Steve Podmore:
00:11
David Haslam has spent his career shaping the health service. He's worked for forty years as a general practitioner and then scaled the heights of the health service to be the president of the Royal College of General Practitioners, the president of the BMA, the chair of NICE, and a number of other really quite incredible roles. He's also written a book three years ago, Side Effects, and it it really has, had great acclaim from Waterstones and from the Observer and from many others. And it digs into, how the NHS is broken and, and and what it takes to fix it with compassion and consideration and, and great sense. So I'm looking forward to getting into the discussion today.
Steve Podmore:
01:03
We have had a a pre discussion, just a few days ago, we covered some of the subjects. And, for Let's Fix the NHS, the goal really is to dig into what's necessary, to, address the systemic challenges within the NHS and to, really figure out where the solutions are gonna come from and to help craft them. But to get started, David, welcome. Is it sir David or or David? What do you prefer?
Sir David Haslam:
01:31
Please, sir David, only when I'm booking restaurants. Otherwise, David, please. Thank you. Not that it ever makes any difference in a restaurant. It's worth trying.
Sir David Haslam:
01:43
I
Steve Podmore:
01:44
would imagine if you go to The United States it could be a little different, but there we go. So let's just get into it by talking about the book, and what kind of response have you had. It it's, probably over three years now since you, sat down to write it, and and obviously, COVID was was going going strong at the time. So, yeah, just kind of curious as to that experience just to get us started.
Sir David Haslam:
02:13
Well, it's it's been fascinating. It's really good to talk to you, Steve, because this whole issue of trying to fix the NHS is what's brought us together. I was really struck by the fact that the NHS is struggling, and it's been struggling for most of my professional lifetime. I'm a total fan. I believe that the concept of treating people without the need to worry about how you pay for it, offering quality based on need rather than ability to pay.
Sir David Haslam:
02:48
I think that's one of the great great activities of humankind. I mean, I I know that sounds a bit cheesy, but that's that's the way I feel about it. The NHS was a 64 old when I was born, so it's been a real core part of my my life. But what I've heard, and as you kindly said, Steve, I've had a a large number over the last couple of decades of leadership roles, and I've worked at the at the top of the health service. And I keep listening to the same answers coming up that we need to to do this, that, or the other, but never quite seems to shift anything.
Sir David Haslam:
03:30
So we keep having restructurings, different ways of organizing things, and everything carries on very much the same. We have some wonderful care. I owe my life to some wonderful care that I've personally received. We have some unacceptable care. We certainly have levels of waiting that are completely unacceptable for so many conditions.
Sir David Haslam:
03:54
But I think the thing that struck me is that you can't answer the question if you don't quite know what the question is, and and it feels like the question is, what do we do about the NHS? And that's not quite enough. You need to know what's what's wrong with it, what is the problem, and and you're only gonna be able to answer that if you know what it's trying to do. And that might sound a very simplistic statement. I think if you or I are ill and we see a doctor, we know what we want them to do.
Sir David Haslam:
04:29
They want we want them to sort us out to get us back to health. But is that it is that just it on a national basis? Is it is are we trying to deliver health? Are we constantly expanding the expectations, the offer? If you've got a constantly expanding offer and a constantly changing offer and a fixed budget and near infinite demand, that's gonna end in tears.
Steve Podmore:
04:58
So you have to start looking at these things. As we talked about the other day, it's like infinite growth on a finite planet is a mathematic impossibility. And and and that need and that perception of need does expand significantly. People are clearly living longer. You know, you mentioned when you were born.
Steve Podmore:
05:24
And if we take the number of people on the planet then and and now, it's roughly doubled. And that that in itself creates a need. Well, on a yeah.
Sir David Haslam:
05:37
On a simple human level, part
Steve Podmore:
05:41
of
Sir David Haslam:
05:41
the reason I call the book side effects is because a lot of the problems that we're facing are side effects of previous previous work, previous good intentions. Sometimes this is down to policies that governments have come up with. A classic one I talked about was the the drive by previous governments to improve access to general practice, which was a fantastic idea, but it destroyed continuity, and there's lots of evidence that having a doctor who knows you and who you know is a good thing, but unintentionally, a side effect of trying to get access better destroyed continuity.
Steve Podmore:
06:16
Well, I find I find that fascinating. Sorry. I I find that fascinating in multiple contexts because, you know, having we talked about my mother's, stroke and and the fact that she was, four months initially and and and then after a second stroke another month in hospital. And it it just dawned on me that the the amount of time spent on handover, it it's just it's just crazy. And and not just I'm talking between shifts.
Steve Podmore:
06:44
You you virtually never even in that time, it's very rare you see the same clinician, the same doctor, the same consultant. And, you know, and then I thought of that in the context of the the general, you know, general practice, it's the same. And and in your book, you highlight that, but my question is how do we how do we in this modern data driven world where there's a lot of information, how do we do we go back to relationship based medicine? It's almost like banking. You know, we talked about finance as well, and and one of the big, criticisms is is we've gone into a data based banking world, as opposed to a relationship driven world.
Steve Podmore:
07:28
I think a hybrid is ideal, but but how do we systematize that? How do we create that? That's the question.
Sir David Haslam:
07:35
Yeah. No. That that that's absolutely right. And the technology is gonna give us a a lot of help in this. It's inexcusable that people have to repeat their medical history over and over again with every clinician that they see.
