Battle for the NHS? Dissecting plans for the future of health and care

Matthew Taylor

Hello. This week we're recording Health on the Line at NHS ConfedExpo in Manchester and we're discussing the future of the NHS against the backdrop of the general election. In just under three weeks the country will go to the polls and if the latest opinion polling is to be believed we're heading for a change in government. As we sit here in Manchester we've had the manifestos of the Lib Dems, Conservatives and Greens this week and just up the road in an hour and a half, Labour is about to launch its manifesto in Manchester.

What's clear from manifestos so far is that the NHS, as expected, is among the priority issues. Most polls say it's the most salient issue. But it's also clear that there are many unanswered questions about what the main parties would do on health and care if elected. So to help us dissect the manifestos, what they mean for the NHS and social care, I'm delighted to be joined by two seasoned followers of politics and NHS reform. 

Firstly, we have Victoria MacDonald, health and social care editor at Channel 4 News. And without wanting to age you, Victoria, this is your seventh election since working at Channel 4. I've got one of those kind of statistics as well, which is that the last three Labour manifestos, which are then followed by Labour victory, I was involved in it in some way or other. And if Labour does win, this will be the first manifesto, the one being launched in an hour that I won't have been. 

That's a poignant for me, even though I'm now, of course, a totally independent chief executive of a charity. So Victoria and I, we've been through this. 

Victoria Macdonald

We've been around. 

Matthew Taylor

We've been around. We've been through this before. I'm also, though, delighted to be joined by Richard Sloggett, founder and programme director of Future Health, and also former special adviser to Matt Hancock when he was Health and Social Care Secretary of State. I'm tempted to say that when he was sane, but I'm not going to say that. That’ll be a little provocative.

Richard Sloggett

I'll let you say that then. 

Matthew Taylor

Okay. Well, it's great to have you both here. And I'm going to start, Victoria, by calling on your experience over these several elections. 

What do you think of this election campaign? How does it compare to previous ones you've been involved in or observed?

Victoria Macdonald

I've been, I was at the Sunday Telegraph before I was at Channel 4 News, so actually I've probably been involved in way more elections than even that. This one is playing out actually in much the same way that a lot of the last elections have. The public says that the NHS and social care are very high on their priorities. I would say the last three elections, it's polled second with the economy usually sort of first. But it does not get as much prominence, it's not as much in the debates as that polling would lead you to expect. 

And what tends to happen is that it comes to the forefront when there is a misstep, when there is a Sharon Storer on the doorstep confronting Tony Blair about cancer waiting times, I’m really going to age myself by going back to 1992 with Jennifer's ear, which threw both the Conservatives first and then Labour into disarray over health policy. And I am sort of waiting for that to happen this time. 

Matthew Taylor

So, sorry, Richard, it's not just going to be Victoria and I playing all our yesterdays. I can beat you for going back. What about Denis Healey's wife? That's what I was thinking of when Keir Starmer said he would never use private healthcare, I remember Dennis Healy being confronted by the fact that his wife had had private healthcare in, I don't know what election that was, but that's so, just to make you feel young. Just to make you feel young. 

Victoria Macdonald

I was in New Zealand, then – we were having our own health issues then. 

Matthew Taylor

Yeah, absolutely. 

So Richard, I kind of made a prediction before the election to folk, which kind of explains the point Victoria's made, it’s the number one salient issue but yet it's kind of bubbling under a bit and that is in a way both parties have got a problem with health. The Conservatives have got a problem because they don't want to talk about their record and Labour have got a problem because they don't really want to answer the question, ‘Where's the money gonna come from?’ 

Do you think that explains why it’s the most salient issue but has not broken through in the way that for example tax or immigration has? 

Richard Sloggett

One hundred per cent, Matthew, I completely agree with the analysis. I mean, Rishi Sunak made cutting waiting lists this one of his five pledges when he came in to become Prime Minister. That is not materialised in the way that he said it would. The wider state of the health and care system is, as we know, very, very challenging. The Conservatives are normally behind Labour anyway on health, but on this time they are a long way behind. 

