Episode One - Sir David Sloman

Welcome to the first on-prescribed podcast where we're going to be joined by accomplished health system leaders to hear about their candid journey, their learnings and opinions. I couldn't think of a better first guest than David Slavin. David joined NHS in 1983, starting out as HIV and AIDS coordinator in Camden and then went on to be CO of NHS Harringay, then the Whittington Hospital, then the Royal Free Hospital Trust and then NHS London before becoming the COO of NHS England. Most hospital chief execs will probably know David and most doctors who trained in North Central London over the past 20 years will remember you greeting them on Monday morning at the front door of the hospital. David was awarded a knighthood for services to NHS in 2017, nearly years on his and that was before your London role or your national role or leading the country through a pandemic. So very very well deserved and you should probably do another award now. So thanks for coming on and joining us David, how you doing today? Live pleasure, very good, you keep telling nothing about deserving another award. You keep spreading that, keep spreading that. No, I'm good for them, good for them, sun shining, it's good. So you started in this role as HIV and AIDS coordinators, was that your first role in the NHS? No, it wasn't actually, it's slightly wrong. So I joined the NHS as a national management trainee, as part of the national training scheme back in the day. Actually in the same cohort was one or two people who were also still around the NHS, so Peter Redding was part of my entry group. So it is a truly fantastic to your training programme, it's a very, very privileged to have it. I say my first grown up job was the new Blues, we AIDS and HR, Vika, order later, which people who weren't around with the time will forget. I mean, he was quite extraordinary, the level of misunderstanding, you know, he was things like don't go to the swimming pool and it was just absolutely incredible. And of course the treatments were being produced in real time. So it's an extraordinary, extraordinary couple of years actually. But I learnt a lot, and there's a number of us in that era who were getting a still around, the Director of Public Health for London Professor Kevin Fenson, he was part of the Blues for the AIDS and HR V team and Ridley was the AIDS and HR V team who were the United Down Language, Lewish and Monsubdoc. So it's quite, you know, really good group of people to work with. A lot of very impressive people, it did GMTS, they're always wondered why it isn't bigger, why they aren't taking in more people each year. Yeah, I think they have grown over time, and when I joined the annual interview was about 50. I think it doesn't quite mean, but yeah, I think it's much much bigger now. Relative to the size of the NH, that's one person per trust, right? It's not huge. I think you're challenging the wrong person, it is. So that's where you started out, and then today's 31st of March, 2025. Where were you five years ago today? Well, that's a great question, because of course I've been reflecting on that a lot over the last week. So because I've been having a number of texts, essentially, in emails from people saying, do you remember? So five years ago, last weekend, not the weekend just gone by, the weekend before, we were in the boardroom of Great Ormond Street and in the London offices, trying to work out how we would get London and the state of readiness for COVID. And then of course, last week, five years ago on Monday, the country was put into lockdown, and I then had the, I don't know, it's just strange, sub-word serration, but it was an extraordinary privilege to lead the NHS across London through the first waves of COVID. So it's two o'clock now, so I think at 12 o'clock I'd have had one midday meeting. We used to, we used to meet at a huddle at midday, at eight in the morning, at midday, then we would convene a meeting of the chief executives of the trust and ICBs across London every night at six o'clock. Look at the data, look what the data was telling us, work out what we needed to do between then and the next warming, and then the next day we would start again. It was, it was verified, actually. But as I say, I look back and I reflect, with some pride, I'm not going to deny some pride, but it was an absolute extraordinary privilege, actually, to lead London through something which you wouldn't wish upon anybody, that's really clear. And we're still recovering, when I still do believe that this is the sixth year of the COVID pandemic and the nation as a whole, not just the NHS, it's not back to where it was beforehand. But you've seen a lot of crises in the health system, including different infectious diseases, like what was the tip-in-point for you where it clicked that this isn't just like something else that's going to, it isn't just a bad fleece reason, this is actually going to be history defining. Well, there was a few things going on firstly. You know, we were at, and it's, it's, the time feels very, very compressed, actually. But we were aware, you know, we were starting to see this footage of songs that were going on in Italy, actually. And about three weeks before that, I was thinking of going on leave for a week, actually, to Italy. And I went and talked it through with one of my, an evening, actually, one of my regional director colleagues. I thought, I think I've got a holiday, did you think to Italy? Do you think, "Shut your sweat." No! So, it was very, very clear advice. And then, of course, what we're starting to do is to look at the data, you know, you're starting to look at the data, you're starting to look at the prevalence, you're starting to look at the incidents. And of course, the doctors are starting to talk about it in general, awareness is starting to rise. Then you're starting to see your first admissions to hospital. Then the doctors are starting to tell you, "Yeah, we're starting to know what it's like now, and somebody comes in with COVID, we can tell." You know, because of course, the more they get it, the more they could see. Then I was starting to get calls from very senior clinical leaders saying, "This is real, and we need to think now about what we need in terms of our capacity to deal with what we think we've got coming." So, that was accelerated. And of course, this was global. You know, it was global. You know, it was on the news, wasn't it? It was around. So, but it's a combination of those things. Is what people were saying, what we were hearing, what the data was telling us, what the clinical voice was giving us. You know, it's the public health position, and the acute positions in the GP is it was just generally, something is big here, something is big. You said it was a privilege to lead London and later the wider NHS through that. What were some of the points that have really stuck with you? Oh, God, I'm even. So, I often crawl out there, otherwise, this is a point that I do start crying. I remember crying in front of the team during Caperna. But it was such an intense emotional time. I'm not even on it back there. I will cry if I tell a particular story. But it was, you know, it was, it was the extraordinary fact. If I look back, you know, what I was, we developed a really strong community of leadership across Covid. I mean, you know, the NHS, in London it's competitive and it's crowded, you know. And, you know, to problemise it, you know, when your neighbour gets in trouble, you're often from Gipman Lodge and Nickdair services. Well, well, this time, if your neighbour was in trouble, you just picked them up. Yeah. Yeah, we need you. Excuse me, it's going to close myself. No, it