Sir David Haslam:
07:50
It is completely barking mad, and I don't understand why we haven't been able to sort that one out. Again, it's probably because of the side effects of very reasonable anxieties around confidentiality and issues like that, which are really important. But, you know, the excellent has been the enemy of the good, and we're nowhere near the good in terms of of this yet. But, yeah, like in banking, most of the time, most of us are very happy with our apps and very happy with, an ATM machine. But now and again, you need advice, you need help, you need a human, and it'd be quite nice if that human knew you.
Sir David Haslam:
08:27
And the thought of that in the banking sector now is laughable. In the medical sector, it'd be great to see be able to see the doctor who knows you. And I'm not I'm not being cheesy about some 1950s style, always there, twenty four hours a day doctor. I'm just talking about the ability to sometimes be able to talk to the person who knows you. And some practice my own general practice is now trying to work I'm I'm not practicing anymore.
Sir David Haslam:
08:55
I'm a patient there. It's it's it's doing all it can to make sure there is continuity, that you see the same doctor if you possibly can. They've recognized the importance of that, but that's all too rare, and I'm glad that at least in some of the government's pronouncements, they've talked about that being important and bringing back that relationship because relationships medicine is a mix of art and science, and the art bit is a human art.
Steve Podmore:
09:24
Can we go back to the, you know, that initial thought? What is the purpose of health care? I mean, you know, to lose its way, we have to figure out what that direction was initially, and it would really help for you to define, you know, for people who may watch this, what is your vision of the purpose of healthcare? Well,
Sir David Haslam:
09:51
when it was for the the arrival of the NHS, I think was fundamentally came out of the insurance systems that have been working prior to that, which were ways of trying to guarantee the workforce kept working. And the NHS, to begin with, I think part of the the aspiration was that it would deal with all the sickness that was stopping people being able to work to get UK plc working again. How many times have we heard that sort of thing? Also, there was the most breathtaking error of judgment, an assumption, right at the start that the health service would reduce cost because as you improved health, demand would fall, and it could not have been more wrong. What it what the availability of the NHS did was suddenly disclose the extraordinary amount of need and demand that there was there for for dentistry, for for, you know, for for for eye care, for, you know, glasses and all the rest of it.
Sir David Haslam:
10:53
All these things suddenly spread out and costs escalated and escalated pretty well from year one. And none and none of that is to be critical of people who seek demand. It's just to recognize that it keeps changing. We've seen this particularly in the the area of mental health. The definition of what is, mental illness or what is unfortunate and sad emotions is a difficult one.
Sir David Haslam:
11:19
And I'm not gonna even pretend to say where the barriers of that are, but expectations we've seen over generations have changed dramatically, which means demand for services constantly increases. You know, things that my father's generation put up with, I didn't put up with. My kids won't put up with things I put up with. You know, that's that's human nature, but it just changes changes the game, which is why I don't think it's for me or I don't think it's for any expert to say this is what the NHS should do, but I do think it is for the public to at least recognize there are limits and work out where those limits are, and I think you can do that through things like citizens' assemblies. This would not be an easy piece of work.
Sir David Haslam:
12:02
It'd be politically courageous, as they would say in yes minister, but it I think it's got to be done. We've we cannot go on the way we go.
Steve Podmore:
12:10
The idea around Let's Fix the NHS was really to give people a voice, and those people could be the nurses or the healthcare assistants or clinicians at any level, you know, or the GPs or those who are in care homes, you know, the whole system really I in talking to people, I found an awful lot of people felt helpless. And whether it's junior GPs who who want to go to Australia, you know, you know, TikTok and and and Instagram is full of people venting and and and saying how frustrated they are, and and that's really worrying. It it really is. But part of the solutions is making sure those solutions are crafted in the open. They're transparent.
Steve Podmore:
12:58
They're thoroughly stress tested. For people to have overall involvement gives them buy in. And that could be something simple like voting on an idea and listening to that idea, or it could be something significant like fully costing and formulating a proposal, it should be fairly and properly evaluated and in the context of the bigger system. Generally, those things are happening in dark rooms, there's not that much transparency. I think key to actually fixing this, if it's possible to fix it, you know, is figuring out where those problems are and listening to the solutions wherever they are.
Steve Podmore:
13:48
And and and I'm sure in your many years of service, you'll have found an awful lot of incredible solutions by the people who are at the conference. Absolutely.
Sir David Haslam:
13:59
There's wonderful care and wonderful things being delivered all across the NHS, but the trouble is they don't become generalized, they become localized. There's a terrible tendency sort of if not invented here, things tend not to get used in quite the same way. Often also it's just people don't know about them or people immodestly don't share them because they don't think they're that big enough a deal. You you can have, I mean, really simple things, really simple things like district nurses who who visit people in their own home, need sometimes in some areas to get a dressing they then have to contact the general practitioner, the general practitioner then has to write a prescription, the prescription has to go to the pharmacy, the pharmacy has to collect the create the prescription, the nurse then has to collect it and take it back to the patient. Now that is bonkers.
Sir David Haslam:
14:53
It's completely bonkers, but it's norm in so many areas, could be solved by ensuring the district nurse has sufficient dressings. It might mean things have to come out of a different budget, but isn't that what management is for? It's to try and sort that sort of thing out. Now that might sound really trivial, but actually multiplied up by the workforce that's the fourth biggest workforce in the world, then start looking at
Steve Podmore:
15:17
these things. All these things add up. So that brings on a very interesting question of what is leadership in this context, because an awful lot of leadership is leadership out of fear, and it's applying a set of rules, and it's not sticking your head above the parapet and wanting it to be, you know, for fear of it being shot off. And the reality is risks need to be taken. If there's no risks, whether that's the leader that would sanction that that, budget diversion or whatever it might be.
