NHS boss Penny Dash: ‘We can’t just blame the politicians’

{"text":[[{"start":7.52,"text":"As Penny Dash and I settle into our corner table at Old Queen Street Cafe, a Westminster haunt with a buzzing bistro vibe, her heart, I learn, is several miles further east."}],[{"start":19.12,"text":"Conscious that the choice of restaurant for Lunch with the FT is supposed to reveal something about the guest, the chair of NHS England explains that, had her next meeting not demanded she stay close to Whitehall, she would have opted for “somewhere semi-trendy in Shoreditch”."}],[{"start":34.8,"text":"Dash’s role overseeing a sprawling behemoth that consumes almost 40 per cent of day-to-day government spending means proximity to politics is unavoidable. But the food here is good, she assures me, and in the past she’s found it a pleasant place for an after-work drink. “That would be one of my other criteria. I do quite like a glass of Crémant.”"}],[{"start":57.52,"text":"Britain’s free-to-use health service has always held a special place in its citizens’ hearts — the nearest thing to a national religion, as one former finance minister famously put it — but in recent years the country’s collective faith has been sorely tested."}],[{"start":72.92,"text":"Only a little over one in four is satisfied with how the service is running, according to an authoritative annual survey, but so dire has sentiment been since Covid, this actually represents good news: the first rise in satisfaction since 2019. During the intervening years, no fewer than eight changes of health secretary have at times cost the NHS consistency of purpose when it most needed it."}],[{"start":98.18,"text":"During our time together Dash will give me one of the most clear-eyed assessments I have heard of the state of the NHS. But first there is the business of ordering. In the middle of the working day her favoured French bubbles would be an extravagance too far, and we settle on a single course: smoked salmon and mackerel terrine for her and seared sea bream with hummus for me."}],[{"start":119.38,"text":"As the assiduous waiter bustles around we turn to the big challenges facing Dash. The first is to oversee implementation of a 10-year plan intended to revivify a service ministers had starkly described as “broken”."}],[{"start":132.8,"text":"Her second task is to wind down the very body she heads. Just two weeks before Dash came into the post in April last year the then health secretary Wes Streeting announced that he was scrapping NHS England, and folding its functions into the Department of Health and Social Care, ending a 12-year experiment in operational independence for the service. Dash’s own role will end with its abolition, which is expected within six months, although recent reports have suggested the timeline may be extended."}],[{"start":null,"text":""}],[{"start":162.32,"text":"When the government published its blueprint for the NHS 15 months ago, it included a warning that the service must “reform or die” against a backdrop of ballooning waiting lists and alarming inequalities in life expectancy. Preventing, rather than simply treating, illness by shifting resources from hospitals into the community, and using technology to provide faster, more convenient care were among its animating principles. But the lack of a clear strategy to build on the vision it set out is “quite staggering”, Dash tells me."}],[{"start":193.68,"text":"So much planning in the NHS is not undergirded by rigorous analysis, she adds, and gives me two examples. She’d expected that preparation of a mental health plan due to be released later this year would involve an examination of current levels of expenditure and workforce, the size of the relevant estate and reflection on “what good would look like” in this vital field. In fact, “you discover that nobody’s done that work at all and the work that has been done is very anecdotal”."}],[{"start":220.24,"text":"Another instance of policy outrunning evidence was a decision to base a raft of new urgent care centres alongside hospitals to ease pressure on emergency departments, seemingly without any consideration of the potential countercase for locating them with primary care centres."}],[{"start":235.32,"text":"“There’s pros and cons of each of those [options], but no one has ever stepped back and said . . . ‘What would efficient scale be? What would the unit cost be? What would the whole-system cost be? What would the outcomes be of A versus B?’ There’s just gut reactions that say, ‘Oh, we’re now going to go and build a whole load of urgent care centres alongside hospitals’.”"}],[{"start":255.12,"text":"Is this an intrinsic aspect of NHS culture or just the way it’s always happened? “It’s both of those, and it’s a lack of skills and capabilities.”"}],[{"start":264.66,"text":"A centrepiece of the 10-year plan was an ambitious pledge to change the way the NHS’s billions are spent, reducing the sums going to hospitals to invest more in services at, or close to, patients’ homes."}],[{"start":null,"text":""}],[{"start":277.56,"text":"When I ask how feasible it is to achieve this rebalancing, Dash’s response suggests the will may be lacking, not only in the NHS but the political class too. “Well, it’s extremely feasible. It’s more do we want to do it?”"}],[{"start":292.12,"text":"Progress is being made, with both headcount and spending in hospitals now coming down. But that, in turn, is “causing quite a lot of squealing”, not just from staff reluctant to change ways of working but sometimes from politicians whose instinct is to protect their own local institutions."