Speaker3: [00:00:00] But I would welcome in a number of areas the nanny state. In all metrics, the NHS has been improving. Not enough. We've got a long way to go. I think the NHS app has the potential to be revolutionary. It's the fact that society is becoming sicker and therefore is more demanding. Because if you have the relevant experience and talent, we need you.

Speaker2: [00:00:22] Voices of Care, the healthcare podcast.

Speaker1: [00:00:25] Richard, I'm delighted to welcome you to Voices of Care and thank you for giving us your time.

Speaker3: [00:00:30] Thank you for asking me, Suhail.

Speaker1: [00:00:31] So you're steeped in the NHS, no question. Now, you mentioned Lord Darzi's report, and I think we should come to that. That's obviously published in September, and coincided with the performance stats for July, which showed elective waiting lists, etc.. And Darzi, I think the thing that people have taken away was saying that the NHS is in a critical condition, but its vital signs are strong. What do you say to that?

Speaker3: [00:00:57] Well, first of all, I think I'm, I think it's a really good report. And, personally, but also I know that the board and the executives were delighted that the government had asked our Darzi to do this review. We think it's a very sensible step to sort of give a it's almost like a balance sheet date picture of what is the state of the NHS today? Because without that fact base, it's very difficult then to determine what priorities should be invested in. To reform and transform and improve the performance of the NHS. So we welcomed it. In terms of critical condition and then vital signs, the critical condition, I think it comes basically from one of the key points that Ara raised, which actually has been a multi-year period of underinvestment in capital. He also clearly talked about, which was very helpful to bring the narrative up around the fact that society is more demanding. It's a sicker society, whether it's surgery, mental health or obesity, challenges of obesity. So we face significant greater demand. He talked about the pandemic and the impact of the pandemic. And interestingly, the consequence, for instance, for waiting lists and electives. So the decisions made as government and the health service battled with that pandemic. And this other theme I think was which was very strong, is actually our mutual interrelationship with social care and the challenges in social care and how we work with social care across the boundary. So there are real challenges. I'll just give you a couple of stats to think about where we are. Comparatively, in terms of our physical capacity to offer service. So if I look at the position of beds in our secondary sector. I think there were about 142,000 beds in the year 2000, and it was 122,000 in 2010. And today it's about 97,000.

Speaker1: [00:03:07] A dramatic fall.

Speaker3: [00:03:07] So you've seen a significant fall in that secondary bed capacity. And it's been much managed by reducing length of stay and improving efficiencies. But at heart, when the population is 15% greater, larger, and older, and therefore more co-morbidities, there is a real physical capacity problem. It extends to diagnostics. So if you look at our MRI, CT echo diagnostic capacity, the NHS in England has less than half the average diagnostic capacity for the OECD. So you've got real challenges in physical estate and you've got real challenges in diagnostics. So, we need to invest behind those. And we have been and we are doing. In terms of vital signs being strong. They are. And I pay tribute always actually whenever I go around the systems, just the sheer hard work of the people in the NHS. But we are today providing absolute record levels of healthcare and I can give you stats around that would help if you'd like to hear.

Speaker1: [00:04:12] No, I'd like, I would like to come on to that, but I think just to slightly expand on what you just said, because it's really important, because I think in his letter when he delivered his report, Darzi says it very clearly. He says that, you know, the demands placed on the health service are from a society in distress. And I think you've gone on record as highlighting a couple of things. Behavioural changes in society, I think gambling, obesity, these all don't come to mind necessarily when we're talking about the NHS, but they have an impact on terms of the demand.

Speaker3: [00:04:41] Well they do. And so, you know, I think we've just opened our 15th gambling centre to deal with gambling addiction. We've opened our 30th specialist centre looking after obese children. And so as society gets sicker, the health service has to deal with whatever the shape of that society is. 28% of the population, the adult population is obese. And we know that it triggers at least 13 cancers musculoskeletal, cardiovascular, diabetes two. And so actually obesity is a sort of a real scourge on the health of the nation, and yet the health service has to deal with that, in spite of the fact that obesity levels and the consequences have grown really quite quickly over the last couple of decades. And you talk gambling, social media. It's very interesting. I think it was only last week that in Australia they're thinking about bringing in regulation restriction on social media aimed at either under 16 or under 14, because actually, I don't know, I'm not a scientist, I'm not in this space. But I would believe it. It is plausible that social media is definitely contributing to some of the mental health issues that we're seeing surging in our younger people.