Steve Podmore:
16:01
Someone's going to take a risk, and if you avoid risk at all costs, it increases the overall risk. So I guess, how do you get leadership on every level that's fit for modern times? That's really yeah. Which includes that flexibility. That's such an easy question to answer in
Sir David Haslam:
16:20
a minute, Steve. I mean, it's I think a lot a lot of it comes down to tone. It comes down to one of the one of the problems that we've struggled with, and again, this has been the the metrics used to measure quality activity across the health service were brought in for very good reasons to try and ensure that people really did deliver, but over and over again we've got to the situation of the cliche goes in healthcare hitting the target and missing the point. So you manage to deliver the numbers that you have to deliver in terms of work done, but somehow nobody's happy in the entire scenario. We see that sort of thing over and over again.
Sir David Haslam:
17:12
So I think personally you have to free up local delivery systems. You I don't think you can begin to run something the the size of the NHS on a national basis. The trouble is the trouble is if you try and break it up into smaller units that might function more efficiently, then you get newspaper headlines about postcode prescribing or post post postcode postcode variability. How is it that in in Southampton you can have this and in Winchester you can't? That's a scandal.
Sir David Haslam:
17:42
But if you really want to deliver what's needed for a local local area, you have to have those differences, and we have to understand that. But politically Can I
Steve Podmore:
17:51
just throw this in? So I hate to talk about Rudy Giuliani, but I remember a number of years ago, he wrote a rather good book on leadership, I love it. And this was before, you know, his sort of, you know say again?
Sir David Haslam:
18:06
I have it on my shelves, and I think what happened to Rudy Giuliani in the in the Trump years has been a tragedy because that that was a great book.
Steve Podmore:
18:16
Unbelievable tragedy, but, you know, we take what he did in New York as as the mayor, and, there was something they used called, wasn't it? And and that's where they took the different borough chiefs and, heads of of the police force and the different and fire department, etcetera. And on a regular basis, they got them to share their best practice ideas. I think it was once a month or something. And they had a system of of capturing all their data for their crimes or fires response times, things like that.
Steve Podmore:
18:54
Essentially, they physically got these people together once a month, and they had to defend their drop in statistics or explain their their their improvements. And something about that idea struck me as as as being something that could work in an NHS context. Because when you have both transparency, whether you got, you know, comparable data and you've got competition, and and the communication process that that system, elicits, you know, it it could be something that could help people share that best practice more effectively than they're doing right now. And I think we have to look at other parts of the world for systems that have an an historic times when the systems that could be relevant and could be valuable. And I agree that the yes.
Steve Podmore:
19:45
It's difficult to run this on a national basis from purely centrally, but at the same time, if you look at some of the bottlenecks of the trust situation right now and the the the the differences, we've got to find a better a better way, a hybrid way where where best practice and excellence can be shared quickly and effectively.
Sir David Haslam:
20:05
No. I I absolutely agree, and you've reminded me something I've completely forgotten, which is nearly forty years ago, I was involved in running a series of evening meetings for general practices in the area of Cambridgeshire where I practiced all get together, different practices would get together each time in a different practice and the host practice was asked to talk about three things that they were proud of and three things that they found a real problem. And we all used to hear the proud things and say, those are great ideas, and take them away. And the things that were problems, typically, one of the group of the visitors would say, why is that a problem? Why don't you try such and such?
Sir David Haslam:
20:45
It worked an absolute dream, and it's a it's a model I need to to think about again because as I say, it was a long time ago, but it was exactly that sharing of of practice. But I think part of the the challenge has been the the I don't want to simply blame politics and politicians because we get the politicians we deserve, which is a tragic thought some of the time. But but so we guess at the moment, we've got the secretary of state talking a great deal of sense about some of his priorities. His priorities around focusing on primary care, which, as you'll know from my book, I'm I'm passionate believer in the importance of focusing on primary care, on prevention, on the potential use of tech. And that we all of those really, really important and got fantastic potential.
Sir David Haslam:
21:37
However, coming out of number 10 is the message that the one thing that really matters is the waiting lists for surgery or for being seen in hospitals. And so the metric on which everything is being determined is that one, which pretty well guarantees that none of the other three are going to at least succeed in the way that we would hope. So we've got this complete mismatch between political and and again, I understand the waiting list thing. I absolutely understand why number 10 would say, you know, we we really gotta get waiting list down. It's the thing that it matters to the population.
Sir David Haslam:
22:15
It matters to. But the more we focus on that,
Steve Podmore:
22:17
the more we So I I guess there's two words there's two words in response to what you've just said. Perverse Mhmm. Incentives. Absolutely. And and we have those all over, you know, our economies, you know, and and, all over our systems, public, private.
Steve Podmore:
22:39
But but, obviously, these political incentives, they're wanting, you know, people, special advisers will be telling him something simple, something measurable, you know, something that everyone cares about, regardless of whether it's good sense or not, whether it's congruent, whether it's aligned with the three shifts, which is what you're referring to. And I agree, you know, from a it's not I don't think those three shifts are are new, but I I do think that they're focusing on them is is But, Steve, that's the is a good strategy for sure.
Sir David Haslam:
23:15
The tragedy is not only aren't they not new, they've been said by almost every secretary of state that I've ever known, but they haven't happened Right. Because of the perverse incentives elsewhere in the system. That's where the real change is. So way, way back, prior to the Blair era, so we're talking early 90s, they were talking about a primary care led NHS, and it never became anything other than a phrase because because it's simply the focus was always on on hospital waiting times.
