The new ICB blueprint: what’s the future of system working?

Matthew Taylor 

Hello and welcome to Health on the Line from the NHS Confederation, the organisation that represents members from across the health and care sector. Just before we get started, a quick plug. We're only four weeks away from ConfedExpo 2025, the biggest and best health conference in the UK. So, if you haven't signed up already, well, it's not too late. Go to nhsconfedexpo.org to find out how to join us in Manchester. 

Now, the results of a working group looking at the future ICB operating model have just been sent out by NHS England to ICBs and others in the form of a blueprint. It says in the document, the delivery of the ten-year health plan will require a leaner and simpler way of working, where every part of the NHS is clear on its purpose, what it is accountable for and to whom.  

Now, obviously, these changes for ICBs have huge implications for systems, but also for the whole of the service. And I'm honoured, I would say, to be joined by two leading ICB leaders who were on the working group that helped formulate this blueprint. I've got Jan Thomas, who's ICB CEO for Cambridgeshire and Peterborough, and David Melbourne, ICB CEO from Birmingham and Sully Health. So welcome, Jan and David, to Health on the Line.  

So, Jan, let me start with you. We know this document has been developed at pace. I remarkable pace, actually, I think, in two weeks or less from it being kind of commissioned to being published. I was really impressed when I was at the recent gathering of chief executives of Jim Mackey that Glenn Burley, talking about the document, said that it genuinely was a collaboration between the centre and ICB leaders. Was that how it felt to you, Jan? 

Jan Thomas 

Yeah, Matthew, it did actually. I think what was really helpful about it was the group that was involved was really diverse from big ICBs to small ICBs to different parts of the country. And I think that helped get different perspectives around. There was a mix of chairs and chief executives on the group to get a different perspective. So I think it started strongly with how it kicked off with just that sheer diversity of who was in the room.  

Then what was really helpful is that say locally, I was able to kind of bring some of the thinking back, speak to my peers in the region, knock ideas around, how does this feel, how does that feel? And then kind of take that back into discussions as well. And what was also really helpful is it was just an open email exchange where we could email in and say, look, I've had this thought, what about this? And you always got a response. Yep, we'll think about that. Yep, we'll look at it. So I think, started strongly, able to give feedback, I think we were able to be quite open with peers about what it contained to enable us to have those discussions.  

I know they received a lot of comments and a lot of input into it, but you're right, it was quick. So, did we get to speak to everybody about all of it before it came out? No, but I think a lot of people had a sense of what was going to be in it. 

Matthew Taylor 

And David, what was your view of the process? My goodness, if we could always make policy this quickly, things could really move along with reform, couldn't they? 

David Melbourne 

Yes, yeah. In terms of the group, I'd back up everything that Jan said. And what I was incredibly impressed with was the transparency, the openness, and also the willingness to listen to ICB leaders. And I know that there can be a criticism, well, this has been developed by committee. But I think what you've got is a document in the end, which gives flexibility and room to manoeuvre. And I think it was really useful that we did have different people with quite different views within that group.  

So the national team could see the difference of opinion and weigh that up and make a judgment call at the end of what went in there. So for me, it was good. I think this is probably the way the NHS should start thinking about looking more at policy and developing it. Probably not quite at this pace all the time, but I think it is good. It provides great guide roads to the document itself. 

So it's an enjoyable group to be on as well and a friendly group and well led by Penny. 

Matthew Taylor 

Yeah, just on that point, David, I completely agree. And one of the things that I've been saying is that with the abolition of NHSE, we do need to think about how it is we make sure that the service is in the room when decisions are made. I used to be a bit critical of NHSE because if NHSE says, we are the voice of the service and sometimes felt they were the voice of NHSE, which is not quite the same thing.  

So it's great, isn't it, when leaders are directly involved in the conversation. I thought the same thing about Elizabeth O'Mahoney talking about the community of chief finance officers. So I think that's a good sign about the culture. But that's the positive point. And both of you are very forward-looking people. But I have to ask this question, which is when the announcement was made of the 50 per cent cuts in ICBs, which kind of came out of nowhere, we've responded to that. I mean, in a sense, when you look across this, what's happened across all of the last few weeks since that first announcement, we're making the best of it, but what's your view of the way this all started? David? 

