Welcome to this special one-off session of the Health and Social Care Committee, looking at the implications of the recent announcements regarding the abolition of NHS England, the 50% cut to the headcount of NHS centralised staff—if we want to put it that way—and the 50% cut to ICB running costs. We have three panels today who have come to us at very short notice, and we thank everyone who is appearing in front of us today. Like you, I am sure, we all want to make a bit of sense of what this might mean, but also what implications and dangers we need to be looking for as further details are announced. May I ask the first panel to introduce yourselves and to tell us what you do?

I am Sharon Brennan. I am the director of policy and external affairs at National Voices, which is an umbrella charity with over 200 health and social care members. We focus on lived experience, patient voice and health inequalities.

I am Professor Henrietta Hughes, the Patient Safety Commissioner for England. I am a practising GP and a visiting professor at the institute of medicine at the University of Greater Manchester.

Good morning. I am interested to bear down on what will be the impact of the NHS reorganisation on patients. What kind of differences would we expect patients to see due to the reorganisation in the short, medium and long terms?

First, thank you so much for inviting me here today—I am delighted to be in front of this Committee again. When I appeared at my pre-appointment hearing, I was asked what I was going to do, and what I have been doing is listening hard to the views and voices of patients and their representatives, but also to the views and voices of frontline staff, the leaders of multiple different organisations, and MPs, APPGs and Members of the House of Lords. What we really need to see is that these changes have a positive impact on patients. Listening to the patient voice needs to be absolutely central to these changes, so that we focus on patient safety, outcomes and patient experience. By doing that, we will be able to get the clinical engagement and buy-in that will then help to deliver the 10-year plan.

What do you think needs to be in place for patients to have that greater voice in the running of whatever organisation replaces NHSE?

I know that the Secretary of State is passionate about the patient voice being central to the design and delivery of healthcare services, and we have seen that in the development of the 10-year plan—that intentional, deliberative listening to people, communities and staff. It is important that that then continues in the delivery of the 10-year plan, including through roles such as mine—I champion the patient voice as an independent commissioner—and by having that networked working across a range of different organisations that have that focus. I think the very fact that the Committee is starting this morning with the representatives of patients, then the representatives of the workforce and then the representatives of organisations sets the tone of the culture we need to see in how the health system works.

So a patient-first focus going forward. How do you think the changes to the system will specifically enhance that patient voice, or could enhance that patient voice, beyond what we see at the moment?

By having simplicity. We know that patients sometimes struggle to understand which part of the system to go to—we know that it is quite a complex labyrinth—so we need that navigation through the system. There are examples of great practice in that, but I get a lot of correspondence from patients and their representatives who find that they do not really know where to turn in the system, and we help to navigate and signpost them if it is an area that is not under my direct remit. What I would really like to see is a much more cohesive and collaborative approach to listening to patients, not only when they are in front of a clinician but in helping to design and deliver health services in this country.

Are there risks to patient safety when the reorganisation takes place? Have organisations flagged that, in the past, reorganisation has led to increased risk to patient safety while it is under way?

Absolutely, when there are changes happening. I was in a PCT when we had the last major reorganisations to the cluster and then to the national commissioning board, which became NHS England, and there is always a risk of a loss of organisational memory and people being quite distracted by what is happening. What I have done is I have spoken to current and incoming senior leaders in NHS England about what plans they have in place to make sure there is an effective handover, and they are already starting to have those conversations. My organisation, although very tiny, has multiple active pieces of work open with NHS England, ranging from valproate and mesh all the way through to the deprescribing of antidepressants, thinking about consent and transparency, and a whole range of different areas. What I will be doing is identifying which policy teams will be picking up on that work, so that we can make sure that none of those balls around patient safety is dropped in this transition process.

Sharon, what are patients not experiencing at the moment—in terms of how much their voice is heard in the current system—that you think they could experience under a new system? Also, where are the blockages that should be taken care of in a redesigned NHS?

We know that patients are still struggling to trust the NHS, and we know they are still struggling with really basic things, like admin. National Voices, along with the King’s Fund and Healthwatch, recently published something on this. A quarter of people felt that the administration of the NHS was poor. One fifth have seen letters appear for appointments after the appointment has taken place, so we are slightly worried that, in the process of reorganisation, that could get worse. On trust, we have seen a lot of VCSEs working with patients to try to improve certain aspects of care that are vital to them. One example is Kidney Care UK, which has been working on improving access to individualised payments to pay for trips to dialysis—people go three or four times a week. That is an ICB-led initiative, which we now know might be under threat. That is one initiative where patients have been involved in co-production and been promised something, and it looks like it may or may not go ahead. So initially, there is something around trust and admin. In terms of where patients are less listened to, there are concerns and opportunities. You can argue over whether NHS England has worked well or not, but it does have a really strong focus on patient experience. It has some very strong teams, it has a clear purpose and it has PPI leads from ICBs feeding into that. We want to make sure that knowledge and expertise are retained, and that we do not lose organisational memory. In terms of where patients are struggling to be heard, it is felt that there is little clarity on where responsibility for patient experience sits within an ICB. We feel that there is a tendency for systems not to prioritise this work, and we are already hearing from our member organisations that people are facing cuts to co-production work from ICBs because of the previous 30% reduction, so I think there is something about how you ensure that patient experience is genuinely heard in the local community. We are struggling to do it now, and with the coming cuts in ICBs, it may become harder, especially if there are conversations around merging, so the ICB footprint grows larger while communities remain the same size. I think there is something around that.

Would you say that patients experience a lack of accountability at the moment that they find quite frustrating? You are concerned about the population growing and accountability diminishing, so what would work?

We would like to see an officer at ICB level who is responsible for patient experience and who has accountability at that level. We know there are a lot of patient experience surveys run by various different organisations—the CQC, the friends and family test, and the GP patient survey—and there is an opportunity here to try to centralise those surveys in one area so that there is better read-across, and then we can do more in that area. We are currently thinking about what it would be like to put a patient-centred metric at the heart of the NHS—a culture shift so that patients and their outcomes are actually seen alongside things like the 18-week target and the A&E four-hour wait target. We think that could really shift the culture, so that the patient experience is at the centre. We are quite reassured. We know Wes Streeting is very focused on patient experience and ensuring that the NHS is patient-centred, so there are some strong opportunities here. I would add that one of the barriers is still how VCSEs connect into ICBs. They are still struggling to do that. For example, there isn’t a clear mechanism for how a respiratory VCSE can connect into the respiratory team in an ICB. That has still not been ironed out. Again, with 50% cuts and the transition from NHSE to DHSC, that could worsen.

Thanks very much for being here. I want to follow up on my colleague’s queries about patient safety and get a clearer idea about that. The inquiry into the Mid Staffs scandal found that restructuring NHS services can create risks to patient safety. NHS England is not directly responsible for patient care, but with your expertise, could you comment on where the potential risks are and whether you have a clear sense of how the Department can help to mitigate those in partnership with the ICBs and the rest of the healthcare service?

When it comes to the events around Mid Staffs, there was a clear concern about the relentless focus on finance and productivity and that the voices and views of patients, families and staff were not listened to. That lack of responsiveness had horrendous effects, causing enormous harm and death to patients. I would like to point to how we are changing that culture. The Martha’s rule pilot has been running for the last year, and I have given the Committee an example of how many parts of the system need to work collaboratively together to make those changes happen. What has been fantastic is the engagement of family members, who are able to escalate concerns—we have had over 2,000 calls, which have led to more than 300 patients having an improvement in their care and over 100 ending up being escalated to an ITU or equivalent. This shows that patients and families have really valuable information that we can listen to, and if we act on that, we improve safety and reduce harm to patients, but we also improve staff morale, reduce the number of complaints and so on. In my previous role, I was the national guardian for the NHS and set up “Freedom to Speak Up” in the wake of the Francis report. One thing I can say for certain is that when change happens, people want to speak up. I would encourage everyone, whether in NHS England, ICBs or providers, to listen attentively to what their workforce is saying—I know you will be hearing from workforce representatives later this morning—but also to listen acutely to what their patients are saying

For the benefit of those at home, can you briefly describe what Martha’s rule is and what the Committee has in front of us?

Martha’s rule is an initiative that was started after the tragic death of Martha Mills, and it is about giving patients and families the opportunity to get a rapid review if they are concerned about the deterioration of a patient. It has been piloted in 143 hospital sites, and it is about giving staff the ability to act on their clinical judgment and giving patients and families who are concerned that they are not being listened to the ability to get a review from a critical care outreach team. I have been chairing the oversight group for the last year, bringing together dozens of organisations that have a really important part to play as representatives and patient groups, as well as the professional regulators, officials and the team at NHS England that has been leading the pilot.

Which is fantastic. That is really helpful. Thank you. You will forgive me, but I have been in the health arena for 20 years—I am sure you guys have been there for quite a long time, too—none of this is new. What you are saying about listening to the patient voice and about how patient safety is very important has been around in various forms, probably for longer than 20 years. I want to go back to a phrase that you used, Sharon: organisational memory. With this reorganisation, in terms of patient safety and the duties of NHS England, how is that organisational memory being passed on? Do you think we are in danger of reinventing the wheel again?

