Keynote: Sir James Mackey, Chief Executive, NHS England

Good to see you all today. There’s a lot of people here as usual and it’s a really pivotal time for the NHS.

So that no one underestimates the sort of things that everybody is having to deal with and what might be coming in the next few weeks and months, I just wanted to have a conversation going over the ground of how we’ve ended up where we are.

At about 1pm the Chancellor will announce the Spending Review and I can’t clearly tell you what’s in that for the NHS, but I’ll explain as much as I can. And we’ve got the 10 year plan coming as well. And then I’ve got just a few key messages picking up on things that Penny and Victor have already said about what we’re actually trying to do, how we’re trying to focus on key priorities for this next period as well. And leave you with some thoughts to stimulate the conversation and questions.

But first of all, it’s been said already – it’s been a tricky few months by any standard. The NHS got really used to turbulent times, lots of change, lots of complexity; there were a few weeks where an awful lot of things happened at extreme pace, with lots of shocks.

The abolition of NHS England, the headcount reduction, where we were with the planning round, that worry about the bond markets, you know, etcetera, etcetera. An awful lot of things happened in a rush. And not in an ideal way. So none of us would have set it out that way or had the ability to to think ahead and plan it all properly and communicate it all properly. But it was a manifestation of an extreme situation.

This is a big moment for the country, but also for the NHS. Colleagues have been involved in a lot of the discussions since then. So from that big first chief exec session that we had in mid-March, and then how that’s flowed through into other actions, the first thing that we really needed to get given where we were with the public and with political colleagues was to get a leadership response, to ensure the NHS could actually understand the circumstances that we’re in.

Honestly, the leadership response has been absolutely fantastic. We are really grateful for the way that people responded in very, very difficult times to start confronting difficult issues and then make a start. No one assumes it’s easy and no one should ever assume it’s finished. It’s all a work in progress. So what you’ve heard from Penny, what you’ll hear from me and through the next couple of days, will be set in that context, that none of us have got all the right answers. It’s really, it’s a really tricky period. We’re trying to work things out.

It is a combination of things. So you’ve seen a lot of it in the media over recent days, and there will be an awful lot in the next 24-48 hours, and the NHS has done really well relative to other parts of the public sector. But we all know it’s never enough because of the scale of advancement.

So we’re always going to be in a world where we want more money. But I think everyone’s starting to accept and understand that we’ve got what the country can afford to give us and we really need to get better value for that money. It is broadly the equivalent of the GDP of Portugal. So it’s a huge amount of money by any standards. So we all need to stay really focused on that.

It’s a huge amount and the government has done us a really good turn compared to other parts of the public sector, but it’s not going to allow us all to take our feet off the pedal and just run loose and do what we want to do in this next period. We’ve still got an awful lot of difficult things to do.

When you see the 10 year plan. And we’re just about to start the process with government. These things always dilute as you go through the process – you get more and more frustrated as you go on, and it gets challenged and it gets sorted and diluted. It is still really, really impressive. So there are still bits where you’ll read and you’ll get lots of energy from.

Penny has already talked about neighbourhood care and I think that part of the plan is still a really big stand out for me. It really stimulated for me all the things that we were trying to do in the North East 10 years ago, 15 years ago, 20 years ago and have been knocked off course a little bit in this last period. The focus on quality again, I think it’s really welcome and we have lost our way a little bit coming out of Covid.

So, you will hopefully see that, read it and think thank God for that. This is for the first time in quite a long time a bit of a stretch, a bit of ambition – there’s lots of stuff in there that we really want to go out and deliver.

Let’s not turn that into something that becomes a tribal thing where we all argue about who’s in charge of what. You’ll have an operating model that allows us to deliver, but hopefully it will release a lot of energy for us all in the next few years.

Coming back to this spending review and the financial position that we’ve got – we are having to work through this quite carefully as well the in last couple of weeks about what’s affordable in that context, how to convince Treasury what we can do, and what we say we’re going to do, but also not bust the bank. So that’s a very active discussion currently so that when it’s published, we can go as hard as we can on the things that we’re very clear about. We need to do that through medium term planning and  there are things that we’ve already committed to.

That is all tricky enough as it is without the thing that I’ve mentioned lots of times. I’m not going to apologise for it, but the really big shock in all of this period for me was that British Social Attitude survey where we all thought we’d bottomed out last year and it’s got a lot worse this year. It’s even got a lot worse where things have improved. So there’s a sign in that about our disconnect with the population.

That is a really big problem for us all. If we lose or break that materially, we are in really big trouble. Throughout the next 48 hours, we’ll know what the spending review means and then what the 10 year plan means. Let’s all remember that the NHS is owned by the population. We’re all part of that. It’s not something we own and as NHS England, we’ve got to cherish that bond as much as we can and deliver the population needs within the resources available.

I just want to explain in terms of how and what we’re actually all trying to do – certainly at the centre and with the leadership community, there are three main things that we’ve been really trying to focus on. Again, they are work in progress, they’re not all finished. They’ll develop through this year and hopefully we’ll build trust and confidence in each other that these things are all real and we’ll work together on them. And the first bit is trying to reset how we work together.