David Melbourne 

I think that some of this was inevitable, if I'm honest. I know colleagues won't agree with me on this, but I think it's inevitable because of two, well, three or four reasons.  

The first one is the architecture, the local architecture in ICS should have been developing already with the development of provider collaboratives and a greater delegation to those collaboratives. I know that's what's happening in Birmingham. Matthew, I think you had Richard Kirby on last week from Birmingham Community Trust and he's taken on our neighbourhood health for example. So I think it was inevitable because of that.  

It's inevitable because of the money. We have to be honest, the NHS is in a really difficult financial position. We had to do something.  

The third reason is there is too much duplication as a result of that and a degree of confusion about who should do what. And I think that inevitability means that almost we need to accept that we've gone through one phase of integrated care boards. We need to start thinking about the next phase. Now, I'm sure there's lots of arguments about this could have been done better. The announcement came out of the blue, which it did. I accept all that. But I think if you were looking at and reading the runes, which what was going to come out of the ten-year plan, there was going to inevitably be some change. And I expect that this will be actually baked into the ten-year plan.  

So, yes, it is difficult. It's a difficult piece of policy to implement at pace, but I think there is an inevitability about it. 

Matthew Taylor 

Jan, obviously one of the points that people in the centre who were sceptical about systems would make would be about the variation in the quality of them and actually both of your ICBs would often be in that sentence as well. Those are great ones but there are others that aren't so great. So obviously that's part of the story.  

But Jan, do you agree that what's kind of slightly implicit in what David's saying is that in some ways, ICS has had this coming to them because they hadn't managed as far as possible, as much as possible, to be able to kind of get into the right relationship to focus on quite the right issues. 

Jan Thomas 

So look, think, what is it people always say? There could be lessons learned from how things have happened. I think what has been difficult was just the kind of the speed of the announcements and the expectation of next steps and just how far the number needs to take us. I think that is the bit one is the shock factor. But I completely agree with David, if I'm honest, which is there was something kind of inevitable. And in that question, Matthew, you've just asked because we have to get to a system where we are able to really understand how we get sustainability, not just this year, but three years, five years out. And we're all looking at our population predictions and thinking, blimey, if we don't do something different, you know, there is no way we can afford X amount of new hospitals and X amount of new beds in order to meet this demand.  

So I do think if you put the things together, we've got to remember we've got patient and public confidence in the NHS at it's lowest. We've got people waiting longer for care than they've waited for a while. We've got an even bigger set of demands coming down the tracks. And I think as ICSs and ICBs, we've got to think beyond just about integration, which is critically important, and start to get into the science of this and saying exactly what is it I need to do to bend the trends? What does the health economics say? And what can I do at both locally and scale in order to deal with that demand?  

And I think when I read the blueprint, what I think is I can see a path to me be more able to do that than I could when I think about some of the restrictions we had put on us when we were setting up ICBs. And we shouldn't forget that this is far more permissive what we have now than what we had when we were setting up the ICBs, which were really prescriptive about what we needed, how we should do it, who we should have on our boards, what we could do, what we couldn't do.  

So, I think however difficult it felt because of the speed and the depth of what we dealt with, the style of this, the risk that's coming down ahead of us at speed about demand in three or four five years’ time, I don't think it's inevitable; I think it's essential that we learn how we can evolve to be able to deal with that because we are accountable for the money that comes in and how it's spent. We need to really focus on making sure it's going to where it's going to drive the biggest return in terms of health gain for our population. I'm not sure we've been able to do that in the past. 

Matthew Taylor 

Well, Jan, that's a great prompt for my next question to you, which is obviously at the heart of the blueprint is this concept of strategic commissioning. And I want to explore that a bit really. And I think there's kind of two elements.  

The first is, you know, it's not the first time that we've talked about commissioning as being the key thing that's going to change the direction of the health service. You know, this is our third, fourth, fifth time in that kind of on that rodeo. So we need, don't we, to learn the lessons of past commissioning because if you look at the evaluations of CCGs, evaluation of primary care, trust, whatever, what you'll see is, you know, that they kind of were okay. They were reasonably efficient overall. They didn't really have much impact on population health or a shift to focus on population health. They didn't really have much impact on health inequalities. And also, there was a tendency for commissioners to wrap themselves around the existing provider architecture because that's so difficult to shift for a whole variety of reasons.  