We would urge them not to start from scratch. Obviously, Wes Streeting will appear before this Committee on 8 April, and he may well have a clearer transition plan, but we urgently need to know what a clear transition plan looks like. We need to ensure that the day to day is being done during the two-year period in which the transition will happen. On patient safety, you are right that we hear stories of care going wrong all the time. The one thing to highlight from Mid Staffs is that, although ICBs are facing a similar environment in terms of finances and the push on elective care, there is now a better patient experience landscape in terms of collecting information. The friends and family test came out of the Mid Staffs review. It is not perfect, but it is a mass collection of people’s experiences of care. If I were going to advocate for anything, NHS England used to have a directorate just for patient experience, but it was subsumed into the nursing directorate. There is an opportunity here to put a directorate back that leads just on patient experience, showing that it is really important—that goes back to the idea of accountability at ICB-level. I have just one warning: we absolutely have to ensure that we hear from a diverse community. Addressing health inequalities is essential to the Labour manifesto, and it is a core function of the ICBs, so we have to be really careful about how we listen to patients. For example, National Voices has gone out to do some focused work on translation issues, and we had to go out into grassroots community charities and hire an interpreter to understand their concerns. Doing everything online, or doing everything on an English-focused app, is not necessarily going to be the solution to hearing concerns from everyone.

What impact assessment would you expect to see from Government on the reorganisation or merger?

It is the health and inequalities aspect that really worries us. We have spoken to various members and gathered some evidence of where their concerns sit. Groundswell is a charity that focuses on homelessness and provides peer advocacy services across 11 London boroughs. It is worried about the ICB cuts and whether that work will be continued. We are hearing of recruitment freezes in clinical networks, which enable people who have suffered a stroke to receive vital rehab. Mind, the mental health charity, said that it is hearing that the cuts in ICBs are likely to be equity-focused. TransActual, which focuses on healthcare for trans people, is worried that the shift to DHSC will make healthcare in that area more political rather than evidence-based. I also add that the LGBTQ health team sits in NHS England, so there is a real issue about how health inequalities are being listened to and assessed. That is where our main focus would be, because we know that Labour has a manifesto commitment to reduce the life-expectancy gap between the poorest and the richest. We would argue that it is about how that will be achieved alongside this transition.

We published the patient safety principles last October, after a public consultation, and they speak not only to identifying and mitigating health inequalities but to a focus on equity. We know that equality is not sufficient; we have to aim for equity. The principles also set a way for senior leaders to make decisions from the patient’s perspective, and we know that is something that has not often been done in the health system. As much as people will create an infographic that puts the patient at the centre, as a GP, I know very well that patients have to work around very complex systems. As Sharon was saying, we need to include the views and voices of the widest range of people to ensure that we create services that work for the most vulnerable. Next Monday, I am publishing a report called “The Safety Gap”, which looks at the needs of people with sensory impairment, such as vision loss and hearing loss. These are huge numbers of patients who really struggle with safety in their medicines and medical devices, but we know that they do not always get a voice at the table. The approach to the 10-year plan has been very broad and deliberative. It is now about how the system will be ready to deliver on those plans, and how the responsibilities at ICB level will be enacted if there is going to be a reduction in their headcount.

There seem to be two elements to an impact assessment. One is an assessment of what the new, reformed Department will look like once it emerges, and how it will differ from what we currently have. The other is the impact of a disruption full stop. It does not really matter what the disruption looks like, but it is such a massive organisation that sits at the top, and there are the staff cuts as well. An assessment needs to sweep up both those things.

I would really like to start with a focus on outcomes, and work back from outcomes to understand what structures, teams and roles are required in terms of the people. I do not discount the impact on individuals who are fearful about their roles being at risk. That in itself can be very impactful on morale and people’s optimism about being able to function in the future. I also think we have to look at the very broad context. These are big changes being proposed in the context of the 10-year plan and the Dash review. There is something about ensuring that we have an absolute focus on the needs of patients, service users, families and communities. The system then has to adapt and design itself to be able to meet those needs, rather than shoehorning in something that will have a negative impact on patients at the end.

Given that the reform of NHS England is only one part of the Government’s plan for changing the NHS, albeit a big one, is there a risk on the flipside that it will fill up the whole space of thinking about reform, and too much will be pinned on the difference that it will make at the end? You could come out at the end with no better or worse patient incomes, but actually you could improve those things regardless of what sits at the top of the whole structure. Is there a risk there?

One of the concerns is how we can deliver 50% cuts to ICBs by December, on top of the 30% already asked for, as well as transition NHS England into DHSC and ensure that the staff remain during that transition. To be clear, at National Voices we empathise with our NHS England colleagues about the way in which the news was delivered. We had many calls from people who were really shocked and upset, partly because it was on the back of a reconfiguration that happened just two years ago. So one of the concerns is about how we can do all that while also trying to deliver the 10-year plan. Moving to the neighbourhood health teams is a good idea. It helps us to think about how we can develop prevention in communities, reduce reliance on acutes, and ensure that people with long-term conditions can better understand and manage their own health with the support of the NHS. It feels a very big stretch to try to bring in these three shifts—from analogue to digital, hospital to community and treatment to prevention—while also trying to deliver the transition. The concern is the disruption around that. There are also really basic things, like the day-to-day stuff. The charity Mind told us that everyone in the ICB they work with has been told they are up for redundancy. People are not answering emails and it feels chaotic at the moment. Obviously that will settle down, but I agree with Henrietta: it is about focusing on the outcomes and building from that. I believe that is what the 10-year plan will look like, but how do we do that while also going through these seismic changes?

As you mentioned, Sharon, we have Wes Streeting in front of us on 8 April. If you had one question for Wes Streeting—I am not promising we will ask it—what would it be?

It would be something about the centrality of the patient voice. Sharon mentioned the patient experience directorate. There is definitely something about bringing that into the absolute heart of not only decision making but the organisation that does. The organisation that does, in whatever form it is—the mindset shift, the focus and the measurement of how patients are experiencing care—is really important. That is what I would call for.

Similarly, we know he is focused on patient experience, so how will he provide reassurance that, in the current financial difficulties and pressure on patient access, patient experience remains at the centre of the mission for the Government, so that the NHS is focused on patient outcomes rather than getting bogged down in the transition period?

Thank you both very much. We will move on to the next panel. Witnesses: Dr Jeanette Dickson, Professor Phillip Banfield and Professor Nicola Ranger.

Welcome to our second panel, the focus of which will be on workforce. Will the panel please introduce themselves?

Hello. I am Jeanette Dickson and I am the chair of the Academy of Medical Royal Colleges, which is the umbrella organisation for all 23 medical specialties throughout the four nations. We come together to talk about cross-cutting factors such as education and training and workforce. I am a past president of the Royal College of Radiologists, but I am also a practising clinical oncologist.

My name is Nicola Ranger and I am the general secretary and chief executive of the Royal College of Nursing, representing more than half a million nurses and nursing teams.

I am Phil Banfield and I am chair of the BMA. I am still a working obstetrician, delivering babies at four o’clock in the morning. The BMA now represents nearly 195,000 doctors.

The Government have said they are going to cut the total number of staff at NHS England and the Department of Health and Social Care by 50%. What impact might that have on frontline services and the staff who work on the frontline?

I am not sure it will make any immediate difference to the frontline. The frontline feels that those running the NHS, whether that be NHS England or the Department of Health—the politicians—have become too detached from the frontline. That is also how it feels on the shop floor in terms of trust boards. In daily, “What does it feel like on wards and clinics?” it is probably not going to make any difference.

Are you saying that you feel you could cut 100% of the Department and NHS England and the frontline would feel no impact? Alternatively, is it about reallocating what those two organisations do, or a combined organisation does, to make a bigger impact on the frontline service?

The frontline feels that it needs to be facilitated and enabled. The reallocation of those functions from NHS England or Department of Health to enable doctors and nurses to get on with the job is needed. It is not a case of cutting the expertise—you need to retain that expertise. The most obvious way of expanding that to the benefit of both the frontline and the population is to invest more heavily in public health medicine.

At the moment, the Royal College of Nursing represents nearly 4,000 nurses and nursing teams that work in NHS England and ICBs. They are not bureaucrats. They are clinical nurses who run all sorts of brilliant services for patients—safeguarding, infection control, nurse leadership. Every nurse in the UK counts. We do not want to lose that expertise. We do, however, recognise that at the moment, as Phillip said, it is really tough for anyone delivering patient care. We think it is understandable that the Secretary of State is bringing that level of accountability back up to Government. Let us be honest: the NHS is in a really difficult place for both staff and patients at this moment in time. That level of accountability to improve what is a really challenged environment for everybody working in it is key. We can understand that level of focus.

Are you confident that the proposed changes will increase accountability, or do you have a fear that we may replace one bureaucracy with a new bureaucracy?

That is what we cannot do. I was listening to how tough it is for patients, and we all know that. We did a report earlier this year about corridor care; that is a symptom of a failing system. What we cannot do is have a big reorganisation that never makes anything better for staff and patients. That is sometimes the difficulty with a reorganisation. People understandably think, “What does that do for me?” We have got to mitigate that human, genuine understanding with the fact that we are in crisis, we had a really difficult winter and things are difficult for patients at the moment. We have big issues that require laser focus, and that is what has to be mitigated. Reorganisation has got to be done ethically and well with people at the centre, but we cannot be distracted from the patient and the task at hand. We know from experience that big organisations can be distracted from the fundamental things, and that cannot happen, particularly at ICB level. They are the key commissioners for getting people out of hospital into their own homes or where they need to be cared for. A 50% reduction cannot come at the expense of patients. This is going to take real skill to do wisely.

I echo what has been said. The folk on the front line absolutely want to give the best care for patients. What they want from the centre is the enabling function to allow them to deliver that care. It is important that we do not lose sight of some of the slightly unsexy things that need to continue unabated in the background, such as medical recruitment to training posts, training of all staff, IT connectivity and the work done to deliver that, and cyber-security, which has a huge potential impact on patient care—all those things that the centre does at the moment that need to continue, whatever is going to happen. I take your last point. What needs to come out is something that works better than it does at the moment, not just a slimmed-down version of what we have. Going back to what Henrietta said earlier, it is about the outcomes. Looking at what the outcomes in the centre need to be and then building the functions around that is the best way to ensure that we have a fit-for-purpose organisation that enables the frontline.

