General Sir Gordon Messenger: The workforce deserves the best leadership they can have

Sir Gordon on leadership, equality and diversity and why a focus on leadership and workforce is utterly central to better patient outcomes.

3 August 2022


What did General Sir Gordon Messenger really think of health and care leadership? Following the release of the highly publicised review into health and care leadership, co-chaired by and Dame Linda PollardSir Gordon sits down with Matthew Taylor to unpack the recommendations, his hopes for implementing the reforms, why equality and diversity is mission critical and why a focus on leadership and workforce is utterly central to better patient outcomes.

Health on the Line

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  • Matthew Taylor

    A couple of weeks ago, I caught up with Sir Gordon Messenger. We talked about his review, what he's learned about the NHS and what he hopes to see next. That's coming up in a moment on Health on the Line.

    As for me, I'm on holiday right now observing events in the UK, but also being reminded in my visits and conversations with fellow travellers, that health systems just about everywhere are under strain.

    I feel increasingly strongly that we've got to shift our thinking about health and care fundamentally. To move from a model in which health spending is seen as a drag on the economy, something that stops us investing in a better future. Instead, we need to see functioning and innovating health and care systems as the bedrock of our economic and social future. The foundation for a better society.

    Sadly, the present debate is a long way from these fundamentals. The Conservative leadership contest is spawning headline-grabbing announcements, many of which are unhelpful. For example, Rishi Sunak's pledge to fine patients who don't turn up for appointments. The Confed recognises that leaders are working hard to use their stretched resources well, including using face-to-face and online appointments. But the reasons patients do not or cannot attend their appointments will be complex. Penalising them unfairly will not solve the problem. The administrative burden fines would place on the NHS risks being considerable and almost certainly would outweigh the money brought in by the fines.

    We'll continue to urge politicians to undertake a reality reset about health and care, including the impact inflation is having on current funding. We can only hope that future proposals on health and care address the long-term systemic issues, including addressing the yawning capacity gap, especially in relation to workforce and capital investment.

    The Confederation represents health leaders. But for some time we've been saying the number one priority in investment is social care. As we've been saying in the media, more than 9 in 10 NHS leaders have warned us of a social care workforce crisis in their area, which they think will get worse this winter. And nearly all our NHS leader members across the health and care system say the lack of capacity in social care is putting the safety of patients at risk. More than 4 in 5 of our members have warned that the absence of care packages for people to be able to return home or to be moved into account is the main reason why medically fit patients are stuck in hospital longer than they should be. And this, in turn, is a huge factor in the higher demand on A&E departments and longer ambulance response times that we're currently seeing. We've absolutely got to tackle this social care crisis if we are to end ambulances sat outside A&E departments for hours.

    So even from where I'm sitting on holiday, I can see the NHS leaders are facing an incredibly challenging job right now, even though it's the middle of summer and it's only going to get more challenging. So, it's important these leaders get the right support and development. And on that topic, over to this week's interview,

    Matthew Taylor

    So, I'm delighted to be joined for this edition of Health on the Line by General Sir Gordon Messenger. Gordon joined the Royal Marines in 1983. He became chief of staff at Joint Force headquarters in 2004. From 2010 to 2012, he served as chief of staff operations at the Permanent Joint Headquarters. In January 2013, you see in the position of deputy commander at NATO's Allied Land Command in Izmir, Turkey, in July 2014, he became the deputy chief of defence staff, military strategy operations in the MoD.

    I'm saying all of that because we can sometimes forget we are so focussed on ourselves in the NHS. We sometimes forget how distinguished Gordon's career was before he came into our orbit, because of course we know Gordon better as the author, the joint author with Dame Linda Pollard of the Messenger Review into NHS Leadership. Gordon, welcome to Health on the Line.

    Sir Gordon Messenger

    Thank you, Matthew.

    Matthew Taylor

    Let's go back to the beginning and the announcement of the review in October of last year. When you agreed to do this, I'm assuming you didn't agree immediately, but you kind of reflected on it. What led you to agree to do it? What did you hope would come out of it and to what extent of those hopes been fulfilled?