So Jan, what do you think could make this attempt to put commissioning at the heart of transformation different from previous attempts? 

Jan Thomas 

I always struggle with the word ‘commissioning’. I always have done because I think, what are we actually talking about when we say that? Because you ask people and they'll give you different answers. But what I think is really important is if you look at what does work, we know that clarity of what we're trying to do and what we're expecting the outcomes to be is really important. We know that having a thriving market able to meet demand is really important. We also know that we can't just do those first two things, have best plans, understand what's happening with capacity and demand. We can't just get the greatest specifications and kind of financial agreements in place and think it's all going to fall into place.  

We've actually got to manage how people are using their healthcare. And I think what's different about what's being proposed now and why isn't just commissioning is, I read this as how am I going to make sure that healthcare is utilised in the right way and what initiatives are we going to put in place to do that?  

Can I just give you a quick example, Matthew, think just some of this. In Cambridge on Peterborough, we've been using health economics now for about 18 months and we asked them the question, instead of evaluating if something is a good use of a pound, we've said if you've only got a pound, where would you spend it? And don't forget in the past we've been very prescriptive about where our money should go.  

But if we take it from the basis of just trying to work out where we should spend our money, it's clear that the investment needs to go in areas like metabolic disease, cardiac health. And with that kind of information as a strategic commissioner, what I can then do is say, all right, so that's what I need to do. How have I done that in the past? Well, we've used some brilliant primary care services to look at how they are prescribing. If I just use lipids as an example. Post-event, those people that should be on lipids, how many are, how many aren't.  

In the past, what I would have done is I'd have looked at what is my commissioning of a lipid pathway. Now, under strategic commissioning, and when we were in ICB, we actually set up with a strategic commissioning unit. What that unit did was they went away, they looked at the data, they looked at the options, and actually we've got three pathways for our GPs to follow locally. One which says, you can carry on doing this yourself. A second one that says, let us go and help identify the patients that you need to go and get on lipids. And the third one is we will do everything for you - we will find the patients, we will contact the patients, we will educate the patients - and then we'll come back to you and say, this patient is now ready and they want to start a lipid.  

What we've done through that is we've now got early results of that work. And it shows that actually when we offer the complete pathway, where we personalise care for patients because we've offered options, where we are working with primary care to free up their capacity and support them to be successful, we end up with better results. And there is clear blue water in our results from the practices where we've just detecting things from them and where we're actually supporting them doing the whole new pathway.  

To me, that's active commissioning, that's managing care and managing utilisation because the savings that come out of us doing lipid management differently are far greater than they would do if I looked at the return on investment on a service line.  

So Matthew, I just use that as an example that says we talk about strategic commissioning as always the big stuff. What it should allow us to do is say, I'm going to invest the money in the right place. I'm going to be innovative with pathways and I'm going to help manage that as well without getting in the way of providers but effectively enabling them to be more successful. 

I think we've got to be bit nuanced about just how we describe strategic commissioning, if any of that made any sore sense. 

Matthew Taylor 

Absolutely it did. And David, when you look in the blueprint at the grid with the functions of ICBs going forward, it is a daunting list and it requires some, range of capabilities from very specific focus capabilities around contracts and bits of commissioning to kind of broader abilities, which aren't so much in the document, but we know are necessary, the kind of political skills that are involved in commissioning for different patterns of care, which can involve difficult choices. 

How confident are you that ICBs, albeit we may be talking about 25 rather than 42, will have the capabilities they need in time for strategic commissioning to make the difference that the government wants it to make? 

David Melbourne 

So I think in time, I am confident that that skill set will be developed. If the status quo had remained, I would not be confident. I was talking to John Turner yesterday afternoon. He's the chief exec of Lincolnshire ICB. And he made a really good observation. saying, well, rather than continuing to call ICBs, ICBs, why didn't we call them strategic commissioning boards going forward and actually fundamentally reset what they do. Cause for me, Matthew, this is a fundamental reset. Whether you have to come together on a different footprint or on a new footprint or stay the same, you don't have the level of reductions required without having a fundamental rethink of what you do. And what that blueprint does give you is absolute clarity of what we've got to do in the future. 