}],[{"start":308.8,"text":"She returns to her core point about a lack of strategy. “We can’t just blame the politicians, though I have to say the obsession in politics with keeping hospitals open is a problem.”"}],[{"start":320.56,"text":"“We, as the leaders, need to be much clearer about what is it that needs to happen and almost the first thing that needs to happen is we need to establish that out-of-hospital care”. Staff would then feel confident in discharging patients, and they, in turn, would have faith they will receive the care they need from home, she says."}],[{"start":338.8,"text":"Dash’s perspective on the NHS is informed by her own experiences on the service’s frontline: she spent 11 years training and then practising as a hospital doctor."}],[{"start":348.32,"text":"Her path into medicine began with her grandfather, a paediatrician in the then-Czechoslovakia, who managed to ship her father and aunt to England on the Kindertransport before the outbreak of war. He and Dash’s grandmother later managed to make their own escape and the family settled in Stoke-on-Trent where her father eventually became a dentist. Her mother’s life, as she tells it, was a parable in social mobility. Helped to get into a selective grammar school by a family Dash’s grandmother cleaned for, she went to university where she met Dash’s father, later becoming a Labour councillor."}],[{"start":382.24,"text":"Dash says she was encouraged to “strive high” at her comprehensive school, and later won a place to study medicine at Cambridge. But she was already conscious of the invisible barriers that could face even a dentist’s daughter 45 years ago if she was not at a private school."}],[{"start":null,"text":""}],[{"start":398.24,"text":"She applied to the newly opened Robinson College, believing she would not stand a chance at getting into one of the university’s more venerable institutions. “[Even though] I came from a perfectly middle-class family . . . you still felt that the odds were stacked against you.”"}],[{"start":412.28,"text":"Once there, her accent was mocked and she was called “coarse”, “common” and, with geographical imprecision, a northerner (Stoke is in fact in the English Midlands). “I’ve always been quite gregarious [and] an extrovert and it was absolutely staggering going to Cambridge and meeting people who were completely snobby and demeaning to me.”"}],[{"start":431.22,"text":"She was struck by an interview she came across with Streeting, now defence secretary, who attended Cambridge from a working-class background about 20 years after her. “He talked about feeling like you’ve come from the wrong side of the tracks, and it actually being a big drive to do more — almost ‘I’ll show them’. And I have to say that was always my reaction as well: I was going to show them.”"}],[{"start":452.56,"text":"We pause for a few minutes to savour our food that has now arrived. My fish is a perfect expression of Mediterranean cuisine. Later, Dash pronounces herself more than satisfied with her “delicious” terrine."}],[{"start":463.44,"text":"Of a similar age, we share our memories of the NHS in the 1980s when we were starting out on our careers. Aids was the new, terrifyingly mysterious scourge and having secured a coveted post working with Stephen Semple, a respiratory physician who was professor of medicine at London’s Middlesex Hospital, Dash found herself on one of the country’s first Aids wards caring for “fantastic young men” who were often in their final weeks of life. “I was covered head to toe in probably extremely HIV-positive blood,” she recalls."}],[{"start":null,"text":""}],[{"start":494.84,"text":"Semple had an ethical clarity about the unfolding crisis. “He said: ‘This is the need of our time. I am going to look after these people. They’re human beings.’” Other senior colleagues refused to treat Aids patients and shunned Semple personally: “It challenged one’s sense of the morality of the healthcare profession.”"}],[{"start":512.84,"text":"This huge new clinical challenge aside, it was also a period of rising tensions between medics and the government over long hours and health secretary Ken Clarke’s plans to inject more competition and cost consciousness into healthcare, a radicalising time for many young doctors, including Dash. The British Medical Association’s fightback, I recall to her, included a remorselessly ad hominem advertising campaign, with the strapline: “What do you call a man who ignores medical advice? Mr Clarke.”"}],[{"start":542.48,"text":"On the first weekend of a surgical rotation, her boss insisted Dash scrub in for the entirety of what turned out to be a 30-hour operation even though the patient had little chance of survival. Having had two hours’ sleep in the course of her 80-hour shift — “needless to say, the patient died” — she crashed her car on the way home. It was “just a bump” but it was also an epiphany. She remembers with not a little relish that during one protest she was handcuffed to the railings outside the Houses of Parliament."}],[{"start":569.6,"text":"Even though the European Working Time Directive has long since put a limit on the time doctors can legally toil without a break, “working conditions are still, I think, terrible for staff. That really infuriates me.” One tiny, petty example: staff are unable to get a cup of tea or coffee, or even find a water glass to slake their thirst, after arriving at work, she says."}],[{"start":594.68,"text":"She eventually left medicine, becoming a partner at McKinsey and taking charge of its European health practice before bringing a management consultant’s appraising eye to her current role."