How is the NHS coping with this winter’s pressures?

Matthew Taylor

Hello and welcome to the latest edition of Health on the Line, produced by Health Comms Plus on behalf of the NHS Confederation and of course, happy New Year. It's our first episode of 2026. 

Before we get into the content for this episode, I need to tell you that there are still, well very few, tickets left for our Care Closer to Home conference in London on the 24th of February.

It's going to be a stimulating and challenging day with lots of keynote speakers, important workshops at a really important time as we kind of emerge from winter and we start to think how we can progress key elements of that ten-year plan. So, do book your place to go. You can do that at nhsconfed.org/events.

So, I said Happy New Year, but is it? For health and care leaders, the depths of winter pressures continue, but there's some signs of progress. It feels at the moment, I am touching wood, as I said this to you, that this winter has been a less bad than last winter, less bad than our worst fears.

I've got some great guests who are going to give us some insight into how winter 25/26 has been so far and what the health and care sector needs to do to continue those very, very fragile first green shoots of recovery that we seem to be seeing right now. 

But first, before we get into that, we are, well, it says, I'm reading my script, it says, ‘delighted’. No, we're not delighted, we're overjoyed, the NHS Confederation is now the new home for the Q community, the membership community collaboratively accelerating the improvement of care in the UK and Ireland. We, the Health Foundation and Q already benefited from a strong partnership. 

As part of our leadership and improvement offer, we and Q deliver a programme of system improvement support, which is a tailored service for health and care leaders and their teams to help them transform services and achieve sustainable improvement. 

But sharing a home and working together is going to offer our members even greater support with their improvement work, with your improvement work. So earlier I spoke to the director of Q, Penny Pereira. 

Penny, it's great to have you on Health on the Line again and have you at the Confed. You like me, are suffering from a cold, but we're both going to battle through. So just to start off, tell us a bit about Q, Penny. Introduce the community and why it's particularly important right now.

Penny Pereira

So we've been around for ten years and our mission remains as kind of critical as ever. So, with a kind of established improvement community across the UK and Ireland involving people from all backgrounds working to accelerate improvement in health and care. What we do is we bring those people together to work through the complex challenges that people are struggling with in the health sector, and then we also help to create the culture and conditions within which those improvement efforts can succeed.

We've been around for a long time, but actually we probably have most visibility and engagement with the people who are delivering improvement at a frontline level. In recent years, we have really stepped up the connection and visibility with organisation and system level leaders. And that's one of the reasons why I'm so excited about this move, the partnership that we've had with you and the move now to join you at NHS Confederation because I think that's going to allow us to go that further step in terms of connecting the people who are accountable and leading organisations and systems with the people who have the expertise to deliver change effectively. 

Matthew Taylor

And Penny, tell me more about the network because that's when I first got to know you and the work that you were doing, that was the thing that really I hadn't been fully aware of was the scale of that network. What kind of people a part of that Q network?

Penny Pereira

So you can apply from any background. We ask people to have some experience of approaches to improvement, but we interpret that in a way that's broad. So we have over 6,000 people who have joined over the years. Recruitment is open on a rolling basis.

We have a lot of people who are clinicians and managers leading improvement work closer to the point of care. We do also have over a thousand people who are directors or chief execs who are supporting improvement from a level of leading organisations and systems. So, there are many brilliant improvement communities for particular professional groups or particular regions around particular projects. 

What's really unique and important about Q is that it brings people together from across groups, across sectors. When we think about the challenges in the ten-year plan and equivalent strategies in other parts of the UK and Ireland. That ability to be able to convene and support change that spans sectors is, I think, really critical.

Matthew Taylor

I always think, Penny, that the secret to leadership, certainly my secret to leadership is to take something that's already happening that's really good, but that people don't really know about or they misunderstand. And then just explain to them that it's good to get the credit for it. And I'm kind of partly hoping to do that.

Let me explain a bit more. I think there's a perception in some quarters that that Q is great, but it, it isn't really tackling the kind of the big, difficult, challenging issues. That it's a group, a little community, they're nice people, they're doing great stuff at the margins, but it's not really getting to the grips of the really, really tough stuff.

First of all, just confirm that really isn't true, that perception. But then secondly, what is the opportunity, do you think, with Q now working with Confed, not just to kind of nail that misconception, but to really get people to understand the scope that we now have to help people with those challenges?