was. Take your time, Dave. Yeah, no, it was fine. It was fine. I was thinking, I knew, I knew, I knew when I was coming here, but this would have more work. That was every bloody time. You think five minutes in. No, that's absolutely. So, there are other moments. So, you know, the, when the combat military technicians turned up to help us in the ITU departments when they were at their most stretched. That was extraordinary, you know, sort of. You know, and I remember this thing to the, um, sorry about this, we'll come back now. So, yeah, the woman in charge of the ITU, the senior, senior sister in charge of the ITU at Bards. So, as you thought, was he lost control? Or the ITU. She said, she said, it was on the edge. She said, we thought we were losing control. And then the combat military technicians turned up. And just to be honest, they did. And it reminds me of the metaphor. It reminds me of, you know, it's like the last scene of, um, the middle film of the Lord of the Rings trilogy, you know, when they're all in trouble. And suddenly, over the hill, come all these men on course, all of us is to the rescue. I mean, it really was. And these were medical techniques. What they call, they call combat military technicians and what they are, they're not, they're not, very, very senior clinicians. But what they have is a set of basic core training that enable them to look after an injured soldier right in battle until the more senior clinical people tell them, they're going to have to help. So it was to optimize around three hours. Very, very basic, basic skills. But they, but it was just fantastic. I mean, you know, this, this was a really senior clinical leader, really senior. So I thought we were absolutely controlled. Wow. And then these people turned them up. So that's how clever it was. On that second wave, we were really close. So there were moments like that. There were, I can remember my 60th birthday was during the first wave of COVID and the reason I know that is that the key data we used to use actually was the patients admitted to ITUs and only occupied bed days. And these were kind of up and up and up and up and up. On the 13th of April, which was my birthday, it was the first time that the one that number went sideways rather than up. So it was literally on my 60th birthday it took and then it started to go down until the second wave turned up. And that was the toughest one actually. That was the story I've just told you about the combat military technicians. I mean, the other side to it, I should say, is that in the year prior to the pandemic turning up, I spent a year working on a, to develop a vision for London, you know, to make London the world's healthiest local city. And that involved a lot of working with London councils, it involved a lot of working with, with Cedric Khan and the GLA. And those, therefore, well-established relationships were so important to getting us through COVID. I, it wasn't just about the NHS. It was about local authority leadership, it was about political leadership. It was, and we, you know, we got what we deserved actually because we put strong years work into the value of strategic relationships that we've seen still as a single state. And then still as a single state, when we had to do the COVID vaccination campaign, which was possibly one of the most intellectually challenging things I've ever had to do. That was hard. That was hard. And these relationships, these were people, you, you know, you then, you had them WhatsApp, you could just call on where you used to me. I think the pen contingent on where, you know, the level of pressure in the system, which sometimes meet daily, which sometimes meet weekly, the leadership of London councils and the councils of London and the GLA was all fantastic. You know, everybody came to the party in a really joined way to turn in to keep the health and health services of London, to optimise it to the best of our ability. You know, we wanted to keep people well, but if they were sick, we needed to make sure that we were able to treat them. And I mean, it's like, well, as you say, Jacob Mike, Mike, career is an interesting one in this case. I did that job in age of H.R.V. in the middle. We looked after the Ebola patients that draw free. Then I ended up doing COVID and all that teaches you leaving is that there'll be another one. So this is why learning the lessons of COVID is so important to get that right. But it's hard when the system has all this pressure to prioritise something so prevented. We started out doing an antibiotic resistance, which is sort of potentially the biggest extent throughout the modern medicine, but the challenge we found is with all the day today pressures, it's so hard to get people to prioritise that. Yeah, it is. It is. It is. It is. It is. It actually, what tends to happen, the prioritisation process goes through three phases, actually, grows and grows and grows and grows and grows. And then you determine what we need to show up for set of priorities and it gets down and we go down to ten and each of those has one A, one B, one C, one D. You know, you get all of that. But then of course what co-le gave you was actually a single thing to focus on. No, it's single. And it is difficult, actually. And it's not easy choices to make. I think government's got tricky job on its hands, prioritising one thing over another. And there are only so many things that clinicians can do, actually, and keep up to date with. We'll get onto the priorities point in a bit, but I'm interested in, so you're leaded to just the sheer volume of change that was enacted in a very short space of time where this is, was literally like by the day, seven days a week, new services being stood up, new pathways being designed. People on teams at eight in the evening, I think I was six in the evening, what are you doing tomorrow? How long did that last? Because there was a lot of, there was that initial momentum at the start. But certainly over time organisations have gone back into things taking longer. Was that gradual? Were there any sort of reflection points? Good question. So the thing I would emphasise as well, I mean, I happened to be the bloke with the title regional director for London. So that was why it was, I didn't do it. It was done through switches and teams and processes. Be brilliant together. I used to put, I used my power to convene. I'm not downplaying what I did, but I just want to emphasise the ICBs on those five London foot prints were fantastic. The providers worked across, they worked collaboratively. I mean, if you look at, well, I think the R&O H turned itself into an emergency hospital, a COVID hospital, a very active recovery hospital, they were actually, I mean, it was extraordinary what that hospital did and everybody did something. So, so, wait, there was a real sense of, there were different phases, there was a real sense of urgency on phase one. Phase two was a game that was the most challenging actually because that, that, that, where that peak, that's where, that's one of the few times in my life I've been genuinely, genuinely anxious about what I'll be going to do now, you know, you know, really. So this is what I went to, yeah. And I wasn't, I wasn't actually on my own believe you, I don't, I had people helping me around. Then of course, the, then the on the crumb way was very different. So what on the crumb like was just fantastic at spreading. If you remember, it wasn't as pathogenic, but it was brilliant at spreading. And of course, what people ignored, you know, the NHS staff, our members of the great British public and if it's sweeping through the, great British public, it's sweeping through the NHS