If you ask who the public most trust on health, Labour has got a significantly 30-plus points. The approach this time is very different, of course, from where was in 2019, where the campaign was very, very different. Boris and Dominic Cummings and Lee Kane and others said, we're actually going to put health front and centre on the back of the Brexit referendum, on the back of the bus – side of the bus. We're going to push really, really hard on, we're going to invest in scanners, we're going to invest in new hospitals, more nurses. 

And actually that did cut through, but this time the approach is totally different. And you're absolutely right on Labour, they've got this big lead on health, they're trusted on health, but the unanswered questions, if you start answering those questions, the questions will immediately come back to Rachel Reeves and John Ashworth about how are you going to pay for all of this when you're ruling out significant tax rises? So for both sides, it's quite a convenience not to talk about it. 

Matthew Taylor

So following that up, Richard, if you were in Victoria's job and you were sitting with Wes or with Keir, and you wanted to ask them the most challenging question, you think in terms of what Labour's saying, I mean, obviously, they're going to say in full because it's only being released in an hour, but what do you think is the question they are finding hardest to answer at the moment? 

Richard Sloggett

So I think it's my one hat and my trying to be a journalist hat. So what would a journalist asks, what are you going to do that's actually different? So, and what they'll say is, their line is, we're going to do is weekend appointments. Some trusts already do that, so, how are you going to roll that out more widely? But it's not really a game changing piece. It's a move forward, but the scale of the challenge is so large, the policy proposals being put forward don't really stack up. 

Now, one of the things is we've got lots of plans. So we've got a primary care recovery plan, we've got an elective recovery plan, we've got an urgent and emergency care plan. We've got a lot of plans. The challenge is execution and delivery. So the question for Labour, I think would be, so how are you actually going to do this differently, given this real scale of the problem that we've got? 

And you are ultimately, let's be honest, you are going to have to find some money from somewhere. The lessons from the 2000s are you have to put more money into the system in order to get things working. If you want those consultants and those nurses and those doctors to work extra shifts, you've got to pay them to do so. And also we didn't have at that point, we didn't have a pandemic, we hadn't had a referendum. We haven't got those sort of wider societal and cultural dynamics and practical dynamics. 

So the situation is really, really tough and the proposals coming forward at the moment are sort of, they step forward. They're not the stride that you really need. 

Matthew Taylor

Victoria, what would be your kind of killer question for Kia or Wes? And by the way, I should apologise to listeners, we are going to mainly focus on Labour in this conversation, simply because, not because of any political leanings that I might have, but because that's what the polls are telling us. So we'll talk about the other parties, but we're going to largely focus on what will happen if the polls are right. But what would be your killer question to Kier and Wes?

Victoria Macdonald

Well, it would be, what are you going to do on day one? You've got the junior doctors issue, you've got the GPs who are threatening to work to rule, you have winter coming up. And we know that winter planning should have started now, but the money hasn't gone in yet. We don't know when that will be released. They're going to have to find that money if they do not want to have a dreadful first winter. 

So those are three issues that need to be dealt with on day one, pretty much. And there are also three expensive issues that will need to be dealt with. So where are they going to get that money from? How are they going to put that into the pot immediately? Then you can start talking about the waiting lists. You can start talking about the staff shortages, social care, which is my particular bugbear, about how little is being said about social care and about how desperately that needs a reform. But it's those three issues first off.

Is that a killer question? 

Victoria Macdonald

Well, it is, but I'm going to ask you, to kind of almost answer your own questions. You've watched a lot of elections, but you've also watched a lot of first hundred days. You've watched what governments do when they, you know, when they do take power. What's your prediction? What do you expect to see from Labour? And I've heard, for example, no one's going to be going on holiday in July and August. It's going to be a determination to demonstrate a difference can be made quickly. How do you think Labour's going to operate from that day?