Penny Pereira

So Q has been set up to support people to self-organise and learn and connect across the full breadth of improvement work.

And so we are a community that allows people to go away and do work that may not be the top of the priority list at the moment for the government, but might be the seeds of the work that's really innovative or challenging that will become more important further down the line. 

In terms of the work that we directly support and where we put the vast majority of our resources, over several years actually, we have focused entirely on the big challenges facing the sector.

So reducing weights, helping to support integration across different sectors, support things like neighbourhood health, improving productivity, improving equity and diversity. So yes, I think you can be assured that Q is there to help people focus on the kind of priority challenges facing the sector. 

I guess one of the things that I would invite and challenge to people who are leading organisations who might be like members of Confed, and indeed providers, is that I think it is an institutional challenge for many organisations and systems to be inspiring and galvanizing and aligning the expertise and energy that exists around improvement, around the really tough challenges.

I do see within the community that people are often doing the work a little bit under the radar, focusing on the things that may not be the top and most difficult challenges, but the things where they feel that they can get some momentum and do some positive work. 

So, while we do work within Q that is squarely focused on the top challenges for the sector, I think there is a legitimate question about, like the improvement, expertise and energy that exists out in the sector and in every part of the health sector, and whether we are yet inspiring and drawing people in to genuinely be focused on the most difficult challenges. 

Matthew Taylor

That's a really great challenge to be setting for our new relationship. 

Just got a final thing, because I think it's, another thing that's really important for people to understand about Q is that, I mean, I had a one-to-one as I do every month with Darren who runs NHS Confed in Wales and Darren's always going you know, you treat Wales like a bit of an afterthought too often. One of the great things about Q is you operate across the United Kingdom and indeed in the Republic of Ireland. Just tell us a little bit about that, and do you see benefits of being able to be doing work looking at similar problems but in different health systems?

Penny Pereira

That has been absolutely central to the ethos and value of Q from the start. So yes, we've been operating with our kind of national country partners across the full breadth of the UK up until 2020 and the 2020, the Republic of Ireland also joined us. It creates so much opportunity when it comes to thinking about different ways of supporting improvement, supporting integration, for example. There are very few people and networks that are actually thinking systematically about how to share learning across the different countries of the UK that have in many ways gone somewhat further and in different directions in relation to, in relation to integration and personalisation of care, for example.

One of the areas where we're seeing kind of huge traction and opportunity is around how organisations kind of systematically manage quality. So the concept of quality management systems, it sounds a bit technical, but in essence it's about how do we get organisations really capable of planning, sustaining, kind of improving, controlling and assuring quality. That is something that in England is at a relatively early stage, but is going to come right up the agenda with the new quality strategy. Elsewhere in the UK and Ireland, it's more mature and actually we're generating loads of really interesting opportunities for learning and collaboration by connecting the five countries on that agenda.

Matthew Taylor

Yeah, that's fantastic. There's far too little of that learning taking place generally, so it's great to see that you're doing that. I think from my perspective, Penny, we've been growing our improvement muscles, our improvement confidence, doing more work for a number of years, and then our partnership with you really grow that. And you now coming into the organisation, we really do feel that we can make an impact. It's incredibly exciting. 

And of course Q, joining Confed is not the only big change that's happening because we are on the very edge of merging with our colleagues at NHS Providers into a new organisation.

Does that, I mean that, I have to say, for me it just feels like, oh my goodness, there's just so much going on. But I think that's another opportunity as well, isn't it, Penny?

Penny Pereira

Well indeed, I mean we have been an improvement partner for NHS Providers for some years around trust-wide approaches for improvement and kind of board development for improvement, for example.

And we've been really, really excited and by that work. So the idea that these, these organisations are now coming together, I think will allow us to be so much more impactful and actually create a new centre of energy and kind of widespread basis of support to the sector around improvement that's actually embedded alongside and with organisations and systems.

I think it's such an exciting time. 

Matthew Taylor

Absolutely. Now, if you want to know more about the work that we've already been doing and the work we are continuing to do with Q network, then do listen to the podcast that Penny and I have been recording over the last 18 months or so. It's called Leading Improvement in Health and Care; Leading Improvement in Health and Care. And you can find it wherever you get your podcasts. 

And if you want more information about. Q, then visit our website, Q.nhsconfed.org. 

