An open letter to the next Prime Minister

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Chief Executive of The King’s Fund, Richard Murray, has written an open letter to the final two candidates in the race to become Prime Minister outlining the issues he believes require political action to support the health of the nation.

To the final candidates for next Conservative leader and Prime Minister of Great Britain and Northern Ireland:

Congratulations on reaching the final members’ ballot for the Conservative party leadership. The debate during the leadership contest has of course been dominated by Brexit. However, when the results are known in July and a new government takes shape, we believe that there are three issues that should be a priority for any government with an ambition to improve the nation’s health and the quality of health and care services. It may be helpful to set out what we believe these three issues are.

You will be well aware of how valued the NHS is in our country. The long-term financial settlement and the vision set out in the NHS long-term plan provide welcome investment and direction. But the health and care system is facing significant challenges that continue to have a real impact on people: more people are requesting publicly funded adult social care but fewer people are receiving it; waiting times for routine care are at levels not seen in a decade; and health inequalities are widening. Worryingly, after decades of steady progress, improvements in life expectancy have stalled in recent years (more so in the UK than in other comparable European countries). These challenges have not escaped the public’s notice – satisfaction with the NHS has fallen to its lowest level since 2007, while those who understand the social care system widely regard it as inadequate, confusing and unfair.

In this context, the first priority is reforming adult social care: fixing a system that many recognise is not fit for purpose and is at crisis point. The system is failing the people who rely on it, with high levels of unmet need and providers struggling to deliver the quality of care that vulnerable people have a right to expect. These combine to place great pressures on families and carers.

Solving this will require the government to tackle the vexed question of how to pay for care in the long term, when demand for services is rising from a growing number of older people and people with disabilities. As a nation, these demographic pressures mean we will have to pay more to provide good-quality services that treat people with dignity and respect, and we need to strike the right balance between the individual and the state. We hope you and your Cabinet will rise to this challenge and demonstrate the leadership on this critical issue that previous governments have failed to provide. As the current system struggles to manage, the financial and human costs are mounting.

Significant reform will take time. In the interim, if you wish to avoid these costs mounting further, the government will need to increase local authority funding in the next Spending Review. Public spending on adult social care has reduced considerably since 2010/11, forcing councils to reduce access to services. We must all recognise the value of social care as a vital service in its own right, which supports people to live well and independently, rather than as a pressure valve for the NHS.

Next, with improvements in life expectancy flatlining and health inequalities widening, improving public health and prevention should be a much higher priority. People’s health and wellbeing are determined by a wide range of factors, so Cabinet ministers will need to work together to embed health across government policy. Ministers should make use of the full range of levers at their disposal, for example through bolder use of tax and regulation to address public health challenges, building on the success of the soft drinks industry levy. The public health grant has been progressively cut since 2015/16, with significant consequences for local services such as sexual health clinics, stop smoking support and children’s health visitors. A government fully committed to improving the public’s health will need to reverse those cuts in the Spending Review. The present government’s commitment to publish a prevention Green Paper provides an opportunity to set out a new direction but it needs to be bold and ambitious if it is to address the challenges to the nation’s health.

The third area for action is the health and care workforce. Around 1 in 10 of the total workforce in England work in the health and care sector. They are the system’s greatest asset and are key to delivering high-quality, compassionate care. Yet, they are working under enormous strain as services in the NHS, social care and the voluntary sector struggle to recruit, train and retain enough staff; analysis suggests current shortages of more than 100,000 staff across NHS trusts are set to increase unless action is taken. These shortages intensify pressures for the staff who remain, creating a vicious cycle of stress, pressure and further retention problems.

Without urgent action, the aspirations of the NHS long-term plan will not be met, and quality of care will deteriorate. Health and care leaders are already engaged in developing a response to these pressures and the government should stand ready to provide them with the support they will need to make this work. For example, in the short term, the immediate workforce shortfall is so severe that it can only be managed by recruiting staff from overseas (including ethically recruiting 5,000 nurses a year). This cannot be achieved without the government’s support for an immigration system that can meet the needs of health and social care, which should include accepting the recommendations of the Migration Advisory Committee to make it easier to recruit health and care staff. In the longer term, to create a sustainable workforce more staff will need to be trained domestically. This will require either additional funding in the Spending Review or resources being diverted from other health budgets, recognising the consequences that this would have on the ambitions to improve (or even sustain) services.

Of course, in addition to these three big challenges, leaving the EU is likely to have significant implications for health and social care. As the Secretary of State for Health and Social Care is legally responsible for securing the provision of adequate health services, all due diligence will be needed to ensure that essential NHS services are on a secure footing, especially in the case of a no-deal Brexit.

Effective leadership is needed to tackle these challenges, without which the risk is that much-needed changes in health and care will stall. We look forward to working with the new government to ensure that this does not happen.

Yours sincerely

Richard Murray
Chief Executive, The King's Fund


Umesh Prabhu

Previous Medical Director of Bury NHS Trust and Wrightington, Wigan and Leigh FT,
Comment date
15 July 2019

Very well written letter from Richard Murray. Your sentence 'Effective Leadership is required' is what NHS needs. It was Henry Ford who said 'If anyone thinks politicians can sort out all the problems one must look at the plight of American Indians! It is all to do with culture.

