’ve heard rumours about Number 10 wanting to legislate to have more control over NHS England and NHS Improvement and bring in other changes to the current legislative framework. I don’t like talking about rumours, but this is an interesting one, so we may as well. So, I just wondered, Paul, what’s your take on whether they’re serious about doing this?
PC: I think any government that comes in and has made all these pledges around the NHS will immediately say, “We want more control why are we being held to account on something that’s down to Simon Stevens and this is all wrong. In political terms it feels wrong that you’re held to account. And so, the rumours that were around in January, I suspect will disappear because actually taking control means taking a lot more blame. So actually, you’re then just responsible, not just for these targets but you’re responsible for a death in Oldham and that is something that is horrific for a Secretary of State. So, when the perm sec was the Chief Exec of the NHS then the reality of that experience was the Secretary of State could be held to account for anything and I think once they get into thinking through that, I think they’ll probably say no.
MM: I think a natural question is to say, we recognise the public’s issues of concern, we’ve given extra funding to the NHS, we want to make sure there are improvements made. I think that’s quite different to taking over and controlling the NHS. What we did see before the election was a good cross-party debate about what legislation was needed to improve how the NHS works and I think there are several areas where there could be improvements. So, we could see legislation perhaps in a year or so’s time on the NHS but that could also be about improving how it works rather than taking direct control and there are many areas that could be improved.
HM: So, I just wanted to ask a question about social care, so we’ve seen that Matt Hancock has moved to set up cross party talks on reforming social care funding, that’s something they talked about in the manifesto. So, Alex, one for you, how willing do you think this government will be to expend some of their political capital on this issue?
AT: As a matter of fact, I was in the Cabinet Secretary’s office and close to the centre through the 2017 general election. So, while we weren’t involved in the campaign we were watching that closely, but that baggage leads me to think, “I just can’t quite see a government grasping this third rail and really doing something on it.” I hope that’s unduly pessimistic, but all my instincts are that this is going to get in the too difficult box and there’ll be something superficial there’ll be some process around it, I’m feeling a bit pessimistic about that at the moment.
HM: Michelle, Paul is that similar views from you?
MM: So, we’ve talked for a decade how if only we could copy the policy process that Adair Turner went through on pensions. It’s not been the case for nearly a decade, your lovely colleague Sally talked very passionately about her disappointment on the progress on social care in a recent podcast. I think it should be one of the highest priorities of this government and of course when we look at the change that’s needed, not only the funding, the people the capital, the diagnostics, long term settlement for social care, makes infinite sense. I hope the government has infinite sense.
HM: As do we all, Paul?
PC: I agree with Alex that I don’t think they will grasp this; however, I think probably in a year to eighteen months, they won’t have a choice. I think the system is crumbling and may well wall over. So, if people stop coming, speaking as an older person, then the system will fall over. If the New York Fund Managers decide to withdraw from elderly care in this country, the system will fall over. So, I think the chances of this continuing as fragile as it is for another four years without something big happening, I think that’s not going to happen, so I think something bad will happen.
HM: But it might be reactive policy rather than strategic.
AT: Do you think there are any political wins for someone who grasps the nettle? PC: I think you feel good.
MM: It’s the right thing to do.
PC: I don’t think it’s as simple as … the relationship between the public and social care and the relationship between the public and the NHS, is so many streets apart. HM: So given the current climate I don’t think we can get through this episode without mentioning, Covid-19, Paul I wanted to ask you because you worked in government during SARS so you’ve witnessed first-hand how the government machinery deals with issues like this. Can you talk us through how it works?
PC: My experience of this, and what we’ve seen in the last few days has been the British people have fallen in love with experts again. We’d been told the British people had had enough of experts and I think that’s very, very important. So certainly my experience is that when anything like this happened, the Chief Medial Officer was put on a pedestal and they were listened to and the crucial thing is that sometimes experts don’t know and I think its just as important to listen to them then, as well as in my experience, “You’ve got to do this.” Because actually I think what’s going on at the moment is an incredibly measured experience between knowledge and not having knowledge and that was true with SARS. SARS in the end didn’t travel the way in which the coronavirus travelled but it was unknown, and we still don’t know ever such a lot about this virus and so the wonderful thing is actually following expertise that are saying, “We’re not sure.” Because that’s the right thing to follow and it’s a lot easier when people say, “This is what you’ve got to do” but actually the politicians have to make their mind up, at the moment around things that are quite difficult to make their mind up. I think we’re seeing more and more of that listening to expertise and I think we will continue to see that. I think now the government’s got into the swing of that as its mode, I think that will continue that will be very important for the nation. I also think, our colleague Chris Hobson was on BBC News the other day and he said, “This may seem a very odd thing to say but if you’re going to be anywhere in the world when this thing happens I’d like to be here because I think we have a system which actually can respond to this and is going to be awful but actually it’s going to take place within a system and with a nation that has a rough idea of what to do.”
HM: Thank you, before we finish, if you had to pick one thing that you’d like to see at the top of the government’s agenda for health and care I’m going to ask you to do it in a single word or phrase, what would that be, Alex, I’m coming to you first?
AT: Slightly counter to what I said earlier, I would say social care is clearly the most important thing for this government to grasp.
MM: To have a properly funded workforce, diagnostic and capital plan, to improve diagnosis to 75% of cancers at an early stage by 2028.
PC: Sort social care.
HM: Great, so two are on social care and a …
MM: Properly focused.
HM: Brilliant, so that’s it from us thank you to our guests, Paul Corrigan, Michelle Mitchell and Alex Thomas for joining us. You can find the show note for this episode and all our previous episode at www.kingsfund.org.uk/kfpodcast. Thanks as always to our podcast team, our policy advisor Jonathon Holmes and our Producers Ian Ford and Sarah Murphy and thanks to you for listening. If you enjoyed this episode please subscribe, rate and review us on iTunes or wherever you get your podcasts it helps others find us and helps us improve the show. We hope you can join us next time.