To pick up on your last point, the rationale behind the supposed merging is to remove duplication within the two organisations, which most people would agree with. There may be a lack of awareness that NHS England at the moment is not just a policymaking organisation. As you have mentioned, it is probably one of the largest and most complex IT providers, it is a massive training provider—it does not provide the training itself, but it manages it—and improvement programmes run out of it. Might those things, which we can maybe all agree are benefits to the system if they work properly, be lost or diminished in the merger? What impact might that have?

We need to recognise that those things exist and that they have a benefit, rather than saying, “We need to take out 50% across the board.” You need to look at every function in itself. As I said, there is a concept that NHS England does only policy, but it does all those other things that are absolutely critical to maintaining, improving, developing and changing frontline patient care. It is important that those functions are looked at forensically and that it is decided what they should be, and that the new organisation is tailored to deliver that with the expertise of the clinician.

There are things that are at risk of being lost, and I echo what was said about the workforce in particular. We know we have a big nursing challenge. We have a real challenge with the nursing profession in recruitment and retention. That has not been done as well as it needs to be by anybody at the moment with regard to nursing, so there are some functions that need to improve and remain. I am genuinely worried as well about the environment we are working in. It is about not just NHS England and ICBs saving money, but providers. Dr Cooper, you mentioned Mid Staffs; we know that one of the big challenges for Mid Staffs—this was in Sir Robert Francis’s review—was nurse staffing. At the moment it is not just NHS England and ICBs being asked to make savings; it is coming to providers as well. I know that posts are being looked at to take frontline nursing out. There is a real danger if you put all this together—it may end up being a real risk. So it is going to take real skill to get this right.

I was shocked but not surprised at all by the announcement, because doctors have been telling us for a long time that NHS England has lost the plot over workforce planning, training, training bottlenecks, not listening about physician associates, and its response to the latest Royal College of Physicians exam debacle. The training bottlenecks come at a time at which we need, for example, more anaesthetists. People want to train as anaesthetists, yet the number of training places is artificially restricted. The disconnect between the need and the ability to train is just bonkers. That needs to be replaced with something that delivers what patients need.

Looking at the potential opportunities that some of you have touched on, what few specific things would you like to see come out of the merging of the two organisations, practically, that would make lives better for staff and patients?

For me, it follows on from what Phil has said. There is no NHS without its staff. It is about having a real look at what patients actually need—not just on affordability—and how to both recruit and retain brilliant clinicians. That is not where we are at the moment. I think there is a real opportunity to do something different from what we are doing which puts—

Just to push you, practically what?

I think we do not look at, exactly as Phil was describing, the acuity and dependency of patients. For example, if you look at mental health, you see that the way we train nurses is to separate physical and mental health. The reality is that mental health and physical health are completely merged in many settings. This is an opportunity to think, “How do we really train and educate nurses for what the patient need is, at scale and with the right calibre of people, and look after them?” It is about things like that, looking at population health. What kind of clinician do we really need for modern-day medicine and nursing?

I do not disagree with anything that has been said. There is a lot about functions relating to how we retain staff, how we make staff feel valued, and how we do the basic things like pay them on time when they start and at the right banding, if you cut out, for example, 50% of HR. It is about how you signal the value to people of being an employee—of being someone who delivers frontline care in a very pressurised environment to patients by valuing the staff. That includes how you retain those staff. There is a lot of very good practice. I am a clinical oncologist; we work very much in an MDT function. But there is also sexual and reproductive health in the community, delivering care for patients—for women—where they need it. Those exist now. It is about how we then bring that out as being the model that continues.

There are three quick fixes. One is to fix general practice. Without NHS England stopping contract reform, there is an opportunity to have general practice as the most effective and efficient part of the health service. You have a complete paradox, where there are over 1,000 GPs either underemployed or unemployed, yet one of the biggest patient complaints is that they cannot get to see their GP. How bizarre is that as a situation to be in? Secondly, use public health. Public health was fragmented by the Health and Social Care Act 2012, so let us get that back front and centre. If you want to know how to reduce health inequalities and what is effective across your health service, really invest in the public health expertise. That will cut through all the different agendas, especially if you give them an independent voice. Then you have to not just train your workforce but retain it. You have to value the staff; you cannot expect people to care if they do not feel cared for themselves. That is about a top-down philosophy, but it is also about listening from the bottom up.

Thank you. You have all given me relatively broad “nice to haves”. I am not sure that I fully understand what it is you think NHS England or the Department of Health—whatever it is going to be called when merged—would actually do. I will ask the question a different way: what would you say is the primary purpose of this new organisation?

I think it is to enable frontline staff to deliver the best care for patients by doing the things at the centre that add huge value at the centre. Things like, for example, a strong overview of training and medical recruitment, IT connectivity, central procurement of IT, and central estates management to allow the best value. It is the stuff that you do at the centre that adds value to the frontline clinician, as well as devolving to the localities what they can do best.

Could I summarise that as doing the stuff that no one else can do, and the stuff that no one else should be doing? Is that a fair summary?

I think other folk can do it—you can have local procurement—but it is about where it should be done centrally to get that uniformity and basic level of connectivity and IT infrastructure that allows seamless movement of patients between primary and secondary and community care. What should be done at the centre is the stuff that the centre can do the best.

I would like the centre to really focus on key performance in getting people out of hospital and into other areas—that shift to the community and getting people out of hospital. I would like it to really focus on those measurable things. We focus a lot on the front door waiting times, but there are patients who wait an awful long time to get to another environment, and you do not get the sense that there is real grip on how long people are waiting.

Are you talking about social care?

I am talking about both social care and community care—district nursing and packages of care. I have been listening to a lot of social care providers and other community providers, and they are all saying that there is capacity; it is about commissioning the right things and having the right funding. If there is a focus on that shift, it would make a very big difference to hospitals. A lot of people can function—30% of people do not need to be in hospital. At the moment, it is not clear who is really driving that—I do not think it is clear.

Should it be this new organisation? Should it be the performance manager of primary care trusts, hospital trusts, mental health trusts, community settings and social care?

There is a real sense that people want local ownership, which I understand, but at the moment we are in a real crisis. My view is that you need a bit of central grip and focus before you have local devolution; experience has shown us that. If it is pushed up to the Government, what is important is the key things they are going to do with real focus and investment—some of it will take investment—so that we start to get the change. There is a danger that it all gets devolved a bit too quickly, and there has to be connectivity between local and central to get this right.

It is not clear to me who actually runs and is responsible for the health service. It is a high stakes announcement, because the Secretary of State and the PM are now clearly responsible for the delivery of healthcare in England. Austerity has led to poor health, but someone will need to decide what is provided and what is not. That needs central direction and an honest conversation with the public. We will deliver whatever you ask us to deliver, given the right tools, resources, staffing and beds to do what you ask. If you do not want that done, then do not commission it, because we have been doing too much with too little, and that has led to patient harm.

I shall leave it there because I am sure other colleagues will want to pick it up. Thank you very much.

I am going to focus on staffing, but before I start, I was listening to the discussion about how a lot that is done in the centre now should not necessarily be done by NHS England or the Department of Health. Quickly going along the panel, could you all name one thing currently done at the centre that you do not think needs to be done after the reorganisation?

I think what you need is local performance management that is not centrally driven but is responsive to local needs.

I come back to workforce. I think some of that needs to be maybe a little bit more independent, if we’re to see exactly what is needed for patients rather than affordability. I would like to see workforce done slightly differently.

So the workforce plan should be regional workforce plans, not a national one?

I think it is going to have to be both. We know that when it is managed centrally that affects costs, but we do not always look at what we need. I would like something separate and slightly different.

At the moment NHS England collects vast amounts of data that is duplicated by the Department, but it is not converted into information that means anything on the frontline. That could be got rid of with a very small effort to make sure that any bits that are missing are provided elsewhere. A number of functions that NHS England currently performs can be done in a public health setting. Screening and specialist commissioning can all be done within a public health model.

Moving on to the meat of my questions, the Secretary of State thinks that this process is going to take two years. How do we protect the frontline and the staff there from being distracted by the buffeting caused by the broader health service changes during that two-year process?

At the moment, for a lot of people on the frontline in hospitals and other organisations, NHS England and the Department are one step away from them, so it will not necessarily affect their day-to-day lives. What they are worried about at this moment is the absolute savings that they are being asked to make within their own services. They would be less worried if it was just NHSE and the Department that were restructuring, but they are being asked to make significant efficiency savings across the board. At this moment there is no one in the NHS who is not having to really look at their cost base or is unworried about taking posts out. At the moment, a lot of frontline staff will feel like it does not directly affect them; what is affecting them is the difficult circumstances in which they are having to give care, and now having to make further savings. The entire system is going to be focusing on money.

To paraphrase, your suggestion is that generally staff will not be too worried about the broader reorganisation, but the drive to efficiency is something that you think is probably creating some anxiety?

Correct.

Professor Dickson, in the Academy of Medical Royal Colleges you have a very broad view of quite a lot of different specialties. I would be interested in what impact you think the changes to the national body will have on the frontline, and how we can best protect the frontline from that.

I echo what others have said: for many on the frontline, NHS England and the DHSC are at one remove. What the frontline really wants—I hear what Nicola is saying and do not disagree with her about the cuts—is a centre that enables them to deliver excellent patient care with the least amount of interference. It is about, for example, the monitoring of data: how many times do you give the same set of data to the or to two or three different places in a slightly different format, and it is not automated because you are not enabled for it to be automated? Looking to the future, the staff on the frontline are concerned about the cuts to the frontline and about that future enablement, but also about the retention of the things that need to happen that people do not think about, like medical recruitment and training.

I will come on to training in a bit, but just to test that, you talk about not wanting interference, but I wonder where in your view accountability stops and interference starts.

