NHS leadership: what do the changes mean?

MATTHEW: Hello, and welcome to Health on the Line from the NHS Confederation. The organisation that represents members from across the health and care sector in England, Wales, and Northern Ireland. 

Before we set sail, a little sales pitch. Just to say to our regular listeners that there's never been a better time to join the NHS Confederation, if you're not already a member. Do have a look at our website for details for all our forms of membership and all the resources and events you can access. It really is value for money. 

And that includes our new conference, focusing on one of the government's big shifts, our Care Closer to Home event, happening on the 23rd of April. Go to www.nhsconfed.org to sign up and join us. 

On Monday, I sat down to do an interview with Richard Sloggett. He's a former special advisor at the Department of Health and he's the founder, director of Future Health, a research organisation focusing on the future of the healthcare system. Richard and I talked about the relationship between the Department of Health and NHS England, how that relationship is changing.

We talked about changes of personnel. And then, as the interview drew to a close, Richard said, my goodness, Julian Kelly has resigned as director of finance at NHS England. So, trying to be responsive, we had a bit of a chat about that as you'll hear. What we didn't know, what I didn't know till we'd gone off air, was that Emily Dawson and Steve Russell had stood down too.

Anyway, I've listened back to the conversation that Richard and I had, and in view of those resignations and other announcements we're hearing all the time, I think you're going to find it even more relevant. 

Richard, welcome back to Health on the Line.

RICHARD: Thanks, Matthew. Thanks for having me back on.

MATTHEW: So obviously it is a crowded news agenda and I guess most people are thinking about foreign affairs a lot of the time, but for us in the health world, it's also been pretty lively. What do you make of what's going on, particularly in relation to NHS England?

RICHARD: Yeah, Matthew, I think it is lively. You mentioned at the top, a number of different roles that are changing on the NHS side of the system, alongside those roles, there's also a couple of other ones. One is, we'll be getting at some point in the near future, a new, permanent secretary at the Department of Health and Social Care, which is obviously a very, very important role.

Chris Wormald, who held that position, is now the Cabinet Secretary. And we're also going to get a new chair of the Care Quality Commission as well. Obviously, Julian Hardy's gone in as the CEO, but there's going to be a new chair appointed there. So lots of change. 

And I think what's quite interesting about the most recent set of announcements is obviously they're more on the NHS side of the system. So in the last three, four years, what we've seen is mostly lots of churn and change on the political side, lots of different secretaries of state and ministers and general stability at the top of the health service in the NHS. Now we're getting the kind of inverse of that. We're getting more change on the NHS side, and we've got maybe a bit more political stability with the new government.

And as you say, this will have quite big implications, I think, going forward about where power lies and what the priorities are.

MATTHEW: I think we know that Mike Richards is taking up that CQC chair. role. So as you say, you know, lots and lots of change. Let's start with Amanda Pritchard. I've always said to her and to other people, I guess that she's got one of the toughest jobs in the country. And she should be, of course, commended for what she achieved in those challenging circumstances and for being the first woman to run NHS England. Now the kind of dust has settled slightly on her announcement, what's your take on her leadership?

RICHARD: I think you're right to commend her role and how she performed in it we have to remember that when she took over in the summer of 2021, the pandemic was still very real and very much with us. And also then her tenure was about the sort of recovery period after that. We know the huge impact that covid had on our healthcare system. And Amanda was the person who sort of had to pick things up and then try and sort of drive forward a sort of recovery plan to that. 

I think she has a quite clear North star about what she wanted to do. In particular, she really made a big sort of push on making sure NHS staff tried to feel more valued and more supported. I think she took workforce policy in particular, a lot more seriously than maybe some others have in the recent past. And she went about her business as a sort of what I would say in a more traditional public service type of way. So she was active more behind the scenes than sort of in front of the camera. I think that's where she was more comfortable. 

And I think how that sort of generous sort of came out was through the publication of the NHS, his first major workforce plan, which was a huge achievement given the, you know, the treasurer has always been very, very skeptical of doing something like that. And obviously the stars that align somewhat with Jeremy Hunt being in there. 

She also had to work in a fairly unstable environment. So as I noted, there's lots of different bosses that she had. She had several bosses over a very, very short period of time, all of which had slightly different ways of working and slightly different operating models.