    Sir Gordon Messenger

    So, I'll answer the second bit first. I mean, what I hoped would come out of it would be that I and the team around me would be able to add value and to recommend improvements that essentially were beneficial to the workforce of health and social care. And to me, that sounded like a, you know, a laudable goal. I didn't know at the time how achievable that was because I was truly an outsider to both healthcare and social care. But when asked and when having discussions about the terms of reference, I felt that there was a potential and that is why I, I agreed to do it.

    Matthew Taylor

    At the end of that process, as it has it lived up to expectations exceed your expectations? What has changed in your kind of perspective as a result of the process?

    Sir Gordon Messenger

    I wasn't short of of observations, I would say. So, the idea that this was a sort of mature, perfectly formed approach to leadership of management in healthcare and social care, I quickly realised wasn't the case.

    I recognised that within both sectors there was a workforce that was actually really quite desperate for improvement and desperate for change, but somehow struggling to enact that because of the levels of empowerment and pressure elsewhere in their in their profession.

    You ask how well I did. I mean obviously it's for others to make the judgement on how we did. But I would like to think that this was a review that was that sought to improve the lot of the workforce in healthcare and social care. And I'm of the view that if the recommendations are enacted that that will lead to that that that improvement.

    This was not about beating up any or all parts of the workforce. It was recognising that they were doing a first-class job in really quite difficult circumstances and that they deserve the best working environment and the best leadership and behaviours around them that they could have.

    Matthew Taylor

    You, as I described at the outset, had a life in the military. What would you say were the kind of biggest differences and also the biggest similarities between the culture that you experienced as a soldier and the culture of the NHS.

    Sir Gordon Messenger

    In terms of military leadership, I mean, the military is structured in a very hierarchical way. People understand leadership in that they understand when they see leadership, they understand what being led and leading looks like and feels like. And I think that makes leadership in the military in some regards easier than many other sectors.

    I don't think that that sort of simplicity of structure and hierarchy exists across the board, and therefore it can be more complicated to lead and to manage well in in healthcare, because the relationships and the responsibilities and the accountabilities aren't always as clear as they are in the military system.

    I suppose the other difference I would say is that in in in the military there's a very sort of strong emphasis on team building. There's a recognition that that the toughest of challenges can only be surmounted if one can create that team and use that collective spirit and that unity of purpose to achieve things.

    I saw that in bits of our investigation into healthcare and social care, but I didn't see it as often as I might have expected. And one of the recommendations talks about how one needs to balance your approach to the task ahead with the building of the team and the managing of the individuals within the team. And an observation is that whenever there is crisis, whenever there is pressure, one tends to focus often myopically on the task. And that comes to the detriment of the team and the individual. And I would strongly recommend that a rebalancing would be of value.

    Matthew Taylor

    Let's start looking at some of the recommendations, Gordon, and let's start with the first, which is around collaborative leadership and organisational values, induction mid-career program. So, I want to try and get to the essence of what lies behind this that there's in a sense is, that we that we need at the beginning and in the middle to remind people, remind leaders in particular why we're doing what we're doing. The purpose of what we're doing and the values that underpin it.

    It's almost a kind of focusing process that, as you say, we can lose sight of the fundamental reason why we want to lead in the public sector or in health. We can lose sight of the values that motivate us behind the day-to-day pressures and therefore instilling it at the beginning, renewing it in the middle; does that get to the essence of that recommendation?

    Sir Gordon Messenger

    It really does, actually. And I'm glad you picked that up because I regret the emphasis of the word induction on that particular part of that recommendation, because that sort of throws up the notion of here's your fire exits and here's your leave policy. When actually it was all about exactly as you describe, taking key moments in anyone's career. And it's not just about leaders. It's about anyone who chooses a profession in healthcare and social care. And using that key moment, which everyone shares the moment at which they join the organisation to set the culture, set the expectations, build awareness of what it is that they're there to do. Ideally build awareness of the system as a whole rather than the specific parts that they are planning to join and to maximise that moment to try and build a sort of collective identity.