Thank you Penny for joining me, and I look forward to doing lots more work with you in the future. 

Now my next guest is a man who surely has seen everything in the NHS – after 46 years. Yes, 46 years. 

He's just stepped down as CEO of East Suffolk and North Essex NHS Foundation Trust. So I'm delighted to be joined by Nick Hume, who's held a whole range of senior positions in the NHS, including chief executive, Croydon NHS Health Services NHS Trust, chief executive, the Ipswich Hospital NHS Trust and the chief executive Colchester Hospital University NHS Foundation Trust. Those two trusts merged to form East Suffolk and North Essex NHS Foundation Trust from which he's just stepped down. 

Everyone knows Nick in the NHS, but the public know him as well because he is often been a really informative commentator on what's going on in the NHS and the national media.

And to give us a steer on how the ambulance service has coped so far this winter, we've got the NHS Confed’s own Anthony Tucker. He's not even 46 let alone 46 years in the NHS, but doesn't mean that he isn't perceptive. He's our policy advisor for out of hospital care, and he's going to be telling us a little bit about what our ambulance service members have been telling us.

So Nick, Anthony, welcome to Health on the Line. 

So Nick, you must be more than ready to put your feet up, and thank you so much for coming onto Health on the Line. Just tell me first, when you walked out of the hospital door for that final time, what was going through your mind?

Nick Hulme

Thank you, Matthew. I mean, so many mixed emotions. A real sense of sadness that after such a long career I was leaving a job that I love doing. A job that's a privilege to do. But also a bit of a sense of relief. You know, as any chief exec knows, any senior leader knows, it's a huge responsibility and it's a 24/7 job in your head and in your mind, if not physically on the site where you work.

So the idea of not having to wake up every morning, it's been a really strange week to wake up and not immediately think, how many ambulances are waiting? Or what's happening in A&E? Or what's going on? 

Yes, I suppose a sense of sadness, a sense of a job reasonably well done. Things I wish I'd done better. Things that I was really quite proud of. And also a sense that it is time, it's time for me, it's time for the organisation, and I think one thing about leadership is knowing when to step away. And for me it feels like absolutely the right time. 

Matthew Taylor

Well, Nick, you know, obviously on behalf of the whole service, thank you for all that you've done for us.

Let's explore some of this, and let's start with the period we're now in, and I've got a, appropriate enough for a conversation about the winter period, I've got a raging cold as I interview you now. 

As you went through your final winter period, and obviously you kind of left in the middle of it, how did this winter compare with others?

How much do you think we've learned about how to manage winter? I know that, speaking to Jim Mackey the other day, there is a sense that it's been tough. Possibly a bit better than last year. There are things that do show some signs of improvement. Do you think that after the kind of particular challenges of the post-covid years that we're, we're starting to get a bit more resilient through winter? Or maybe that's not how it felt to you? 

Nick Hulme

No, it did feel like a slightly easier winter this year. I think there were aspects that were more challenging. Clearly the earlier surge in flu that we'd planned for meant that we had all of our additional surge capacity open really pretty much from the beginning/middle of November, which of course then when you suddenly realise with a full hospital protocol, there's nowhere to go once you've opened everything, that is a quite a worrying time. And sadly did lead to patients being cared for in inappropriate spaces in corridors and boarding on wards in additional spaces. 

But I think overall it did feel as though we did cope. I think every year, you're right, we learn a little bit more. I think there's also something at some point, this is a more general point, really, we need to kind of stop with the transformation. We know what works. We know through GIRF what works with a lot of our clinical services. We know how patients should flow and can flow through a hospital. We know what best practice looks like nationally and internationally. And there is something for me about let's just deliver what we know works rather than trying to reinvent something every winter.

And I think that's where we've got to. We know from the national team, we know from the local teams what works. And I think each year we learn it a little bit more. 

Of course, the other component this year that was different was the resident doctors strike. And although that caused challenges of its own and clearly disadvantaged and made life difficult for some patients, and indeed some staff, it did give us a bit of a fire break.

We know that when we see consultants at the front door, senior decision makers discharging patients a bit earlier, not ordering so many diagnostic tests, not admitting as many patients through the front door. So having that, you know, I wouldn't advocate it as a policy, but having that fire break just before the Christmas period, Christmas did feel a little bit like Christmas of Christmas passed. Walking to Colchester hospital on Christmas morning with a hundred empty beds is something I hadn't done for probably five years. 