Steve Podmore:
23:51
So we'll come back to those perverse incentives in a minute, but, just for a moment, you know, just for a bit of fun, I'm gonna make you king for the for the day, for this session, and I'm gonna hand you £5,000,000,000, and I'm gonna ask you, how would
Sir David Haslam:
24:10
you allocate that? £5,000,000,000 to do what? Because if I wanted to spend 5 billions on the health of the country, I would probably put it in housing and education and possibly prisons. Now if you want me to spend it on the health service or or even more on social care, I mean, I wanted to spend 5,000,000,000, I put it on social care. If if we want to improve health, we do those first three.
Sir David Haslam:
24:36
If we want to get out of the crisis where we are at the moment, you put it on social care. Why we have this ridiculous boundary between health care and social care other than for fiscal rules? Explain
Steve Podmore:
24:50
explain that boundary and explain what social care is versus
Sir David Haslam:
24:55
I'm I'm gonna struggle because it's not a logical one. If, there are some conditions some conditions that are deemed to be health problems. Your your you've told me, Steve, about your mother's experience of of of stroke. Stroke is clearly a health problem which requires NHS input and the amount of care you receive may be variable and the amount of availability of nursing care in the home and so on may be very variable and less than one would like, but it it exists. But for some other conditions like, say, Alzheimer's, you're almost I mean, not quite on your own, but you're much less likely to receive any NHS support.
Sir David Haslam:
25:38
Now tell me why that makes any sort of sense at all. Social care doesn't just apply to the elderly and to applies to sort of younger people with various lesser abilities of one sort or another. But there is no logical boundary, but there has been boundaries drawn that says these conditions are health, these conditions are social, these we, the NHS, will look after you, these you're you're on your own sunshine. You'll have to pay for everything yourself. Now, that doesn't make any form of sense.
Sir David Haslam:
26:11
We then end up in this situation. What is it they say? Around about thirty percent of acute beds are being in hospitals are held by people who could be discharged home if there was someone to look after them. But if they go home, the what's wrong with them doesn't need NHS input, so they don't get anything, so they stay in hospital. Madness.
Sir David Haslam:
26:31
Madness. Completely the wrong place. And and and from 5,000,000,000, thank you very much. That's where I'll put that.
Steve Podmore:
26:43
I'm picking that. It's complex. Right? So I have an auntie who has she's my sole remaining auntie, and I've had quite a few, and she has Alzheimer's, dementia, and has done for maybe twelve years. She's in a home.
Steve Podmore:
27:02
She's been in a home in Bovington probably for the last six, and she's at the point where and prior to that, a couple of other homes that she was in. So she's been in homes for maybe ten years, and, you know, she's at the point she doesn't even remember the the village that they grew up in, you know, or or anybody, but she still has got her innate charm, that that she can tell anyone who comes up to her how she loves the blouse that they're wearing or whatever. But yeah. And it's complicated, and I've visiting my auntie, auntie Nora and others, You see people who who I mean, we we talk about sometimes taboo subjects not enough, and end of life care is is one of those subjects that has to be also talked about. I know it's something you're very passionate about, but what I've seen continually is people are kept alive past the point where it it it's reasonable for them to have quality of life.
Steve Podmore:
28:10
I'm not saying it in my aunties case, but I've seen it multiple times. And where does that fit in terms of is that care or is that NHS? And and that sort of endless antibiotic sort of treadmill and admission treadmill. I mean, these are sensitive subjects, so I don't want
Sir David Haslam:
28:33
to ride rough shard over people's feelings, but They're very sensitive and they're incredibly important, and I'm really clear that any improvements that we can do to end of life care, which we absolutely should do, mustn't be for financial reasons. I want to separate that completely out from the challenges for the health. It's got to be because it's the right caring thing to do for that human. You don't simply I mean, I I do not understand why so often people are rushed into hospital from care homes where people who are almost in the end stage of their life are rushed into hospital for where they die in hospital. The care home was their home home, the the the the clues in the word.
Sir David Haslam:
29:29
And sometimes I think that is just down to fear. It's fear of litigation. It's fear of we didn't do everything that we possibly could. It's fear that the relatives will complain. It's fear that someone will complain.
Sir David Haslam:
29:41
And that just feels we've made a misstep there. I've taken the humanity out of those last moments of life. Again, good palliative care can be fantastic, really heartwarming, if that doesn't sound a ridiculous thing to see. We're all going to die, so it's something that we should be talking about. But improving that is to try and avoid some of the overmedicalization of what is a normal step, but doing it for the right reasons, are human and humane reasons, not because we can't afford to do it in the expensive way.
Steve Podmore:
30:18
These subjects are difficult for some people to talk about. For those who are very sensitive and very emotional, it really is hard, and in a way, of our education system, you know, the the in Manchester, there is something they call it live well. It's a program to do, with health in the community and and bringing things like blood pressure assessments, and there's much that can be brought onto a community basis in order for people to live well, and it includes housing, and it includes some of the other social determinants, I think the term And that seems like it's a good model to follow. But in those community centers or religious establishments or clubs, In a way, we need to create a national health curriculum, or a local, you know, or adaptable health curriculums so these discussions can be had, and they can be less taboo. And and I think, you know, social media and and YouTube can help.
Steve Podmore:
31:27
This potentially can help, but it's one of the things that strikes me that, you know, going through it with my mom and and previously my brother, it is something that that hits you very suddenly. And all of a sudden, you've got to make difficult decisions when you're not really prepared for them. And and I think many people are in that same boat. And and the going back to care for a moment, the complexities around selling asset, paying for, you know, what what are people eligible for from their local councils? What are, what are they not?
Steve Podmore:
32:01
It it's a minefield. It's very complex, and it it doesn't feel as though it's very personalized. It it certainly doesn't feel it's very, errant in my experience.
