Is the NHS inherently political? What are the biggest changes in health in the past 40 years? Helen McKenna talks with Professor Sir Chris Ham, as he prepares to move on from his role as Chief Executive of The King's Fund, about his career so far, health policy and what makes a good leader.
- A vision for population health
- A year of integrated care systems: the journey so far
- Delivering integrated care: learning from experience
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- I: Interviewer Helen McKenna
- R: Respondent Professor Sir Chris Ham
I: Hello, 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 going to be your host for the next 30 minutes or so. Today I'm honoured to be joined by our Chief Executive Professor Sir Chris Ham. Chris, as well as being Chief Executive of the King's Fund, you have a number of other roles including being emeritus professor at the University of Birmingham and Honorary Fellow at the Royal College of Physicians and the Royal College of GPs. This year you received a knighthood from the Queen for services to health policy and management and at the end of this year, after nine years as a Chief Executive, you're going to be leaving the Fund to embark on a new chapter in your career and hopefully we'll find out a bit more about your plans later in the episode, but Chris, welcome to the King's Fund podcast.
R: Thank you.
I: So for this episode we've invited our audience to contribute questions for you via Twitter and we've had some really good suggestions which we'll come to later, but to start us off I want to start you with a nice easy question. So when you were a kid what did you want to be when you grew up?
R: I didn't really know Helen. I was the first member of my family to go to university and my parents didn't have that opportunity. So they hoped I would go into a profession which in those days would guarantee you a job for life. Things have changed a little in the last 50 odd years.
R: Particularly my father would have been delighted if I'd have gone into medicine or the law or accountancy and I contemplated doing that, but at university I decided that wasn't for me and I wanted to pursue more of an academic career. I got interested in ideas, I studied politics at university, I decided to stay on and do MPhil after my first degree and eventually I got a PhD as well. So I think the short answer to your question is I had no idea and the ideas began to form later on as I got more and more interested in different things.
I: Yes. That's really interesting that you were the first in your family to go to university and then yet you ended up working in academia for quite a bit and so what made you then shift over to health? So you started in political science, what attracted you to health?
R: Well it was serendipity. I had no plans to pursue a career teaching, researching around the health service, but the first proper paid job I got was at the University of Leeds. I was appointed as a research assistant back in 1975, seems a long time ago now, I was fascinated by and curious about the NHS and particularly the politics of the NHS. So those two streams came together, my academic training in political science and then the interest in the NHS. So I ended up writing a political history of the Leeds Regional Hospital Board which I don’t think is what they had in mind when they made a grant to the University of Leeds. They wanted something that was more for speech day rather than judgment day. I got interested in understanding the dynamics of power and policymaking and who was influential in making the decisions that shaped how hospitals are run in places like Leeds and Bradford and York at that time and that was the work that led to my first book, Policy Making in the NHS, published in 1981.
I: Yes, and so it's quite interesting that you bring politics, political science to health policy. What do you think about the relationship between politics and the NHS and how that has changed over the time that you've been involved in health?
R: So they're inextricably linked. The NHS as a major public service that matters hugely to the population and consumes a large sum of public money will always be political. Partly it's party political because there will be debates between Labour, Conservatives, Lib Dems and others about the direction of the NHS if not its fundamental principles, but also politics with a small p, the discussions that take place in the NHS itself between managers and doctors and between others who have got a stake in it and its future and both of those dimensions have been a focus of my career.
I: And so because I think the Lansley reforms tried to in one way remove or slightly remove politics a little bit further back from the NHS and in some ways that hasn't quite been successful. Do you think it would ever be practical in this country to split off the NHS and politics?
R: It's always going to be very, very difficult if not impossible to separate politics and the NHS when you're talking about spending over £100 billion of public money every year funded through taxation, when the Secretary of State is accountable whatever the Lansley legislation said or intended to parliament for how that money is spent. I can see how you might devolve accountability for some of the micro decisions, but in terms of the overall stewardship of the NHS, which is what the government of the day is responsible for, the setting of priorities, the strategy direction, that is inherently a political question and quite properly elected politicians are held to account on the floor of the House for that.
I: Okay, and so I'm just trying to tot up the years. So have you been … I'm just doing my maths, have been you been involved in health … in the health arena for about over 40 years, is that right? 44 years?