And I think she has taken her role to be one of the trying to get on with the delivery rather than maybe focus more on the sort of political dynamics. So where her predecessor was more interested in sometimes trying to play the politics to extract benefit. I think she was more interested, maybe trying to work behind the scenes get some of those benefits such as that workforce plan.

So I think she should be very much commended for the efforts that. That were made and there was some real progress made, in that particular on that workforce piece that she can look back on. But now clearly she feels it's time for a change. 

MATTHEW: Well, Richard, you and I both heard Amanda speak at the Nuffield Health Summit a few days ago. And it was a funny, warm, rather brave speech, really. She's clearly proud of many of the things she's achieved. And you're right about workforce. Just a few days ago, we saw improved retention statistics. Last year's staff survey was a bit better than we'd seen the years before there's a new staff survey being published this week. And I suspect that will also show progress.

So a lot that she's achieved. And like all leaders, you don't really see the full effects of your leadership often till you've moved on. But let's look at the kind of political strategy bit, because that's I think where some people would have questions. You were a special adviser in the later days of Simon Stevens tenure at NHS England, and he had a different, slightly more kind of combative way of thinking about his role, didn't he?

RICHARD: I think Simon just has a slightly different licence to operate than Amanda did. If you remember when Simon came in 2014, it was on the back of the Lansley reforms and ministers very much wanted the NHS to sort of go quiet. They wanted someone who they could trust to get on with running the system, who could manage, frankly, the politics for them.

And if you think about Simon's tenure between 2014 and into the 2020s, it did coincide with the Conservative Party being the largest party at those elections in 2015, 2017 and 2019. So politically, it sort of worked. Amanda's licence to operate was very, very different and actually was more reflective of her character, which was given the impacts of covid and the need for ministers to get a lot closer to the service and ask more of it, she was much more focused on the core delivery and actively chose, I think, not to meddle in any of the sort of more wider political arguments. 

Occasionally, Simon would pop up on a Sunday morning on a sofa in BBC and talk about the need for social care reform, which hadn't necessarily gone through ministerial clearance. Amanda was never going to do that. And she was much more of a sort of behind the scenes type of operator. So they were very different characters, but they also had very, I think, different licenses to operate based on their sort of timing of when they were in place.

MATTHEW: And Simon is rated highly in the health service because there were those moments when he went out particularly over money and kind of laid an ultimatum down to government, which government found it hard to resist. But, you know, many people told me that that wasn't viewed entirely positively in Whitehall, which might have been why Amanda was given a different brief. 

I guess my experience, Richard, sometimes was that what you would hear from NHS England was that they were in tough negotiations with government and there'd be a kind of implicit suggestion that we and NHS providers should go out and kind of emphasize the challenges facing the service, the need for more investment.

And then a figure would emerge, and this is really from the previous government in terms of funding and NHS England would then be very, very positive about it, you know, that it would demonstrate their success in negotiation, but it didn't necessarily feel that to the service.

The challenge is if you adopt an approach, which is I'm not going to make a noise externally, I'm going to try and win these arguments through backdoor channels, through private conversations. The problem is if you don't seem to be winning that many arguments, that does have an impact on your credibility.

RICHARD: I think, I think that's right. Simon's tenure was more reflective of him being a specialist adviser, picking moments to have more political type arguments and structuring those arguments in a certain way in the public sphere and Amanda being what would be more from a sort of civil services, more of a private office approach, sort of making representations behind the scenes.

But I think in a very, tricky, challenging environment which Amanda found herself in when she took the job. Sometimes I think there maybe was a perception for those in the NHS that what was she getting for that sort of what would be seen as being perhaps loyalty to the government. And I think that's where the pointing to the workforce plan is, is a major output of that strategic approach because I think she took the view that making those behind the scenes representations got that outcome and got the positive outcome, which had never really happened before. 

So different styles, different areas, different ways of operating strengths and weaknesses, I think, to both. And as we look to the new person coming in, it's going to be interesting to see what approach is now adopted.

MATTHEW: Yeah. So let's turn to that new person, to Sir Jim Mackey. Let me share with you something that someone said to me just before they went into NHS England in a senior role a few years ago. They said NHS England's got three roles: managing up into White Hall or managing down into the system and being an effective arm’s length organisation. It spends nearly all its time doing the first, some of its time doing the second and virtually no time. doing the third. 

Now that's pretty harsh. I suspect, however, it does reflect the perception sometimes out in the service. Do you think Jim is the person to kind of change that, particularly now that kind of first role that arguing with the department is kind of diminished now because the expectation is that NHS England and the Department will really work as a single team?