Speaker1: [00:05:55] And I think that you talked about the other bigger picture. I find it remarkable. You mentioned Covid. I think we're only a few months away from the memorial. The first death in the UK was February 2020. It seems remarkable. And there's still a recovery. I think it's a five year recovery. So this Covid imposition in terms of resources had a big impact. So you can't unpick that in a very short space of time.

Speaker3: [00:06:22] I think that's right. And Amanda Pritchard, um, our CEO has always said actually that it will take a number of years, I think 4 or 5 years to recover from Covid. And I think that's right. I mean, if you look at waiting lists, currently about 7.5 million, I mean, there's a sort of a natural level of waiting lists that people don't really think about, which is just if you were going a constitutional standards, which we're not meeting. I do understand that. The natural waiting list is probably high three. So 3.6, 3.7 million. The significant increase in the waiting list was coming before Covid before the pandemic. It clearly was. I think there were 4.4 million people on the waiting list as the pandemic struck. But then actually, the way the health service had to deal with that singular issue of Covid meant, actually that there were many more delays. Days. And yet last year, the NHS performed, I think it was 17.5 million interventions, treatments, surgeries that would count to the waiting list calculation. So 17.5 million elective interventions, it's over 25% more than a decade ago in terms of the number of those procedures that we were doing. So 25% more than ten years before. But that 17.5 million was to hold that waiting list flat. So we need to accelerate further to cut that waiting list. 

Speaker1: [00:07:44] And now looking at some of the performance you talked about, Darzi has pointed out, as you said, it's a welcome report. There's lots of things that need changing. And Lord Darzi is very familiar, having been involved with the NHS over the period of his analysis. You talked about scale, I think in your annual accounts in 22/23, you said that it was truly amazing, the scale, that was of delivery, perhaps you can expand upon them GP practice numbers and the number of appointments. It's a staggering number. I think it's 10% of the population.

Speaker3: [00:08:17] So absolutely. And one of the things that we grapple with all the time actually, is just the scale of what's offered and just the scale of the health service. If you think about the sort of 230 trusts and 550 hospitals and over 6000 practices, and it's a phrase I used earlier that, you know, the NHS is today providing absolute record levels of healthcare. So to your point about what's going on in primary care, and again, a huge tribute to GPs and not just GPs, but all the people who work in primary care, whether it's in the GP practices or whether it's in pharmacies or local community pharmacies. But actually last year, if you do the calculations, it's about 370 million appointments in primary care. So it's about 7 million a week. So more than 10% of the population has an appointment with primary care every single week. And that's 50 million more actually, than pre-pandemic. So a huge tribute to primary care and GPS for just that scale of provision. And in spite of that, we also do recognise that there are real access problems. But there are not access problems everywhere. I'm not being glib or pollyannaish, and there are parts of the system where you can get your primary care appointment more easily than others. And there are some real hotspots where it's very, very difficult to get that access. And the NHS has done a lot with primary care to try and help in this. So I think now virtually every practice, it's not quite 100%. Virtually every practice now has digital telephony as a way to actually speed up that. 

Speaker1: [00:09:57] Cloud-based access.

Speaker3: [00:09:58] And so there's lots of ways we intervene. Cancer, again, it's remarkable. I think, again, there are lots of measures where we're absolutely not doing well enough. But again, last year there were 3 million cancer referrals. That is up from about 1.3 million again ten years before. So it's about 140% increase in the speed at which we identify and refer and check people for cancer. And, you know, so again, record levels of healthcare being provided today and I could list loads more sort of stats, but I think, you know, 9% greater last year, 9% greater A&E, A&E appointments, 9% greater ambulance call outs than just a year before that. And so there's lots of areas, I think, where in spite of the pressures, in spite of the critical condition, the vital signs are strong. And the workforce of the NHS.

Speaker1: [00:10:57] Which has grown significantly in secondary care.