staff. Then there was big phases about the COVID vaccination reports, the COVID vaccination stuff coming out and that was a massive focus of work. So it kind of went in waves. And I mean, where, where, of course, what, then we started to get services back on the road and we had intense periods of recovery. I mean, I was chatting to Tim Orchard actually this week. There was a chip executive imperial about how he clinically led the work, I asked him to lead on the endoscopy recovery because he's an endoscopy of our background. And that game was intensive, you know, and what I learned, you know, one of the big ones, I was really easy to turn services off, but wow, it's difficult to turn them back on again. Oh, do not underestimate, you know, so, you know, it takes time to get things warmed up again. So is it easy to turn them off as well? Well, it's not easy to turn them off, but you can just shut the door, come back. Right. You know, you can say we're counting the list or we're not doing that. So, and again, of course, what the clinicians were excellent at as identifying those patients who we still need, really urgently needed to treat. I mean, the speed at which, I mean, why I'm telling a London story here, but this was true everywhere. And certainly when I let my chief operating officer roll through the subsequent waves, you know, all across the country, the clinicians were working at hand, we can figure out our elected capacity. So we make sure that urgent cancer, urgent heart stuff is done. So, I mean, they were brilliant. I mean, they really were brilliant, actually. And it was quite interesting, you know, what teams who should we say were slightly more competitive, so I believe found themselves working at the same buildings. And you mentioned the vaccine programme. I remember often, I've been used it as a case study, often centralised leadership, because I, as the vaccines were, you know, getting into the late phase trials around September and October and those whole question of how are they going to be delivered with all the cold supply chain needs and just the throughput needs. We ended up providing a solution for GP practices to book in patients. And I remember going out to these vaccination sites and they had their kids stewarding in the car park, they had put some vaccines in the car and drive the to another centre like, all this like on the ground problem solving that you need in a time like that. And they loved it. Yeah, actually, they loved it. You could see how energized there were as some as I, I visited the packs. I mean, they did want to, they did rep top models with football club actually, which is best team in the land, wouldn't they? They did want to, well, they did want to Westminster Abbey. You know, and they did when Bounds Green, they were, you know, we live. And you know, it's just, it's probably got my, it's probably got my, it's probably got my job. They were just so, you know, and they were really, actually, they were just phenomenally efficient. Lots of them were the real centre community spirit, actually, I went up to, I think it was Barking Town Hall. And you could see, you know, there was, all life was there, if you like, the, the, the mix of people who were volunteering. It was fantastic. I spoke to the blitz, I spoke to, it wasn't there really. But, yeah, and you just really did show what you could do. People were up for it, people were at it. How do you think we keep up that momentum of change and improvement when we don't have a pandemic? Because you're on the surface, you look at the scale of challenges facing the system. And whilst they are not as acute, and we don't have, you know, rationing decisions and I to use about ventilators and things like that, we don't have lockdowns, the scale of them is still completely immense. And the, you know, the growing birds and the long term disease that weight less than the staff burn out crisis. How do you think we maintain or encourage that momentum? Well I think I look at that in two ways. What we do right here, right now, to improve the performance and productivity of the existing model of care, and improve the health wellbeing and motivation of the staff to provide those services. And within that, the agency of the patients, yeah, and I have full-cock, full-store, new paragraph. We then need to work out how we're going to transform the system in a way which genuinely does make the shift from sickness to prevention, from hospital to community, to animal to digital. Yeah. And as we know, people out there with the moment are crafting the ten-year plan to kind of explain exactly how we're going to do that. And meanwhile, I think we've got a bit of reorganisation on our hands between DHSC and LHSC, but we will need to get the structures and the processes right. So the very earliest management theory on a billion is your structure, you've got your structures right, you've got your processes right, you let your outcomes right. So, to deal with those things in order, or. Or Commways Law. We had a Commways Law. Commways Law is that the product you deliver manifests the all structure. So, like, you go and look in a car and the locks and windows are here and the heating and aircon is there and all the drive train starts with all this behind the steering wheel. And it's basically a manifestation of the all chart in the service. Interesting. The other one I like about that is it's behaviors to drive performance and context to drive behavior. So, which is broadly the same, you know, broadly the same thing. I look at, you know, in terms of getting the best out of what we've got right here right now, there is something about ensuring that we're taking a unwanted variation because there is huge unwanted variation in care. And, you know, it's easiest to measure on the impatient bit where you look at a number of patients on the list or you look at early and late starts or you look at your first to follow ratios or you look at your day case by default stuff. It's the timid timbreings and the girth team and others have done. And so, there's something about really, really focusing on that. And my experience of working with clinicians, which I always really enjoyed, is if you bring clinicians together around the data and give them the opportunity to improve, they will play. And the definition of opportunity is capacity and capability. You need to give them the time. You can't expect them to do it as well and you need to give them the results. You know, they usually need some admin staff and some data wherever you see that work. I used to do that at the free. That was our big mantra. You know, what we wanted to do, we always say we wanted to create an organisation which was clinically led and excellently managed as well. But, as well, we did so. And I've always been a great believer in clinical leadership and medical leadership and I think there's this episode you give. But you can't just say, "Do that as well as everything else and we won't give you any support with the developers and resources." It's just time. Time is the other huge results. Do it as an evening hobby. It do as well. And I was always very clear about showing me that you have caught the time because of course, often, the people who have volunteered to do the leadership are also doing the research and they're the busiest in clinic and they're doing the teaching and they're doing the politics, exactly. So, I think in re-engaging and re-igniting the clinicians, in making it easy for them to do their work. So, one of the reasons I work with you guys, you know, using the products that you've got, enable clinicians to perform the optimum of their potential and take out some of the cognitive load associated