RICHARD: Yeah, I think it's interesting on the sort of tripartite kind of ambitions. There's a couple of interesting things with the Jim appointment. One is of course, that he's very much being positioned as a transitional appointment, albeit for a transitional period of up to two years.

Now, normally in any job of this nature, someone being given a sort of more interim role would be slightly odd and would almost be a kind of with people sort of looking at it saying, well, how, how long is this going to last? How's this going to work? I don't think those questions are actually being asked here for a couple of reasons.

One is lots of people nationally and within the NHS know Jim and know him very, very well. He's very well respected and he worked obviously on the previous elective recovery plan. And secondly, because he's been appointed by a new secretary of state with quite a clear kind of remit on the back of the planning guidance that came out recently to get on and deliver particularly on the government's number one priority, which is to get the elective waiting this down, which is very much in Jim's sweet spot.

So the optics of it are quite interesting in terms of we're going to appoint someone on a more interim basis, but at the same time, this is a familiar face. He knows his way around, probably get things done. On the third part of your three elements creating an ineffective arm's length body, I think what Jim's remit here will primarily be is clearly to slim down NHS England and focus on fewer things and doing them better. 

And we've heard this before, but this is clearly where the government is going. Some of this is to do with necessity. There isn't lots of money to spend on lots of priorities, but also I think, sort of philosophically, I think Wes Streeting has also bought into the fact that you can't do everything from the centre and you do have to devolve and delegate. 

So I think Jim's coming in at a very interesting time. But he's also going to hit the ground running. He's not going to be one of these CEOs who comes in and spends three months doing a review, meeting everyone, and then sort of another three months doing an external kind of tour. I think he's going to be straight in as indeed he is already, and he knows what his job is, and that's to deliver on electives.

MATTHEW: Really interesting, and I remember a comment that Amanda made to me more than a year ago. I was, lamenting, as I often do, the kind of level of output of NHS England, the amount of different things they were trying to do, the amount of different programmes, the overlap, the lack of joining up.

And I remember she said something to me like, well, you know, she said, sometimes I go out of my office and I wander around and I ask people what they're doing and I realise there are lots of things happening that I'm not fully across. This is an organisation that just seems to generate stuff.

And she was articulating her frustration with that. And I think she made some impact in that regard, but maybe it did require and has required this bigger political shift in order to be able to change that kind of culture in NHS England that they kind of need to have a national programme for everything that moves in the NHS, that more profound process of prioritisation, doing less, maybe getting partners like NHS Confederation, Providers and other organisations to do some of the heavy lifting. It doesn't all have to be done from the centre. 

I think Amanda could kind of see that. But as I say, do you think it needed this bigger political moment - Wes Streeting in really leaning into this and being very, very clear that he wants change to be able to shift that culture?

RICHARD: Yeah, I think you do need ministers to kind of set out quite clear expectations. And it's quite clear that Wes wants to do that. In some ways, Matthew, what we're doing, the pendulum is swinging again, isn't it? Policy wise, we're going back through Lansley because interestingly Lansley's original vision for the NHS commissioning board as it was then was as a thin management layer but we're also really going back to the kind of late 2000s where you have to sort of another sort of tripartite model of governance with the Department with the secretary of state at the top and you have the permanent secretary running the Department of Health, you have to chief executive of the NHS, running the NHS, you have the chief medical officer looking after the health of the nation.

And I think we are moving back to that sort of a model and the rumours and murmurings are that that's the model that they're most attracted to. And obviously that was the model that was run under the previous Labour administration and that will involve lots more tough decisions at NHS England about headcount.

And I do think it also explains why Amanda probably feels that now is the right time to move on because the NHS England has just completed, or fairly recently, completed a head count reduction significantly. And for her to then front up another head count reduction would, I think, have been very, very difficult, both personally and actually just practically. 

So, I think both of those things were a factor here, but I think, structurally at the centre, we're probably moving back to the sort of that late 2000s era on how things were structured at a much leaner top of the NHS as a result.

MATTHEW: And what does this mean for the relationship between the centre the service? I think broadly speaking, what I hear from people is that this explicit recognition that NHSE and DHSC need to work hand in glove is good, because fiction of NHSE's independence has been clear for a while.