Victoria Macdonald

Well, actually, I find it quite hard to predict because they have been, not muted isn't quite the right word on it, but they have been so careful not to make us think that they're going to do what Tony Blair eventually did and throw a massive amount of money. What we know is that I think the people who were advising Tony Blair…

Matthew Taylor

Of course, Tony Blair put the money in immediately. mean, he waited three or four years. 

Victoria Macdonald

And I think what I'm hearing is that they see that was a mistake and that they should have done it sooner and that to wait those three or four years when there were huge waiting lists, really absolutely record at the time waiting lists and waiting times, that they should have acted sooner. 

Now, I suspect from what Wes Streeting and his colleagues have been doing and talking to some of the advisors from the Blair government that maybe they will see that they do have to act sooner. And they will just have to find at least that pot of money to deal with those critical issues first off. I wouldn't be surprised. I mean, getting the junior doctors sorted would be a really wise idea because you do not want that hanging over you for the first 100 days. 

Matthew Taylor

So Richard, let me throw it back to you because obviously you've been inside. One, as far as we know, hopefully this isn't going to change later this morning, one thing that's going to be different is that, of course, the last two times we a change of party in government, we had Andrew Lansley ripping everything up by the roots. That wasn't a great success. Before that, if you go back long enough, Frank Dobson abolishing the internal market only for it to be recreated later, getting rid of GP fund holding when he probably could have just tweaked it and made it work. 

So one good thing is Labour says it's not going to reorganise, but what would be your advice to an incoming government on how you deal with that those first few months? 

Richard Sloggett

Yes, I think you've got to do signal and substance. So the signal has to be there is a change, and then that has to be backed up by a piece of substance, which then comes back to the junior doctors. And you have to settle that dispute because it signals that you're prepared to work with the system, work with the professions to find solutions, as has happened in Scotland, as has happened in other countries.

And then it also then leads you onto an agenda, which I think you've talked about a stabilisation agenda, which then means that there is clarity about your workforce to deliver some of your targets and commitments. You need to do both the signal and the substance. And that's why that dispute is so important. Now, last night's Sky Leaders debate, I was really struck that Keir Starmer said, he used the phrase: ‘I will get in the room and negotiate.’ 

Now, I'm not sure if he misspoke, but I was very struck that he as Prime Minister in waiting was saying he will actually physically get in the room with the junior doctors to find an agreement. Now, as said, I don't know if he overstepped the mark on that, but I thought that was quite a significant commitment to say, actually, this is really, really, really important. 

And the money, we don't know where it's going to come from, but they will have to find it from somewhere. 

Now, what we think is, Rachel Reeves is looking at these kind of not the main taxes, but some other sort of taxes and equalisations. And can they free up some money there to say, look, let's settle this dispute and let's move forward?

It won't end the industrial challenges though. As Victoria said, we've got GP challenges, we have pay review bodies coming back round, cost of living is still an issue. But it will set a different tone. And that's why I think it's really, really important. 

Matthew Taylor

So just stick on that point for a moment. If there was some concessions made to the junior doctors, that's what the public would like, the junior doctors would like. But as you say, they have that kind of a knock-on effect in relation to what GPs are saying and to relation to what nurses, who are far from happy about what happened last year. So how would a government resolve the junior doctors without the danger of creating a kind of inflationary expectations across the rest of the workforce? 

Richard Sloggett

Yeah, so I think what you're hoping for is a new government coming in, you have a, know, Labour could win here, a significant majority, is there is a sort of glowing effect that you have, you have a bit of a honeymoon period in which to negotiate things and frankly trade some things out, which the existing administration after 13, 14 years found it very, very difficult to do. 

And my argument has always been that the current government's approach to worrying so much about inflation basically meant that they didn't deliver on their NHS targets, which has basically completely snookered them in this whole dispute. Now a new government can come in and say, look, we are one step at a time, let's get the junior doctors, they'll come on the nurses, we show we can get deals. We didn't do the last negotiation, let's look at this, let's try and find a way through. 

And I think Labour's approach to that and how it approaches the engagement and what substance it has, I think there'll be a freshness to it, which might create opportunities which didn't necessarily previously exist. Both sides might be more willing to get in the room and negotiate, whereas they weren't necessarily 12, 18 months ago.