I: 43 years? Okay, and so in those 43/4 years that you've been in health, what are the biggest changes that you've seen in how health care is delivered?
R: Well obviously at a superficial surface level the organisation has constantly changed because I've always said if governments can't address the real issues in health care then they can give the appearance of trying to change and improve by shuffling around the deckchairs and there's been constant and rather unhelpful distracting organisational changes, but more importantly there's been a transformation in how health care is delivered and the opportunities to do good for patients and for populations. Numerous medical advances in surgery, in medicine, new drugs becoming available, different ways of helping people and we've seen the results of that. We're living longer lives, we've achieved huge success through the NHS in reducing premature deaths from cancers, from heart disease and from stroke. We are achieving more success too in treating people with chronic and long term conditions like diabetes and like arthritis, like depression and anxiety as well. So on all fronts it's the story of huge progress, but as soon as you succeed in tackling one set of issues another set pop up to challenge you. For example, around risk factors today smoking rates are going down but rates of overweight and obesity continue to rise and the burden of disease that follows from that around diabetes, around heart disease will have serious consequences. That's what Derek Wanless warned us about back in -
I: Yes, some time ago, yes.
R: - his report in 2002, if the NHS didn't fully engage, that was his phrase, people and communities in taking more responsibility for health and wellbeing perhaps the NHS would become unaffordable. Some people would say that was a timely warning and perhaps we're reaching that point now.
I: And what do you think stopped policymakers from taking heed of that warning?
R: Well I think one of the reasons is it's really difficult to fully engage people and communities. What we're talking about here is engaging people across the population, across the educational spectrum, across the income spectrum. We know it's much easier for some people to be actively engaged in making healthy choices that will promote their health and wellbeing than others and we absolutely have to design our strategies around prevention but also things like self-management support, really important in a context of the growing burden from chronic medical conditions. We need to tailor the support, the care and the policies recognising those differences across the population. So at one level we are achieving some success, but perhaps that's why health inequalities are persistent and in some respects widening because people who have higher incomes and live in more favourable circumstances may be more likely to heed the messages about lifestyle choices and behaviour than people less able to do that and health inequalities remain a scar on our society.
I: And earlier I asked you about what you think the most important changes are in terms of what you've seen in how health care is delivered, which one would you say has been the favourite policy of yours that you've seen?
R: I don't think there's a favourite policy I can point to hand on heart and say, "That is the one." So for me over the last 20/25 years there's been a dawning recognition realisation on the part of policymakers and many others that there's huge opportunity to do far more by putting patients and people at the heart of health policy development. What I mean by that is partly understanding how people experience the health service when they come into contact with it, so the growth of patient surveys and the use of survey data to improve health care, beyond that recognition as we were discussing in relation to prevention, that if we recognise the assets that we all have as individuals and our communities, then isn't there a lot more we could do not through formal medical or nursing interventions but by drawing on community resources of different kinds?
I: And what role do you think organisations like the King's Fund should play in the health and care system?
R: Well the fundamental role we should play is to speak truth to power. That might sound trite but it's true. Our role as independent foundations is to use our endowments and particularly our expertise through our staff and our people to tell it like it is, to hold up a mirror to the system and hold up a mirror to what politicians are doing and go beyond that then to come out with practical actionable recommendations on how health and health care can be improved. I'd say where we work at our best here at the Fund that's exactly what we should do.
I: In order to be challenging but also be listened to and heard by senior influences in the system we also need to be part of that system in some ways and that creates quite a difficult tension I think at times. How do you manage that and what has been the most challenging and difficult thing that you've had to say to the system?
R: I think there were three or four areas in my time where we've been challenging in a constructive way. Initially I took up post in April 2010 during the general election campaign and of course we know that as a result of that Andrew Lansley became the Health Secretary, produced his reforms at that time and we were critical in 2010/2011. We described them as the wrong reforms at the wrong time knowing that the NHS was going to be faced with huge financial problems and that that should be the main focus, but the reorganisation that he'd put in place was going to be a massive distraction and we said that at the time and we spoke out loudly. Perhaps in some ways that meant we didn't get the access we would have liked to Lord Lansley and the senior officials within the Department of Health, but I always say to colleagues here, "Our job is to be respected not to be liked and loved," and if that means going out on a limb where the evidence justifies that then that's exactly where we need to be.