Matthew Taylor

Now that's fascinating, Nick. So just on the first point of what you said, which is this kind of issue of transformation, I guess the challenge is not just in the hospital, which is primarily what you talked about, but in terms of what we can do to reduce the number of people turning up at the front door, the quality of care coordination. That seems to be the stuff that is harder because it's not within an organisation, it's between organisations and how they work together. Have you seen that kind of work improve over recent years? 

Nick Hulme

Yes. I mean, we've had the privilege at ESNEFT of running community services, both in Ipswich and east Suffolk and in north east Essex, so that gives us the, perhaps more levers as more opportunities in terms of reallocating resource into the community.

Really being able to invest in, in fact, take investments out of acute beds and invest in, for example, virtual wards. Having our clinicians working across the whole spectrum of community care, having responsibility for patients in the community, particularly through our community geriatricians.

So I think that's something that we've been working at for, for many years. Covid did slow us down a little bit, and I think that that is certainly where my successor, where the team will be focusing their efforts into the next year. 

But certainly in terms of that community care, providing more safe, appropriate care for patients in the community, I still think there's a major challenge. Every time I hear anybody talk about, you know, we're going to move to a digital, digital care, we're going to move to more virtual care, there's a huge road for us to travel down in terms of giving both the patients and the staff confidence in a new way of working.

I talked to somebody yesterday, I remember the first time I ever booked a flight online and being absolutely convinced that when I turned up at the airport, you know, I wouldn't be able to get on the plane because I didn't have confidence in the system. And I still think that's where we are with a lot of the kind of IT work, the virtual work, the applications that we're using, for the staff and the patients. 

So I think that's absolutely, you are right that we need to be investing more, doing more in the community, but not just assuming that people are just going to accept that the care that they're going to receive in the community is going to be as good, probably better or more appropriate than that they receive in an acute bed.

Matthew Taylor

I want to come back, Nick, in a moment to the lessons of industrial action. But Ant, I'll just turn to you on this issue of care coordination. Obviously the ambulance service is central to that. And the ambulance service aspires to be central to that. What have you been picking up in terms of the kind of continued development of better collaborative working around winter with the ambulance services part of it?

Antony Tucker

Yeah, I think that point about care coordination is going to be vital. We can see in large parts of the country significant differences where, especially where 999 and 111 has been able to be brought, for example, under the ambulance trust. And often combining very well with services like urgent community response, which is allowing people to have almost a one-stop shop where you can have one multidisciplinary team under one roof determining what an individual really needs.

And as Nick pointed out, that's often not being taken into hospital. But at the same time, both patients and the staff making referral need to have the confidence in what that alternative is. 

Ultimately, all NHS staff want to do is what's best for patients that can often turn to being risk averse in the patient's interest. But of course, an admission is not always in someone's best interest, and I know ambulance trusts are driving forward, becoming system navigators who can really help people get the right care in the right place. 

Matthew Taylor

Yeah. One of the lessons I've learned in going around the service and is, it's a very prosaic point, but in terms of care coordination, that having people literally in the same space from different services, working in real time to reduce pressures to ensure that people go to the best possible place to see how services are working really does make a difference.

And you talk there Ant about risk aversion. I remember Nick going to a ed department, I don’t know, 18 months ago on the outskirts of London and the chief executive, there was a group of frail patients waiting for medical assessment and the chief executive saying to me, look, if my consultant geriatricians on duty, she'll work out how to send all six of these patients home.

If resident doctors are on duty, then most of these people will have tests and a couple of them will maybe be admitted. Are there lessons that we can learn from how things go better during industrial action, or is it just, the reality is we've got to train resident doctors? It does mean a difference skill mix. People are going to be more risk averse. What could we learn from that? 

Nick Hulme

I think for me, it's about having senior decision makers at the front door who have the confidence to make a decision to discharge. Because I'm very, very old, I remember a time before acute medicine being specialty, so each specialty would be on call on a certain day.

This was when I was general manager of medicine at King's and on certain days we had a 25 per cent drop in admissions. We could never understand it. And then when we an analysed it, it was because the cardiologists were on take and cardiologists didn't admit people with chest pain. Everybody else did. And well, they obviously admitted some people with chest pain, but they made a really safe decision at the front door. Everybody else admitted somebody with chest pain and then referred to the cardiologists. 