Matthew Taylor

Yeah, and also I think trade unions are less inclined to challenge governments that have got the fresh legitimacy of having one election. 

Victoria, you talked about social care. Both Amanda Pritchard and her speech yesterday, much less significantly myself in my speech, we talked about social care because of its importance to the health service. 

Both major parties have heeded the lessons of previous elections, and you know, for those people who can't recall this, of course, Theresa May suffered severe damage from putting forward a credible plan on social care in the 2017 election. Do you think that there might be a shift here in the sense that I guess one of the things we might expect from Labour is there will be a moment quite early on where they kind of say, my God, we've gone into government, you'll never guess what we've discovered. 

All this terrible stuff, we're going to have to do some things that we didn't think we were going to have to do. Social care might be one of those things. And maybe there's a lesson here from the previous Labour government, which is that tax rises are more permissible if they are apothecated for a cause that the public believes in. So do think there's any chance that Labour might actually quite early on say, we've really looked at social care now, it is in a terrible state and therefore we are going to raise a tax of some kind to pay to get us out of this social care hole? Do think that's possible? 

Victoria Macdonald

Well, I mean, Gordon Brown did it and he did it very successfully and perhaps they might do it. It would go against everything they've been saying so far. But yes, they have that leeway, when they first get into, as you said, to say, my goodness, it really is way worse than even we had expected. 

I mean, there have been strong hints that they will support what the current government policy is, which is to bring in the £86,000 cap, which is a start, and I interviewed Sir Andrew Dilnot the other day, who of course wrote the coalition requested paper on this and advised that you have this cap that you also move from the £23,250 means testing up to £100,000. There are strong rumours that Labour will accept that.

Matthew Taylor

That helps people, but it doesn't deal with the funding. In fact, it makes the funding issue harder. 

Victoria Macdonald

Yes, and it doesn't deal with the terrible staffing issues. But just on that, on that funding issue, that is what people are caring about right now. It is the ever thus that the British don't want to sell their houses. They want to save them for their children.It plays very strongly.

Those of us who watch the social care system know that the biggest critical issue is staffing. You have to increase their wages. You have to deal with the immigration issues about how many people you're going to allow to come in and whether their families should be allowed to come in with them. You have to deal with the fact that care homes are closing at a rate of knots because they can't afford to keep them open. 

Local authorities are going bust all over the place and they pay for social care, that's where the funding comes from, all of those issues. But if you want a big electoral headline saying we're not going to take as much value of the house into account as we had before would play very well. 

Matthew Taylor

What do you think about that, Richard? If you were advising either a Labour government or a Conservative government, having achieved the greatest turnaround in political history, would you say, look, there are ways of funding social care which feel like they fit in the sense that we now live in a world where there are more millionaire pensioner households than pensioner households in poverty and whether it's new council tax bans, capital gains tax, inheritance tax, there are various ways in which you could do that which wouldn't break the rules that the parties are set for themselves. 

Would you encourage an incoming government to do that quickly? To get on with it so that maybe in four years, five years the pain has passed?

Richard Sloggett

If you're going to do anything on social care, you need to do it in the first two years. Otherwise, nothing will happen. That's the history of this. If you start creating or calling for commissions, or you start doing consultations, you are basically kicking this can down the road. 

You'll then go through a cycle of governments and everything becomes less popular, local elections will happen. The idea that you're going to have abilities like raise taxes or create anything of those things Matthew. So if you come in with a big majority, you do have a window of opportunity to think quite radically and quite bold on this.

I'm more sceptical about whether Labour will go here in a substantial way. If you listen to what they've done on social care so far, it's been understandably highly tentative. I think Wes Streeting had six paragraphs in his 2023 conference speech - two on social care - two of those are about Angela Rayner. And I think the way at the moment it's phrased, and it's right, as Victoria's just articulated a whole stream of issues here. 