Phil talked a bit about the data and it flowing into NHS England and not then flowing back to the trusts and the providers to say, “This is how you could improve. We have used your data, we have taken your data and we have done this. We are helping to show you where you need to focus.” The accountability is there because the data goes back up. You need to slimline how many data points you have, but you also need to get that data back to the trusts to enable it to be used in real time.

What I found fascinating about the data is that it was NHS England data that Lord Darzi used his report. It is a shame that it took Lord Darzi to hold the mirror up and say, “This is the state of the NHS,” because the data was sitting there.

Interestingly, when we spoke to Lord Darzi he said that often he had to threaten to FOI it before he could get some of the data out, so perhaps there is an openness challenge for the NHS. Having worked on a large health service-related survey in the past, I recognise some of that.

I know that I work in Wales and we are talking about England, but I would have spent my entire 30 years as a consultant without a usable maternity information system to give that immediate feedback about what we are doing and how we are doing. Who knows what will happen over these two years? I have never seen a reorganisation that is smooth or cheap or that works as it is supposed to work, but I know we have an immediate need on the frontline. It is not just about waiting lists and waiting list targets; there are hidden waiting lists in mental health, as well as child and adolescent mental health. You cannot get away from the elephant in the room: social care and freeing up beds. If you are not going to give us more beds, you need to free up the beds we have, but you must also recognise the immediate issues. The Secretary of State talked about the NHS having more pilots than the than the RAF. We are expensive experts, and we need to be used to allow that expertise to be applied to the patients who desperately need it, rather than us doing other things. That can be facilitated while any transition goes on. There is nothing preventing that from happening.

I will now quote directly from you, Dr Banfield. You said that retaining appropriate expertise during the reorganisation will be vital to “the coming battle to mend the NHS.” What particular areas of expertise need to be retained in the central function?

Certainly the specialised commissioning services—that might go from rare cancer services to kidney dialysis. You need to retain the expertise we have in public health and expand it. We have expertise in different specialties, and I am sure the colleges will do more and help more to make sure that the specialist expertise is looked after and enhanced for the benefit of patients. There are screening and immunisation programmes that need expertise to come across. There are lots of examples, including 1,500-plus doctors and dentists who may be affected by this. No one wants to see people’s jobs at risk. They have expertise that we lose at our peril.

I will quickly shift to training. Health Education England was merged into NHS England about five years ago, so responsibility for staff training and education will now sit in the Department of Health and Social Care. To what extent is it appropriate for that to be delivered from the DHSC? Is there an argument for keeping some of those responsibilities at arm’s length from the Government?

There is always a tension with training. We are mainly now talking about postgraduate training, so doctors and nurses who are already qualified. HEE was a multi-profession educator; it educated doctors, nurses, radiographers and pharmacists who were qualified and working as doctors, and therefore delivering frontline patient care, but being trained to become independent specialists.

One of the things that I most wanted to get across to the public when I worked at the GMC is that most care you receive in hospital is from some level of trainee.

Yes, and those trainees—resident doctors—are concerned at the moment about their job prospects, given some of the stuff that Phil has spoken about. There are also things such as an expansion of medical school places. We know that some areas are significantly under-doctored, and the population funding the health service are not receiving the same care as those in other places. It is about how we utilise the national view of education to make sure that there are training opportunities, and that training is happening in every part of the country, not just in areas that are attractive to certain groups. That is why I feel that some of the functions of a central education system work really well, because they can have that overview of, “Where are the needs for other healthcare professionals to be trained?” Also, it has a longer view—by definition, a five, 10 or 15-year view—of what medicine needs in the future, and it can deliver the healthcare training for that future delivery model, which is very different from today.

Professor Banfield, do you feel that centralised training with a broader look at the health service would be a better model?

I do. It is the same pot of money that looks at, “Here is the health service. These are the professionals we need to train for our health service,” but then we fragment it by saying, “The Medical Schools Council and the universities will get this pot. The royal colleges will talk about what the postgraduate training will be. The GMC will oversee that.” It is just not joined up to how you get a doctor or nurse in front of a patient. Removing one layer creates an opportunity to improve and to focus on specialties and where your deficits are. To a certain extent, that is a political decision to make. If you invest in undergraduate places, you have to invest in the academics who will train them after that. You cannot just plop 10,000 new medical students into the system if there are no jobs for them. We have already got to a stage where a significant number of the students qualifying this year with £100,000 of debt do not know where they will be in August. That is a ridiculous mismatch of planning.

There is a huge reliance on IMGs in the system as well.

The Nuffield Trust has just said that we have an over-reliance on red list countries. We are bringing in doctors from overseas and promising them training that we cannot deliver, when what we actually want is for them to staff our hospitals. That needs much better focus.

If more care is to be delivered by SAS-level doctors, that is a different debate we need to have. I am conscious of time, because I am at the end of mine, but I want to go to Nicola—we were talking about medical training.

We desperately need something very, very different. We have no faith in the NHS workforce plan. It talked about increasing the number of nurses, but at the same time they made more nursing tutors redundant last summer than ever in my lifetime. CPD for nursing is not ringfenced, so at the moment it could go into the bottom line in ICBs. Nurses are desperate for postgraduate education, but it is not ringfenced. We need to change that. Professor Banfield was absolutely right: we are so reliant on international nurses—50% of the NMC register last summer was international nurses.

Is that all registrants or new registrants?

New registrants. It is now 33% of all registrants, and it was 50% of those qualifying. With the potential cuts and potential reduction in vacancies, students graduating from nursing this year are already worried about whether they are going to get a job. That is a disgrace, so it has to be changed.

Thanks to everybody for coming along. I should declare before I start asking my questions that I am a member of the BMA. I did not bribe Professor Banfield to give that endorsement of public health, but I do want to talk about public health functions. There are many questions around public health and the implications of the reorganisation for it. The BMA has said that it has concerns about public health functions and the public health workforce. For the record, I should point out that we had Public Health England, which then splintered into the UK Health Security Agency and the Office for Health Improvement and Disparities, and there is the local authority function as well. We have that splintered make-up now. With your areas of expertise, could you talk through the opportunities that merging DHSC and NHS England potentially bring for public health—particularly in the area of health inequalities, which we heard from the previous panel was an issue—but also the risks it brings for public health? If you want to talk about the budgets as well, that would be really interesting.

I think we all recognise that public health is the key way to improve the health of the nation going forward—primary and secondary prevention, all the health monitoring and all the screening. As you rightly pointed out, they have had a very rough ride recently and a lot of changes. It is incredibly important that, as part of the discussion around the 50% headcount cut, we are absolutely clear about what functions we want and need to be at the centre, and what that outcome looks like, and then build back the number of staff needed for that.

To be clear, Jeanette, do you think the OHID should remain in the centre as part of the Department of Health and Social Care? Do you think the health inequalities and disparities piece is best served in the centre?

I would defer to my public health colleagues on that. There are pros and cons to everything, but it is about understanding that the function needs to exist somewhere, with national population-based oversight. There is lots of different locale stuff, and there is lots of place-based stuff, but we need that national oversight.

Where public health sits is obviously with the experts. Some of the key people for public health are health visitors and school nurses, and they have reduced by 45% since 2009. They are crucial for people and communities. We would love to see this incentivised so that the number goes back up to the 2009 figure, even as a start. Nurses are the constant, 24/7 presence in many areas. We would love a real focus on prevention and public health as part of their day-to-day lives and work if we could find a way—both as a profession, which we can do, and externally—to liberate nurses’ time. They are a really good army of public health-committed people.

Absolutely. Perhaps I could reflect on what you were saying earlier about the current bizarre training programmes for nurses, where mental and physical health are separated. Do you see the public health function of more holistic training being part of the redesign?

I would really like to see it, and we are looking at that as a college. Things are far too segmented. You have one person in front of you with so many different needs. You need someone skilled who can assess what you need both now and in the future, and what the problem is. We need to relook at the nurses we are educating, to really put the person at the centre. At the moment, though, I am afraid that nurses pick up too many jobs that other people do not want, and they have too much bureaucracy. In order to function for the public as we want to, we need to liberate nurses’ time in a slightly different way.

That is interesting; I might come back to that. Professor Banfield, where is the BMA on public health systems?

Covid exposed just how fragmented and dismantled public health had become. By splitting a big chunk of public health away from the health service, we wasted billions of pounds that we did not need to spend, and more people died than needed to because public health was not in the state that it should have been. This is just an opportunity to repair that.

How do we not waste billions of pounds this time?

It doesn’t matter what structure you have if you have the people there with the function to take a big-picture view. It is about inequalities in the population and inequalities in the workforce, and about valuing diversity and appreciating that a large number of the workforce have disabilities. The public health function can do that. An enormous amount of public health prevention work goes on in general practice, and it is carried out by nurses in general practice as well. This is a huge opportunity to reset that.

Great. Let me just move on with that thought to think about holistic health service provision, the staff and the staffing opportunities that are there as this new function develops. Professor Ranger, I wonder if I could come back to the comment that you made about nurses picking up roles, and perhaps healthcare professionals picking up different roles, at the moment. Could you comment on the manager-clinician relationship in staffing and how it works or does not work? Do you have any thoughts about how that might be more appropriately managed as we see the changes at the centre and at ICB level?

This is a really good time to take a really good step back and say, “What’s good governance, and what’s bureaucracy?” Clinicians are extremely good at knowing what they do that is a complete and utter waste of time. Let’s try to get people to work at the top of their licence, wherever they are. We are quite risk-averse, and making a good patient decision requires a little bit of judgment and risk. A lot of things are done by protocol—whether they are assessments or risk assessments—because people are scared of someone falling or getting a DVT or whatever it is. So we are quite protocolised, which sometimes takes a lot of time. Some things are essential, but some things could be stripped out, and it feels to me like a good time to take a look at everyone to see what they are doing now and what they would love to be doing for their patients. We have to work differently; some of that is about risk and people being understandably defensive in how they practice, because it can be tough if you make a mistake, but that takes a lot of time. That would free up clinicians to do what they know is right for patients.