As I said, on the Today programme on Saturday, Steve Barclay had kind of screens up in his office telling him exactly how many ambulances were waiting outside every A&E. This is not the behaviour of someone who's devolving operational leadership to another organisation.

But at the same time as this, at the same time as, in a sense, In the centre, we're seeing power centralized within the department. Wes Streeting talks a lot about wanting to devolve more to the service. Indeed he was wanting to point out that in the recent planning guidance, several targets, ring fences had, been removed.

So how do these things work? I remember somebody telling me about why, well, many, many years ago, The, the thing about Whitehall was that on the one hand, England was a very centralised country. The power really lay in Whitehall, but on the other hand, Whitehall itself was quite devolved. It had quite a weak centre, particularly in Number 10 and the Cabinet Office.

So these two things are related. We're now going to have a stronger united centre between the Department and NHS England. Does that mean it will be a more controlling centre? Could it mean it becomes a centre which, both wants to and has to devolve more?

RICHARD: Yeah, I think this is really, really interesting. I'm not sure if you saw recently, but the Health Service Journal devised a chart showing the different people influencing the, or feeding into the lower ten-year health plan. It was a real array of faces and names, from a whole range of different sort of central organisations, whether they were non-executive directors at the Department, special advisers who are not special advisers, but have been hired in new chairs of arm's length bodies, a new DHSC strategy team and others.

And there's a sort of this sort of who's who of sort of central health policy. We just sort of got an impression that the centre was sort of growing, not shrinking. And a lot of cooks trying to sort of feed into that ten-year plan recipe. But I wonder whether what we're seeing is something a bit, or I'm going to use the phrase ‘Osborne eyes’ in terms of its structure when thinking about how government ran economic policy in their sort of 2010s.

So if you think about what George Osborne did with the economy in terms of reducing spending, what he did was he protected certain budgets and was very clear about that, whether it was the NHS or schools in particular after parts of the defence budget, then other budgets were sort of asked to be cut back and trim back and particularly local government.

And what you see with the sort of Wes Streeting model here is you see protection of certain targets, certain budgets. So particularly thinking about electives and other things in the planning guidance. Some support for the shifts. So, public health grant being one example that had an uplift recently and the GP contract, which has an uplift; both very, very important to making those hospital-to-community treatments or prevention shifts.

But then the ask of the service, which is, well, locally, you need to then decide what is cut back and what is trimmed and we will back you to do that. And what we're seeing with that, with those kind of local decision makers having to make quite tough local decisions is coming through already. So again, a piece in the HSJ just today, I think it is or this week on cuts to cancer and new cancer services and cuts to virtual wards.

The architecture is quite interesting, which is essentially, we're going to set some priorities. We're going to try and protect the funding for those. We're going to some targets we expect you to deliver. We're going to try and support some of the shifts relating to the plan as well. Then everything else is really up to you.

And then there's the call of we'll back you to make the tough call, which will be interesting to see how that plays out when those tough decisions genuinely do play through in terms of cuts to services.

MATTHEW: So Richard, I'm going to get you to imagine that you're sitting with Wes Streeting in your former role as a special adviser and where's treating is saying to you, well, look, here's the strategy, Richard: it is to unify the team at the centre to do less, but to do it. better to be absolutely kind of adamantine about the need to hit our key kind of retail targets, particularly the waiting list, which appears to be as far as I can see, the only thing that Number 10 really cares about, but also to devolve beyond that, recognising that if we're going to put systems and providers under the kind of financial pressure they're under, we have got to give them latitude to kind of get on with it as best they can. 

Now, Wes Streeting says that to you, and then says to you, but Richard, what do you think are the dangers?

What are the perils of this strategy? What do we need to do to make sure that this is something that sticks?

RICHARD: Yeah, this comes back to the centralised system and this comes back to parliament. So, when local NHS leaders have to make tough calls on where to spend pounds and where not to spend pounds, and those things appear in the media, whether it's the health media or whether it's local media or indeed even national media, What's your response to that as a health secretary going to be?

Is it going to be, well, this, we haven't sanctioned this, they need to look again, which would I think create a lot of confusion in the system about, so if the health secretary doesn't like it, it's not going to happen. Or does the health secretary then lean in and then explore an argument for why these trade-offs have to be made and what the upside is of making such decisions and why you have to make the decisions as they are. 