Speaker3: [00:10:59] It has grown. Particularly in secondary care. Yes, that's true, but it is providing record levels of healthcare to the population.

Speaker1: [00:11:07] And just one final point in terms of the bigger picture, before we delve into a couple of the more specific things, I wanted to talk about. Your appointment, if not coincided with just almost immediately prior to quite a seminal piece of legislation, which is the Health and Care Act, and bringing integrated care systems to life on a statutory basis. And in your interview before the committee, I think you said that they presented a real opportunity. I think you've used the phrase for a material uplift in performance two years on your observations and hopes around the ICBs, because things have changed quite dramatically in terms of collaboration.

Speaker3: [00:11:46] So I'm glad you said collaboration, because the other part of that health act, of course, was actually a new model.

Speaker1: [00:11:53] Away from competition. 

Speaker3: [00:11:53] Away from competition to collaboration. I think that's really important. And actually, my last executive job, admittedly in a financial services organisation, my then-CEO used to talk about pathological collaboration. It's the only way to work across systems multinationally which is what that bank was. And one of the reasons I in the end took the role was I liked the ICB structure and I actually think that we need to be patient with it. And the performance is variable across the 42 ICBs, but I firmly believe they are the right way to go, and the more we can devolve to them, the better we will be because they will be closer to the local relevant need. And that's the point. And actually, when I look at one of the shifts that the Secretary of State wants us to make to move to community and move to prevention, actually it's a far better gateway to get that done with an ICB structure than it would have been if it had been some sort of monolithic delivery gate. So I think the ICBs are a really important structural change.

Speaker1: [00:12:58] Absolutely. And I think looking ahead, I wanted us to see if we can hone in on a couple of key areas around productivity, etc.. We'll come on to I think the Health Foundation has done some important work about projecting where demand is going to go. We've seen a big increase, I think 60% increase in over 70 since 2010. We've got more than one major illness. We're looking at 2.4 million people additionally, with major illnesses by 2040, massive increases in mental health, people presenting with mental health challenges. So there's going to be a big shift. You've talked about the Secretary of State, missions, etc. all of this will require a step change in leadership. Almost certainly. And I wanted to talk about that subject because I know it's close to your heart. And the board report back in July of this year from the NHS, highlighted the idea that the restructuring of NHS England has allowed you to focus. Can we go back to that restructuring? There's been quite a lot of work you've been involved in. I think people talk about three. I think it might be five different organisations. You've had to restructure, put into place governance and accountability. Can you just briefly walk the significance of that and what it entailed?

Speaker3: [00:14:16] So I mean, thank you for asking about that because I do think that, it probably hasn't had enough profile or realisation. So it doesn't need sort of powerful profile, but realisation about how much there's been change. So actually the upper entities of the NHS, there were five. And actually over the last two years, a couple have been absorbed. But the last three were then brought together. And it was a major structural change.

Speaker1: [00:14:50] So NHS Digital and NHS England and Health Education England.

Speaker3: [00:14:55] Health Education England. And what's really important about that is that there were 24,000 or so people, and we had an ambition to simplify and reduce the bureaucratic burden on the systems. And as a result, there's been a sort of a 35%, approximately 35% reduction in that headcount. And I think it's the largest ever public sector restructuring transformation just in terms of that number. And it's provided about 500 million of resources otherwise spent at the centre, in head office, down through into the systems, which is really, really helpful. But the most important point, I think, is that it reduces the pressure of the head office asking for lots of information and sort of circular reporting, but at the same time has allowed us to focus very clearly on certain key priorities. And I do think one of the things that Amanda Pritchard and her exec team really represent is very clear thought around managerial and operational improvement year on year. And certainly over the last 2 to 3 years in all metrics, the NHS has been improving. Not enough. We've got a long way to go, but actually in each of the last 2 to 3 years, those metrics have all have all improved.