Management is not something that miraculously appears because you are a clinician. I think you really need to be trained, and trained well, for it. There is an absolute value to having clinician managers, because they see the full picture and the nuance of the unintended things that sometimes happen. I also think that, in many roles, management is not an incentivised role—it is not supported. In an industry, you would not take senior clinicians, ask them to do management and not support them with training or coaching so that they can do their best job. Most managers in medicine, nursing and the healthcare services generally retain a clinical role and flip in and out of clinical and managerial roles. There are a few who continue to be pure managers, but most flip in and out of those clinical roles, so they go back to being within their clinical group. How you prepare that clinical group to be managed, and to accept management, and then to move on is a really important thing that we do not focus on enough.

That is really valuable. As the centre rearranges itself, it will, as you say, be an opportunity to revisit some of this. My final query is for Professor Banfield. I am very keen on institutional organisational memory, and you have been in this longer than I have. As you have previously said, there have been several reorganisations, so what lessons would you urge the Government to draw from previous attempts to reorganise the NHS, particularly in managing the impact on staff and staffing?

It is going back to basics, isn’t it? You have to define what you want your health service to deliver, and define where your priorities are. Is it the elective service? Is it the emergency service? How are you going to transition from hospitals to community? It is about having that overall picture, and then using the expertise that will help you get there. Sometimes you will need to speak truth to power, and it will cost you more to do it that way, but what we need as a service, and as a country, is long-term ambition and long-term investment, not short-term political papering over the cracks. Fundamentally, this is an opportunity to change the culture of the NHS. We have heard this morning about patients and listening to patients. That is not just about how your health service is organised; when you are a medic, the patient will tell you what is wrong with them, if you just listen to them, and they will tell you when what you are doing is wrong. But we are still in a system that blames the individual on the end of the mistake. We are in a safety-critical industry. Stuff goes wrong all the time, and it is amazing the amount of harm and error that we trap every day. So this is about making sure that advocates of the system needing to learn are still in place and still being heard. What we get, and there have been very high-profile examples, is an NHS that feels like it is has to hide stuff or look after its own bit of an organisation, instead of being open and transparent. This is the opportunity to reverse that and to listen to the concerns of both staff, including doctors and nurses, and patients.

Excellent. A learning system sounds very wise. You have mentioned this a couple of times, so I want to pick up on what the NHS is there to do, and what we are there to deliver. I think your answer was fairly comprehensive, but in your expert opinions, when you go to your respective jobs and speak to people, are you clear about the boundaries for the national health service in terms of what clinicians are there to deliver, and how we are there to deliver it? Does it feel that it is ever-expanding, that we are doing a lot, as Professor Banfield said, with not enough, and that it is not clear where those boundaries are? I do not know whether I have phrased that correctly. Does that make sense?

I may have misunderstood your question, but what people need at the moment is a bit of hope. What they are doing, they want to be doing well; even if you extend the boundaries, people just want to be able to do the basics well. That is what this reorganisation has to do. Patient satisfaction in the NHS is the lowest since we started measuring it. People are looking for more private healthcare than they ever have. Staff are a little bit fed up and demoralised. The best thing this reorganisation can do is start to improve on some metrics, even if it is not everything, because people—both staff and patients—are starting to lose little bit of faith in the NHS. That will be a disaster. Whatever is decided centrally, and with clinicians and providers, if something needs to get better, let’s get it better. At the moment, almost everything is struggling.

That is interesting. Jeanette, do you have any final thoughts?

I think Nicola has got it right. Patients need to feel that the NHS will be there when they need it. We ration already; we are just slightly quiet, uneven and inequitable about it. Can we deliver everything for every person in the population? No, but how do we deliver the best care we can with the money we have? That is about enabling clinicians to do their job, by providing the basics, which are good staffing, good infrastructure support, and a culture that learns, understands and does not blame individuals.

Thank you so much. That just leaves me to say thank you to you all for being here—it is much appreciated. I am going to very quickly ask you the same question I asked the last panel: we have Wes Streeting in front of us on 8 April. What very short question would you ask him?

Are you going to listen to the frontline?

Are you going to sort out the nursing crisis? Without doing that, you will fail.

How are you going to ensure that there is an effective clinical voice and clinical leadership in DHSC to ensure that patients benefit?

Exemplary. Thank you so much. Witnesses: Matthew Taylor, Nicolas Timmins and Siva Anandaciva.

This is our third panel. We will be looking at broader structures, previous reorganisations and what lessons we can learn. Thank you for coming to see us at such short notice. As with the previous panels, I invite you to introduce yourselves and what you do.

I am Matthew Taylor, and I am chief executive of the NHS Confederation, which is the organisation that represents all parts of the health service in England, Wales and Northern Ireland.

Morning, everyone. My name is Siva Anandaciva. I am the director of policy, events and partnerships at the King’s Fund think-tank.

I am Nicolas Timmins. I am a senior fellow at the Institute for Government, which is a think-tank that tries to make Government work better.

Thank you very much for joining us today. It has been reported that many Health Ministers and Secretaries of State since the Lansley reforms have reported frustrations about ever-increasing—or perhaps never-diminishing—levels of political accountability for the performance of the health service. Ultimately, at election time, it is the Government and the Secretary of State who are held to account for NHS performance. They report frustration about not necessarily having all the levers of power since the Lansley reforms and the establishment of NHS England to drive the change they want to see. Do you think that that is a fair characterisation of the power and levels of accountability that exist, and the balance between them?

We could all talk for hours about that, so we will try to restrict ourselves. You need to get to the root of the problem, which for me is overcentralisation. It is not political accountability per se; it is the fact that the centre seeks to be in charge of too many bits of a complex and interdependent system. In a different world—in other countries—you would not have this level of direct political accountability. People say to me about other health systems, “Things go wrong, but you don’t blame the President or the Prime Minister,” but in this country we kind of do, and we almost take pride in it. That is just the way things are; I don’t suppose that is going to change. If you have that, you really do need to try to focus on a relatively small number of genuine national priorities, and then you need an effective way to devolve power within the health service. That requires you to have a system of incentives and rules that gets the different bits of the health service. We should never, ever underestimate the sheer complexity of the health service. You need a set of rules and incentives that encourages people, at a local level, to work together in the interests of patients. Those are the two things you need: a smaller list of national priorities and an effective way of devolving to the health service, whether we are talking about places or systems. We can get into what structures might be the best at a local level later.

That is a helpful summary of your view of the system. Your assessment is that we currently have an overcentralised system with NHS England; what is your view of the potential change, with the assumption of some of those responsibilities—we do not know at what level—at the Department of Health and Social Care? Do you think that will improve centralisation, or get right the balance you want to see between discrete priorities and accountability for the system?

The merger itself is kind of largely irrelevant to that, partly because what we are essentially seeing is the making de jure of that which was already de facto, and partly because it is not really about the relationships in the centre; it is the relationship of the centre to the service beyond the centre that matters. Yes, there is and has been a growth of the duplication of functions, and there is real scope to reduce the headcount and size of the central operation without any loss to anybody, but unless you address the core issues of having a more manageable set of national priorities and an effective form of devolution, what happens at the centre is not the critical question.

Can I come in quickly on political accountability? If that is how they feel then, absolutely, that is how they feel, but I have to admit that I am a little confused. I have read Nick’s book about the history of Health and Care Secretaries, “Glaziers and window breakers”, and when politicians need to step in, they step in. Whether it is removing leaders of NHS organisations or recalibrating the system, it does not feel like political accountability has been absent, which is absolutely right, and politicians get the blame when things go wrong. I absolutely accept that there could have been friction—you have a political or policy objective that you want to achieve, and there is friction there—but I would be surprised if it was the case that politicians were trying to deliver change and the machine kept saying no. One of the things I keep coming back to is that classic James O’Brien question: in two years’ time, when NHS England is legally abolished, what announcements will you be able to make that you cannot make right now?

You have answered my last question, but that is great.

I agree with all of that, basically.

Matthew, that is a fair challenge to the question. If the crucial part is where the balance lies—empowering the system locally and then holding it to account on a discrete set of measures—what that is done by the centre today needs to stop? What functions of either DHSC, NHS England or other aspects of the centre do you think need to stop as part of this change?

Arguably, if you were being critical, you would say that the centre has not sorted out problems that it could and should have sorted out, but has interfered in things where it does not necessarily add a great deal of value. People in the service have frustrations around conflicting incentives—around the fact that the general direction of travel that the Secretary of State speaks of seems to be contradicted by the short-term imperatives of the system—and that quite basic things like information governance are not sorted out. There are things that the centre should do a bit better and a bit tighter. But on the other hand, the proliferation of things that the centre does has led to great frustration in the system. There is no question but that NHSE suffered from mini-empires growing up and a perplexing lack of joining up as a consequence. For example, one team of people would be working on the reform of urgent and emergency care, and a completely different group of people working on the future of primary care, even though primary care has an incredibly important role to play in trying to reduce unnecessary demand at A&E departments. We would see that over and over again. Often, I would meet or talk to people in NHSE and have to tell them about projects taking place in other parts of NHSE that clearly impinged on their role, but which they did not even know about.

This is a general point, but is there ever an aspect of healthcare that does not in some way deal with another aspect of healthcare? If you shift that responsibility locally, would we suddenly have an integrated health and care system where all parts of the system planned and worked together?

I spoke earlier about the inherent complexity, but I think the fact is that at a local level, you somewhat reduce that complexity because you are closer to the frontline. You can get the key individuals who, for example, need to develop a new approach to urgent emergency care, into one room together. It is always complex, but it is massively more complex if you are a long way away from it and you are trying to do something in 42 ICSs or with 200 different providers.