But that requires a really strong political communication strategy, and I think you have to link that back over to that ten-year plan reform agenda, and you have to communicate that really, really clearly because you will have a lot of parliamentarians in particular areas who will be inundated with letters about particular cuts to services or clawbacks who will then be making representations to you.

So, reform is not cost free. And if you're going to put more money into one part of the system, another part of the system is not going to necessarily see the same amount of money. So you, you've got to have that really strong political communication operation, and you've got to then really kind of follow through on that and that's where all eyes I think are turning particularly to that ten-year plan.

MATTHEW: Yes, and here I think, an opportunity for Penny Dash and Jim Mackey, who can represent different parts of the service, Penny the ICS movement, Jim, obviously prominent acute leader, incredibly successfully acute leader. If strategy is to say, you've got less money, you've got to deliver these targets, but in other areas, we're going to give you an attitude to get on with it, and we're not going to contradict you when you have to do difficult things which might upset backbench MPs and local councillors and whoever it might be.

I think it's going to be important, isn't it, for Jim and Penny to say, look, if that is the strategy, you have got to stick with it because if that's the strategy, then every few months you say, Oh, no, no, we can't do that on popular reconfiguration over there. No, no, no, we can't cut that service back there, then you really are moving to a situation where leadership is almost impossible.

What we've been saying about the financial situation, which I want to come back to in a second, is that we all know the reality. We all read the newspapers. We know there's no more money, not this year and almost certainly not next year and not the year after, but the centre can't simply dump that risk onto the shoulders of leaders. It's got to think about how it supports leaders in making those difficult choices.

RICHARD: Yeah, Matthew, that's absolutely right. And it also comes back to the role of Number 10 here and their wider political strategy. And I know you had Bill Morgan on recently talking about some of the dynamics here and some of the risks if Number 10 isn't necessarily across all of these discussions, because, I agree with you, at the top of the NHS, senior NHS leaders need to lean in and back those changes, if that's what the model is, ministers in the Department of Health need to do that. 

But that's why the government also needs to be on board for this. There's a letter from a cabinet memo that went around from Keir Starmer recently that the BBC got hold of. And I'm not sure if you saw it, but it's very, very interesting on the kind of government's wider political strategy, basically saying that delivery is not going to be enough. ‘Deliverism’, just improving things a bit, is not going to be sufficient politically. And in the letter, which Laura Kuenssberg of the BBC got hold of, uses a phrase which is very, very interesting, which means taking on vested interests of all kinds, and it means challenging laws that hold Britain back.

So that kind of language is really, really strong, and I think lends itself to one of, politically, Number 10 saying we will back you if you're doing the right thing and you're moving things in the direction that we've said is correct. But there is a wider question here, which you've alluded to, which is Number 10 cited on elements of this and, and what does it actually think? Is it going to be there in the trenches when these really difficult conversations do come to light? So, yeah, some fascinating dynamics there, I think.

MATTHEW: Which then takes me to my kind of final question, which is all of this possible. I mean, we are talking about, as I say, not just next year, but the years to come, the tightest financial settlement, tighter even than the kind of harshest years of austerity. And of course, austerity came after the NHS had had many years to invest, where arguably there was a bit of fat to be trimmed from the bone. That's not where we are now. 

So, we've got this context, we've got a government demanding really rapid progress in, in those key kind of delivery areas. We don't have any reform of social care on the horizon and, and you know how big a challenge that is for health service as well. Do you think it's possible to get through the next three years without plunging into crisis and last-minute bailouts and all of that.

And if it is, what's your view, what's your advice to leaders? What, what do they need to do to turn these next three years, not just from a kind of terrible war of attrition, but into an opportunity to, do things really differently?

RICHARD: I think it comes back to the sort of discussion we were having is around permission and a license to operate and to deliver change. And the thing I think is just going to be fascinating to see is, is how much license local leaders are really given to make change happen and what lever they're going to be given to do that.

I think there's a big, big question mark on this ten-year plan. When this was commissioned back in the autumn, the environment was very, very different. This was a government with a big majority. It wasn't such issues with the Trump administration and defence spending, and we hadn't seen national insurance going up and everything else.

We hadn't seen reform surging in the polls as they sort of have done in recent months. So the runway for landing that has got a lot narrower and the big strategic call for Wes Streeting in all of this is, does he double down and go, right the NHS is broken. We are going to do radical reform. We're going to move money around in a certain way. We're going to make some really difficult decisions. 