Speaker3: [00:16:18] What it also did it in that same period. You refer to the ICB. So we've shrunk the head office. We have a board agenda now, which is compartmentalised, well organised and has two predominant themes. The first theme is real time pressure. So that is urgent emergency care access, waiting lists, cancers. Winter. Always a big, big challenge for us. And then a concentration under strategic of relatively few enabling priorities. And I have a view which the board I know shares, if we can stay focused and invest steadily over a number of years behind these enabling priorities, we can be confident that in five, six, seven years time, the NHS will then look very different and much better than it does today. So long term workforce plan, long term capital plan, target architecture and hygiene principles in our technology architectures. Primary care transformation running pilots now, frailty pilot looking at how we manage for better outcome. The elderly population which is growing so relatively few enabling priorities and they have to meet all the transformational. 

Speaker1: [00:17:38] And that's been a major piece of work. And I'm just going to touch on that further because obviously the corollary of that this is facilitated or should facilitate more effective decentralisation and devolving power, but also a cultural change, because that's quite important. Culture is extremely important. General Sir Gordon Messenger Review you're very familiar with. And I think he quotes that the NHS has some brilliant managers and in some cases world class. So this is very much part of the cultural transformation. 

Speaker3: [00:18:09] It is. And I think and that's a really important point. I would also, though, say that one must be very careful not to be simplistic about the culture of the NHS.

Speaker1: [00:18:17] Absolutely, yes.

Speaker3: [00:18:17] There are many cultures in the NHS because it's 1.4, 1.5 million people. But I think Gordon Messenger's work with Linda Pollard was excellent, and we are busily seeking to enact a number of his recommendations. I make a plea, actually, here's an opportunity for me. I mean, one of the things we're anxious about is the pipeline of individuals willing to come forward and sit on boards for us, either as chairs of boards or non-executives on boards, potentially to become chairs. And I'm talking there about board roles in ICBs and board roles in the trust and actually as an appeal to people who might be listening or watching this actually to come forward. Because if you have the relevant experience and talent, we need you.

Speaker1: [00:19:07] Okay. Well, we'll definitely make sure that that message is clear. And in fact, just as a very final point on this, there's been some strengthening and broadening of the board of NHS England, clinical leaders this year.

Speaker3: [00:19:19] Yes. So we brought in a number of people over the last two years. So let me step back. It's always the case that a board evolves, and it's partly because good governance says you get timed out after a certain period. But actually we've brought in a number of very able additional board members to join us. And they have, whether it's Mark Walport or Robert Lechler or Simon Wessley or Mary Watkins, or on the commercial side, Mark Bailey with very high technology skills, or an associate, Tanuj Kapilashrami, who has very good HR people skills.

Speaker1: [00:19:55] Dame Helen Stokes-Lampard on the clinical side.

Speaker3: [00:19:58] Dame Helen Stokes-Lampard I didn't mention it there. I should do because she's brilliant, absolutely brilliant. But of course she's going off to New Zealand as the imminently actually, which is our great loss in New Zealand's great gain. She's going as a chief medical officer to New Zealand, which is a testament actually to her as a member of our board. So I have an excellent board. We're about to go out and advertise for a number of new non-executives as part of that normal evolution.

Speaker1: [00:20:24] Wonderful. I wanted to hone in on perhaps one of the key issues or predicates of the long-term workforce plan, any new long-term plan, the 2019 plan, whatever plans there are. And this is turning the dial on this oft-mentioned, ill, sometimes ill-defined issue of productivity. Now I want to talk about technology as an enabler. Lord Darzi has made it very clear that there has to be, I think, in his word, the tilt towards technology. He highlights some great examples, but his claim is that the NHS is very much I think he uses the phrase very much in the foothills when it comes to tech, but wanted to speak about some of the work that's gone on with technology. I mean, the NHS app strikes me as an interesting point. I think it's got more subscribers or double the subscribers of Netflix if my research is right.

Speaker3: [00:21:14] That's right.

Speaker1: [00:21:15] 34 million.

Speaker3: [00:21:16] So I think the NHS app has the potential to be revolutionary and it's already showing signs, I think, of really encouraging signs. And under Jo Harrison's leadership, actually it has been turbocharged in the last 18 months or so. And where do we see its benefit? We see its benefit in a number of areas. So I think there were in July of this year, there were 1.7 million online consultations on the app. There were 4.4 million repeat prescriptions on the app. There were 30 million occasions in July where people looked at their patient record. We're increasingly managing or having patients able to review their appointments in secondary on the NHS app. Now we have to be careful here that because we can do it linked to some of our hospitals, our secondary trusts, we can't do it with all of them. It depends on what their underlying legacy system architecture is. But over time, you can see that we can build the app to be a much more important interface between the patient and health, predominantly in primary care, but also going across into secondary.