What are we talking about? We're talking about capping households, workforce, immigration policy, quality of training, local authority budgets. There's such a plethora of issues. I think where they'll come at this, as they've been quite transparent, is fair pay. That's the thing they'll really try and demonstrate that they're moving forward on. Could they alongside that bring in the cap to neutralise it as a political issue? Potentially. 

But I would say you've only got so much bandwidth in government. They're talking about a wider sort of health related mission. They've got all the NHS challenges. Is social care going to get squeezed out again? Possibly. But I do think they will need to do something. But whether it's a more tactical thing on pay and the cap, they might think that's sufficient.

Matthew Taylor

Richard, it was fascinating for me looking at the Conservative manifesto on health, because apart from a bit of inevitable manager bashing and kind of culture war titillation, actually the core of it was pretty good from the perspective of the Confederation, what we argued for. We were briefed by an advisor to the Prime Minister that this package represented 3.6 per cent a year growth in real terms.

And there was a real emphasis on shifting investment into primary, prevention, community. I mean, obviously the problem for the conservatives of all of that is, well, if that's the right thing to do, why is the health service getting less than half a per cent this year? And why have you not done these things in the past? 

But that links to a deeper question, which is that it does seem that there has been a shift in the sense that all the parties are talking about how do we move resources upstream?

They're all talking about prevention. They all seem to recognise what, again, both Amanda and I said yesterday, which is that if we don't change the pattern of investment, the NHS will never move out of crisis management. So I guess my question to you, Richard, sorry, it's just a long question, is how do you actually do that? Because the reality of the last 20 years has been the insight that we need to do that. But in reality, as Malcolm X said, “It's the hinge that squeaks that gets the grease”, and the squeaking hinge is electives and waits in emergency departments. 

So you end up recognising you need to shift resources, but you end up sticking it at the end of the chain to deal with the problems in acutes. Now you must have wrestled with it.

Richard Sloggett

Yes, and I think there's also in the wider political context, it's very, very frustrating that we've spent, because of the way the agenda has been set, we have spent the last 18 to 24 months talking about electives pretty much. We've pretty much talked about a large number, is it going up or down? And that is not really the question that we should be asking in health policy.

The NHS can get elective waits down. It's done it before. If you give it the resources, if you give it the time, it will deliver and it can deliver. But fundamentally, as your speech, yesterday, Matthew and Amanda's speech said, is you have to make the shift. 

There's some thinking going on how you do this. I think the one example that we have is in mental health. So if you go back 15, 20 years, nobody was really that bothered, mental health was never on the political agenda. It was never on the top of the NHS agenda. It was sort of parked to the side. Suddenly, for a whole range of different reasons, some of that to do with strong leadership, some of that to do with societal changes, some of that to do with the environment in which we live, we started to talk a lot about mental health. 

Now, the of the NHS grappled with how to deal with this, and they came up with quite a crude lever. Sometimes crude levers are the things you need to start with to make the change happen. 

And what they did was they said every clinical commissioning group has to spend a certain percentage of its budget on mental health and report back on what that is being spent on, which meant that then at every clinical commissioning group meeting, there was mental health in the agenda and it's like, how are we going to spend this money? Now I get the argument from a policy perspective about, that's a really crude lever, distorting, can you game that? I get all of that. 

But actually to start a signal and a different type of conversation, it was actually quite helpful. And actually we've got a long way to go on mental health. Services aren't in the place we need them to be, but there has been a change.

So you have to come back to the money and how you allocate resources and how you distribute power in the system. And that means frankly, a bigger role for primary and community care. It means delivering on some of those funding shifts that we talked about in the 2019 NHS long-term plan and putting in levers to say the money must flow and you must collaborate and you must find a way to engage and then report back on that and what the benefits of that actually are. 

But we also need to try and get out of this transactional approach to reporting on health: how many operations, how many appointments, how many missed appointments. And that's a bigger journey and a conversation which you started yesterday. But is there a mechanism that the government could say, which is to say, you need to allocate X per cent or something like that onto more prevention led services, and then start to corral consensus around what that should be spent on, what good value looks like?