Or does he go a little bit more cautious and say, well, we'll nudge things forward a bit. We'll make them slightly better. And by doing that, we can show a trajectory, which politically we think will be sufficient.

Now, the rhetoric from Wes and his team and others has been very much in the former camp rather than the latter. But the proof of it will be in the pudding when that ten-year plan out. And our minister is prepared to make these very difficult trade-offs and empower leaders to make these difficult decisions.

And that's where all eyes are on, I think the next five or six months, which will set the tone and model of change over the course of this, parliament. And that's why that ten-year plan is so, so important. We've been here before with other plans, but when the health secretary stood up and said, The NHS is broken and I'm going to do it up a ten-year plan to fix it. That raises expectations quite highly. So it's going to be fascinating to see how that's landed.

MATTHEW: Well, Richard, you know, we like Health Online to be topical, but how about this? As you and I are speaking here on Monday lunchtime We've just heard that Julian Kelly is leaving NHS England. Now, I've loved working with Julian. He's a really, really nice guy. And I shared Amanda's dismay a few months ago when he was getting a lot of stick from the HSJ and others, in terms of the way in which he was putting pressure on providers and systems. But he's been a kind of pretty fixed and reliable part. the architecture.

So how do you respond to that information that's literally arrived as we're speaking?

RICHARD: Yeah, it's obviously a major news because, as you say, Julian's been sort of in the top of the ages for a long time, obviously previously in the civil service and treading the Treasury very well respected, been clearly at the forefront of some of these sort of difficult discussions that have been taking place with the new government about where to prioritize spending and what the trade-offs are.

He was in public recently saying that the new money that was being announced would pay deficits primarily. I'm not sure that went down too well with ministers, but what we're seeing, Matthew, is a clearly a big clear out of very, very important figures. I mean, you've got the chief medical officer, the chief executive and the CFO all at the same time, quitting.

This is a significant shift of power within the system and it's just another example I think a minister is really wanting to take greater control. There's been talk for a while about greater financial oversight from the DH and more sort of joint working on financial arrangements, but Julian's decision to go, as we're recording, is really big news.

MATTHEW: And I guess over this announcement, there will hang the same question that still hangs a bit over Amanda's announcement, which is, did he leave because he felt he was being pressured to leave? Or did he leave because he felt that what he was being asked to do in relation to the service and the financial situation was just too difficult?

Knowing Julie and knowing how professional and discreet he is, I suspect we'll never know.

RICHARD: And, and also, obviously we've got this planning round going on right now. There was a meeting of, last week, I think it was on the deficit situation, where initial plans had been submitted and, the NHS England was talking to local systems about what those plans meant.

So that again, just creates further instability into that sort of planning round that's, taking place right now, Matthew, it's unclear who those plans are being agreed with those sort of major figures having, taking a step back. So, Department of Health and Social Care needs to be very much, across that because you've got the finance director now stepping away.

MATTHEW: Well, Richard, thanks as ever for your insights. No doubt we'll speak again as all of this unfolds. Thank you for joining us on Health on the Line. 

RICHARD: Thanks, Matthew. Great to speak.

MATTHEW: And that just leaves me to introduce Our latest Leader in Six interview, which I was delighted to do on a visit recently in my own hometown of York. I spoke to Sarah Coltman-Lavelle, York NHS place director. There's really some fantastic stuff happening here in York. 

So, Sarah, first question, what's the biggest challenge you are dealing with at the moment?

SARAH: I think the most, pressing issue for, for place and the health service in general at the moment is that everybody is focused quite rightly on doing the right thing within their sector, within their organisation, within their service, particularly with the drive around delivery for 25/26, so nobody is working harder than they could already work. 

Bandwidth I think is a real issue and I think the priority is to do the right thing by your service, which can sometimes mean you're doing the wrong thing by the person. So when we think about system and we think about partnership, and we think about residents, and we think about giving professionals a, a satisfying job to work with, to support and to help people, the system isn't always conducive to that. and the more, the harder that and harder that people work, the harder it is to do the right thing. So I would say it's about bandwidth to be able to engage in really supporting, healthy living.

MATTHEW: Tell me, Sarah, what's the innovation you're most excited by in the York place?

SARAH: So in York place, it's been a real journey over the last couple of years, I think, in terms of getting to a place where partners trust each other, where there's a credible leadership environment to be able to lead and actually get to the real heart of the power and the potential of place.