with having the clunky systems and processes that we've got. So, that's the kind of right here right now stuff. I've used PlanCare and you know, bits as examples, but by and large it's a consistent approach. Bring the clinicians together around the data, give them the opportunities to improve. Second thing is empower the patients. And I'm a great believer, you know, and the words I often use is give the patients more agency for their own care. And that's where the app, I think, has just got extraordinary potential over time. My standing joke is, you know, I've got an underlying chronic disease, which is GATS, which I'm trying to re-brand as the disease of the former Olympian athlete. So, I actually ordered my alipurin online biomei within about 30 seconds. I haven't seen a doctor or a pharmacist for years. I don't need to. I don't want to, you know. So, there's something about taking me out of that system. I, where I, where there's an appointment at my GP practice, you know, that I've told you the story. When I try to renounce in GP for years, and they said you're not allowed to get an appointment here until you've got a three-digital triage. Now, people have that's us. Yeah, you. People have there who know me. Well, no, this is not, you know, this is not my comfort zone. They said, "It's coming to your phone now. So, I did it on my phone really quickly in a couple of minutes. Then less than 10 minutes later, the practice calls back and says the doctor will see you at 11. It was absolutely fantastic. Now, there. And then you get into the other stuff. I mean, you know, all I can see the future where, you know, through these apps, you're getting all the health promoting stuff, all the nudge stuff. You'll get more and more remote monitoring. So, there's a whole stuff about giving the patient agency, enabling the clinicians to work to the optimal their ability. Then, then starting to, so that's the right here, right now stuff. Then you start to work on the shifts. Yeah, I think there's often a lot of concern with patient agency that it's going to create all this demand. But as a patient, I often have hospital appointments, I know I don't need. And they're impossible to cancel. I've tried cancing, and I just get a new one generated automatically. And we actually did an experiment up at LASTA where we called patients who had an appointment in two weeks time. And we said, do you think you still need it? 20% of them said, no, one of them said, thanks so much for calling. I was just going to be told the same thing as every other appointment. Oh, happily. Yeah, as long as there is another channel where if they've got a problem, they can get in touch. So, yeah, definitely agree that patient empowerment is. I think a lot of people agree it's the right thing to do, but I think it will actually have some much more immediate operational benefits of these patients. Yeah, I think that's right, Jacob. If you put these two things together, you know, patients initiated follow-ups is kind of what we're talking about. Him and his, it's the Piffu stuff. If you look at the variation across England or the utilization of Piffu, it's just, you know, there's loads to go. And of course, you're not going to your outpatient appointment to be told that what you already know or you've been told once before means the slot is available for them to see somebody who does need to be seen. It's a win-win. Well, I know. Because it's so hard to reschedule a can sound left with this moral dilemma. Maybe you know the answer. I've never been able to get it. Is it worse to go to an appointment? You know you don't need. It helps my wife's doctor and she can sort of clinically verify I don't need it. Or to DNA. I don't know the answer. Are you shouldn't DNA? Don't DNA. If you're not a patient. If you can't cancel it, you've tried day after day calling up. Well, going on. We need to find ways to enable you to cancel it. Yeah, well, no, I can definitely agree with that. I didn't DNA, don't worry. But it is really interesting. It's because 85% of the weight in the list sits at the non-admitted end of the pathway. 85%. If we got the validation right, if we gave patients different ways of communicating with the organisation, which was able to make well informed, the people behind those patients are, they're all off. They know if they're better all worse. They know if they need to be seen. Well, also, the reason there on that list in the first place is because they went to their GP to say I have a problem, right? In most cases, unless they've been referred to. That's right. Yes, indeed. But they can't. So I think there's a loaserscope of using the multiple channels to empower patients more, both in terms of their own health as well as their own health care as well. So I think it'll be a bit of both. I think Piffy's like the best concept, but then just the implementation dies in a lot of places. We end up in these debates of should 3% of patients be able to get in touch or 5% or an outlier with 13%. But imagine a GP practice where they're saying, "What percentage of our patients should we let contact us?" It would just happen. But what you can do, you can. What you can do is you can do improvement work between and across practices. If you've got two practices who are 200 yards apart, looking up to probably similar communities of patients, and you've got the fairly different Piffy rates, well, you need to have a conversation to look at why, don't you? Well, it'll settle. In general, practice has been doing Piffy since forever, right? Because anyone can get in touch. I mean, it's now this. Imagine if your GP practice at David will see you every three months, whether you need it or not. If you need it sooner, go to A&E. I'll get your point. No, get your point. So then, what do you say, you speak about K-DOT? David as with this huge privilege with a lot of pride very like clearly just I mean unprecedented time became the cliche but it was it we couldn't be more true. What are some of the other proudest moments leading up to that? Yeah so it's good question so I've been really lucky actually so I've really enjoyed all my jobs and you know my first half of my career well yeah the good first chunk of it was spending community health services you know in district nurses and health visitors and you know all that sort of stuff. I remember working to the tennis down Daniel Wake on a thing being part of the team but I looked at the Winkentish Town Health Centre you know back in the day. I love I you know her and get her and get primary care trust you know I fondly remember little things like the winter slipper exchange ski where we used to get you know when you get people with a slimy bottoms you slippers that you haven't changed for years. We need a free slipper exchange ski with you to stopping people for to go slipping and having falls in the winter. That is the prevention and health. This population health that is us looking at the data segmenting the data and identifying that the intervention is with as you say slippy sugar. Slippy slippers and that's the shift from treatment of McAfee Mr Prevention. Exactly so I've been low sort of thinking it was fun as you can see I was wondering about I love the bit of that. I really had a great time at the Wittington I enjoyed the Wittington I love we opened the new hospital that we did the PFI there on my watch which was again was great and then going over the heat to the raw fricking. Taking the raw free through the process of becoming a foundation trust was again a great really thorough and jaw authentic because it got the hospital right up to match fit you know it was you know we were picking up a clear about our strategy our policies we had