Sir David Haslam:
32:11
It doesn't have to be this way. You know, it's quite simply we can't go on like we are because as you've said, pretty well nobody is is satisfied with the current situation. Many patients aren't. Many carers aren't. I'm not just talking about care of the elderly and so on.
Sir David Haslam:
32:28
We've we've talked about junior doctors, senior doctors, hospital doctors, GPs, nurses, physiotherapists, everyone's feeling this isn't right. This isn't how we want it to be. And an awful lot of that in my mind is to do with the almost the over industrialization of health. It's become more a transactional getting stuff done than doing stuff with people. And and and again, I don't wanna be cheesy about this, but the emotional relationship between carer and cared makes a difference, makes a difference to both.
Steve Podmore:
33:08
Now, ten minute appointments or fifteen minute appointments, That's a lot to build a relationship, isn't it, within a a short period of time? And and can we go back in in discussing that to that sort of 5,000,000,000 allocation? So, you know, to make the you it's it's not the end of the day yet. You still got, you know, some of it to spend. So let's go back
Sir David Haslam:
33:36
to how would you spend it? If I had to invest it in the NHS, I would very definitely invest it in primary care, and I'm not doing that simply because I worked as a general practitioner, I've worked in lots of sectors in the NHS. I'm looking at international evidence which shows that investing in primary care reduces health inequalities, improves overall health outcomes, improves satisfaction. Most of the I mean, one one of the great mysteries is is that if if you were to ask any secretary of state what you want to achieve, it would be improved outcomes, reduced inequalities. And what do they then do?
Sir David Haslam:
34:19
They put their investment elsewhere in the system, which seems to get more bangs for the bucks quickly. But investing in in in in primary care, in in high quality first contact, if that is carried out well, the overuse of the rest of the system can be avoided. Emergency admissions can be avoided. A lot of practices are now developing much more sort of social strategies within their practices as well where you you link population members who are frequently lonely. You population members.
Sir David Haslam:
34:54
I'm talking about humans. What a
Steve Podmore:
34:56
dreadful piece of cliche that was. Talking about human citizens, getting them to to just link together in a social way, and and In your book, you talk about this concept of medicine being developed for loneliness, which is like a crazy a crazy concept. I I mean, to
Sir David Haslam:
35:16
be honest, the current focus on obesity as being a problem that we have to treat with as many drugs as we possibly can, in the short term, I absolutely get that. Obesity is a massive problem for the health service in every sense in terms of heart disease and cancer and arthritis and all the rest. Diabetes is a huge problem, but surely the way to tackle this is around diet and lifestyle, and I'm talking about the food industry more than anything, And yet, we're now pouring the the Tony Blair Institute today as we're recording has said we should be pretty well sending on demand drugs to obese patients. They don't need to see their doctor. It just yes.
Sir David Haslam:
36:05
Short term, fantastic. Long term, madness.
Steve Podmore:
36:11
The irony is it's like a sticking plaster over an open festering wound. It's, yeah, you gotta get to the root cause of it. When you look at outcomes and measurable outcomes, I think the you know, you can track first of all, big pharma and big agriculture, they're two big questions, and we talk about perverse incentives. So, yeah, I mean, I know from the book, talked about your brother and your father, they would not have passed so early had some of the medications been around that are around now. And you also mentioned that you're not anti the pharmaceutical industry.
Steve Podmore:
36:52
I'm not sure where you stand on the food industry, but from my perspective, we're doing an awful lot to destroy our soil and to keep people addicted both with pharma and with food. And we need to to have a a planet that's sustainable and and and intelligent. We have to to really, rethink a a a great deal of how we live. And and I'll rephrase that. I don't know.
Steve Podmore:
37:22
I think a lot of that thinking has been done, but it needs to it scaled and and and become mainstream. But if you look at finance that plows into that farmer and finance that plows into those food industries, they push the extremes of behavioral science to sell and market things to people that are not always good for them. Yet they still use these serotonin inducing mechanisms to satiate people's appetites. I think it's
Sir David Haslam:
38:02
it's it's pretty pretty clear that a lot of the activities of the food industry over the last decades have been very similar to the tobacco industry in the 1950s when the problems of smoking were becoming medically apparent, and yet all the research as much research as possible could be buried. I I I find it deeply, deeply disturbing.
Steve Podmore:
38:28
If we go back to the per perverse incentives, you know, we how do we hold them to account, and how do we give people better choices? You know, when we spoke previously, you talked about, how the trend of obesity and and all of the all of the issues, it wasn't the same when you were a young boy, and and you think something's happened.
Sir David Haslam:
38:56
Well, I mean, classically, whenever you start talking about obesity, there was a letter in the Times a couple of days ago saying for heaven's sake, all people need to do is exercise more and eat a bit less and we don't need to worry about all this stuff. Now I'm always struck by photographs of the Woodstock festival, that's my generation's first festival. All the photographs of all the people in that, you could see their ribs. Everybody. They were all today's metrics, we would call them skinny.
Sir David Haslam:
39:27
I do not believe all the subsequent generations have just lost willpower and are just lazy and don't I don't think there was anything superior about my generation who was skinny at that age. I think the food we were eating was different at that age, and I think if if you look look at what's happened to the just go down any high street and see the average size of the average person, you realize something really quite dramatic has happened. Very taken by Chris Van Tulligan's book ultra high processed food, there's some really interesting work he talks about in that, but whatever the cause is, there's no doubt it's a societal thing, not just individuals being greedy and gluttonous and lazy, which some people would like to say. I cannot accept that. I don't think whole society has changed like that, but food industries certainly changed like that.