Now, we can't have cardiologists on the front door the whole time, but we do know that if you look at frail and elderly, we look at respiratory and we look at cardiac cases, if we had more senior decision making and use that decision making as the learning opportunity.

The idea that we bring people in and we almost use them as kind of test cases for resident doctors to order a whole lot of tests. But I also think there's a change in the mindset of the resident doctors and the consultants. I talk to residents and they say, well, you know, we ordered all these tests just in case we missed something, and we get asked at the post-take ward round by the consultant, why didn't you order x?

If the consultant was actually at the post-take ward round saying, why did you order all these tests? You've completely a) you've put the patient through the inconvenience. You've also caused a lot of cost in some cases, for these inappropriate requests. So both senior decision makers, but using those senior decision makers adds that learning experience for the resident doctors is probably, I think, the way forward.

That will mean more investment in consultant staff, but I think when you weigh that off against the reduction admissions, it's going to be worth it. 

Matthew Taylor

Nick, you did an interview recently with the Guardian’s Polly Toynbee, I used to be on the NHS Assembly with Polly, and you said that we need to improve the NHS fast or people will fall for charlatans.

What's your biggest fear for the NHS as you step away from it and do you think the current government has the right approach to try to get things back on track? 

Nick Hulme

I think over many, many years, we've all been involved for, you know, literary decades in the NHS, and we've heard every single argument about how to improve it – more investment, changing the staffing profile, moving from hospital to community, prevention.

We've heard all these arguments, but there's never been, if you believe the polls, there's never been a credible opposition saying that the whole structure or the premise of the NHS is wrong. So for the first time ever, we now have politicians with the potential of ending up in senior leadership positions saying that the NHS isn't fit for purpose and we need to move to an insurance-based system.

And I've had conversations with those individuals and they've been very clear in a sense saying to me, you are giving us the ammunition for our argument. Because we've seen more investments in terms of money and staff and buildings. We've been incredibly lucky, fortunate where I've just stepped away from in terms of £350 million of investment in new theatres and new AD departments, new paediatric departments, new breast units. And yet despite all that investment, there doesn't seem to be able to shift the dial in terms of productivity, efficiency and critical outcomes. 

So I think it's doubt of the NHS within the next couple of years. To really address some of those challenges that we face. It's not easy, and I'm not suggesting for one minute that that many people aren't working incredibly hard to address these challenges, but I think the NHS is vulnerable and I don't think the NHS has ever been vulnerable before in a way that it is now.

What we can't do is hand over the NHS to people that want to destroy it. The most precious thing I believe about living in this country is the NHS. And it's at real risk now. I'm not quite sure what the alternatives are. I don't think necessarily reform where there's a short thought through the alternatives. Certainly my discussions with them, they're a bit vague, but there is that threat. 

So that really worries me. It worries me for the NHS, it worries me as a patient, as a, where's my family [sic], as a future patients. We've got to do everything we can to retain it and the best way we can do that is to really give a return on that investment, give confidence back to the politicians, back to the public, that the NHS is safe in our hands.

Matthew Taylor

In that interview you also talked, Nick, about the impact of poverty. I wonder whether you share my regret that the government's commitment to this kind of mission-driven approach to health, to seeing health as a priority across the whole of government, that that does seem to have fallen away in favour of a more traditional agenda, focusing on kind of activity and clearly the things the public say they care most about, like waiting lists and GP access, is very important things, but kind of slightly losing sight of that commitment to a more holistic approach. It sounded from the interview as though you felt we do need to think about health a bit more, a bit differently.

Nick Hulme

I absolutely agree with that. I think where I, you know, the area that I work in or just finished working, has one of the healthiest, wealthiest elderly populations in the country in Aldeburgh and Southwold, and also has the most deprived electoral world in Europe, in Jaywick and Clacton. So I see those two extremes, and you can imagine where the health services are really, really good – they’re in Aldeburgh and they're in Southwold because there's political power, because there's money, because there's influence in those areas, where it's absolutely not there in places like Clacton, the Tendring peninsula Jaywick. 