the models right what are some of the things yet like practically what are some of these yet to sort out become a foundation. Well so you know in a way you're talking about are you being it's all about the government actually many ways from that are you well government and there was a whole framework that you needed to look at but basically you need to be really good at your strategy you know you you had to really think it through so then you need to think through okay that is the strategy what is the plan that we've got over far be as to implement that strategy how are we going to resolve sin and the resources of course are people and capital people buildings and IT is what you've got actually and what you've got is the other results you've got is the money to pay for all that and you've got to work that stuff through you need to get your leadership you need to be well laid and so it was you know we built all of these things and we and it was good you know we did a good FT application we did a good board to board as they used to say and then of course we got going and of course shortly after that we acquired Bonnott Hospital and Chase Farm hospitals which again I'm absolutely clear was the right thing to do again you know for me a privilege bright learning you know really great learning and pretty short after that we knocked down one of them we knocked down Chase Farm built rebuild Chase Farm was the most digitally enabled the hospital in the NHS of the TARG which again was I mean it's you know isn't it but the other thing is I don't know what I love the Mosque pit you know if you really want to know what I loved you know I love getting out of the car and just you can you can smell outside the hospital you know what sort of night it has been and what you are going to be going into I still love the doctors and the poor you mean the fires yeah just not just in them in the middle with the down the way I was used to say the job is you've got to find that where the riot is going on and going standing the middle of it that's what you've got to do you know the if you had a time the Gemba in like Toyota so I'm trying to manufacture it's the Japanese time of like the place where the work happens so dear that you know leaders should be spending at least 20% of time in in the Gemba you'd probably argue more than that but you know walk your own line they're not car for it that's right no nice I know I still love it I mean I love the visceral nature but I like to say I was very proud and thoroughly enjoyed the work we did across London about the R-ambition to make London as a world's healthiest global city so and the other thing I've said we should have reflected on lately is towards the act towards the back end of my NHS career as well as this contenty stuff is the real thing you try to do is bring on the next generation you know so you know you have a role and a responsibility actually to mental and coach and develop and I'm really pleased pretty proud actually if you look at the people I work with on my teams you know Caroline Clark went on to either Chibisakler or Freed and actually is in charge of the NHS across London Katie Don Laby was on my team she's just been appointed as the ICB Chibisakler in South of us London Peter Ridley was on my team he's currently the acting Chibisakler of Malfield Steve Powers was on my team he became the medical director of the NHS you know there's a whole you know there's a whole stable if you like of people that there are more I'll stop there but there are you know that particularly as you get towards the letter and if you go that's what you're there to do you provided that for you well I had I had the person the two defining people that so there's something called Louise Smith Louise Smith was the chief executive of Camden and Islington Community Trust where up with Chibisakler for about a decade and actually he's interesting when I go about the chair was one rabbi Julian Noriburger who was the chair back in the day who's of course now the chair of UCLH and Laby was great you know he told me about the importance of clinical leadership he really did he told me about a professor Mike Ardler was there at the time and he was the professor of AIDS at the chief president of GUM and I really learnt about importance of clinical leadership and patient engagement actually working with Louis if you have a service which is really clinically well-maged and informed by the needs and direct input of the patients and as good a date as you can get because we were learning there so I learnt loads from Louis a lot from Louis and I learnt a lot from my last chairman Dominic Dodd who was my chairman for we worked together for a decade and of course there have been others around the ball tables so I've worked and I've worked in a quite few of them now over the years but it's very different ways actually very contrasting ways Louis and Dominic I learnt an awful lot from as the people that I worked for and I always advise people when you're looking for your next job don't even bother reading the job description just look at who your boss is going to be because what matters is who you work for so what how do you just still greatly leadership then if you think that's you look at your bosses have heard these these anecdotes of the junior doctors seeing you on Monday morning at a Monday morning reception like how do you just still so I think I think people people have heard me talk about this so I think in leadership in the NHS is about being relentlessly patient and citizen focused yeah absolutely patient citizen focused secondly eternally optimistic yeah optimism is a very very precious commodity and now it's hard it's hard out there it's really hard that's not but you have to be optimistic is it if as a leader you're not optimistic well what the hell the front line going to do you know you need to lead these people so optimism and the third the third thing is making decisions and doing difficult things you know that's what for me it's about patient citizen focused optimism and being decisive and getting stuff done so another there's another one I think is very powerful actually is in a how you do it you have to lead with humility and conviction yeah so humility is really important yeah you need to listen to people you need to ensure that voices are heard do not assume that you've got all the answers yeah but when you've listened when you've decided what you know you lead with conviction you know you don't go half in you know you go all in I've heard this from assists sad barker consultant Wittington telling me about you in meetings of gay grounds what do you think what do you think would it and then and this is my decision yeah that's right and actually well my experience is if people feel that their voice has been listened to and I use that we're going to say who their voice has been listened to but the on balance the decision is we made to go in a slightly different variation they will work with it yeah contingent on them knowing you have listened to what they've got to say and you've factored it into your decision making and somebody's got them and by large frankly if you do that if you listen to what every else has said you think oh well I think it's probably that they've faced so you believe in you at some point you've got to follow your gut yeah well well it well what I'd say is most decision making most decisions are about two things about data and judgments yeah so in a way that guy was gathering the data isn't it then basically you make your judgment based on your data and the more you practice the better your judgment becomes you know if you look at the medical more they call it medical practice for a reason you