Steve Podmore:
40:28
We talked about the economics. We talked about my previous project or the project that's on hold, Transform Global, and the idea to to kind of create a financial institution that can get capital better deployed in a way that can, create more jobs, deliver more innovation, create more tax revenue, and and gainfully employ many, many more people than than than is the case with our concentrated capital, system. Major corporations are useful, but they don't actually, they strip out more employees than they than the the jobs that they create. Not always. There are some amazing large organizations, but, the the reality is we need to rebalance our economies.
Steve Podmore:
41:21
And if we don't do that, the poverty and the the inequity and inequalities, you know, just keep on increasing the gaps between those haves and have nots, are huge. And and so I guess my question is is the links between intelligent economics and healthy economies and a healthy population. How important is that? To your theory, something's going on. Could that be part of it?
Sir David Haslam:
41:51
Yeah. I think it's extraordinarily important. Linked to what you're saying, one of the things that always bothers me is the way that, certainly to the treasury, it looks like the NHS is always a source of demand rather than benefit. The the worry is always how much does this spend, how much does the NHS cost, rather than what benefit can a healthier workforce, a healthier nation make to our country. So it's always seen in terms of cost rather than benefit rather than investment.
Sir David Haslam:
42:27
Investing in health and improving the health I think addresses so many of the issues that you flagged out there. This widening inequality can only end in tears.
Steve Podmore:
42:45
Right. And that's where I I think, you know, in terms of, the innovation, getting innovation right the way through the country, and and and we need intelligent models of finance to help Yep. Fuel that. But we also need it in the health, you know, in the health care system, both internally and external to the NHS. So my view, one of the things we've got to do is is really have a sort of root and branch analysis of where we're overpaying for services, where we're not using intelligent energy, where we're you know, there's so much waste in the system, and often that's because many incumbents are involved.
Steve Podmore:
43:26
Now, the NHS is for sure free at the point of delivery, although we do have to pay for prescriptions, and we do have to, you know, pay for for certain other services, as you know, and and and and the like. But many of the suppliers into that system are private enterprise, aren't they? You know, and there's a big debate over, over the privatization of the the NHS, and and there's an awful lot of strong feeling quite rightly, and I write to the back of this conversation, you said, you know, you are a massive fan, and I am a massive fan. I think the principle of free and the point of service is should never be on the table. But innovation should be part of this, and and this hybrid system that we've got should be improved.
Steve Podmore:
44:22
Where do you stand on on getting innovation into this complex massive organization? I think for me,
Sir David Haslam:
44:33
fundamental principle should be who pays rather than who does. So I don't mind who does whatever is required provided the average person doesn't have to pay for it. What worries me is when the only way you can receive certain aspects of care is if you offer to pay. What worries me is seeing general medical practice, the risk of it going the way of general dental practice where theoretically there's dental availability, but for the vast majority of the population now the only way you can get timely care is to pay for it. And it would be an absolute tragedy if that happened, for general medical practice.
Sir David Haslam:
45:21
And I think if it happens, it'll happen by accident and by negligence, and, no one will claim that it was their policy, but it it it it would worry me. But in terms of the private sector being involved, I don't feel paranoid about that. I worry about, I do worry about things like aspirations to profit levels. Personally, I'm completely mystified by things like, you know, the PPE scandal in the in the in the COVID pandemic when I cannot imagine how people thought that that was a good time to make themselves rich. It's just not a thought that most of us would have crossed our minds.
Sir David Haslam:
46:02
But, yes, we need private enterprise to be able to help help us tackle some of these issues, and I have no problem with that at all as long as at the end of the day, it's not the patient who's paying.
Steve Podmore:
46:15
Agreed. And it's I I guess really competence of procurement is a major issue there, therefore, you know, within the system. And I think one of the challenges, and this often happens in government, you know, politicians are to some people's view, they're paid a lot, but to others, they're not paid so much related to their in relation to their industrial counterparts. So in in the NHS, the people who are responsible for very, very large budgets have paid, you know, relatively small amount of money compared to the pharmaceutical giants and and their executives, you know, or construction or, you know, name any vertical that supplies the NHS. And and their senior people and their salespeople are paid an awful lot to essentially sell into that system.
Steve Podmore:
47:08
And if you look at Donald Trump and, you know, tariffs and if you look at, you know, the deals that, you know, are are being discussed probably behind closed doors, you know, we have to be very careful that that we're not the the the the confidence of those doing those deals and making those procurement decisions is up there and and able to counter those very high paid executives whose motivation is very often purely financial. Yeah. No. You make some really interesting points there and working out the the best solution to that is gonna be and where where things
Sir David Haslam:
47:48
like like AI may be able to help us in that is a way forward. The solution isn't going to be sort of matching managerial salaries in the NHS with managerial salaries in big pharma. That won't won't solve this. It this it's however much they might like it, it wouldn't be the solution.
Steve Podmore:
48:11
No. But but I do think somehow, you know, getting bonuses based upon savings or based upon, you know, I I think it's getting the incentives right. I think it's really, really important. It's important in government. It's important everywhere.
Sir David Haslam:
48:24
Absolutely. But I've never seen an incentive that didn't drive the wrong behavior somewhere along the line. So it's it's the it's those unintended consequences from incentives. When the incentive becomes the thing that drives you, you often lose the point of why the incentive was brought in and that's, as I said right at the start, that's one of the things that happened with the incentives to get people seen by anybody within forty eight hours, which was a Blair government target, destroyed continuity and that was a disaster.