So that means moving away from the over-prescription centrally, the over-control labyrinthine approval processes. All of the things that were naturally built and grown over time – these things are a bit cyclical, partly response to COVID, partly response to industrial action and the financial pressures. There’s not much point in trying to explain it all, but we’ve ended up in a very complicated system with far too much over-control and over-prescription. So we’re trying to reset that so we can trust local leaders more and get much more focused on doing only what the centre should do.

I’ve spoken here in a previous life and talked about similar things. These are hard things to do, but there’s a very, very strong intent from our perspective to work with colleagues, flatten the hierarchy, work alongside each other and change the relationship with each other. We have to pick up pace in all of this. So we need a different operating model that trusts people, with clear rules and allows people to get ahead of the game and get on with what you all want to do.

Secondly, one of the big things we can do at a national level is create the conditions for success. Again, I think Penny mentioned this earlier on. We can create expectations, financial mechanisms, allocation policy, national service frameworks that may be in the 10 Year Plan to allow you to do what you need to do and what you know is necessary in your local system.

Sometimes something will have to happen right across the country. We’ll try and avoid that as much as we can so that we are actively trying to make it easier to get where we need to be. The complicated approval systems, the over-regulation, the over-prescription, because we all know that we’ve got lots of complexity in our communities and even two neighbourhoods next door to each other can have really different demographics, really different drivers, really different services.

So that means being more focused on outcomes and results rather than inputs. There’s not a week that goes by without a chief executive or another colleague getting in touch with me to say, “I know you’ve said this, but here’s an e-mail” or “here’s a report that says I’ve got to do this certain thing.” Every time that happens, I’m breaking it. We’re going back and saying that’s not what we’re doing now. We’re focusing on outcomes rather than inputs.

So, we all need to stick together on that and again, it’s a job that we’ll have to do together as this year goes on, hopefully you’ll see from the UEC plan led by Sarah-Jane, released last week. We are taking a risk of trusting people to work things out to suit your local circumstances with clear expectation of what we need to deliver. We’ll give you a bit of room for manoeuvre.

The third bit that really now desperately need is to release the ambition that we all know exists all over the NHS. But it’s felt like it’s been depressed and compressed over recent years, because of the financial issues and industrial action, Covid.

It has felt like we’re all losing our ambition, we’re losing the push, we’re losing the ability to win the bid. When you’re in a national role, you quite quickly get conditioned to think that the NHS has lost all these things and isn’t doing the things that we’re about to tell you all to do.

The ambition is actually already there in lots of places, but we really need more energy on that. And if we get the conditions right, we’ll work together better and differently. We have to stretch ourselves now, and let rip a little bit to try and deliver the scale of change, the pace of change and the impact of change that we really need to pull off.

Going back to that earlier point about the British Social Attitude survey – that’s something we can do a bit nationally and we can try to not constrain you with over-prescriptive planning guidance. If there is more you can do then I’d go for it. Absolutely go for it.

What we really want in all this is for people to get out so far in front of us, at the centre, that we’re struggling to keep up with you. That you are asking us. So that means rapidly changing your role, creating a new freedom, creating a new flexibility – so we can’t keep up with you. That’s the challenge for today. Let’s all go for this and go for it together. That’s a lovely problem that we want to have if we’re really going to deliver what we want in all of this, over the next few years.

None of us think this is easy. We’re all talking about transformation all the time. We’re all talking about trying to avoid incremental change year on year. That’s one or 2%. There are a couple of points really into that. In our last NHS England board, one of our great non-executive directors made a challenge when we’re talking about productivity – we had an energised conversation about productivity! What a bunch of geeks in NHS England!  But he made the point, coming from a technology world, that whilst we’re all talking about one or two or maybe 3% movement year on year, his organisation is deploying technology that will get many times greater productivity benefit from that because they’re just tearing the model up.

They’re adopting a completely different model and we have done that before. We’ve done it in the Covid period, which we can all remember – still vividly I’m sure. And I think this was the Nightingale facility in this area, but it is quite relevant today.

A lot of you said to me, how do I create that “Covid feeling” again where we have less prescription, we have less regulatory oversight, we have more ability to innovate. It was, to be honest, a single issue. We’re good at dealing with single issue problems, but we now have to open that up and create the circumstances whereby we can deliver what we want in the years ahead.

Most big clinical advances have happened in extremis, they have happened in wars, have happened during financial crises or have happened during pandemics – steroids, antibiotics, surgical practise, trauma care, PTSD management, vaccines – all these things happened in extreme times and we are in extreme times, there’s no doubt about that. We are in a messy place.

But if we do the things that we’ve talked about, we reset our work together, work more actively together in a more interactive way, we’ll be more effective in creating the conditions for change so that you are able to do what you want and need to do.

And together we release the ambition and energy that’s out there in our clinical and operational teams, so that managers get alongside clinical teams and work out how to tear up all the frustrations that we’ve got about the technology that doesn’t work, the multiple touch points with patients, all the duplication that we all have and we all live with every day. And it drives you mad, especially if you’re in it as a patient or as a relative.

Now is the time to tear it up, but we need to do it together. So thanks for what you’re doing. And best of luck.