Final thing on this, it was quite a long question, so I'm giving you a slightly longer answer, is could you do something like this, which is you could say, right, in a ten-year funding settlement for health, every pound that goes into the NHS, new pound, a certain amount of that needs to be allocated to a set of services which are primary community services or mental health services. So the new money, you're right, the new money goes in and goes straight down the most in the secondary care rate. Do you say, right, the existing money we need it to work better, but actually any new money that comes in, there has to be some sort of deal and agreement that will definitely be spent in this way, in this direction.

Now the challenge to me here is, well, you're just creating boundaries and more complex funding arrangements and don't we just need pooled budgets and everything else? But unless you fundamentally direct, we know the history tells us it won't change. These are the kind of things…

Matthew Taylor

That's really interesting. And Victoria, in a way you're part of the problem…

Victoria Macdonald

It’s only 8:30 in the morning!

Matthew Taylor

…only in the sense that it's newspaper headlines that tend to drive this obsession with acute. And when you talk to people about the health service, they tend to think firstly about hospitals, they don't think about GPs, they don't think about mental health services, they don't think about community services, they don't really think about prevention. 

So first of all, do you think I'm right that that's starting to change, that when you report on the health service and you say, actually the problem is how do you shift resources, the problem is prevention, the public are now kind of accepting that argument? 

And then taking Richard's seat, how would a government articulate that to the public if they wanted to try to change the way the public understands how we should invest in health? 

Victoria Macdonald

Yeah, I mean, that's quite a complex question, actually, because, yes, people see both the headlines and the reality of not getting their treatment and hospital in a timely fashion. And we can see the headlines today about cancer waits, which is distressing and shouldn't be happening.

But people are also understanding that they need a better GP system, that there are pressures on that system. Prevention, I'm less sure about what the public thinks on that, because I don't think it's been articulated very well, and I think that is partly the media fault, and I think it's partly the way that, as you said, all the focus goes on secondary and tertiary care and not enough on other aspects. 

I mean, I have a particular interest in public health measures, but right until covid. mean, people probably didn't understand how the public health system worked, and maybe they still don't. 

Matthew Taylor

Is it partly Victoria, because politicians are afraid to sound like they're blaming the public? We know one of the big issues is we're living longer. mean, not so much recently have life expectancy, but broadly they've increased, but we're not staying healthier longer. If you talk about that you're no longer saying, it's the NHS, you are saying to people, actually lifestyle issues and diet and these kind of things matter.

Victoria Macdonald

Oh for sure. I remember John Reed, when he was health secretary, saying, why shouldn't people living on a council estate in poverty smoke? What else have they got in their lives? Which didn't actually go down very well in media terms, but I suspect went down pretty well on that council estate. One of the issues that hasn't come up, enough, I think, is devolving health and social care and putting much more, I mean, we're sitting here in Manchester where they're making an attempt at doing this. 

Some of it's working, some of it less so. And that's where you can start to have that conversation way better because you're talking to your local population. You can discuss things like hypothecated taxes or, you know, whether you're going to bring in together housing, social care, primary care, whether you're going to move the services into the community. I think that's where the conversation will be more interesting. 

Matthew Taylor

So that takes me to a final question. Well, no, a penultimate question. But Labour's going to be talking this morning, I suspect, about its mission for health, the idea of joining up. Now, I remember in 1997 we talked about joining up. And you've described, Victoria, one element of that, which is the relationship between local government and health. 

If we do want to tackle obesity, that's not going to be something we do in the health service. We have to do it through a whole variety of interventions in schools and regulation of food, et cetera, et cetera. How much hope do you have that an incoming Labour government will be able to work government in a different kind of way so that we don't just talk about, when we talk about health policy, we just talk about the NHS, but of course it's much, much wider than that. 

Or do you think that the reality of government will mean that these grand ideas about doing it differently will fall away, a bit like they did for Labour? 

Victoria Macdonald

Yes. How much hope do I have? I honestly can't answer that because it's very hard to read the room at the moment on that. I hope that it happens, personally. And I think any of us who have watched the health and care system as long as we have, which we've already established, is that you know that it has to be built into every government department. 