    So, I joined the Royal Marines in 1983. It didn't take long for me to have that sort of cultural sort of ethos implanted in me which sat with me for the rest of my career. And I think there's something quite powerful about that if you can get it right. I think there's a risk of it being over centralised. I think there needs to be a certain amount of central branding and value setting. But it also needs to have the right amount of local variety to tailor it to the location of the workplace. But that's, as you describe it, is exactly how this recommendation sees itself.

    Matthew Taylor

    So, let's move on to the to the second, which was around kind of deepening our commitment to equality, diversity and inclusion.

    Now, amongst your critics, there has been the kind of suggestion that you have somehow been captured by the health service blob and that this focus on EDI, to use the shorthand, is kind of evidence of that; there's a certain implication that you had to write this stuff because that's what's expected if you do anything for the NHS.

    Now I know you and I've spoken to you and I know that that's not the case. So, tell me in a sense why you felt this was so important. Is it part of trying to get people to see that EDI is not something that you do as a hygiene factor, but it's actually integral, integral to the vision and purpose of NHS leadership.

    Sir Gordon Messenger

    Yet again, thank you. I didn't feel captured in any way. I don't regret any of the points you make and I would continue to make them now despite, as you say, the criticism.

    So, to me it is clear that how those with protected characteristics are always treated and the equality of opportunity for those who with protected characteristics is not where you would want it to be for for any organisation, and particularly for an organisation such as the National Health Service. So, it is an area which requires focus and that's at the more extreme end in terms of sort of discrimination, but it is also about the sort of equality of opportunity and making this a real level playing field where everyone is judged by their skills, experience and qualities rather than by any other form.

    The other, I think, really key thing about the EDI, it's almost the sort of bellwether of how an organisation values its workforce more generally. And if you get that if you get that bit wrong, then I think it sends a message about how much value is associated and given to the workforce as a whole. So, for a variety of reasons, I felt it was it was really important and to get it right. So, send such a strong message about the organisation as a whole.

    Matthew Taylor

    And you know, we very much welcome this element of the report and I totally agree with you, Gordon. It's a journey I've gone on as a leader, I think. Moving from seeing equality, inclusion as something which you should do because you're a virtuous person, you want to do the right thing, into something which is absolutely essential to being a good manager, particularly obviously being a good people manager, but also really being committed to maximise the impact of the benign impact you have in the world.

    Sir Gordon Messenger

    On that, I would also say that the recommendation two was specifically about EDI. I would like to think that almost all the other recommendations have a very positive approach to a more equal, a more level playing field in terms of how people are trained and developed, how people are selected, how people are managed. I would like to think that all recommendations, how people are appraised, are likely to lead to a beneficial outcome for EDI.

    Matthew Taylor

    So, let's turn to the third and the fourth recommendations - consistent management standards delivered through accredited training and a simplified standard appraisal system for the NHS. I'm going to put these together with a with a reflection from my own career and from my experience of talking to other people.

    So, I'm incredibly impressed by the leaders that I speak to in the health service. And one of the reasons I enjoy talking to them, I'm sure it's the same for you Gordon, is that is the kind of the colour they give in terms of the particular challenges they face in their community. Sometimes it's quite prosaic things like the kind of problem of the estate, the hospital they've got, the way the space stops them doing things they want to do, whatever it might be. And now that's really important. And throughout my leadership career, I've offered accounts of why a particular context is difficult and challenging.

    But I suppose I want to say this without being unsympathetic to any of that. It's all real. It's all important. That, in a sense, sometimes that sense that one is uniquely, in a uniquely challenging context, there's something very particular about one's context can almost be a way of avoiding the fact that in the end, there are some core things that good leadership is about. There are perspectives, there are skills, there are ways of dealing with problems which are more generic. And is what these kind of points are trying to get us to, is to say that we have to balance all the kind of specificity of every job in every organisation with a recognition of those things which are common to the NHS leadership experience?