Speaker1: [00:22:27] Some potential pathway to co-production in sense where the patient's really taking quite an active role.

Speaker3: [00:22:32] There's going to be a real nudge potential here. How to be healthier, how to be fitter. It can be very prompting. So it isn't just flat data that this requires the patient to look up. Actually, it can prompt the patient to look up and that can be tailored. It can provide introductions through into other agencies of support. We also have the federated data platform. That is a really important I think, pursuit technological pursuit.

Speaker1: [00:22:58] That's now come on stream. It's been procured. It's 43 trusts are using that.

Speaker3: [00:23:01] 43. We hope to have 100 trusts by the end of the year. And this is essentially improving the interoperability of our basic data in secondary. And the great benefit, in the end, will come when we can make that connection better between secondary and primary. But one of the problems with NHS data, which is hugely rich and potentially hugely valuable, is it's not connected. And so the FTP is a really good step forward, transformational in actually getting that data interoperable. And then we also have electronic patient records, which are now I think.

Speaker1: [00:23:34] 90%, something like that. 

Speaker3: [00:23:36] Something like 92% of trusts and 98% of primary care practices. You can have an effective electronic patient record.

Speaker1: [00:23:43] So quite a leap. And we've been very privileged to have Joe Harrison on Voices of Care a couple of years ago. Very excited about the app. So I think he'll be delighted that you've called him out.

Speaker3: [00:23:53] And we purposely invested hard in the NHS app. And I think it's again, I mean, a really good, again, testament to the team that sits at the team and thinks about improving functionality and resilience. And then also the last point I would make because it is complicated, there's a great danger. And the banking apps and I come from that industry. Banking apps came in. They essentially allowed you, first of all to see your account. Flat data and okay, you see your account sort of useful. They became really useful when you could transact. And transacting meant you had to connect that front end to the underlying transaction systems. And that's complicated because the legacy systems are multiple and they're often on different platforms and they have different capabilities. So actually, to get the app to really be revolutionary, we have to drill back behind that front page of what the patient sees, the citizen sees, and re-engineer the underlying enabling technology. And that's one of the reasons why at NHS England, we're doing a lot of work around what we call target architecture and also hygiene principles, which are simply minimum standards that any supplier of technology anywhere in the system needs to provide. And so over time, as contracts come to renew, we'll build to a minimum, a coherent minimum standard across the whole system from what is currently a mosaic of very different standards. 

Speaker1: [00:25:20] And that promises quite a big opportunity. And the other point just to make is, of course, the 34 million is a staggering number and a brilliant feat. And some people don't like using apps, so they'll obviously be a quiet priority to make sure any digital transformation remains inclusive.

Speaker3: [00:25:38] Always. But the other way to put that is actually not to stop the transformation which enables that majority of people because a minority of people can't use it. But to make sure that we compensate with other gateways or other greater proactivity for those who don't want to go in via the app.

Speaker1: [00:25:59] I'm going to jump to something slightly more esoteric and futuristic. Lord Darzi talks about I think he uses the phrase where the NHS is on the precipice of an AI revolution. There's a reference to the Royal College of Cardiologists, I think, or radiologists. Sorry, saying that in 56 trusts the AI tools are being used by radiology departments. We can't tarry here too long because it's a huge topic, but that also promises in terms of technological revolution and productivity, etc.. quite, quite an appealing vista. 

Speaker3: [00:26:31] And so again, I agree. And we're looking at it hard and already it's much more used than you might think. So in radiology.

Speaker1: [00:26:38] That's what I was interested to hear.

Speaker3: [00:26:39] In histology. In Ophthalmology. So retina scanning and so on. It's being used. We're looking at voice-to-text, something called ambient documentation. And if you think that up to 30% of a clinician's time, certainly in a hospital, actually is captured in producing the paperwork that enables patients essentially then to be discharged, actually an ability to go voice-to-text to talk into the machine, which produces and links to the systems, actually will save a lot of admin time.