The question I would ask is, if you take all those points, why is primary legislation the answer to them? I don’t see that it is. The question is, why do we need primary legislation? You can take all the points that Matthew and others have made, and it is clear that the relationship between the Department and NHSE has not been good for some time—it has all become a bit sclerotic. There is overlap, but it is overlap around policy and operations. There is a lot of other stuff that NHS England does—such as IT or its improvement work—that has no overlap. It is just the policy and performance operation where it has become second-guessing and overlap, and that needs sorting out. The Secretary of State has been perfectly clear about that, and he is absolutely right about it. What does not follow from that is that you legislate to abolish NHS England, when, as far as I can tell, no one has any idea what will be put in its place.

I will make a quick point based on what Nick and Matthew said. I find it really hard to answer your question without knowing what the new architecture of the system looks like. To answer, “What is the centre going to stop doing?”, you need to know, what is no one going to do in the new NHS versus what is going to shift to ICBs, versus what is going to shift to provider collaboratives? At this point in time, we don’t know what the future state or size of those organisations will be.

To drive the point home slightly more: the Secretary of State said in Parliament that he could do most of this without the legislation; hose with longer memories will remember that that is exactly what Andrew Lansley said about his 2012 Act, and there are no fans for Andrew’s 2012 Act. He could have done most of it without legislation—he was absolutely right—so what is it that needs to be done that requires legislation? I don’t know the answer to that.

That is helpful. There are more questions than answers at this stage. I suppose we are trying to get a sense of what you would, ideally, want to see from the emerging reforms. It feels like you are saying, a slimmed down and more focused centre, and more emboldened local leadership, which we hear is the direction of travel. How do we ensure effective accountability of the local leaders? At the moment—we had a session earlier with representatives of patients—how do you hold your local leaders in this new system effectively to account for their performance, if they are being judged nationally, at least on a very slimmed-down set of measures by a more slim and focused centre?

I will go first one more time and then stop. To reiterate, my view would be that the critical determinant of whether this reorganisation improves things is whether the centre devolves. If the centre does not devolve, this reorganisation will not achieve anything. If it is a pathway to greater devolution, then we might look back on it and say that this was an important and positive moment. I want to be categorical about that. On accountability, different types of system need different types of accountability. What excited many people about the integrated care system model is that it offered the opportunity to balance top-down vertical accountability with greater local horizontal accountability. That is very important when you are addressing issues like population health and health inequalities. As I am sure the Committee has been told by many people, only 20% of our health outcomes are the result of what the NHS does. If you really want to improve population health, you need very close work not just between different parts of the health service, but with local government and others. One of my critiques of NHS England is that it was very focused on the silo accountability within the NHS, especially accountability of providers. That is kind of fine, although often there was duplication with regions and systems in that regard, but NHS England never really got its head around the idea that it had created organisations that needed also to have the scope for lateral accountability and to work with partners at the local level. Because NHSE does not have a brief to work beyond the NHS, whether it was neighbourhood working, place working or system working, it could not understand what its role was if local partners wanted to work with people outside the health service. That ought to improve with the Department, because the Department has responsibility for social care, so there is more of a link there.

My question was how, as a patient, do you hold local leadership to account in the new system? At the moment, patients tell us it is quite hard to navigate the health system. As we discussed, Ministers are seen as very accountable, but in your ideal model of a slimmed down centre, focused on a reduced number of things, how is the local dealt with? I infer that a trust-based, collaborative system will work better and deliver better outcomes, but if it does not—if there is local failure, or failure of local leadership—how is an emboldened local leadership held to account effectively?

I have thoughts on that, but I will pass over to someone else, because I keep going first.

Until you asked the question, I had not realised what it was I was struggling with: how do you get the current way of operating, holding to account and regulating working in a system where everything has shrunk—both the people being held to account and the people holding them to account? I guess part of the answer is: you can’t. You don’t have the same model of accountability. There was a time—it wasn’t all wine and roses—when Monitor was authorising foundation trusts. That relationship is very different. You have a very slimmed down number of metrics that demonstrate good progress and that are reported up nationally, and then you have a lot of local accountability through things like governors and members. That wasn’t universally working, but at least then you had a model of accountability that could work when there were far fewer people in the accountability chain. Finally, you also have other bodies, like the CQC, that play a hugely important role in assessing leadership and accountability systems.

We heard from the previous panel about some of the core national functions that should really be done nationally—healthcare planning, say, or digital capability, for which NHSE was responsible and which was subsumed into NHS Digital. Do you think those core functions and driving the rapid change we want in digital and workforce planning will be possible with the reduced staffing and resources that are planned?

There is a real issue about digital. It is one of the areas where there seems to be tension between the Secretary of State’s vision—from analogue to digital is one of his three big shifts—and where investment has gone in and capacity exists. Of all the issues that you have correctly identified, arguably the most concerning in terms of the vulnerability of the centre’s capacity is the digital space, where the opportunities are enormous but the capacity at the centre, which it could be argued was already insufficient, may now become even more insufficient. One of the challenges for the Secretary of State is to ask, how are you going to achieve your third shift—your analogue-to-digital shift—with the capacity you will now have at the centre to drive that?

Digital is one of the key issues. A lot of the talk about duplicated roles across NHS England and the Department of Health and Social Care is about policy and strategy, finance, HR and communications. Digital is one of those things where a lot of the history, the expertise and the leadership on the digital agenda was housed in two bodies: NHSX, which folded into the Transformation Directorate, and NHS Digital, which folded into NHSE. You have a first-order decision over what digital things you will do at the national level. Will digital leaders be subject to the same 50% cuts, and if they are, what will you segment? There is one way of segmenting, which is basically the hygiene stuff that makes sure that electronic prescriptions flow, and that there is an electronic digital record. What goes is some of what Matthew was talking about, such as the analogue-to-digital shift. Also—I will finish on this—there is a small number of teams on things like cyber-security and the rolling out of a new electronic procurement system. Those are low-frequency events for a healthcare system, so it makes sense to have a central team that does them. I am worried that digital is one of those areas that you look at and don’t immediately see flab to cut.

In terms of mass savings, it is not going to make a hell of a lot of difference. The figure being thrown around is £500 million, and that is the savings you will eventually get after redundancy costs for nearly 20,000 staff. In the NHS budget, that is a relatively small amount of money, so that is not going to be transformational.

If you cut enough heads, it is. Yes. Sorry, what was the second part of your question?

The answer is that we will know whether it makes a difference when we know what it is, because we genuinely don’t know what it is. Is the proposal just to roll NHS England into the Department wholesale, which it might be? You could do that; you have 42 ICBs, and there will be fewer ICBs by the end of this, because integrated care boards will have to merge with the scale of—

We will come back to the whole ICB thing a bit later.

Okay. In theory, I suppose, you could just roll it all into the Department. But the point has been made that the areas where there is overlap, and duplication that needs to be removed, are relatively limited, around finance, operations and policymaking. Are you going to take the improve programmes like GIRFT into the Department and put them there? Are you going to take all the IT into the Department and put it there? What about the NHS England regions, which do a fair amount of performance management? Will they be part of the Department, or will they stay with the NHS as a regional tier? In that case, you will have to legislate to create them and decide what they will do. Lots of stuff flows from this that is absolutely unclear. To answer the question whether it will make a positive difference, don’t know; can’t tell. That is not being obstructive—it is just: don’t know, can’t tell.

I think it is realistic to expect savings in the order of hundreds of millions recurrently. We don’t know what the exit scheme looks, but that is realistic after you get through that exit scheme. I think there are two constraints on how much you can go at. First, how much actual duplication is there? When you are bringing together one organisation of 4,500 people and another of 14,500 people, there is only so much duplication to go at overall.

I think it is correct for some functions, but it is simply illogical to say that two organisations are that duplicative when they have that many different functions and that different a headcount. The other bit on how realistic it is, is that there are some functions that NHS England does that are in statute, so they must be done by someone somewhere. Again, there will be that two-year transition period. I want to come back to your positive angle on whether it will make a difference. I think it can make a difference. Like Matthew, with unique teams that work on capital locations policy in NHS England and the Department of Health, I can absolutely see the benefits of having one coherent view of what sort of health and care infrastructure you want for the future, how you are going to fund that and how you are going to get that money out to the system.

Any of us who has worked in organisations that have been through major reorganisations knows that they are weapons of mass distraction. All your workforce are worrying about keeping their jobs, and that is not the best frame of mind to be in for decision making. If you look at the literature around reorganisations, one of the things that makes them more likely to succeed is a really clear account of the direction that they are going, which refers in a sense to Nick’s point. That is why it needs to be connected to a commitment in the centre. Hopefully, what we will see articulated in the 10-year plan is not to devolve but to empower. Yes, there are areas of duplication. I think there are thousands of people in the communication and strategy teams, for example. So there are areas where it is pretty clear that if you are willing to not do lots of low-value things you can save money. For example, let us take improvement, which is an area that Nick said has to be done in the centre—or that is done in the centre, and maybe that is a good thing. The NHSE’s model of improvement tends to be, “We are going to define what needs to be improved, we are going to define how you are going to improve it, and then we are going to censure you if you don’t do it in the way we say you should.” I think an approach to improvement should be much more empowering. What the centre should be doing is saying, “Look, there are all sorts of people interested in improvement. There is the NHS Confederation, NHS providers, royal colleges and the think-tanks. Actually, we need to create a community of people who are interested in improving. We will sit in the middle of this and say what we think the national priorities are, but what we are trying to do is to empower and enable a culture of improvement rather than do it all ourselves.” I think if you had that kind of approach, it would be one of the ways that this reorganisation would not only save money but actually make people in the health service a lot happier.

Yes, but only because I am an optimist. There are no empirical grounds for it; it is just a reflection of my character.

