Niall Dickson has only been at what he describes as the ‘waterfront of healthcare organisations’ since January, when he took over as chief executive of NHS Confederation.
The health service veteran, who has been at the helm of the General Medical Council (GMC) and served as a BBC journalist, is quick to see all sides of an argument. While he encourages NHS leaders to keep ‘banging on’ for more cash, he recognises that the service also needs to radically change the way it is organised.
Niall Dickson has only been at what he describes as the ‘waterfront of healthcare organisations’ since January, when he took over as chief executive of NHS Confederation.
The health service veteran, who has been at the helm of the General Medical Council (GMC) and served as a BBC journalist, is quick to see all sides of an argument. While he encourages NHS leaders to keep ‘banging on’ for more cash, he recognises that the service also needs to radically change the way it is organised.
But he has a stark warning for a Government consumed with preparing for Brexit: the whole service is on a precipice, don’t ignore it.
What is your key priority, the one thing you would like to have achieved by the time you’re finished here?
I would like to have helped the NHS move from what is fundamentally a 19th and 20th century model of healthcare provision towards something that meets today’s challenge – and today’s challenge overwhelmingly is about older people with co-morbidities, with long-term conditions. That includes both physical and mental health issues.
Moving towards a model where care is provided at the right time and people are sustained in as healthy a position as possible is, I think, the goal that the health service should have and by and large does – and it’s certainly one that I would be seeking to facilitate.
What does a 21st century NHS look like in your view?
The first thing we have to solve is the problems that we were trying to deal with in the noughties – that is to say access.
So individuals should get access quickly to any form of urgent care they require, to any form of elective care, and if they have a mental health problem.
We need to make a much smoother service for people as they move up the system. It’s too jumpy and jerky at the moment. There are too many faxes still around. We’re well beyond that stage. We should have far more seamless connections between the different parts of the system.
What would you say is the biggest roadblock to the sustainability and transformation plans (STPs)?
I think there are a number of challenges they face. The first and most obvious one is money. If the S trumps the T, there is a danger that the T doesn’t happen, and you end up in exactly the same position again. Simply pouring money into the existing system will not solve the problem.
A lot of areas are struggling at the moment to keep the system sustainable while moving ahead with transformation. At a practical level, there is the problem of how to build up new styles of service when you’re having to keep the existing service going at the same level and meet huge areas of demand.
Do you think the idea of parallel running has been taken into account when allocating money?
There was a nod towards it in the Budget. They said there was some amount of money – I don’t think a proper calculation has been done across the whole of England, and actually it would require each STP in a way to do an estimate of it.
The notion of parallel funding was introduced way back when they tried to shut long-term institutions for people with mental illness and learning disabilities. That was done with parallel funding.
People had money to build up the community service while they shut down the institutions. We need a bit of that now.
When you spoke at the Mental Health Alliance Conference you mentioned that health executives shouldn’t worship the new god of integration. Can you elaborate on your concerns?
It’s not that I’m anti-integration; I just think that sometimes you hear people and they become religious in fervour about these things and think they will solve all our problems.
The answer is that every single organisational approach has flaws within it. We should know this. We’ve reorganised the health service far too many times and I’m not saying there isn’t another reorganisation needed now. I think there is because I think the 2012 Health and Social Care Act was little short of a disaster in terms of the way it was set up. I think it was a big mistake – and that wasn’t all the fault of the original architects, it was how it eventually was formed. It wasn’t just that these organisational forms were created or not created; we never attempted to get them integrated with one another.
What kind of reorganisation do you think the NHS needs?
I’m not sure it needs a reorganisation at the moment. I don’t think there’s any prospect of primary legislation to introduce anything else. I think the system should find new ways of operating and new arrangements that can be made within the current structure. At some point in the future there will probably be a need to regularise that and put in a legal framework. But generally speaking, formal old-style reorganisations have always had high ambition and have always under-delivered, so the key area is relationships at local level.
The Prime Minister seems to have the will to push forward with the parity of esteem agenda for mental health, beyond just focusing on the health service. What do you think needs to be done to make parity of esteem a reality?
The funding story is not a good one, I have to say. There are lots of other aspects to parity of esteem.
For instance, training of staff – it is very important that professionals are trained in mental health and that it is something they’re tackling with all patients.
As far as the Government is concerned, I think there is something about the centre keeping pressure on the system and the services.
I absolutely sympathise with people who are making decisions about what appears the most immediate and dramatic problem that’s presented in front of them. I fear that because mental health is not so prominent it can sometimes get squeezed. And we’ve absolutely got to tackle that.
How far away do you think we are from full parity of esteem?
I think we’ve got quite a long way to go. I don’t want to be depressing about it, but I think changing that kind of mindset and culture is very difficult. I think it would be interesting if you look at younger people, and that’s always our hope, that you start seeing changes in attitude as they come through the system.
How would you describe the current state of the NHS? Are these the dark days or is this just the calm before the storm?
I think these are quite dark days for the NHS. There are lots of parts of the system that are working really well. The NHS is so big that you can describe almost anything and it’ll be true of what’s happening somewhere in the health service today. But I think the overall picture is one of a service that’s degrading a little, in some cases quite significantly.
I have to say, I was wrong – I thought the wheels of the health service would come off after about three years of austerity, and we’ve had it since 2008/09. We went through a period of huge growth historically but then we didn’t go back to a normal rate of funding. We’ve gone right down to flat funding for some of these years and very small increases.
So it’s more difficult going forward. And I think that is a cause for real concern.
I don’t think we should be saying money is the answer to everything. But I think we’ve got a legitimate case for saying the nation must get what it pays for, and at the moment given the levels of demand, and the way the service is organised, the reality is over the next few years unless we get further injections of money, there is only one way forward. We’re going to see further degradation of some services and slippage of the big targets.
Could the wheels still come off the NHS yet?
Yes, they could. And I think everybody will try and stop that – indeed people are doing that at the moment, and keeping the thing running. My fear is that the Government is very distracted at the moment, it’s concentrating understandably on the deficit and Brexit, and therefore my fear is it’ll have to become bad before more action is taken.
How bad do you think it has to get? Because this winter is record breaking in some of its results.
To be fair, I think ministers are well aware that the system is under enormous pressure. I think there’s absolute acknowledgement of that. And to be fair to health secretary Jeremy Hunt and NHS chief executive Simon Stevens, I’m sure that if they could conjure up more money, they would. It’s very difficult for them to get access to more funds.
But I think we should keep banging on, recognising that the health service has things to do itself, and that the quid pro quo of additional funding even now is to do everything we can to reform the system and try to make it more effective to meet a very different set of challenges from back in the 20th century, which was honestly quite a different world.