    Sir Gordon Messenger

    So, it was definitely about that, but it was about, I hope a little more than that. I was surprised at just how sort of unstructured and almost random the sort of training and development of managers was as it went through. Obviously, there are plenty of opportunities to train and to develop, but they're not in any way sort of mandated or sequenced. Very rarely, to my knowledge, is a certain training and development opportunity a prerequisite to anything. And so, trying to recognise that that that sort of slightly random, slightly arbitrary route to becoming a professional manager with all the skills, both of leadership but also of management, is key to the sort of status and the confidence of individuals as they go through that career. And we got a strong sense from those managers that they would they wanted that.

    We had a number of conversations about whether managers should be an accredited profession or whether the training that they undergo should be accredited training or in a more consistent way. And we went down on the second of those to two routes. But what I would like to think is that people become more of a known quantity. You know, when I went through my career, I wasn't appointed as Gordon Messenger, I was appointed as someone who was deemed to be in a certain bracket in terms of quality. I'd been through a number of training serials that were well and understood in terms of what that gave me as a as a skill set.

    I was struck by just how sort of individual some of the appointing choices were, some of the promotion choices were. And I felt and I got this a lot from the managers that we spoke to, that they felt that something more consistently delivered and accredited and recognised would, would both level the playing field, but also give them a better chance to have the skills that they need to do the jobs they've been asked, the very difficult jobs they've been asked to do.

    Matthew Taylor

    And that framework wouldn't be kind of frozen aspic, would it Gordon? This would be something which would evolve. And in a way, having this kind of common framework enables us to reflect from time to time on whether it's still right, what needs to be added to it, what needs to be taken away from it.

    Sir Gordon Messenger

    Yeah, definitely. And one of the things we shied away from, and I'm very glad we did, was to try and get into here's the specifics of what the contents of these things should be. This was seen as a sort of modularised approach, which no doubt will have some mandatory elements to it in terms of probably leadership that will have some variety depending on what profession, what type of manager, what professions that they're in, what their preferences or interests might be.

    The other point on this is that this was tailored as a recommendation around managers, but I would like to think that the clinical leadership, what you have is a sort of off the shelf modular approach to improving leadership and management. The choice the choice might be reduced a little from the various options that people have now. But it's an off the peg, I want to improve my leadership or my management as a clinician. I can go away and select this or this or this module to try and improve my skills in that regard. So, we're hopeful that whilst the original and that that the first audience for this will be the managerial cohort, that it could have relevance beyond that.

    Matthew Taylor

    What was your kind of reflections on the kind of path to leadership that you see in the NHS? This is something which I didn't really fully appreciate before I came into the job and you know, the vast majority I think I'd be right in saying of leaders in, in the NHS have some kind of clinical background, but not all. And we're seeing more leaders now who are from kind of allied health professions. Do you have any kind of reflection on the on the path that leaders take? Do you think it's it broadly right the kind of balance of people with a clinical and non-clinical background?

    Sir Gordon Messenger

    I don't think it is necessarily right. One of the observations, again, there was a great team that I had and I've used the word ‘I’ to too often, but because of my specific military background, I was surprised that leadership was often viewed through a small, relatively small number of positions and that sort of recognition or acknowledgement that frankly, everyone, regardless of role, has some form of leadership responsibility and therefore can develop in that respect.

    As soon as a nurse passes out of graduate training, he or she are leaders, people look to them, to their behaviours, they look to them, for example. The same is true of doctors. The same is true of AHPs and the same is true of managers. Regardless of what level they're at, people are looking at you and they're looking at you for example and they're looking at you for leadership. And I felt that that, you know, everyone's a leader, everyone's a team player ethos, and you can be both at the same time, I felt wasn't as strong as it could be and that entry level, I’ll call it induction, could be an opportunity to try and instil that.