I don’t know.

As they said, I don’t know.

I think that if you are working on the frontline, most of this feels pretty irrelevant to you, to be frank. What matters to you, if you are working in a hospital, mental health trust or primary care, is that the financial context for the NHS next year with the comprehensive spending review—and one assumes this will be confirmed in today’s statement—is going to be the tightest financial position that the health service has found itself in. Some of the members that I represent are pursuing efficiency targets of 6%, 7%, 8%. That is not an efficiency target; it is a requirement to cut back on and reconfigure services—to do some quite difficult things. That has been forgotten in the debate over the last few days, which I completely understand, but the real challenge out on the frontline of the health service is how do we do more with less. That is a requirement facing almost every part of the health service.

A clear definition from Ministers of what relationship they want with the NHS and a clear devolution down the line to make sure that local people can use their own initiative. Also, clear lines of accountability and with that a clear definition of what integrated care boards are for. At the moment they have at least two jobs and there are mixed messages. At one level it is about the integrating of care, improvement of the neighbourhood and place, working better with local government and the public health agenda, all that sort of stuff. The other question is are ICBs, in fact, responsible for the performance management of the organisations within them? For quite some time there have been differing views among ICB leaders about that and mixed signals coming from the centre about what it thinks is the most important. The most recent view was that they should not do the performance management, and that NHS England should. But since then, we have announced that we are abolishing NHS England, so some clarity on that would help.

On the positive side, you will reduce some duplication, so the centre will feel a bit more coherent. Also, there is simply no way you can have the same model of command and control and top-down management with so few people. Whether you want it or not, you will start trusting, listening and enabling local leaders to get on with their jobs.

I agree with all that, but will also name an elephant that is not yet in the room, which is that this bringing together in the Department should be something that assists in the notion of mission-driven Government. After all, health is one of the Government’s five missions. Unfortunately, things have gone very quiet when it comes to the health mission. A lot of us were quite excited by that idea. Going back to what I said earlier, only 20% of health outcomes reflect what the NHS does, and we need a much more joined up, whole-Government approach to a whole variety of issues, from economic inactivity to addressing health inequalities. This change could have been an opportunity to restart that focus on a more holistic approach to health, but that seems to have gone very quiet recently.

It is very good to see all of the witnesses. Nicolas, I remember “The Five Giants” and the fantastic work you have done making the absolutely unclear a little bit clearer. I have always enjoyed it. Before we carry on, I want to throw in a specific point raised with me by a very senior consultant. At the moment we have about 80 highly-specialised national services which are commissioned and run out of NHS England, such as the DNA repair service and pancreas transplantation, the sort of things that affect 500 or fewer people a year. We have discussed how you are not quite clear about where things are going, but would you expect that they would be moved and transplanted into the Department of Health and Social Care, or might it just fall apart? I wonder if you have an insight on this; perhaps it is a question for Matthew.

Someone has to do that. More specialist commissioning is being devolved to ICS level, which I agree with. As you say, certain functions will need to be approached from a regional or national level. That speaks to a point we have all made, which is that you can move bits of the organisation together, but there are certain functions that still have to be done and one of the things you have got to watch out for in a reorganisation is that important things do not just get forgotten in the general shift. That is really important and organisations like us have got an important role in lobbying Government around some of these things and saying, “In all this change, do not forget that somebody has to do this.” Siva’s point about cyber security is a really good example of that. Cyber security is a massive issue. It is a small and vital team. If people took their eye off the ball for six months, the consequences could be enormous.

I am really glad you asked the question, because part of this delegation of services towards ICBs was predicated on a capability assessment, where they looked at lots of things, but one of them was commissioning infrastructure. Now we are at a point where specialised commissioning is going to be delegated from a body that is going to be abolished to bodies that are looking at 50% reductions to their running costs. It is a really good question to probe around. Are we still assured that this is a safe transfer of responsibilities?

I am not just talking about specialised commissioning, which is about 150 different conditions, but about highly specialised, which is about 80 of those. If you are treating fewer than 500 people a year for a very complex disease, how can you devolve that locally?

To go back to the theme, nobody knows. Whatever operating model you have, there will always be some things that are so highly specialised that you do them nationally. To a certain extent, I think you can be agnostic about whether that is NHS England or the Department of Health. It is about that other tier, which is pretty substantial, where you have to ask where it goes.

Okay. I am not going to ask you that, Nick; I am going to ask you something else, because I guess you are just going to say what Siva said. You all have huge experience, which is fascinating to listen to. One of the biggest challenges is doing more with less. We always talk about NHS 10-year plans. However, we have talked about how we cannot do what needs to happen without local authorities—there is a small sweepstake among my colleagues on how quickly and how often I will mention local authorities, so that is today’s contribution. How can you talk about the NHS 10-year plan when you are not talking about a 10-year plan for the NHS and local authorities, which cover housing, social care and the voluntary sector? Are we right in always talking about new models for the NHS? Should we not be talking about how we can support different relationships at a local level? At the end of the day, is it not the relationships between the different groupings that deliver the better care?

The short answer is that you cannot and should not talk about the NHS on its own without looking at social care and local government. Many of you have experience of local government, such as being on health and care boards. It is clear that the intention behind the integrated care systems was to get closer working between the NHS and local government. You could argue that the current Act does not really help much with that, because we have two separate boards trying to do what was originally done by one. Of course, you need both. We keep talking about the elephant in the room. Rather than having primary legislation to abolish NHS England, it would be nice to have something substantive on the reform of social care, which would enable the NHS to perform better. No, you should not be talking about just the NHS when you are looking at a 10-year plan.

I think the point about relationships is absolutely right. As I go around the country looking at systems that have made progress, and at ones that have made less progress, the key variable is very often the quality of relationships between local leaders. You cannot make people get on, but what you can do is try to remove the incentives that tend to drive people apart. As Patricia Hewitt argued in the report that she wrote 18 months ago, we created integrated care systems but we never really created the circumstances in which they could flourish. As Nick said, this issue of performance oversight has been difficult. In some systems, providers and systems work very effectively together. In others, providers have clearly felt a lack of confidence in the system or have not really wanted to have system oversight, or they have said, “Well, we have oversight from the system, oversight from the region, oversight from the centre, and it is overkill.” I think we have been a bit half-hearted about creating the right incentives, which would encourage people to have those kinds of relationships. Actually, that is critical to the sustainability of the health service.

We have amazing doctors and amazing nurses working in the NHS, but do they genuinely think, in their guts, that there is value to working collaboratively and almost on an authentically equal basis with people in social care, the voluntary sector and others? Will they not always say, “We’ll let you work with us”, without really understanding the other parts of the system that need to work with them on a much more equal basis? Is it always going to be the NHS de haut en bas and everyone else can fill the little gaps that it gives them? If that is the case, will we ever achieve better healthcare in this country?

That is a brilliant question. It varies enormously from place to place. I speak to provider leaders and ask, “How is the system?” and they say, “Well, I am the system.” We are the system, and we work together. I could point you to a part of the country where certain parts of the provider landscape have agreed to put money into a central pot on the basis that the acute provider agrees to reduce its capacity over time as part of the leftward shift. That is really impressive, and it will drive real change. However, I could take you to other areas where the providers and the system do not get on effectively at all. There can be a tendency among the acute providers to say, “Look, the only solution to anything is for us to take over everything” and “Until we take over everything, nothing will work.” It varies from place to place.

My quick observation is that I think a lot of that behaviour has been modelled out. Over my career, I can remember that it was much more, “Look, we have just got to do our job. Our job is to run a good hospital, and that is it. It is not my problem what happens.” A lot of things have changed—partly the reality. If you could be the best-run hospital in the world, it is not going to be enough. You are not going to achieve financial balance unless you do things. We have all seen the same thing: I never thought I would see an acute finance director say, “I am going to try to free up a portion of my budget to support what would have been covered by the disabled facilities grant, because I know that is what is going to stop people requiring my services.” I think we are getting there but, like Matthew said, it is slowly being modelled out, while still being spotty and variable. It is not the MO at the moment.

I agree with that. It is better than it was; it is not perfect.

I am going to leave it there. Thank you.

On ICBs, we had the announcement about the abolition of NHS England, but in a phone call on the same day—I think Matthew was part of that phone call—ICBs were told that they needed to cut their running costs by 50%. Off the back of that announcement, where are they and what more information is there? Is there any more that we have somehow missed?

In the next few weeks, I think we will hear some more thoughts from the centre about how that 50% cut will be achieved. I am always uncomfortable about 50%, because it is just arbitrary—

Yes, it feels like a made-up number.

I think it was 47.3%—someone had actually worked it out. But 50% is a bit like the 50% higher education target many years ago—a bit plucked from the air. Nevertheless, we are where we are. We in the NHS Confederation represent integrated care systems. After a bit of gnashing of teeth and tearing out of hair, we are immediately focused on, “Okay, what does this mean?” At the heart of that question is, what is meant by strategic commissioning? The message is that that is where the core focus is. It is important to remember that ICSs do lots of other things—some bits of service delivery and other things—and that is the point we have been making about the centre: do not forget that there are discrete things that somebody has to do, whatever change is pushed forward. In terms of the core role, however, we need to understand what strategic commissioning means—again, I understand clarification about that will come over the next few weeks. Then we have to think about building the capability for strategic commissioning, because most people who are longer in the tooth than me in terms of their health service experience—not in terms of their actual age, which I do not want to emphasise—would say that commissioning capacity has declined in the health service, probably, and has to be rebuilt. We also have to answer some other questions. At the moment, in the narrative from the centre, strategic commissioning is good, provider oversight is bad. But how do you do commissioning without oversight? You cannot just say to people, “Look, this is what you have to do, and we will come back in a year and see if you have done it.” You have to make sure that it is being done, and you have to intervene when it is not being done, particularly if what you are commissioning—this is critical—is integrated solutions, where you are commissioning things that require people to work effectively together. That is another thing to which we need to see the answer.