I: Fantastic. So you've developed or you've been involved in shaping lots of different policies during your career because you've been at the Department of Health, you've been here at the King's Fund, you've been in academia. So of all the policies that you've worked on that have been put into practice across the NHS, which one are you most proud of?
R: Well if I'm allowed two (laughter), so I think the work we did in the early noughties. I went into the Department of Health in March 2000 to join the strategy unit Alan Milburn set up at that time, just after Tony Blair had announced the big injection of funding for the NHS -
I: Good time to be there.
R: - and it was I think a huge opportunity with lots of other people to make decisions that went into the NHS plan and the subsequent national plans that followed on, on how that money should be used, and over a decade or so the results are there for everybody to see. Massive improvements in the NHS and improvements in people's access to care, in the quality of care, in the health of the population. I'm not claiming I did any of that, but I was part of a group of people who had that opportunity at that time. I think more recently my second example would be making the argument for integrated care. During the Lansley reforms the debate that took place led to integrated care becoming more prominent, enshrined in the 2012 Health and Social Care Act, but particularly after that picked up by people like Norman Lamb in the Coalition government and subsequently by Simon Stevens in the Five Year Forward View. It heartens me that we're now beginning to make a reality of integrated care around the country because if I'm allowed to have some reminiscences here, when the NHS hit its 50thanniversary back in 1998, the editor of The Lancet phoned me and asked if I'd write a commentary piece, he was inviting several people to do so, on the future of the NHS, the next 50 years, what were my personal hopes? I wrote a piece saying I hope there will be much more attention given to integrated care. It shows you have to be patient in health policy.
I: (Laughter) Absolutely and actually, as you say, integrated care is now a core focus of the system and where do you think the NHS has got to on that journey and are you optimistic about the future of the integrated care journey?
R: So the NHS as a whole I think has got to basecamp when it comes to integrated care, but there are parts of the NHS that are further up the mountain than others and we've been working closely with the integrated care systems across England as well as with the new care models and every time I go out and work with them I come back really encouraged and energised by what I see happening. This is not a difficult argument when you're working with front line clinical teams, they want to deliver joined up coordinated integrated care. They've been waiting for the opportunity and they're seizing the opportunity because we're in a phase now, and this is really important, where there is more latitude, there has been more latitude at a local level to get on and do the right thing, not to implement a blueprint that some smart people in Whitehall or Westminster have handed down to the NHS and I'm very encouraged by what I see.
I: But some people say there's lots of barriers in place to them actually implementing it, do you think there are barriers that are standing in the way?
R: There are lots of barriers and mainly they are barriers created at a national level by NHS England, NHS Improvement and I don't think intentionally, there's a legacy effect here. People are being asked to integrate care in the context of legislation that wasn't designed with that principally in mind.
R: It was designed to promote competition not collaboration. So there are legal barriers around thing like procurement and mergers of providers. There are regulatory barriers. Despite those barriers, where there's a will there's a way and that's why the advanced areas of the country recognising the barriers have found a way of overcoming them and making progress which is real and which is tangible and is producing results.
I: Okay, so let's talk about leadership. What do you admire most in the leaders that you've worked with in the health and social care sector?
R: The leaders I work with are incredibly diverse and there are lots of things I admire about different leaders. I think one of them is the resilience that many of them exhibit. It's really, really tough. It always has been going back over my 40 plus years, but it's really, really tough today. If you're a Trust Chief Executive or a commissioning Chief Executive or indeed in a national body, the financial pressures, the operational pressures, the demands, and leading in the goldfish bowl that is the NHS, constant media scrutiny and attention and you take a lot of knocks and setbacks in one of those leadership roles. So you need to be resilient personally, you need to have support available to live with the downs because the ups will follow on but you're never quite sure when that will be. So that for me is a very important quality. I'd say, if I'm allowed to add to the resilience point, it's the passion.