}],[{"start":604.8,"text":"Dash says she had to smile when I reminded her about the BMA’s ad blitz all those years ago, because Clarke brought in just the focus on cost the service has now lost — “and I campaigned against it, much to my chagrin now”. One of the ads, she remembers, showed a tin of beans on a conveyor belt. The BMA’s argument was “he understands tins of beans, he doesn’t understand patients”."}],[{"start":627.46,"text":"“Now, clearly healthcare is not the same as a manufacturing plant for a can of beans. But that does not mean that we can’t try to understand costs. And he was spot on.” Much of the progress made at that time has evaporated over the past decade, she says."}],[{"start":642.28,"text":"Two events contributed to the loss of grip. The first was a set of reforms introduced in 2013 which stripped out a layer of management and moved public health out of the NHS and into local government, removing from the service almost overnight an enormous reservoir of knowledge about cost-benefits and health outcomes."}],[{"start":660.04,"text":"The other was one of the biggest catastrophes in NHS history. Hundreds of patients at a Staffordshire hospital trust died between 2005 and 2009 after suffering incompetent and inhumane care. Suddenly safety was the overriding priority, and health and political leaders alike, she says, developed “an obsession with inputs”, such as staffing levels, “as the only thing that mattered, without regard to outcomes”."}],[{"start":null,"text":""}],[{"start":686.72,"text":"The other legacy of the Staffordshire scandal was an excessive requirement on staff for form filling and training. The result, Dash says, is that England now has “an exceptionally over-regulated, bureaucratic system as compared with other countries”."}],[{"start":700.76,"text":"Across the service, there is so much untapped potential for efficiency gains, she adds. The NHS’s infrastructure is ill-adapted to the needs of 21st-century medicine, with parts of the estate “exceptionally underutilised”. For example, the NHS has probably got twice as many outpatient rooms as it needs, she says."}],[{"start":720.28,"text":"Sharp differences in staff productivity also need to be scrutinised. “Quite a lot of our staff numbers are all over the place,” Dash tells me, with unexplained variations between professionals doing the same job, from the number of outpatient cases seen by each consultant to the number of nurses staffing each bed."}],[{"start":736.8,"text":"Nor do workforce rises always appear to reflect an equivalent rise in demand: “We’ve had this big increase in things like staff in [accident and emergency] departments, but we haven’t necessarily had an increase in people turning up, despite what people think, that would match that.”"}],[{"start":751.96,"text":"In recent years, long wait times and the search for more streamlined care have led Britons to decamp to the private sector in growing numbers. So many people who interact with the NHS have “an exceptionally good experience”, Dash says, particularly those with the most serious illnesses such as cancer and heart disease. “The good people are fantastic. You would absolutely not get better care if you went private. In fact, you may well get worse.”"}],[{"start":777.92,"text":"But, she adds, the thing that keeps letting the service down is the exasperating administrative glitches that should be easiest to fix yet have such an impact on patients’ experience: “‘They lost my notes. They cancelled my appointment at the last minute . . . You can’t book an appointment online.’” Dash is a patient herself: “They drive me mad.”"}],[{"start":796.76,"text":"Can the NHS’s distinctive funding model survive given all these pressures on it, I wonder. “There is absolutely no reason why we can’t have a high-quality, responsive healthcare system free at the point of use, paid for through general taxation. But we need to reform it, adapt it, transform it, improve it.” And use public money much better? “Absolutely . . . It needs major change.”"}],[{"start":815.84,"text":"The NHS, I remind her, has a long history of embarking on restructurings that soak up management time while delivering little obvious benefit to patients. To implement the new ways of working we’ve been discussing, she says, a shake-up is needed. “The centre had become extremely large” with teams duplicated across the health department and NHS England, for example. But it’s important this process doesn’t lead to a loss of focus on making the service better: “We’ve got to absolutely keep an eye on: are we continuing to deliver the improvements?”"}],[{"start":846.52,"text":"As our lunch draws to a close — Dash has a meeting at the Department of Health a few minutes away — she returns to the question of staff morale and welfare, which first led her to take up cudgels as a young doctor and preoccupies her still."}],[{"start":860.04,"text":"Disillusion is widespread, she says. “We’ve got very high sickness absenteeism rates. We’ve got high rates of turnover, and we’ve got many staff who feel that they are overworked . . .[and] there’s not enough resources."}],[{"start":873.52,"text":"“Giving people confidence that we can turn this around, we can get to a better place: that’s probably the biggest challenge we face.”"}],[{"start":880.68,"text":"Sarah Neville is the FT’s global health editor"}],[{"start":883.6,"text":"Find out about our latest stories first — follow FT Weekend on Instagram, Bluesky and X, and sign up to receive the FT Weekend newsletter every Saturday morning"}],[{"start":898.04,"text":""}]],"url":"https://audio.ftcn.net.cn/album/a_1792216697_3195.mp3"}