Do you see any benefit in the local government reorganisation that is happening in parallel to all this?

I want to say no, but I simply mean—

Not really.

One day, yes, but at the moment we have both sides of the equation facing unbelievable amounts of churn and difficulty. It is even harder for us to engage our local government colleagues when they, too, are facing a set of existential questions.

It is worth pointing out that ICBs have already had a 30% cut in staff, which they only finished sorting out at the end of last year, and now they have another 50%. I do not know this for a fact—maybe Matthew does—but my guess is that much of that cut came on the commissioning side, because it was the effect of rolling CCGs into ICBs long ago. Therefore, there are fewer people to do commissioning—that is not necessarily a comment on the quality of the commissioning, but there are fewer people to do it. If strategic commissioning is going to happen, it comes back to the fact that where the 50% cut falls depends on what you want ICBs to do. We have already talked about that. If it is strategic commissioning, are you therefore going to cut on the performance oversight bit, even though—Matthew has just made the point—you need a bit of both. You certainly need some of that for it to work well.

In my local ICB, it was the place-based team that went—so the team that was meant to be delivering neighbourhood health ended up going as part of the 30% cuts. If you are looking to make 50% cuts, my concern is that, across other ICBs, there are more people and more places. Do you share that concern?

That defeats the “integrated” in the titles of both an ICS and an ICB.

I share your concern. Building a new neighbourhood integrated team is not one of the statutory functions of a CCG, so it could be one of the first things to go. The ICBs are a good example of how we know what is being destroyed, but we do not yet know what kind of health system is being created. The last time there were 30% cuts, the narrative was to squish ICBs and what they are meant to be doing, make them more focused on strategic commissioning while oversight goes to a region, and then a lot more of the day-to-day commissioning could go to a provider collaborative. If all of that is being squeezed at the same time, the question becomes: how do you want the health system to work in the future? At the moment, probably not for the last time, we do not know.

Matthew, do you have any sense, from your ear to the ground, of what is the most likely place in integrated care systems to go as they look at where they can make redundancies?

We await further clarity on that from the centre. In the end, even when you have to make a 50% cut, you want form to follow function, so we need greater clarity about function. Siva is right: the relationship between different tiers will obviously be important, and the operating model is clearly important. A major part of the 10-year plan will be about, particularly, the question of how you shift resources out of hospital, and the way in which you organise out-of-hospital care. That boils down to another question: ultimately, the only way you achieve the kind of shifts that Wes Streeting is talking about is if the acute sector consumes a smaller proportion of overall expenditure—as I understand it, at the moment we are going in the opposite direction. The question is: who will then be responsible for trying to ensure different models of care and different pathways to enable that shift to take place? My own view is that it does not really matter so long as you are really clear about the destination you want to reach—so you are really clear, and the incentives are right, and the national rules are clear that you are going to reduce the proportion of expenditure that goes through acutes. So long as you are clear about the direction you want to take, it does not really matter whether it is acutes that lead and commission primary, community and social care to provide out-of-hospital services, or—as in, for example, east Birmingham—primary, community and social care that, in a sense, commission a diminishing resource from acutes. The role of ICSs is to sit above that—which is largely happening at a place level, sometimes led by acutes and sometimes led at more of a neighbourhood level—to ensure that it is actually happening, and to take care of those things that fall between organisations, however well integrated you are.

That is helpful. We also look forward to getting some clarity about the direction. We have not talked much about NHS regional teams—is there anything worth saving there?

Yes.

Yes. There are some things, such as the commissioning of an ambulance service, for which it makes sense. But again, you have a choice. You could group together ICBs, but I will take one step back. Our entire system is predicated on gearing ratios. You have one national body and between four and 10 regions. That makes sense if you have somewhere between 50 and 300 local commissioners. If ICBs start sharing roles and you end up with only 20 to 25 functional ICBs, there is a question about whether you need a regional presence. But, to the extent that you do, things like ambulance commissioning and some specialised commissioning make sense on that sort of geographical footprint.

Perhaps I can make a point about tiers. A lot of people in the health service will complain about the number of tiers. I would say it is really about how the tier works. If it is an enabling tier, it does not really matter. If you are in a system and the providers feel they are an intrinsic part of the system, they will not describe it as a tier because it is just a place in which they work things out together. A while ago, the NHS Confederation published a report on the north-east region, which explicitly had a “four plus one” model in which the regional chief executive, the regional director, was primus inter pares with the four ICS chief executives, and they worked together as a team. In that context, the region does not feel like an overseeing tier; it feels like a useful convening space for a whole variety of different things like specialist commissioning, learning from each other, addressing performance variation and sharing talent. For me, the critical question about regions is: are regions a tier, or are they a convening space for the systems that work with them? If it is the latter, they have a significant and useful role.

At the moment they have a pretty large accountability role, particularly regarding their local ICBs. Would you suggest that is one of the things not to save?

They undertake that role in very different ways in different regions. You can have accountability that is about learning, and you can have accountability that is about enforcing. I think the former works better than the latter.

Nick, do you have anything to add?

No, I agree with all of that. There are things that the regions do that need to be done somewhere. Ever since the foundation of the NHS, there has been some form of regional tier, and possibly for good reason—it is a very large organisation. If you ended up with 25 or 30 ICBs, you might not want some of the performance management accountability stuff that currently sits in the regions. You might not need a region to do that, but you would then need the ICBs to be doing that themselves. You have to be clear about what you want your ICBs to do, and we are not.

Nick, you are the expert on the last large reorganisation. It is fair to say that, while we cannot predict the future based on what happened in the past, we would be fools not at least to take note. As broad principles, what lessons do you think it is worth us all bearing in mind as we embark on this brand-new path ahead of us?

I hate to sound like a broken record, but I would seriously ask why we need primary legislation to achieve this.

You keep talking about primary legislation. Tell me why that is the thing you want us to focus on.

To quote the Secretary of State himself, “I could spend a hell of a lot of time in Parliament and a hell of a lot of taxpayers’ money changing some job titles, TUPEing over staff”—back into the Department—“and changing some email addresses and not make a single difference to the patient interest.” That is the risk when you start legislating, because it is not just about rolling NHSE back into the Department. You will have to define a whole lot of things, some of which are already statutorily defined and some of which are not. You can change some of the relationships without the need for legislation. It seems to me that the crucial question Wes Streeting needs to answer is what he cannot do without legislation. When that has been explained, is it a sufficient gain to make it worth while to go through the inevitable disruption that legislation will cause?

I know the Institute for Government and the King’s Fund have done work on previous reorganisations, both in the NHS and in other Departments. What lessons can we learn from them? How can this go smoother? How can we make this the best reorganisation there ever was? What does that look like?

I suppose the answer is that you need to be very clear about exactly what it is you are trying to achieve and what you are putting in place. Andrew Lansley was entirely clear about what he wanted to achieve.

That is it. He had a very clear vision, and look where it ended up.

It turned out to be unworkable. It was completely subverted.

Clarity clearly is not enough.

Well, clarity on the things you genuinely believe can be made to work.

I agree. If you are going to do it well, have a very clear story about your rationale for why you are doing it, have a positive vision not only of what you are destroying but of what you hope to create, and be very aware of the impact of your decision. Going back to the earlier panels, can you articulate what impact this is going to have on the voluntary sector, which might now be thinking, “Who do I speak to? How will decisions be made in the new system?”? You need to treat people well while you are doing it—I am not trying to be facetious—because there is a good chance that you will be re-employing them at some point in the future. You need to listen to the people who are telling you that this is perhaps not a good idea, and you need to have a good argument in response. Finally, be very clear that this is your big thing. Whether you like it or not, if you are merging the biggest quango we have in this country into a Department of State, that is going to be your big thing, so make sure you are resourced to do it well.

On my visit yesterday, Nottingham ICB raised the concern that it cannot see how social care can be sorted out, on anywhere near the same scale, at the same time as this is happening. Yes, we have the Casey review, which says it will propose reforms in the next year and we will see positive progress on social care. Does it follow from what you are saying that it could be crowded out?

On the positive side, there are bits of the Department of Health and Social Care that could be relatively hermetically sealed from this. There is no massive adult social care reform team in NHS England that is going to be disrupted. There is currently no permanent secretary of the Department of Health and Social Care, but what would have been the No. 1 thing on their to-do list? It would have been either: get out of the operational hole we are in; pull off the biggest set of healthcare reforms we have had in a generation; or the Casey review. Now I guess that the biggest thing on their to-do list would be to manage this massive machinery of government change well. So, yes, I think there will be some distraction and some opportunity cost.

In the Government’s defence, they would say that they have come to this shift because they feel they have been reasonably clear on their priorities, but that that clarity does not seem to have translated into action by NHSE, which is potentially a reflection of the fact that NHSE has become such a leviathan that it was not really capable of directing its attention in the right kind of way. I think this is a response to what the Secretary of State and others experienced of the capacity of NHSE to focus in the way they wanted. I entirely endorse Siva and Nick’s points about the purpose of this. In the end, the Secretary of State is seeking to recover and reform services in the tightest financial context that the NHS has faced. What is his fundamental model of change in relation to that? The Secretary of State talked earlier this week about social care being part of the 10-year plan and wanting to do something there. If you integrate social care more effectively at a place level, and if you see the connections between effective social care and reducing demand through the front door of the health service by getting people out of hospital more quickly, you could potentially create a benign feedback loop whereby you start to see social care investment more than paying for itself in the impact it has on health demand, but you have to design that incredibly effectively at a local level.

Given that we are about to hear the spring statement, we should probably end there. We could have had hours more with all three panels. I thank you all for coming at such short notice.