Steve Podmore:
48:57
Right. Hence, you know, going back to unintended consequence or side effects, that's really the key is is is trying to get ahead and understand where those knock on effects are gonna be. And when I
Sir David Haslam:
49:09
say incentives, don't mean everyone should say go. Just remain clearly focused on the point of what you're trying to do. You know, why we're doing this? What are we trying to achieve? And that's that's that's the critical bit, and that's what I keep coming back to.
Sir David Haslam:
49:25
When you've got that clear in your mind, then it'll make life an awful lot easier.
Steve Podmore:
49:31
And just to wrap up, what do you do for fun outside of this medical world, and what gives you hope?
Sir David Haslam:
49:41
What gives me hope is my lovely family, my grandchildren are are are, you know, wonderful and give me tremendous hope for the for the future. What I do for fun, I live in rural Dorset surrounded by the most idyllic countryside, and I try and walk as much of it as I possibly can.
Steve Podmore:
50:03
Amazing. Well, one day, maybe I'll, take the drive down to Dorset or the train, and, we can do this. We can do a mark two with, with us getting some, some exercise. That might be a nice, a nice way forward. Well, so David, thank you so much.
Steve Podmore:
50:18
Well, David, I really do appreciate your your frank and and your clear views. I think there's many more questions asked than perhaps we've answered. And what I'm I'm curious to, perhaps explore with you another time and and with others is, you know, if we were to allocate capital and understanding into primary health care, which I think is the you know, my conclusion is that, yes, we can better allocate capital in the hospital system. Know, I care very much about thrombectomy and stroke, and we'll be launching a campaign around enabling thrombectomy for one hundred percent of the population. I think the return on investment for government is so high, and it has the potential to save or improve over fifty thousand lives in the next decade.
Steve Podmore:
51:23
And yet, we're only 25, 30 percent of the country is covered with the ability availability for mechanical thrombectomy. So I do think there are occasions where investment into the hospital, secondary care system is necessary, but but if we are able to redeploy understanding, perhaps using the Manchester's live well concept and rolling that out, getting that that money, I'd really want to understand how that would be better allocated, where it would go, and where there's, you know, opportunities to to create enterprise alongside the health system. So economically, it can work from the country as well. You know, the more taxes we generate, the more people employed, you know, the better for the system. So, there's lots of follow on, but but for today, thank you very, very much.
Steve Podmore:
52:18
I really appreciate it. And just the final words to yourself. Not at all.
Sir David Haslam:
52:21
It's been an absolute pleasure. Thanks very much, Steve.
00:11
David Haslam has spent his career shaping the health service. He's worked for forty years as a general practitioner and then scaled the heights of the health service to be the president of the Royal College of General Practitioners, the president of the BMA, the chair of NICE, and a number of other really quite incredible roles. He's also written a book three years ago, Side Effects, and it it really has, had great acclaim from Waterstones and from the Observer and from many others. And it digs into, how the NHS is broken and, and and what it takes to fix it with compassion and consideration and, and great sense. So I'm looking forward to getting into the discussion today.
Steve Podmore:
01:03
We have had a a pre discussion, just a few days ago, we covered some of the subjects. And, for Let's Fix the NHS, the goal really is to dig into what's necessary, to, address the systemic challenges within the NHS and to, really figure out where the solutions are gonna come from and to help craft them. But to get started, David, welcome. Is it sir David or or David? What do you prefer?
Sir David Haslam:
01:31
Please, sir David, only when I'm booking restaurants. Otherwise, David, please. Thank you. Not that it ever makes any difference in a restaurant. It's worth trying.
Sir David Haslam:
01:43
I
Steve Podmore:
01:44
would imagine if you go to The United States it could be a little different, but there we go. So let's just get into it by talking about the book, and what kind of response have you had. It it's, probably over three years now since you, sat down to write it, and and obviously, COVID was was going going strong at the time. So, yeah, just kind of curious as to that experience just to get us started.
Sir David Haslam:
02:13
Well, it's it's been fascinating. It's really good to talk to you, Steve, because this whole issue of trying to fix the NHS is what's brought us together. I was really struck by the fact that the NHS is struggling, and it's been struggling for most of my professional lifetime. I'm a total fan. I believe that the concept of treating people without the need to worry about how you pay for it, offering quality based on need rather than ability to pay.
Sir David Haslam:
02:48
I think that's one of the great great activities of humankind. I mean, I I know that sounds a bit cheesy, but that's that's the way I feel about it. The NHS was a 64 old when I was born, so it's been a real core part of my my life. But what I've heard, and as you kindly said, Steve, I've had a a large number over the last couple of decades of leadership roles, and I've worked at the at the top of the health service. And I keep listening to the same answers coming up that we need to to do this, that, or the other, but never quite seems to shift anything.
Sir David Haslam:
03:30
So we keep having restructurings, different ways of organizing things, and everything carries on very much the same. We have some wonderful care. I owe my life to some wonderful care that I've personally received. We have some unacceptable care. We certainly have levels of waiting that are completely unacceptable for so many conditions.
Sir David Haslam:
03:54
But I think the thing that struck me is that you can't answer the question if you don't quite know what the question is, and and it feels like the question is, what do we do about the NHS? And that's not quite enough. You need to know what's what's wrong with it, what is the problem, and and you're only gonna be able to answer that if you know what it's trying to do. And that might sound a very simplistic statement. I think if you or I are ill and we see a doctor, we know what we want them to do.
Sir David Haslam:
04:29
They want we want them to sort us out to get us back to health. But is that it is that just it on a national basis? Is it is are we trying to deliver health? Are we constantly expanding the expectations, the offer? If you've got a constantly expanding offer and a constantly changing offer and a fixed budget and near infinite demand, that's gonna end in tears.