    To your specific question about leaders, I think we could see more from the clinical side of the house in terms of leadership and investment in system outcomes. Obviously, there are many, many physicians who invest huge amounts of time and energy into that, but occasionally there are also some that do not, and to me a recognition by clinicians that they truly are leaders, whether they wish that moniker or not, and a bit of investment in how to behave, act and to and take responsibility beyond your immediate clinical specialisation, I thought was something that, again, could be more universal.

    Matthew Taylor

    I know you acknowledged this yourself, that you weren't able to spend a great deal of time looking at primary care. But I think, as the organisation that represents primary care as well as the organisation that presents systems and trusts, my sense is that what we've done in primary care is we've asked the primary care team, often GP's, not always, but we've asked them to take on leadership roles without really thinking through the support that they need to go on that journey. And I think if we take forward the recommendations at the Fuller Review, for example, we see more neighbourhood planning. We are going to have to invest, as she recognises, more in enabling people to take that journey into a kind of broader leadership role.

    Let's turn to the fifth recommendation, which is new career and talent management function for managers.

    That sounds a bit dry. What I took from that was a sense of responsibility at regional and national level for the stewardship of talent; that just as we would accept responsibility for, as it were, the resource that is the estate, for example, that we should have a more explicit sense that is the responsibility. You talk about regions, particularly in this recommendation, but also of the centre to steward the leadership, the overall leadership capacity of the NHS and to replenish it and to keep that pool in the kind of state that we needed to be in. Was that part of what you're getting at here?

    Sir Gordon Messenger

    It absolutely, absolutely was. Stewardship is a good word. But I think it's stewardship that needs to view this in two ways. Firstly, support to the individual in making the right career choices - giving them what their opportunities that development profiles might look like; having honest conversations with them about strengths, weaknesses, areas for improvement or areas for greater experience.

    So, the certainty that and then the second is how do you how do you get the most from the system as a whole from your workforce?

    You need to take this a health service approach to this. We know that leaders will be better if they have broader experience; if they've moved out of narrow areas of specialisation into something broader; if they've got greater experience of the system; if they've got experience of where the health sector butts other sectors; arguably, if they've got experience at various levels in terms of local, regional, national, and we should absolutely add the system into that. So how can you dovetail those two stewardship responsibilities whereby people feel better supported, but they're also encouraged to develop to the benefit of the organisation as a whole?

    And to generate something that, rather than the slightly random route to the top and that slight marketplace feel to how senior executives are selected, you have a natural percolation in the system that develops the right skills and the right experience to the right place and ensures that those with the most skills and the most talent naturally percolate to the top.

    Matthew Taylor

    Penultimate recommendation was around effective recruitment and development of non-executive directors. And again, I think this is a very welcome focus for your work. And again for me, Gordon, coming into the NHS from the outside, I had had experience of non-executives which has been kind of pretty mixed both being one actually and also sometimes being subject to their slightly random influence. Of course, non-exec roles in the NHS are much more substantial I think than often non-executive roles are and thinking hard about non-executive is really important.

    So, for example, I’ll just give you one example – I’ll ask you to comment on that reflecting your overall view - which is I think in systems there is a challenge, which is how do you ensure that ICSs, ICBs are genuinely empowering and enabling bodies, not bodies that end up adding to layers of bureaucracy. Now I think that a lot of, I speak to a lot of trust chief executives and they get it and they want ICSs to work.

    But actually, sometimes it's the non-executive directors of trusts who are the ones who feel rather excluded by this. You know, there they have been influencing their organisation and suddenly their organisation is being asked to work in a much more collaborative way which can mean that they feel their influence is diminished. And I've been very impressed, for example, in Suffolk, I think is, they they've created a non-executive directors forum which brings together the NEDs in the system, in the trusts and some local councillors in order that everybody kind of feels part of this. It is really important that we understand the resource NEDs are and that we ensure that they do feel a strong sense of ownership of what's happening around them?