know the more you do it the better you get so what about the so there's some of the things you're proud of and then we could probably spend the next hour talking about more of lots of these examples. What would you say some of the failings of the mistakes or the things you really learned from what I've been? So, so what how I describe mentoring, yeah, is enabling someone to make a totally different set of mistakes to the ones that you made yourself, yeah, so coaching is different, but that's what's mentoring. Often the mistakes make it's not about what you've done, it's about how you do it, and sometimes I think I could have been occasionally kinder and more thoughtful about with certain people in terms of the way I made the decisions which maybe if I just spent another couple of months waiting, it might have been a better so there's something about it. You put that again the more you practice the more you get, yeah, I used to think about when you know, like daughters think a year was forever, you know, it's the only the older you get the year is 20 minutes so so I think it's a special year in nature. Exactly, yeah, so there's decisions about timing, yeah those are the ones, those are the ones I try to try to think I don't think of well, I mean loads of mistakes all the time I was doing the day-to-day basis, you know, getting things right, I think most of the big calls, the big calls I got mostly right, so the mistakes we were about how I did things, rather than what it is, and then probably you know, probably should have been occasionally asked, asked the next question, so again my strength is probably my weakness, is I always say never like the best, be the enemy of the good, and sometimes maybe I should have spent a little bit more time, just digging out, asking the next question before I made the decision, rather thinking that's good enough, let's go. I mean, getting the good reflection, getting, sometimes getting there how wrong but not the what, but I think it's better that way around than getting there, who won't, I've definitely seen the third point you mentioned around leadership around being able to make the difficult decisions is every leading clue, myself being a much more scale on that journey, where leading in sort of easy times is in good times is easy, but that's the real task. And you've got to make the call, I mean, you know, what I did when I implemented an EPR, I didn't have a few EPRs, but I remember getting the team together, you know, so I said, well, we're going to go up to my cell and I'll judge you all on one thing, which is how you behave when it all goes well. Yeah, that's the only thing. Because the only thought I knew is it would all go wrong. Yeah, and it did. It was powerful and they've been told that. But that is all that matters because the only thing you know is it's going to go wrong. And then you just put it right again and then you'd come to the next thing. Yeah, this is the role. You'll never run out of things to again fix. So, I mean, what are some of the, you said you love being in the mosh pit? What are some of the interesting things you've learned on the picked up for the front line? I'd love to know what I think you saw and then that had a big influence on more strategic decisions. Wow, you know, so what the important thing is to give, you know, to give people the opportunity if you want to speak truth unto what they perceive as power, you know. So, you do get, take a side and say, I remember, again, some of the reporters saying, you know, we've just had three portrait post cut and that means we're not going to be able to get to the patient as the operating the others quickly enough. You know, all right. Okay. All right. Now, they've got, I'm not saying they're wrong or they're right, but there's a bit of, there's a piece of data there. And you've got to do, and you have this other bit of data. How expensive a theatre is to be? Exactly. Yeah, I, I, I, I, I, I, I lived local and, you know, you get these great things, but you know, suddenly realize all the, well, the patient's letters are getting sent out and then arriving at people's home the day after the appointment was due to take place and then you find that that's because of one intended person has started sending things, second-class rather than first class, as far as the spending program, you know, it's dying. And, and, and, you know, the, the clinicians will, will tell you about some new stuff that's coming, some new technology that, you know, that you need to think about. Although, you know, people, people will say, no, do you want to, you want to, you want to, I'm a little, what's going on in there, David? You know, well, all people say, so they're often people say, this is, you've seen this, it's fantastic, you know, what there's, um, Guy called Don Berwick, who used to run the Institute for Healthcare Improvement, who was actually Jeremy Hunt's brought him in to be a safety adviser during during the hunt era. And we invited him to the raw free actually, came to the ballroom, I'll never forget what he said to me, so, that he, people comes to work to do a good job and to be noticed for doing it. And that third point is really, really important. So, how is it, what, sorry, the third, but the comfort, the good job of being noticed right, so doing it. So, when I was, you know, at first I used to feel up here, kind of, go, when I used to go and visit on board, you know, I think, sure, you've got better things to do and spend, I mean, the way, yeah, I'm in the way. And there's the alarms going off over here and they're going on. So, you, so you, and of course, the other thing you get is, you know, you find out something good is happening over there, yeah, and the next time you see somebody over there, you tell them about the good thing that's happening over there. So, you get, you know, it's, it's probably a very expensive way of spreading innovation, you've been walking around all over the place all day. But I still love it. And you do get to speak to the patients, you get to hear what they're thinking about the place. You can see if it's clean. I'm, you know, just as if the chief execs doing a good job then. Who are you really proud to showcase? I don't know, it's a good question. So, I, I, I think I'm always very happy to share the things that I've been involved with. And it's not about me. It's always about the teams. It has a point of the team and a lot of things for me is the job of the chief executive is to appoint the team of people all of who were better than you and to get them work together as a team. That's the job, really. Now that's easy, really easy to say. It's difficult to do, but that's the job. So, you know, you should showcase what you do well, but also I'm very, very happy to tell people the things I've got wrong, you know, I've got, come, so I wouldn't do that if I were your arduous. It was absolutely disaster. You know, just sharing, you know, it's, yeah, so, so I mean, I, I, I do think the, the hospital we built up at Chase Falls, interest, it was how those, you know, we got the bar operating theatres, how they work, it's interesting, how they can you explain that. So, what you've got, the wall, wall, they did, well, you know, it was not my idea, but we, we backed it. There's something called a bar operating theatre where what you've got is four operating tables in one theatre. So, you get, interestingly enough, you get increased productivity and increased safety because people are looking across. And actually it was, I kind of, I was bloody crying, I don't know the cry of the other day, wasn't the, they get a day from the raw free on the BBC. Yeah, yeah, I saw that. And they showcase the bar operating