So I'm not convinced at the moment we do have all those skills. And actually what the blueprint does say is we need to look at how we develop those over time. And what Jan just gave is a great example. And we do need to learn from the best here rather than sort of creating all our own. But for me, at the moment, if we kept the status quo, there wouldn't have been the change. And fundamentally we would not get the change from hospital to community.  

Yesterday I had to go through our annual report, I’m an accountant by background, so I don't mind doing these things. But one of things I was looking at is how much we invest in acute care compared with community mental health, primary care. It's not shifted. It's not shifted for, actually it has shifted, it's shifted towards acute care over the last few years. And we need to make that fundamental shift. I think without making these changes, without using those skillsets that Janet's described, we would not do that. 

Matthew Taylor 

Which takes me then to a couple of areas I want to get into, which are kind of around the edges of the blueprint. And I think are very important. So first is the relationship with local government, because it's very interesting what you say there, David. If we are going to have a shift of resource from acute into community and primary, and I think the Confed is leaning towards the view that the ten-year plan has to have an explicit commitment to do that, to make sure that it really does happen and that everybody knows it has to happen.  

That does involve hard choices. It does involve closing wards, maybe even in some places, closing hospitals. And we know the kind of reaction we get to that. Now, one of the ways we can deal with that is if we work with local government and local government understands what we're trying to achieve, they've got direct local legitimacy. There are loads of other areas where we need to work with local government in the kind of population health space, the health inequalities. 

But the documents almost completely silent about that. What do you see, David, going forward as the relationship between ICBs or strategic commissioning boards or whatever they're called and local government? 

David Melbourne 

Well, not just local government, Matthew, but politicians in general. I think we have to continue to engage, to work with local government in a positive way, because we will only get these things done together. Neighbourhood health is not just about, as you well know, and everybody who's listened to this will well know, it isn't just about the health service getting together, it's the health service, social services, the voluntary sector, the faith sector, getting together in neighbourhoods, localities to work together and then we have to continue to do that.  

And one of the things that I do think we need to think about, and I think it comes into some of what Jan just said, is how we get engagement right at a local level. So, I've been thinking through, and Solihull will not stay an island. Almost certainly it will move its footprint. But there is something, if you visit Birmingham and Solihull, there is something about that area. And how do you continue to get the institutions to work together in Birmingham and Solihull?  

That doesn't need an ICB necessarily to do that. Today, our chief execs met, which included local government colleagues as well. And we do that regularly. So I think we have to continue to almost be that strategic convener. And I've got to work out in my own mind what that means in the future for us on a larger footprint. But I do think we've got to do that.  

Local government is absolutely essential to it, having those contacts with both local authority chief execs, directors of social care, children's social care is absolutely essential, as is all the other areas that contribute to people's health, such as housing. So I think as we put our plans in for the end of May, that is something, for example, that I know the Birmingham and Solihull plan will have in how we are going to continue to do that. 

Matthew Taylor 

So Jan, I'm interested in your reflection on that. You've got, even now, I mean, I guess your footprint's likely to change as well, but even now you've got this fascinating kind of area. You've got one of the most economically dynamic parts of the UK, but you also got one of the more deprived cities and towns in the UK. I was in that part of the world just a couple of years ago and talking to one of your GPs. 

We don't seem to be talking about the four goals of ICBs, health inequalities, that kind of wider economic and social impact of health. The sense is no, we need to be much more focused. So how do you think you need to take the relationship with local government forward as you try to improve the health of your population? 

Jan Thomas 

Yeah, so I think we need to remember that the real focus has to be on integrated neighbourhoods, communities and place. And our role is going to be how do we ensure that the place model is successful? How do we make sure that we are clear on expectations around what integrated neighbourhood teams are able to deliver together in a multi-sector way? 

We've just actually had our board this morning and just had a bit of discussion at the board about there are a couple of factors that we need to bear in mind.  