    Sir Gordon Messenger

    Yes. And of course they have that accountability for the organisations that they're on the board of. But to your point, actually if you've managed to generate the types of things that happen in Suffolk, they become a natural conduit for collaboration beyond trusts, between trusts, between sectors. So, if you get the right people in, people who recognise this shift, this huge shift, towards a system built upon collaboration rather than competition. Then what we want are not people who are going to drill solely into their own little stovepipe of responsibility. We want people who are looking up and out and are a natural sort of lymphatic system, a parallel system to encourage the sorts of collaboration that, as you say, we hope to see from ICBs and ICPs.

    Matthew Taylor

    To your final recommendation, which is in a way, one of the ones that got the most kind of publicity, I guess, because it's kind of easiest for the layperson to understand, which was kind of how do we get the brightest and best to go to the most challenging places? And I think there have been various attempts to do this over the years, and they've achieved pretty mixed results. I think it's really important that we take a kind of very human view of this.

    My friend Paul Corrigan has done a piece of work, which I think one day will be published in one form or another, where he spoke to a number of chief executives who had done this. And what he said was fascinating was that some of the issues they had were not the kind of titanic organisational struggles, it was that they arrived in a new place, they didn't know anybody, they had to find somewhere to live, they had to find a school for their children. He described as quite a kind of lonely process as people are sent to challenging assignments. So, if we're going to do this, it is of course it's about pay and about status and about people knowing that they'll be supported even if they don't succeed straightaway. But what we really need to remember, we're asking a lot of human beings, aren’t we?

    Sir Gordon Messenger

    We are, and this was one of the toughest areas because at the moment it is counterintuitive; it is truly brave to take some of these roles. And one doesn't have to look too far back to see how one could come a cropper if things don't play out as you'd want. So that point about support, which has to be from within the system, but I think there's a strong political part to that, too.

    There needs to be realistic timeframes given; there needs to be backed up promises of support and backed up promises that this doesn't necessarily mean a one-way journey; that this this absolutely could and should be a waypoint in any successful career. And it goes back to that point about the needs of the individual balanced against the needs of the organisation.

    If one can make these jobs the most desired jobs, rather than the most feared jobs, because of the status that one gets, because of the support one gets and because it really becomes a sort of a rite of passage for future jobs, then you start to you start to challenge some of that counter intuition that that certainly exists. That certainly exists at the moment.

    I think the other thing is that chair relationship with the chief exec strikes me as really important in these places because, as you say, being in charge of challenged places can be a very lonely place to be and having support and sounding boards. And those two individuals working as a team strikes me as a really critical part of the jigsaw.

    Matthew Taylor

    So, Gordon, I could talk to you for hours, but I'm going to bring things to close. But just want to focus on a couple of the sort of slightly more controversial elements of the process.

    The first is, I mean, you know, we're grownups. You know, you may have a military background, but I could tell you, a sophisticated political player. I guess you knew that there were going to be briefings about why you were asked to do this, about what was going to happen. I mean, did that irritate you that there was this kind of manager bashing narrative in the background that you had to kind of push against? Because I remember when I spoke to you and we were proud to host a number of events for you, were at pains to kind of say, look, you know, that narrative is nothing to do with me.

    Sir Gordon Messenger

    Yes, it does annoy me. You know that sort of deliberately toxic headline grabbing politics is not something I enjoy. I would tell anyone that this is me being disloyal to my sort of political masters, if indeed I have any more. But no, I didn't find that particularly edifying.

    Matthew Taylor

    No, well, it's not. And I thought you handled it incredibly well, if I might say so. And actually, Gordon, that there was a certain amount of distrust when your review was announced. But by the end of the process, I think everybody was looking forward to your results and welcomed them as well. So, you pushed against that very effectively.

    Of course, something that we raised with you a lot and other people raised with you was a regret that you weren't allowed to look at the centre. And since you've reported we've heard NHSE are going to cut 30 per cent of their jobs. I was speaking to Richard Meddings, the chair, the other day about the challenge of sustaining momentum when you're going through an organisational change that big, the centre is involved in that kind of a process of organisation or kind renewing its operating model and new members of the executive. The centre was out of review for you, but you've finished now, and I hope this isn't unfair, would you be willing to share with me any, any reflections you would have about, about how the centre should go about changing its operating model, given what you heard from speaking to leaders in the field?