And I think we are there. I think the work we've done around the neighbourhood model, so establishing through a approach with our council. So council and health, developing our co-terminus boundaries to operate public sector transformation through and the hub models that we've developed in terms of multi-agency right through the life course. So for families, for mental health, for frailty, have also really helped us understand the challenges and the pitfalls of multi-agency working. So now being able to take that learning and into our neighbourhood model having the Holy Grail of co-terminus public health services. Really, really excited by that.

And I think we've probably found some quite surprising benefits to perhaps what we thought were problems as well. So, for example primary care networks, they aren't geographically contiguous in York. Some primary care networks actually span all four the neighbourhoods in the city. We've only actually got one that is geographically contiguous and that's the east of York. But actually that hasn't been a problem at all. So recognising the differences between business models and neighbourhood models. The differences between practices and services working in a neighbourhood and relating to a neighbourhood. So not getting too hung up about some of the problems or perceived problems actually has been quite liberating.

MATTHEW: Brilliant. If you were king or queen of the NHS for a day, what's the one thing you'd do? 

SARAH: I love this question. So, if I was queen of the NHS for a day, and I'm going to stick to the rules and stick to the NHS, I would flat cash the acute sector. I would do that because I think that's what the acute sector is potentially wanting but too afraid to ask for in terms of the level of expectation constantly on the acute sector to constantly meet and demand.

And we are in a scenario whereby every bit of spare cash has to effectively go to the bottom line in order to kind of move out of this kind of greedy NHS gobbling everything up. In the meantime, risks are rising, people continue to get ill and the ability to stop those rising risk falling into the highest risk, year on year is lost. So we're dealing with this exponential kind of higher pool of people who are at the highest risk and therefore highest use of services and we've got to do something to break cycle. So I think if I was queen for the day, I would bring in flat cash. 

Just as a second one, if I was allowed to have another one, I would be redesignating a whole host of acute specialties to community specialties. So geriatric medicine, general internal medicine, dermatology, neurology, why are they in hospitals? So forcing a little bit of change there wouldn't go amiss. 

MATTHEW: Tell us something that's interesting about you, that's nothing to do with your job. 

SARAH: Probably the thing that most people would see first when I walk into a room right now, is the fact that I'm also growing a human in my spare time which is interesting at the age of 44 and a husband who's 50 with a 16 and an 18-year-old at home this is what happens when you go on holiday to California, folks.

MATTHEW: I'm a 64-year-old with a 12-year-old, so. The older you are, the better it is, is what I would say. Much better. Second time ran. 

SARAH: That's tell that to my kids, 

MATTHEW: Tell me what leader have you most admired? Maybe someone that you work with, someone you've read about, but which lead is most inspiring?

SARAH: So who inspires me? I think I'm a bit of a magpie when it comes to leadership. So I take inspiration from many I don't think there's any kind of one way or perfect person, but I, I really admire sort of quiet strength. I admire those who listen more and say less. 

In terms of who I've worked within in the past, I mean, Julian Hartley in Leeds was. often kind of, you know, shamelessly borrow leadership 101 from Julian. But one of the things I do remember him doing, which I was really impressed about, was as an acute trust, he really relished the fact that he was his system leader for prevention.

So, you know, showing others how it can be done and, and leading from the front and being the person who steps outside and looks behind and says, who's going to follow me, folks? 

MATTHEW: Great. Well, Julian's a fantastic person of course. 

Last question. Tell us something that you've been watching on tv, listening to as a podcast, reading as a book, a bit of content that you think everyone else should enjoy, and it can be as trashy as you like.

SARAH: I was going to go highbrow. I am a bit trashy when it comes to tv. I have just been laughing out loud to a Amandaland. If anyone hasn't seen it, hilarious. Follow up to Motherland, which I will be in very soon. So high up my list.

But, given that I just mentioned Leeds, I would also just put a shout out for anyone who's interested in understanding a little bit more about what neighbourhoods are, what neighbourhoods do, check out the local care partnership blogs. Very, very good. 

MATTHEW: Excellent. So something virtuous. Something fun. Sarah, thanks so much for talking to me.

SARAH: Thank you.

MATTHEW: Do go onto our website and listen to previous episodes of Health on the Line, including our recent conversation with Sally Warren and with Bill Morgan on the ten-year plan and, well, everything else that's going on in the health service. But until next time, thanks and goodbye.