The first one is the fact that a lot of what we've just talked about in David's outline is actually about relationships. So how are we able to, as leaders, work together to pick up the phone to say, look, this is coming, this was an issue, this is really exciting, how are going to work together? So I think whatever we do going forward, we've got to be able to maintain the relationships with local leaders. 

But I do think that place will come to the fore. I think place as a delivery and an operating arm to make sure that our provider collaboratives in their wider sense, our organisations that can work together in the best interest of those outcomes, it is the place where the action happens.  

And as in the new world, we've got to make sure that we are enabling that in every way possible. So what is the infrastructure we're able to supply? What is the data we're able to supply? Because the last thing we want to do is have a number of different places that are then all building their own infrastructure for things like population health.  

So I think there's going to be a bit of a skill to this, Matthew, that says we've got to maintain relationships. We've got to provide the enabling infrastructure. We've got to let them fly and we've got to give them more autonomy than we're doing now. And we've got to make sure that we are giving them clear expectations of what we need those outcomes to be.  

I think if we get that right, then this is exciting to do. Potentially bigger ICBs that can do this stuff at scale, in the lipid example I gave - you could do that over millions population. You don't just have to do that over a small because it's an efficient way of working. But actually knowing then that you can work at scale and then complement it with that hyperlocal will be essential.  

I guess what I'm questioning Matthew is the benefit we've had of having something in the middle that was neither big enough to get efficiencies of scale nor small enough to feel genuinely hyperlocal. 

Matthew Taylor 

Well, thanks, Jan. So I've just got one last question for both of you, but it's quite a tough question, I think, because we're scratching our heads about it the Confed and it relates to what you've just said, Jan.  

One of the people at the centre that I last spoke to about the kind of operating model, the ten-year plan, was really saying, well, we're going to have ICSs doing the strategic commissioning and they will commission neighbourhoods, integrated neighbourhood teams.  

And I said, well, what happens in the middle of that? They said, well, we don't want another tier. So they don't want places to be another tier. And then of course, I think the general view is a reasonably agnostic approach to the relationships between providers, who is the kind of lead provider between system and neighbourhood.  

Just give us two or three thoughts about how you think these levels need to connect to each other. 

Jan Thomas 

You couldn't have ended on a simpler one.  

So I've been kind of oversimplifying what this is at the minute, which is I keep saying NHS England is going to be there to enable the ICBs. It's almost like a cascade, but fundamentally act as a kind of performance regulator and step in when things aren't necessarily going smoothly. Commissioners, we are there to actively manage how care is being utilized. 

We need to buy the right stuff. We need to make sure it's doing the right thing. We need to be accountable for good value for money.  

And we need to make sure we've got a market there ready to do all of that. And then the providers need to work together and they need to come together and transform and collaborate and together make sure that they understand how they get better value out of them all working together rather than one taking over the other or one saying they can do it better.  

You know, this is about collaboration. And I think fundamentally, regardless of where we put the lines or put the description, the amount of organisational development and culture work we've got to do over the next few months and years to carry on what ICB started, which is this is a team sport and we're in the people business. 

And we need to make sure that we put that at the heart of what we're doing and decision making. And therefore, how do we all enable each other to fly? Well, we need clarity, we need to be specific, but we also need to maintain the relationships and keep the patients at the heart of it. And if we do that, we should probably do a little bit, should be a little bit simpler than it was in, it has been up till now. 

Matthew Taylor 

Thanks, Jan. And I just want to absolutely echo that point about the investment in organisational design and leadership development. I think we have a terrible habit in the NHS of asking people to do very different things.  

Now, David, you've done some really impressive things in Birmingham and Solihull. And I'm interested in what you've learnt from the way in which you've got providers to work together, the way you've worked with a local authority, a local authority with many issues, the largest local authority in the country. And what you think are the lessons going forward. 

Then just finally, David, in terms of neighbourhoods, how do we ensure that neighbourhoods build on the assets and capacity that already exists in neighbourhoods, particularly if we want them to feel like they're not just tentacles of the NHS, but organisations rooted in community? 