Speaker1: [00:27:12] Huge efficiency gains.

Speaker3: [00:27:13] Massive. And so you see real benefits from voice-to-text in particular. It's not just voice-to-text. It's not just a dictation capability that drops. It's actually, the real joy is if you can then get what's dictated directly linked into the underlying management systems.

Speaker1: [00:27:31] And that potentially allows that productivity dial to move.

Speaker3: [00:27:37] It will, it will.

Speaker1: [00:27:38] Well, that's a promising vision. The last topic I really wanted to touch upon, again under the productivity banner is the whole promise. And again, Lord Darcy does refer to, of course, diagnostics, precision medicine, genomics. The NHS is, he commends the NHS at the scale that it's adopting, genomic testing etc.. It's a huge topic, but I wanted to touch upon that because I think, I think you sit on the board.

Speaker3: [00:28:08] Genomics England.

Speaker1: [00:28:09] Genomics England. If you can unpack that for us. And what could that mean? But what does it mean already? Because I think it's having quite an impact on cancer. 

Speaker3: [00:28:17] So it is. And so I mean, Lord Darzi raised it and he was right. But he also raised it with some sensible and deserved criticism about the pace at which testing is actually provided into clinical care.

Speaker1: [00:28:30] I think he put it in the context that the health service should be a contributor to economic growth, and there should be some greater collaboration. And he celebrated the collaboration with the pharmaceutical industry, for example. 

Speaker3: [00:28:39] So going back to the main thrust of your question. So last year, the NHS did something like almost 800,000 genetic genomic tests, either whole genome or panel or single. And today we scan for 200 cancers and 7000 rare diseases. And if we were talking ten years ago, we might have conceived that as an ambition, but we would be nowhere, nowhere near it. And we've completed on what's called the 100,000 whole genome sequencing, which is brilliant. We've launched a new generation study. So we're now, with permission of families capturing whole genome of newborns. And we're going to build the data and we're looking to see what we can identify in terms of the conditions. 

Speaker1: [00:29:33] Prevention upstream.

Speaker3: [00:29:34] Looking forward. Prevention upstream, access to researchers to find new ways to engage, to find new treatments. So we're building out, I think, a world-leading genomics capability, and that's partly Genomics England. But is the NHS genomics medicine service. And we have seven genomics laboratories and a number of genomics alliances working with private sector and researchers. So I think NHS England, NHS UK, across the UK is world-leading here. You talked about cancer. One of the things I often say, and this is forgive me because I'm not a medic. That's clear. But we're seeing some revolutionary innovation. So in this last year with liquid biopsies. So tumours shed. And a number of cancers are identifiable from tumours that have shed into the bloodstream. And so via liquid biopsies we're picking up an ability to diagnose and catch cancers and then go across to genomics. And in the last three months or so there have been vaccinations given, and one is for bowel cancer and one was I think.

Speaker1: [00:30:48] That's a real milestone.

Speaker3: [00:30:49] Well, I think it is Suhail. But this is why I say I'm not a medic. But I'd like to say that we can conceive a world now where in the next very few years we might have created here in the NHS a fourth armament with which to fight cancer. So currently we use surgery, we use radiotherapy, we use chemotherapy. Imagine a world where we can create not for every cancer but for many cancers, a vaccination, treatment, and that vaccination. The important thing about it is actually the vaccinations that were given earlier on were tailored specifically to the DNA of the patient and the DNA of the tumour. And I think that's a remarkable insight into what might come. And I think what gets lost sometimes in the conversation about the NHS is we have got to fix the basics. But the NHS today is massively different than it was five years ago, and that NHS was different from what it was five years before that. And so it goes back. And Amanda Pritchard had this phrase once, which I always use, which I thought was brilliant, which is the NHS today is no longer the NHS of the iron lung. And there is something about the level of innovation which is happening all the time, whether it's in pharmaceuticals, whether it's in genomics, whether it's in technology with cyto sponges or CDCs or same-day emergency care. There's an innovation which people often miss around the way the NHS continues to evolve.