theatres and, you know, all, all my, chums and colleagues and this and, you know, so it was really moving for me. It felt very perfect. Yeah. So, so, but, like, coming back to question, I mean, I think, I think, I think, transparency is really important actually. I mean, there's taxpayers money, you know, we have responsibilities to demonstrate what we're doing with it. And to share the things we do well, as well as to learn from the things that we, if I made a mistake doing something, my job was to make sure that nobody else makes the same one. You said, so, It's certainly the moment, obviously, there's a lot of pressure on the system, the sort of change in the system now. If you were running, you know, I don't know whether to call it NHS England, anymore, if you were running the centre now, what are the things you would be trying to make happen? Both you spoke about some of the longer term things around empowering patients using clinical leisure, but also the immediate, you know, to the immediate problems. What, what are the some of the things you'd be doing? So, so, sometimes people ask me, you know, they, they, there's a more than question, which, basically, says, how do I manage today in the context of tomorrow? You know, that says kind of all balls down to me. How do I plan for the future while I do the day job? And I would say, well, the way you plan for today in the context of tomorrow is why I'm planning today in the context of tomorrow. It's what you've got to do. It's the job, you know. So, you have to be focusing day to day on making sure the patient's the safe and making sure that you are doing everything can. You achieve the performance and access targets, which are part of the mandate from government. But nobody would disagree with that. Like, at the centre, what would you do? So, so, okay, at the centre, I would be trying to narrow down on a tighter set of processes that objectives, which actually the centre is doing. To be fair, they're getting them on that. I would be given what, given what they're the names that they want to do, I would be as structured and clear as I can be about the milestones and the steps that I will need to go through to create new code, as I'll call it, for short-hand, which is the new organisers that will be together and it's a, because I think you want to get as much certainty into that as possible. As soon as possible. As soon as possible. Because the risk is you get delays in decision-making and you get distraction and versus. I didn't do something that the magnitude of the task that they're taking on. But when I did the acquisition of Bonn and Chase Farm, having a clear integration plan, being clear about what you're doing was reading really important. And so you have to make that as as undistracting as possible, safer than knowledge, I'll say that out there in the GP practice around the corner from here, life's just carrying on as there's nothing's happened anyway. So that's probably more important. So I try to be clear with the providers and GPs where we love them to prioritize their efforts and energies. Yeah. So if it's the weighting, this is the weighting list. You know, if it's getting your cancer screening work, you know, whatever it is being as clear and precise as possible about what you want people to do without telling them how to do it. And then to be clear about where your accountability and where the accountability sits and the performance management structure that you put to place to ensure people are held appropriately to account for what you're asking them to do. People have been saying for a while now. And you know, you know, you know, it's dead to eat that. It's though, it's almost a plunky loss. There's a lack of clarity about where accountability sits. People want to be much, much clear about what they've been to do, what they're only is with a tight set of priorities as possible. We haven't told a lot about the, you know, the third of those shifts about the animal to digital, but much of this change is going to have to be and can be digitally able. The stuff we've gotten out of that we didn't have when I started in my career is we've got data, but we've never had before. And we've got digital technology that's simply didn't exist. I am a TV. Yeah, I'm a TV. I'm a TV. I'm a TV. I'm a TV is fantastic. Now my TV should know, right, all the fat 64 year olds with counts and whatever else I've got, where are they? What do we need? You know? And you can use your predictive analytics to say, OK, we're on my list is most likely to end up with this or in there, you can plan that in ways that we couldn't even follow you. And then you're starting to change the model, which started to start to start because one of my concerns has been a lot of the person digital over the last couple of decades hasn't been changing the model. It's been like, you know, you still come for that appointment, you may not need, but we'll send you the letter electronically. I totally agree, this is about, so this is not about digitalizing the existing model OK, this is about having a digital label channel shift. Yeah. But do you think that's going to be led by the center or that's going to be led by the providers or that's going to be led by the staff on the front line? The answer to all those questions yes. Yeah. So, so, so it is already been driven by the public actually. I mean, what the public are increasingly saying is we all day today are interacting with the world through orphans, yeah, through our apps. The experience of the interactions with the NHS is in a different place to the rest of the world with which we play with. And so there is public frustration actually you've described why the hell can't I cancel the appointment? I don't particularly want to know my solution is every six months. I now reschedule it for six months time. Very good. So it's reverse engineer Piffy. If only every patient. Everybody did that. And do you have any contrary and ideas for a form stuff that you wouldn't have been able to say when you're in MHSC but now you're outside the system? I don't think so. I think you see I think well, come on. I think the Darser report was a very very good piece of work. Yeah. So I think the left shifts make evidence sense. Yeah. The third thing I say these challenges are global. Yeah, it's the same wall. We never unstruck everyone's struggling with the same thing. I think one of the things which is easier for me to say now that it would have been when I was in the Halsers, which is something I think that Amanda Pritchard said when she was there towards the end is I don't think there is ever going to be enough public sector capital to fund the level of transformation that is going to be needed in health care systems. So and so we might not call it PFI, but how we work in partnership with industry, you know, to look at how you, you know, there's a range of options only for buildings, for equipment, for tech, you know, looking at a different range of options. I think is worth it. Yeah, the other thing is, you know, the industry is spread too simply. I mean, we've got too many hospitals, we've got too many GP practices, we need to scale up. I'm not saying things I didn't say when I was there, but I guess it's very is really really really difficult. It is again, for me, this comes back to transparency. Yeah, we need to spend more time looking at the outcomes data. Yeah, which says, I would speak to some, you know, it's all about the end number. The more patients go through a service of the better, the outcomes eventually, the greater the ability to attract an investment from industry. Now, you need to trade that off around access. Yeah, so and it's basically, it's quite interesting. I