NHS doesn't have effective leadership. It has management culture and silos working and there is no accountability for leaders and managers who move from one job to another. NHS also has culture of bullying, racism and club culture.

When I was the Medical Director of Wrightington, Wigan and Leigh FT, we transformed culture of bullying, club culture to kind, caring, compassionate learning and supportive culture. We implemented good governance, staff and patient engagement culture and open and honest culture and duty of candour and staff happiness culture

Happy staff - happy patients. 70 staff raised concerns with me and we dismissed few bad doctors and bullying managers and leaders. and we reduced harm to patients.

For leadership to be effective there has to be good governance and accountability. There has to be fairness the way doctors and nurses are treated. In a fair society everyone matters and everyone must be treated equally.

One has to look at Bawa Garba, David Sellu and many more cases where doctors have been blamed but no system leaders have been held to account.

George Coxon

Various inc care home owner, SW AHSN network associate, STP collaborative Board member,
Comment date
27 July 2019

Having read both Richard’s letter and Umesh’s reply I found it impossible not to respond having just played a sizeable part in a terrific care home focused TED like event in Exeter yesterday (25th July). Our event saw a large physical audience hear several 11 minute inspiring talks from care home activists - leaders of outstanding care homes that is, a hospital doctor, University senior academic, a national co production leader, a modern matron doing amazing intergenerational work on hospital wards, and a national digitalisation lead - all filmed and streamed creating a new care home narrative, #shakingthetree for care homes and truly working out loud in a manner to inspire using the hashtag on twitter #irresistiblecare (do have a look). I mention all of this simply set the scene to say 2 mildly contradictory things:

1- endorse so much of what Richard and Umesh are saying about the new prime ministers focus and essential first acts with a plea that the letter does add more weight and impact to the urgent need to, not just tackle but resolve, the social care crisis and inevitable catastrophe ahead if we endure more ‘kicking of the SC can down the street’ to coin a phrase
2- say strongly and loudly none of us at our event yesterday were whinging, moaning or complaining. We in fact were very much doing the opposite - showcasing essential themes about kindness, enthusiasm, pride, leadership not management, innovation, energy, drive & determination, humour & humility. It was a powerful uplifting day see for yourself using our hashtag
Umesh uses the word culture several times in his response We know it eats strategy, evidence, dynamism, belief, care & positivity for breakfast So Boris this is where you must start culture immersion amongst those that embed values, that create the thrill of doing great things, and having great fun at the same time

Our care home work in Devon with our genuine partnership with the SW AHSN is but a small part and small contribution to add to the ways to influence ICS STP NHS long term plan system integration objectives ( quite a mouthful to contemplate there I know ! ) but it is a model to adopt and spread perhaps Real time credible providers engaging with fellow system leaders shaking trees, planting seeds and building bridges. It’s happening in Devon. Come see Boris and all

Simon Diggins OBE

Executive Secretary, CAMHS Directorate,
South London & Maudsley NHS
Comment date
29 July 2019

Enjoyed, and agreed with much of the letter, and the Blog responses; I also very much appreciated the positive tone, which I think reflects the depth of goodwill to the service, and desire of those in it, to produce and sustain a world-class system.

I absolutely endorse the emphasis on supporting the clinicians and staff who actually look after our patients and service users: within our CAMHS service, we suffer from high vacancy rates, systemic shortages of some specialists, and - often hidden by the figures - all the consequences of 'staff churn'; so let us indeed try and improve that. There are no quick answers but since the problem is systemic, we need to tackle it as a systemic challenge; no single Trust or even ICS will be able to resolve. Some thoughts:

- Universal Recruiting. Staff join the NHS, not a specific Trust. Their qualifications are 'universal'; their acceptability is 'universal'; and so are their appraisals and performance reporting.

- Linked to this, staff are rewarded for serving a contracted-term: a minimum of 2-years, unless they are on a training rotation, and receive a bonus for each year served in a post, up to 5-years. The cost of that scheme would be easily be met by the reduced cost of recruiting.

- Mobility. The premise of 'universal recruiting' is that staff can go anywhere they are required. That is hard to do, with resource, and reward: the resource would be the (re-) provision of staff accommodation; reward, would be extra pay for those willing to serve in hard-to-recruit to, areas. That happens to some extent now - mostly with doctors - but needs to be rolled-out more widely.

Beyond the HR challenges, there is both an enormous challenge and opportunity in the Digital and AI revolution; I'm surprised it doesn't get a mention. If the Topol Review is correct, we will definitely be, 'doing it differently'; more excitingly (for me), we will be doing things that we currently cannot do at all.

Again to use the CAMHS example, the government's ambition (!) is to provide Access to Treatment for 35% of all Children and Young People by 2021. That target is pathetically low - imagine saying we are only going to treat 35% of all breakages, as an ambition - but perhaps also realistic? With the best will in the world, and with every stratagem at our disposal, we might, at a push, with our current structures and systems, bring that figure up to 40%; still well short of the requirement. Of course, good Mental Health for our children requires more than CAMHS, but we need a systemic 'game-changer': digitisation and AI offers that, but it just won't happen, it needs to be planned, programmed and promulgated - not least to the 'doubting Thomas's' - of Umesh's 'not-invented here club culture'.

There's a lot to do!

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