Speaker1: [00:32:21] Homing in on cancer, because it gets a lot of, quite rightly gets a lot of press. And there is obviously targets by 2028 to 75% diagnosis. I think the fundamental thing is late diagnosis, which has caused a major issue, and you're pointing to how that can be changed. And even the community diagnostic centres have played a big role in that.

Speaker3: [00:32:42] Well, I think so. So I think that over the last couple of years and it still doesn't make no, it's made a difference. But we shouldn't lose sight of the fact that we start from a start point of less than half the average OECD diagnostic capacity. Which clearly impacts on our ability to provide the service. But community diagnostic centres I think there were 89 of them about three years ago. And now it's 157 or 158. All that 158 are not operating at 100% capacity yet, but they're on the ground and their operational capacity is improving and increasing all the time. And those are diagnostic centres in the community, and it enables us to offer that faster diagnostic capability to citizens and patients.

Speaker1: [00:33:26] It's a fabulous vision. I wanted to end, if I may, to give you the space to talk about, you know, your vision, your hope. There's dramatic changes taking place. Darzi has, of course, signposted some of those. What's your feeling in terms of the hope that you have over the next few years for the service, if you can even look that far ahead because things change so rapidly?

Speaker3: [00:33:50] So I think there are a number of themes. Just very briefly, one is that I do think that what Amanda Pritchard and her executive team really represent is that as a managerial, operational, year-on-year improvement, and that takes hard work and focus. And yet we're seeing real evidence of we're seeing real evidence of it. The second thing, though is that we've got to fix the basics, and that will require investment, capital investment. And the question then is what do we prioritise? Because you can't invest in everything. There isn't enough money. So what do we choose. And that's a that's a big question. So that then leads me to, we have these relatively few enabling priorities, one of which is innovation. So can we keep supporting life sciences? Can we keep supporting medtech? So innovation is really, really important. But also it's the long-term workforce plan. It's the long-term capital plan. It's running pilots on how we look after our older population, which is becoming a bigger cohort all the time and with co-morbidities. It's pilots in transformation. And it's focusing on technology and data, both architecture but also with better capability. We referenced AI earlier. My last point would be a politically naive point, and one where I suspect many people wouldn't agree with me, but I do when I look at one of Lord Darzi's key points. And when I talked to Sally Warren, and we're delighted that Sally Warren is leading on this work on the ten-year plan.

Speaker1: [00:35:25] She has a wonderful pedigree from the King's Fund, etc.. 

Speaker3: [00:35:28] It's the fact that society is becoming sicker and therefore is more demanding. And so I may be in a minority of views, but I would welcome in a number of areas the nanny state. So I would want to see better challenges to sugars and to fats. I'd like to see challenges to social media. I'd like to see challenges, I think in Scotland actually, against what was thought to be really rather alarmist, what would happen. I think the evidence is that minimum alcohol pricing has been beneficial essentially to public health. So I think we need to have a mission or vision around can we imagine that our country are amongst the fittest or healthiest in Europe or wherever you want to pitch it? But to do that, I think it's important that we try and legislate against some of those contributors to ill health that we can get after. Now, of course, they aren't all of them because poor housing, deprivation, and education. These are long run. And Michael Marmot is very good on these. But actually I would legislate more against things, against factors that we know are harmful to health. And practically I do it because if we don't, the ability of the health service's capacity to meet that exponential growth in demand just becomes more challenging. 

Speaker1: [00:36:49] Well, you've thrown down the gauntlet for policymakers there. On that note, Richard Meddings, thank you so much for your candour and your wisdom.

Speaker3: [00:36:57] Suhail, thank you.

Speaker1: [00:36:57] It's been a pleasure. If you've enjoyed this episode of Voices of Care, please like, follow, or subscribe wherever you receive your podcast. And if you want to learn more about how we're turning the dial on health and social care, please visit newcrosshealthcare.com/voicesofcare. In the meantime, I'm Suhail Mirza. Thank you very much for joining us and look forward to seeing you on the next episode.

Speaker2: [00:37:18] Voices of Care, the healthcare podcast.