I mean, I'm quite sold on the idea of a care service. I thought that that was a good way of describing it. So we stopped talking about health and care, and we just put it together because we know that if you have poor housing, if you have your kids not going to school, or going to school but unfed, we know that mental health is crowding out the GP surgeries. 

All of it has to go together. it just takes a little bit of government political imagination. Just a little bit, not a lot, to actually say embed this into every single government department. You have to be thinking about where you place the chocolates by the till, you know, all of that stuff, which some of which has been done in some not. 

I mean, hope, let's hope that the smoking you know that that kids my daughter would be with is in that exact age group where she would never be able to buy cigarettes. I mean I really hope that they will stick to things like that which gets back to public health doesn't it? You know hopefully they're listening to me.

Matthew Taylor

No, absolutely. We welcomed Rishi Sunak’s commitment to banning smoking and it would be a legacy achievement - he didn't get the legislation through. 

Victoria Macdonald

Well they dropped it in New Zealand where they came up with the idea and it was very disheartening. 

Matthew Taylor

Yeah, hopefully Labour will... It's one of those policies. I was in Number 10 and in fact helped to get the initial smoking ban over the line. You just have to... after three or four years and then everyone says, why on earth would you ever want to go back? But they never got there in New Zealand.

Richard, you've worked obviously in Whitehall, we have a place forum in the Confed where we talk to place leaders, some of whom are local government, some are health, some are voluntary sector. I've spoken to officials in DWP, in DLUK, and said, you know, come and speak to our place leaders and they're delighted. They can come and speak to NHS leaders because they know that if they try to go through Whitehall and engage with the Department of Health or NHSE and say we'd like to engage. It would have taken months, years, not been allowed. 

What would be your bit of advice to an incoming government that wanted to work in the way Victoria has described, across government? I mean, it's actually bloody hard to do. So any advice on how to do it? 

Richard Sloggett

Yeah, it's one of the easiest policy recommendations to make - which could be made in a slew of areas - that we need to join up government. I think the Starmer piece on hiring Sue Gray and trying to build behind the scenes a kind of framework and architecture that might work better shows a degree of seriousness and grown-up approach, which I think is highly welcome. 

With little money, I think they're investing a lot in machinery of government changes in trying to get some of those different departments to work. And then it comes down to, well, why doesn't it work? The reason why it mostly doesn't work is because mostly there isn't money attached to doing it. And also the capacity of the people within the different departments to do it is very, very limited. 

So the interesting thing about Health Mission: love the concept, it's the right approach. Ten years, public health, let's go upstream, let's do this thing differently, let's bring these different people together. Is Keir Starmer going to ask Wes Streeting to once a week chair a meeting on the Health Mission? Which would involve a significant amount of his time, official time and everything else, whilst he's got an NHS system.

Matthew Taylor

And is Rachel Reeves going to give Wes for treating some money? 

Richard Sloggett

Some money to do that. And is then other departments then going to also send their secretaries of state to that meeting? There's also other missions, there's an economy mission and something else. 

So once you start getting into the actual practicalities of how this is going to work, it becomes quite difficult. 

And what that then leads to, Matthew, and you'll have seen this, is you send a junior minister, and then you send a senior official, and by the two years down the line half the people aren't turning up and it's basically a, we've held a forum and a meeting. 

And this is where we don't know how they're to approach it. And the thing from a Wes Streeting perspective, which is really interesting is if Wes is told you're in charge of the NHS, you've got to go and kind of drive the NHS and the department forward. You've got to make sure you deliver. And then someone else is appointed as the health mission person. What does West Streeting think about that? How does West Streeting engage with that person? 

And we've seen this in government where you bring in an outside person or a Tsar and the chemistry around that and the territorial stuff gets quite difficult. There are a load of like really, really practical, tangible things that you need to be really clear about if you're going to try and make it work.