learned so long in my last job about why I used to call geography, demography and infrastructure of the reason. So that all of the seven regions got very, very different geography. I mean, again, London was, I think, it's 670 square miles in a city with the best public transport infrastructure in the world, by all accounts. And that's because it's commissioned by the mayor. There's a single commission that says, it's fully as a manufacturing in the bikes or the camps or the trees or the trains. It's an integrated integrated system. So, so you know, that's the geography, the demography, 42% of the population are from black and white and white, the minority ethnic backgrounds, and it's five years younger than the average population of the UK. And it churns like Billio. It just does it's still as our service in jelly ice to describe it. And if you look at the infrastructure, you know, how many hospitals can you get to within a 20 minutes cycle ride of your house? It's fans are faster pedal. It's health for you know, it's yeah, it's and and the other regions are different. You know, I wish to speak to who are, it's a great, great colleague actually, at least of them are only down in the southwest. And you've even as the geographically the road distances and the transport infrastructure is just a totally different kind of a fish, you know. But yeah, so it's interesting, that interesting, different. We've seen a lot of reorganizations in your time. So I've you've seen how they, if you've seen previous ones have the impact, have you seen any of them? Have the impact you'd hope? Well, it's well again, fuel. So all around the world, somebody has got something right as well, I would say. Yeah, if I mean in parts, if I look here, I know there's a moment when we would the NHS was doing really well at hidden the access targets, balancing the books. Yeah, it was it was in good shape actually. So there have been months and that was when all the levers appeared to be about in the right place. The foundation trust movement was just getting going. There was money, you know, so the NHS was well-resolved. There was more money coming in. Yeah, the modernization agencies, whenever we learn to stick opposed to it notes on the wall, if you like, I'd never stuck opposed to those of my life before that. And it was it was doing all right, actually, it was good. I think if you look at coming back to really a question about what we should be doing now, we should be trying to learn from what worked really well in the past. You know, there was there was more the involvement of the how? Well, the slippers. Yeah, exactly. There's much more involvement on the how. Yeah. And in senses, we're in slightly different places. On the global piece, we've seen from being in the weeds of general practice. And one of the things we forget is the benefit of capitation, which we we've seen up to 40% of what would have been appointments being resolved through messages to being resolved, they think, honestly, and huge productivity getting faster. It's a better experience for patients. In most other developed health systems where you are paid per appointment, your questions wouldn't do it. Whereas here, GP practices have a big incentive if we can provide as good if not in also cases better, more accessible care. With less staff time, we'll do it. And so I think yeah, we shouldn't forget the conditions we've got here that are so. And yeah, kind of thinking is where you head in direction of the ACO model, isn't it? Yeah. So what you do is you just lift that up to the next level. So you're looking at how you manage that to the financial risk right across the pathway, not just in one element of the pathway. So you're absolutely right. So finally, you said, you could lead ship, you could have been optimistic. I think Colin Powercore that forced multiply, you've got to be hungry without appearing hungry and cold without appearing cold. And you know, what keeps you optimistic? So if I, well, let me just click what keeps me optimistic in the NHS is I do think if you come back to those dollars E3 shifts, yeah, you know, same as to prevention hospital to community at Annalty Digital. It's that third bit that gives me optimism about our ability to do the first two. Yeah, we have data and technology. And new medicine and new drugs and new therapeutics available to us now, which we have done in the past. I think the opportunities in those areas for prevention, the biggest, I think the biggest potential gain is secondary prevention. You know, we now have got new medicines which enable us to identify new techniques to enable us to identify people who are at early stages of disease, whose health we can optimize to make new medicines to therapeutic. And also if you look at something like type 2 diabetes, we know exactly how, we've known for years how to manage it, but actually making sure a patient gets their feet checked, eyes checked, you know, renal functional of that blood pressure is a, that's a technology problem. That's a simple technology. Exactly. Reminders. Yeah, exactly. We didn't have this, but we didn't have a list. No, the other way. The technology. I mean, the game changes and the obesity medicine. I mean, that's the sixth, first thing we've had, isn't it? It's just a huge thing. The shift from hospital to community, I mean, I, I, I advise a company called Dockler, so put my hand up to the complot here, but they run virtual wars. We, again, we, we didn't do that stuff before that is looking after people in community settings, who traditionally would have been looked after in hospitals, you know, so. So your career is now going from community to hospitals, don't you think? I'm trying to put it all back to the community. So I do, so I do, so I do feel optimistic about this. I do feel optimistic when I meet people like you. And actually, when I meet people who've got great ideas about how we can really transform the, you know, transform services, I still, I still get inspired when I mean, you know, sort of these, you know, young doctors and nurses and physios, you know, just, just, let us fantastic. You know, they're still full of energy, full of comfort. They really want to get stuff done. There's so much pent up innovation. There's so much passion, there's a bit of innovation. And I, you know, if you look at the old fashioned, it's all very old fashioned now, but the old mass loads hierarchy of needs, if you like. But in some way, tell me, remember the boss, you said he's never worked at an organisation with so many of the possible equipment with things or absence. And so I just, it's not about motivating people. It's about taking the stuff out of the way that is demotivated, standing in between. Why? That should be so much easier to do. So much easier to do. Optable of their potential. It should be. Most organisations would kill to be in that, as they shouldn't work. They want to come to a, they want to come to a, to do a best job in the interest of the patients in the community that they serve. Of course they do. Well, there we go. I don't know if, if we could get a more optimistic note to her. Good. To end on, pent up, pent up our innovation and optimism. Well, thanks a lot for joining. I'll keep plugging for your next, your next award there. Yeah, you go for that. You go for that. And, yeah, really appreciate you sharing these, these candid reflections and, and being, say, being so open, especially with some, you know, relaying some quite challenging memories through your Covid. And, you know, on behalf of all of us in the population who are on the receiving end of all this, you know, all the services, just a big thank you for 40 years of serving health care in the NHS.