David Melbourne 

Yeah, can I just link a few things that Jan said through to this as well, Matthew? And what you said. 

The first one is about organisational development. This morning, so we're commissioning neighbourhood health through our - we are lucky, we've got some fantastic institutions in Birmingham, some great providers - and we're commissioning the development of neighbourhood health through our community provider.  

One of the things that we have recognised is the need for organizational development around that. And we have put an OD planning to do that. That isn't me that's doing that. It's one of our chief execs who leads on OD. And to make this work, we've invested significantly over the last two years in building relationships.  

Every chief exec in Birmingham and all the executive teams, well, we all do development together. We've got a session again next Friday where we all sit down together or stand up or do whatever it is in a workshop and do things together.  

Now people might say, well, that's not really what health service management is about, but it's about building relationships. It's about when you're having those incredibly tricky discussions about neighbourhood health, about who owns what and what footprint you use. You can get over those in a reasonable way. 

And for me, that investment that we've made across Birmingham and Solihull in our leadership development has been crucial.  

And what I've learned is that the more I facilitate, enable and just have my hand on the tiller, but I've got lots of fantastic chief execs in Birmingham and Solihull who can lead this. The more I trust them and let them get on with it by providing the framework, the better it is. And actually the more I get involved, the more complex it will become. So for me, it's letting go whilst also being a really big facilitator.  

And that's what you saw at Washwood Heath. The teams you saw there have been brought together, they're multi-organisation teams. They've been brought together by the organisations themselves. We've facilitated that, we set out the strategy, but now it's for somebody else to implement that strategy. That's my one lesson and I hope we don't lose that as we move to the new ICBs. I'm confident we won't because it's one of the core jobs in the blueprint. 

Matthew Taylor 

And Jan, just a final word, what's your view also about how neighbourhood health, how should it feel? Should it feel like, as I'm suggesting, it's a broad-based community-embedded organisation? Or I have heard other people say, well, no, it's fundamentally about NHS delivery. I don't think there's a dichotomy there, but I'm interested in your perspective. 

Jan Thomas 

Yeah, so it absolutely has to be able to work for the community that it's there to solve. I think to do that, it has to be able to pull on all of the resources it needs. Whether that is about voluntary sector colleagues, whether it is about faith groups, whether it is about community groups, it has to be able to pull on all of that. But to make it really successful, then we have to use a level of science to support it that says, here is where your opportunities are. Here are the people who are most vulnerable. 

Here is what we need you to do in order to make sure that the most at risk are given the most opportunity to improve their health and their outcomes. So I think it is that multidisciplinary cross-sectional working hyper-local group, but with a big power engine really backing them up that really supports them being able to identify where they're best able to spend their time. And that might not be instantly obvious if you do that community up. Sometimes you also need to do that with information and integrated information to give them insights. 

Matthew Taylor 

Well, thank you, Jan. You know, it falls to me, I think, to say that the way the ICB community has responded to being told that they were going to lose kind of half their capacity and some of the kind of slightly disparaging things that were said around that time, I think the way the community has responded constructively to that, demonstrated by the blueprint, demonstrated by the comments you've made today, is incredibly impressive.  

So Jan and David, thank you so much for joining me on Health on the Line. We will at the Confed continue to support system leaders during this transition period and through our work.  

And that just leaves me to introduce our latest Leader in Six interview, which this time is with Kate Shields, ICB CEO of Cornwall and the Isles of Scilly, who I met last month on a fascinating visit to that part of the world.  

So, Kate, first question, what's the biggest challenge you're facing right now? 

Kate Shields 

I think one of the biggest challenges is keeping an organisation focused and delivering when they feel like everything's changing around them - a series of disconnected announcements with very little information after them has made people feel quite wobbly, I think. 

Matthew Taylor 

Not surprising at all. What innovation is there in Cornwall that most excites you and what you do? 

Kate Shields 

The obvious example is the X-Ray car was invented in Cornwall. It's been rolled out across the country and the excitement of our GPs, radiographers, local managers, driving something forward, getting it funded and seeing that it worked. For me that typifies a lot of things that Cornwall does. Elizabeth O'Mahony described us once as having loads of ideas and innovation. She did say at the time if you could manage some of it down and deliver it that would be great. But I think we're starting to deliver such stuff.  