R: The people I work with in the NHS, and there are many of them in different roles, they all are there because the NHS matters to them, it's not just a job and they could go off and do another leadership role in another organisation. They are NHS through and through and they believe in the NHS as a public service, its values, the way it matters to the whole population and they go to work in the morning wanting to do better for the population. That's palpable among the people I see. So I'd say that's very important.
I: And presumably being around that fires you up as well as a leader?
R: Absolutely, I mean in a way by proxy I'm doing what I do for exactly the same reason.
I: Yes. So I want to ask you about system leadership because we talk about it a lot at the King's Fund and the system talks about it a lot, can you explain in simple terms what we mean by system leadership and do you think it's happening in the system right now?
R: So system leaders are people in leadership roles who are working not just in an organisation but they're working in a system which could be defined geographically, but it might be around a particular service area like the cancer networks or the mental health networks we've had and to some extent still have. So these are individuals who can work in those sorts of environments and often without having positional authority. We put people in these system leadership roles and they have to use soft power, they have to negotiate, they have to bring stakeholders together and find common cause and be persuasive and enable change and improvement to happen by getting all the ducks lined up but to do so subtly and by using levers which often have been in short supply.
I: Okay, we talked a lot about your working life, what do you do to relax?
R: So relaxation is critically important if you're in a leadership role because the temptation is to be working all the time and that's not a good recipe for anybody whether at the King's Fund or in politics or in national bodies. So my hinterland, to borrow from Denis Healey, is a combination of first of all family which matters a lot to me, my own immediate family, I now have three grandchildren, and the extended family that I've partly inherited through my wife who's one of four daughters and we enjoy time with that extended family throughout the year. I exercise a lot, that's really important to me and in the last five years mainly through cycling. So when I have the opportunity I'll get on my bike particularly around the weekends and explore the lovely Warwickshire countryside which is close to where I live, that's incredibly therapeutic. I love arts and culture, so I go to the theatre on a regular basis, I see movies on regular basis, I'm an avid reader of a whole range of different sorts of novels. I love travelling and I'm looking forward to doing more of that when I step down from the Fund at the end of this year.
I: And I guess … from my experience I know that you work incredibly hard, you've just talked about the massive amount of culture and extracurricular activities you consume, how do you stay on top of your brief because you have a large portfolio, you've got a big role, how do you manage to stay on top of it all?
R: First of all I stay on top of it by not trying to do everything myself. Very important to … going back to what I was saying about lessons about leading and leadership and working through the senior management team here at the Fund and other colleagues, because I can only do what I've been appointed to do if I'm able to work in that collective leadership way and delegate as much as possible but keeping my own eye on the ball of the things that really matter and as Chief Executive there are some things you can't really delegate. Reputations like ours are hard won and easily lost and for me that's an inherent part of my role.
I: And just in terms of your development as a leader, is there anything that you would … reflecting back on your leadership journey is there anything you would have done differently?
R: So I think I would have sought the advice and support of a coach or a mentor, I'm not sure what the precise language is here, sooner than I did because the first leadership role I had at the University of Birmingham in the early 1990s I sort of threw myself into that and put huge amounts of energy into it at the time. In retrospect, knowing what I do now, if I'd found somebody who could sit down with me from time to time so I could reflect on what was happening to me and how I was doing and some of the mistakes I was making, that would have helped me to be a more effective leader than I was at the time. So always seek ways of finding that help and support would be my message.
I: And on that note, that brings us to questions we've had from our listeners.
I: So a question from Kweku Andrew Bimpong of the British Pharmaceutical Students Association, he's asked for your advice to people at the start of their health career.
R: My most important advice is to spend time out and about. Sometimes I've said to my colleagues in the past, "You need to spend less time in the library and more time in the surgery," because however good your book learning is it's no substitute for actually seeing with the evidence of your own eyes the issues that you're writing about and commenting on. Of course that's an exaggeration, but it's to make the point that you have to find a way of marrying the academic understanding the research analysis that is a core element of the kind of work we do with the direct first-hand knowledge that you can only acquire by, if you like, shoe leather policy analysis, spending time on the road, on the trains, wherever and going to look see.
I: Yes, I totally agree with that. Okay, here's one from Emma Greenwood at Cancer Research UK, she asks, what is the one thing we always talk about in health policy that we've never cracked but if we got it right would most improve health care for patients?