The thing that is most important about the NHS is the safety net for the people who are vulnerable and we should be judged not on how amazing our waiting lists are and everything else. Clearly that's important, particularly for people on the waiting list, but actually what really matters to me, what I think should really matter to us in the NHS is how we care for the most vulnerable. Why is it that people who live in poverty have a much worse outcome in terms of cancer. We know because of late diagnosis, we know because of access to screening programmes, we know because of the cost of travel.

I was talking to a woman in Jaywick some years ago who said it was three buses for her to have her mammogram. A) she couldn't afford it. B) she simply didn't have the time. So I'm really pleased to say we've invested massively in a community diagnostic centre in Clacton to address some of those concerns.

But unless we address those concerns, I don't think we're doing our job. Now, the problem is it's not easy to measure. It's not easy in that kind of political cycle of two or three years that we can say that because this changes over decades in terms of addressing health inequalities, addressing inequity in health.

No government necessarily is going to invest in something that gives a return in five, ten, or 15 years’ time. They're going to invest in something you can count, whether that's ambulances on forecourts, or whether that's hips and knees and the waiting times for primary care and diagnostics. 

Matthew Taylor

I'm going to turn to Antony for a few moments, Nick, but I'm going to give you warning that the last question I'm going to ask you is what are the three tips you would give to someone just becoming a chief executive, who's just become a chief executive. It’s very relevant this, because we're publishing some work, we've actually just published some work, around the turnover of chief executives, which seems to have increased quite dramatically in recent times. So clearly people are finding the job very tough. Not many are demonstrating the resilience you've shown.

So I'm looking forward to your three tips for new or aspiring chief executives. But before we get to that, actually back to you Antony. What have you been hearing from our ambulance trust members about how winter's been going?

Antony Tucker

Thanks, Matthew. So I think in many ways to go back to a Jim Mackey quote he mentioned about the NHS going into New Year, not as a sort of victory mode or a victory lap, but with some of those aspects of positivity that Nick fed into as well.

We know from in November, the NHS was, for example, being able to handle ambulance handovers around 11 minutes faster than the previous year. That's a year on a year improvement from around a 41 minute national average to a 30 minutes, which is a significant difference. That means that most ambulance trusts were also able to achieve that 30-minute cat-2 recovery standard which has been, this is the interim target for some years for your standard cat-2 response, so that was quite positive as well.

Looking ahead though, we also have the question of regional variation. As before, there were some areas the country that are forging ahead and are well on that way as outlined in medium-term planning framework to return to that 18-minute cat-2 standard. And at the same time, there are some areas, country that are still struggling for and maybe good reasons.

Matthew Taylor

When you look at this kind of regional variations, and there's obviously, often variations reflect real circumstances. They reflect issues beyond the control of the NHS to do with kind of population health or challenges of recruiting, of retaining staff in certain parts of the country. But to you, Ant, to the people that you talk to in the service, what seemed to be the critical success factors, which mean that things go better in some places than others.

Antony Tucker

So one thing I'd pull out is the increasing adoption of w-45 policies. That is to say that an ambulance will wait for no more than 45 minutes at an ED before dropping a patient off and going to another call. Of course, that's important because there is always somebody waiting for that response. This is based upon the fundamental principle of collaboration.

I know it's not always going to be easy for acute hospitals to work and ensure work that through. Nonetheless, where it has been possible to happen, we've seen some dramatic examples of where handover times are almost halved, and as we know, there's a direct correlation between handover times and cat-2 response that then feeds into the quality of ambulance response.

After all, only about half of ambulance calls result in a conveyance to hospital. The ambulance service is already succeeding, seeing or hearing, and treating patients on the scene. So a released ambulance may be able to go and treat a patient without having to take them to an ED, which may feed into future ideas of flow. But beneath that one protocol there’s a whole world of incredibly intense and could be valuable collaboration between staff at the front door of ED and ambulance trusts. Something that's never easy, but I think where it's working is paying dividends. 

Matthew Taylor

Yeah, it's interesting, you know, someone like me who has a tendency to be intellectually lazy, you know, I could go, oh, there's too many targets in the NHS. It sounds like this is a target that's worked.

Antony Tucker

I mean in terms of targets being the things you focus on it has worked, as it were, it has worked. I know in the conversations I've had both with ambulance trusts and with trust leads in hospitals, the big variation tends to be not so much even region by region, but site by site. A lot of ambulance trusts have a great deal of sympathy with trust leaders who will have an ED, which is older, perhaps badly laid out and simple and very physical terms can be hard to offload patients quickly, no matter how hard staff are working.