We've got people with very different views of the world that are starting to bring those views into mainstream service delivery. So things like gardening for depression and reducing prescription of antidepressants. Those sorts of things that seem very basic, but actually I think for people add an awful lot into them and to communities. 

Matthew Taylor 

Great, and I've been hearing a lot also about the work you're doing in your integrated neighbouring teams, which sounds really exciting.  

If you were king of the NHS for a day, what's the one thing you'd do? 

Kate Shields 

I'm not sure it would be possible, but I'd quite like to move away from institutional boundaries. So asylums, I was a mental health nurse, we think we've got rid of asylums, haven't, they're alive and well and they're all over the country and they've all got people in them who are, what do we used to say people were when they lived in asylums? [Matthew: Institutionalised]. So, you're institutionalised by the experience that you have within them.  

So if I was king for the day, I'd want everybody to understand how services where you are work, what can happen where because I think our risk tolerances are judged by the information we've got at a point in time and institutions don't help really. 

Matthew Taylor 

Really interesting.  

Tell us something about yourself that is nothing to do with your job. Something interesting about yourself. 

Kate Shields 

Oh, I didn't have to describe it as interesting.  

Matthew Taylor 

Or just important to you.  

Kate Shields 

So I've got five children. So three of them are mine, two are borrowed. My husband says I should say they're mine, but I think their mum might mind. Three grandchildren and a grand dog.  

I was left in charge of my grand dog. So the two kids and their dog for a week. Kids were fine. The dog ate 40 grams of dark chocolate, cockapoo, lot of dark chocolate for cock-a-poo.  

She survived that and then ate a whole medium Domino's pizza. So the dog took advantage of my good nature. I think that probably says a lot about me. If I can be taken on by a cockapoo, then obviously I'm quite gullible. 

Matthew Taylor 

Yeah, well, I've got a calfapoo and, I know all the problems of dogs eating. Why have dogs evolved? Why haven't they evolved to know what poisons them? It's really inefficient. 

Kate Shields 

But Maisy doesn’t eat off the table. In one week, she just found the chocolate – she shouldn’t have found it. And the pizza, she got on the table to take it off back to her bed. But she didn’t eat the box; I suppose that’s the only good thing  I can say.  

Matthew Taylor 

Kate, tell us about a leader that you've met and worked with or in the wider world that you never met who you most admire. 

Kate Shields 

So when I was growing up I would have said David Nicholson because I quite like his clarity and he gave great feedback. I didn't always like the feedback I got but it was very clear.  

John Boyington, don't if you know John from the North West, so I worked with John in a joint prison service NHS unit in the Department of Health, was expanded to the Ministry of Justice. He was just really clear and very kind and wise and he did something that I found was amazing: 

At the time somebody shouted at her, somebody who was junior in my team by email, copied to 50 people. So he spoke to them and said, you need to apologise. And he apologised directly and John went back and said, no, shame publicly, apologise publicly. And his attention to the fact that somebody who was very junior was terribly upset by somebody who was really important, I just think it's fab. That attention to your team is great. 

Matthew Taylor 

Clear, kind and wise. What a lovely trinity.  

And then finally, Kate, share with us something that you've consumed recently. It could be a box set, it could be a podcast, it could be a book, but something you've enjoyed and you think other people might enjoy too. 

Kate Shields 

So I've really, this marks me out as being... 

Matthew Taylor 

Last person I asked said White Lotus, know, honestly there's no wrong answers. 

Kate Shields 

Amsterdam. Have you seen it?  So it's an American series about healthcare and the chief exec just goes around saying, how can I help? I mean it's got a bit boring after 40 episodes, but it was quite compelling to start off with.  

Matthew Taylor 

Is it New Amsterdam?  

Kate Shields 

New Amsterdam, yes. So, he started his first day by sacking cardiologists who were over billing because they were adding no value to people's long-term life or happiness which I just thought how refreshing. 

Matthew Taylor 

So can't believe you did this job and your leisure time you spend watching a hospital drama, but that's fine. Thank you very much, Kate.