And there has to be some funding attached to do it. And I think that bit of it will determine whether it lives or dies. I think one final thing on this with Starmer, which I think is just genuinely fascinating is he genuinely gets prevention. If you go back to his early speeches, he's come in and said, look, I've worked in the CPS, really complex organisation, really political organisation in some ways. 

And he said, look, the cases that I saw, prevention was one of the real mal-drivers. If we could have got these people earlier, we could have avoided all of this cost, all of this pain, all of this difficulty. So I think he genuinely believes it, which is really, really good. But as Prime Minister, when you're dealing with international events, crises, everything else, is there an agenda that's set that he can keep an eye on that genuinely runs? Can he run those trains on time or not? 

So the narrative and the approach and that buy-in is there, but we've been here before and there's several practical reasons why doesn't work. So if you can work those through, maybe, and that's why I think it could be a really fascinating period to watch.

Matthew Taylor

I think, and this brings me to my very last question, Rishi Sunak is to blame for this in a way in the sense that my understanding is that Labour was really intending to spend a lot of the summer thinking bit more deeply about how to make missions work and the rug's been pulled out from under their feet because now we have an election happening.

And that takes me to the last question, which is about unpredictability. Halfway through the campaign, Richard, give me one more, one prediction for what's going to happen in the second half of this campaign. Doesn't have to be about health. 

Richard Sloggett

Oh goodness. I mean …

Matthew Taylor

In a way, nothing much has changed so far. you think anything is your prediction? Nothing's going to change? 

Richard Sloggett

No, I can't see things massively changing, I think the Conservatives needed this campaign. I think I'm quoting from Ed Balls on another podcast, apologies, Political Currency, or was it George Osborne who said, calling in an early election, the Tories needed everything to go right, to even have a chance of winning this. And obviously it hasn't. 

I get the feeling that they, and I watched the prime minister last night, he looks very, very tired. He looks very much like a person who is going with the lines but realises that the game is kind of up. 

The question really for the second half of the campaign is does Labour now decide we can be a little bit more assertive, we can start to roll the pitch on a few things or not? That's the real question. Probably not. I think they could do that.

But yeah, trying to predict what happens next when we've had a betting scandal yesterday. I feel massively out of my depth, but I don't see the polls particularly narrowing a huge amount in the next couple of weeks. 

So Victoria, you've got to make it interesting for another three weeks. Are you hoping something's going to happen that brings a bit of spice to it? 

Victoria Macdonald

Well, I'm not so much hoping because, it's... no, actually, I'm going to take that back. Yeah, I would quite like something interesting to happen because this is where we started the conversation. know, health has not played out as big as I would have hoped. 

I remember coming back from maternity leave early for the 2010 election saying to the office, you're going to need me. And then I sat around, trilling my thumbs because, again, it didn't play out big. I think both parties are going to keep it, try and keep it on an even keel. 

I mean, they both had a pretty bad start to their campaigns with Labour, with the Diane Abbott stuff, and the junior doctors announcing their next strike on the day of the health manifesto launch. And we know what's happened with the Conservatives. So I think they will be hoping that it's nice and quiet and it just stays on an even keel. But you don't know where Sharon Store is coming from. You don't know where Brenda from Bristol is coming from.

It’s those things that just hit them, you know, in the face unexpectedly. 

Matthew Taylor

Fascinating. So I'll make my prediction. 

My prediction is that you'll see the fight moving from the centre ground. That actually, if you look at the polls, Labour's total support is inching down. There's a lack of enthusiasm and their danger in many places is the Greens and the Liberal Democrats. I think that Labour might get a bit more old time religion, because they need to get people to come out and vote and they need to not lose support to parties on the left. 

And they kind of know now that people, they don't really need to convince people not to vote conservative because that seems to be really quite deep in people. And I suspect the conservatives similarly will be returning to a bit of old time religion on conservatives because they've really got to shore up their base. They kind of know it's gone, but they want to be 150 and not 50 MPs. 

So that's my prediction. We'll see how things unfold. Richard, Victoria, it's been fantastic to talk to you. Thank you so much for joining me on Health on the Line.