    Sir Gordon Messenger

    Actually, the centre wasn't explicitly out of scope, but that was something that was said but at no point was I explicitly told that. So, yes, I am prepared to share. I mean, it was quite clear that the relationship between the centre and the rest of the organisation wasn't always what it could be. The sort of notion of poorly expressed, central diktats upon a hard-pressed system that was struggling to cope was, was something that we heard a number of times. The only thing I would say is that firstly, there was a very new team. Amanda had only just arrived when we started and was putting together a team and clearly had priorities of her own. So, it felt a little unfair to drill too much into that.

    Secondly, if you want to enact change in an organisation through recommendations, through an external perspective, it becomes really hard if everything you do is at odds with the very organisation and structures, and people that that would be most influential in driving that change. I'm not in any way suggesting that the centre has got everything right. I'd say that they are under a huge political pressure, and I saw many times an attempt to act as a shock absorber for that political pressure rather than just pass it on.

    I suppose my key observation is on that it is based around that operating model. Any good operating model defines what functions and accountabilities are held at what level. And I felt that too often things that should have been set by the centre were too sort of dissipated and distilled, setting cultures, setting some sort of workforce policies and the like, arguably could have benefited from a slightly stronger central hand to the tiller. And other things that absolutely would sort of flourish and improve best if allowed to be tackled locally, perhaps had too much central oversight. That's very, very easy to say that very hard to try and get it. But I suppose what I would say is that the work that's being done on an operating model, if it succeeds in identifying responsibilities, the accountabilities at each level, minimising sort of overlap and maximising clarity, then I think there's an opportunity there.

    Matthew Taylor

    I agree. And our focus is particularly on ICSs and how it is we ensure that they can be truly empowering and enabling bodies, very different from what we've seen before. Not a bureaucratic layer, but as it were, an organisation which is primarily focussed on making the rest of the system work effectively rather than kind of second guessing what the rest of the system does. So, there's a there's an echo there, I think there's an opportunity here for the centre to model the behaviours that they want to see at system level.

    A final, final question Gordon. I mean and I speak from some position of kind of experience and pain here myself, so it's, it's five years or it was five years two weeks ago since the review I did for Theresa May about employment law and when I published my report, the government immediately enacted all the things that it could enact in secondary legislation and promised an employment bill to enact nearly all the other recommendations. Five years later, we're still waiting for that employment bill. So, Gordon, are you doing anything or have you got any advice for those of us who support your recommendations? Do you have any kind of perspective on the likelihood of implementation? What will you be watching out for to see whether or not in the end your report turns into action?

    Sir Gordon Messenger

    I mean, in the period after submitting the report, I was involved both with senior leadership in the department, in social care, local government and the National Health Service, as to how implementation might be taken forward. And we've spent a bit of time on what the model is, how we try and drive ever more collaboratively our approach to social care and healthcare. And they were fruitful, positive conversations by a team who clearly saw merit in in the recommendations and wanted to take them forward. The challenge, of course, comes when urgency after urgency just drowns out the focus on them.

    What I would like to see is a strong and continual statement from the leadership, the people of influence, that a focus on the workforce, a focus on leadership is something that is utterly central to better patient outcomes and better productivity, because I truly believe it is. But it's the sort of thing that can get lost in the noise unless it has that constant drumbeat from the centre. I don't care whether they're badged as Messenger review recommendations or not. I just want to see that investment in people, that investment in leadership, because I truly believe that is the route to make the work place a much more productive one. And that has to be to the benefit of public health more broadly.

    Matthew Taylor

    Well, Gordon we will be doing all that we can at the Confed to also support that focus on leadership, investing in leadership, valuing in leadership. Gordon Messenger, thank you so much for joining us on this edition of Health on the Line.

    Sir Gordon Messenger

    Thanks, Matthew.


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