At the same time, there were some places where EDs are more modern set up from that and are ideal for w-45 policies. So there is that need, as it were to go below the regional level and in indeed below the trust level and look site by sites where is working best. 

Matthew Taylor

Thanks Ant and Nick, before your three tips just reflect on your own relationship with the ambulance service over, over the years.

You must have had times when the relationship's been good, other times when it's been strained. What lessons have you learned for how best to work with ambulances? 

Nick Hulme

I think the most important thing is that the system comes together and decides where the risk's going to be held, because, you know, the moment we're holding the risk in corridors, in boarding patients on additional wards, not ideal.

It's a bad patient experience, not always bad quality, but it is a bad patient experience. I don't think anybody will advocate that. But it is better than having somebody, an undifferentiated patient lying at home without any access. So as long as the whole system agrees that including, dare I say the CQC, so that we don't get absolutely beaten up as we have been recently, in some ways appropriately, you know, some were making some errors. If the system agrees that then everybody needs to stand behind that decision. 

We enjoy a good relationship with the ambulance service, partly because the chief executive of the ambulance service used to be the deputy chief executive or ESNEFT, so the conversations are slightly easier. It's often about personal relationships. 

But I think to Antony's point, we can't have a situation where the systems that deliver best ambulance turnaround are the systems with the longest corridors. Because that's just wrong. So we, you know, we lower the bar, we lower the bar, we lower the bar to the point at which we forget about patients in the debate.

So there's a lot to do. I think particularly on the c and three, particularly on the cat-3s and cat-3s to 5s. And there's a lot more that we could do as a system to address that. 

It's interesting that you say that there appears to be more success where the 111 and 999 services are run together. I think that probably needs further exploration as these contracts come up, if that is the best way, then why do we even go through a contracting process? Why don't we just make that award and move on with it? So I think that's probably worth further exploration. 

Matthew Taylor

Well, there you are, Nick. Still having ideas even as you walked out of your hospital for the last time. 

I mean, I should say, obviously we would love to work with you in the Confed if you are interested in continuing to spread your expertise to people. But on that point, what would be your three tips for new or aspiring chief executives?

Nick Hulme

I'm going to be a bit cheeky and take four, if I may. Three, which are work related. 

So the first is to be curious. You know, we've got so much data. We've just embarked, we've just implemented electronic patient record. We've got more data than we could ever imagine. So be curious. Look at the data, listen to what your staff are saying. Always, always remain curious. 

The second is to be courageous. We're not encouraged to be courageous. We're encouraged to be to play safe. I've had to make some really difficult decisions in my career, which have put me in a position of huge Ursula abuse and upset many politicians and had, you know, phone calls with SPADs telling me I can't do certain things.

So be curious, then be courageous. 

But I think the most important thing is to remain optimistic. Nobody follows a pessimist. For me the most important thing, it's not blind optimism, yeah, everything will be fine. Yeah, it'll be fine. It'll be fine. But it is to remain optimistic with your team, optimistic with your patients, optimistic with your staff, because people need to see that. People need to see the hope. People need to see the optimism. 

And the final one is never forget what's really important, which is your family, because I probably didn't. You know, my biggest regret is the time I hadn't spent with my children. The time that I've given up things that are probably more important with my partner, with my wife previously, and so never ever forget what's really, really important because without that love, without that support, it's just a job and it's a very lonely place.

Matthew Taylor

Thanks, Nick. I think it's particularly powerful final point, because it's clear the Jim Mackey has had a real effect in terms of kind of leadership focus and delivery in the NHS. But sometimes what worries me slightly is part of the Jim Mackey myth is he starts working at six o'clock in the morning. This is incredible, which is, you know, of course, he runs the NHS, but I do worry sometimes when we think the measure of great leadership is how many hours you're willing to push in every day at the expense of every other part of your life. 

So Nick, thanks so much or joining us. Thank you for your service. As I say, I hope that we can keep in contact with you in the Confed of our successor organisation, which will be launched in just a few days. 

And thanks to you too and for joining us on Health on the Line. 

If you listeners have an exciting or innovative programme of work you'd like to tell us about, please do. You might end up on Health on the Line. 

You can contact us at HealthCommsPlus@nhsconfed.org. That's HealthCommsPlus@nhsconf.org. 

Goodbye.