R: My answer to that would be that prevention should be the number one priority. Back in 1976 Barbara Castle was Secretary of State for social security at the time and the rising young medical politician called David Owen was her Minister of State and together they published Prevention and Health Everybody's Business as the Green paper of the time, setting out ambitions which we've heard about recently from Hancock and no doubt will be in the long term NHS plan. We have made progress in preventing people dying prematurely and in tackling some of the big risk factors like cigarette smoking, but we've not given it the same attention by any manner of means as we have to improving our acute and specialised services and I hope that will change.
I: And another question about why the King's Fund supports integrated care systems and some particular concerns about their risk around increasing the power of private providers.
R: So the reason we support integrated care is to do changing demographics and the changing disease burden. The global burden of disease report in The Lancet at the end of October makes this absolutely clear, the burden of disease now increasingly results from morbidity and not just premature mortality. It's the years of life we live with one or more chronic condition particularly multi-morbidity and frailty in the aging population, not all older people but a significant proportion of people , and you're not going to help people and provide the right care and support through fragmented care. I don't hear or see people standing up on public platforms arguing what we need is fragmented care. We all, including the King's Fund, make the opposite case. It's got to be joined up integrated care including health and social care coming together around those sorts of needs resulting from that change in burden of disease. On the other aspect of that question to do with privatisation, I understand absolutely why there is a concern that integrated care may result in a bigger role for the private sector, but I see no evidence of that happening. Where we're working with the new care models, the integrated care systems, these are about partnerships within the NHS between primary care teams and secondary care teams, between physical health services and mental health services, between health and social care, local government and the NHS working much more closely together. There is no evidence at the moment that private providers are coming in to take on that responsibility and I'd be astonished if that were to be the case in the future.
I: Okay, so in closing it would just be good to hear about what your plans are for after you leave the fund. I understand you already have a role, do you want to tell us a bit about what you're planning to do?
R: Yes, it's going to be a great wrench for me leaving the Fund after nine years, but I'm absolutely clear in my own mind it's the right time to go and I'm delighted that Richard Murray will be taking over in the new year. I want to carry on making a contribution and I've got the energy and the appetite to do that so I'm not going to go away -
I: No (laughter).
R: - any time soon. I'm delighted to say that I'll be taking on the role of independent chair of the Coventry and Warwickshire STP. I've just been appointed as a non-executive to the board of the Royal Free London NHS Foundation Trust. I hope I will also have some more time for writing and for thinking and for speaking and for advising people in the NHS building on the work we've been doing here at the Fund and I plan to keep in touch with colleagues at the Fund as I do all of those things.
I: Good. Coventry and the Royal Free are incredibly lucky to have you, and just as a final question, what do you think the biggest policy challenge in health care is that we face over the next ten years?
R: The biggest challenge is the future of social care because the NHS can only succeed if social care succeeds and social care is facing massive challenges, the lack of funding, the changing demographics, the growing need for social care but the difficulty people have in accessing the care they require. That's why we set up the Barker Commission which reported in 2014 and said fundamental reform was needed to put social care on a similar basis to the NHS and to move over ten years, Barker argued, to a single health and social care system funded by a single budget with more money raised through taxation and national insurance, by reallocating some of the existing public spending on things like attendance allowance possibly, to create a bigger pool to fund health and social care together in a way that meets the needs of the population now and in the future. I hope the Green paper on social care will deliver on some of that. I have to say I'm not optimistic, but I know the Fund will continue to make the case for that because one of the lessons I've learned about working here is that if at first you don't succeed just keep on trying.
I: Absolutely. Thank you very much Chris Ham.
R: Thank you.
I: It's been a pleasure to talk to you. Well that's it from us, you can find the show notes for this episode and all our previous episodes at www.kingsfund.org.uk/kfpodcast. Thanks for listening, I'm Helen McKenna and thanks also to Ian Ford and Sarah Murphy who are our producers. If you enjoyed this episode please subscribe, rate and review us, we'd really love to hear your feedback and if you have ideas for topics you'd like to hear covered in future episodes then please get in touch either via Twitter @thekingsfund or my account @helenamacarena. Hope you can join us next time.