Steve Podmore:
04:58
So you have to start looking at these things. As we talked about the other day, it's like infinite growth on a finite planet is a mathematic impossibility. And and and that need and that perception of need does expand significantly. People are clearly living longer. You know, you mentioned when you were born.
Steve Podmore:
05:24
And if we take the number of people on the planet then and and now, it's roughly doubled. And that that in itself creates a need. Well, on a yeah.
Sir David Haslam:
05:37
On a simple human level, part
Steve Podmore:
05:41
of
Sir David Haslam:
05:41
the reason I call the book side effects is because a lot of the problems that we're facing are side effects of previous previous work, previous good intentions. Sometimes this is down to policies that governments have come up with. A classic one I talked about was the the drive by previous governments to improve access to general practice, which was a fantastic idea, but it destroyed continuity, and there's lots of evidence that having a doctor who knows you and who you know is a good thing, but unintentionally, a side effect of trying to get access better destroyed continuity.
Steve Podmore:
06:16
Well, I find I find that fascinating. Sorry. I I find that fascinating in multiple contexts because, you know, having we talked about my mother's, stroke and and the fact that she was, four months initially and and and then after a second stroke another month in hospital. And it it just dawned on me that the the amount of time spent on handover, it it's just it's just crazy. And and not just I'm talking between shifts.
Steve Podmore:
06:44
You you virtually never even in that time, it's very rare you see the same clinician, the same doctor, the same consultant. And, you know, and then I thought of that in the context of the the general, you know, general practice, it's the same. And and in your book, you highlight that, but my question is how do we how do we in this modern data driven world where there's a lot of information, how do we do we go back to relationship based medicine? It's almost like banking. You know, we talked about finance as well, and and one of the big, criticisms is is we've gone into a data based banking world, as opposed to a relationship driven world.
Steve Podmore:
07:28
I think a hybrid is ideal, but but how do we systematize that? How do we create that? That's the question.
Sir David Haslam:
07:35
Yeah. No. That that that's absolutely right. And the technology is gonna give us a a lot of help in this. It's inexcusable that people have to repeat their medical history over and over again with every clinician that they see.
Sir David Haslam:
07:50
It is completely barking mad, and I don't understand why we haven't been able to sort that one out. Again, it's probably because of the side effects of very reasonable anxieties around confidentiality and issues like that, which are really important. But, you know, the excellent has been the enemy of the good, and we're nowhere near the good in terms of of this yet. But, yeah, like in banking, most of the time, most of us are very happy with our apps and very happy with, an ATM machine. But now and again, you need advice, you need help, you need a human, and it'd be quite nice if that human knew you.
Sir David Haslam:
08:27
And the thought of that in the banking sector now is laughable. In the medical sector, it'd be great to see be able to see the doctor who knows you. And I'm not I'm not being cheesy about some 1950s style, always there, twenty four hours a day doctor. I'm just talking about the ability to sometimes be able to talk to the person who knows you. And some practice my own general practice is now trying to work I'm I'm not practicing anymore.
Sir David Haslam:
08:55
I'm a patient there. It's it's it's doing all it can to make sure there is continuity, that you see the same doctor if you possibly can. They've recognized the importance of that, but that's all too rare, and I'm glad that at least in some of the government's pronouncements, they've talked about that being important and bringing back that relationship because relationships medicine is a mix of art and science, and the art bit is a human art.
Steve Podmore:
09:24
Can we go back to the, you know, that initial thought? What is the purpose of health care? I mean, you know, to lose its way, we have to figure out what that direction was initially, and it would really help for you to define, you know, for people who may watch this, what is your vision of the purpose of healthcare? Well,
Sir David Haslam:
09:51
when it was for the the arrival of the NHS, I think was fundamentally came out of the insurance systems that have been working prior to that, which were ways of trying to guarantee the workforce kept working. And the NHS, to begin with, I think part of the the aspiration was that it would deal with all the sickness that was stopping people being able to work to get UK plc working again. How many times have we heard that sort of thing? Also, there was the most breathtaking error of judgment, an assumption, right at the start that the health service would reduce cost because as you improved health, demand would fall, and it could not have been more wrong. What it what the availability of the NHS did was suddenly disclose the extraordinary amount of need and demand that there was there for for dentistry, for for, you know, for for for eye care, for, you know, glasses and all the rest of it.
Sir David Haslam:
10:53
All these things suddenly spread out and costs escalated and escalated pretty well from year one. And none and none of that is to be critical of people who seek demand. It's just to recognize that it keeps changing. We've seen this particularly in the the area of mental health. The definition of what is, mental illness or what is unfortunate and sad emotions is a difficult one.
Sir David Haslam:
11:19
And I'm not gonna even pretend to say where the barriers of that are, but expectations we've seen over generations have changed dramatically, which means demand for services constantly increases. You know, things that my father's generation put up with, I didn't put up with. My kids won't put up with things I put up with. You know, that's that's human nature, but it just changes changes the game, which is why I don't think it's for me or I don't think it's for any expert to say this is what the NHS should do, but I do think it is for the public to at least recognize there are limits and work out where those limits are, and I think you can do that through things like citizens' assemblies. This would not be an easy piece of work.
Sir David Haslam:
12:02
It'd be politically courageous, as they would say in yes minister, but it I think it's got to be done. We've we cannot go on the way we go.
Steve Podmore:
12:10
The idea around Let's Fix the NHS was really to give people a voice, and those people could be the nurses or the healthcare assistants or clinicians at any level, you know, or the GPs or those who are in care homes, you know, the whole system really I in talking to people, I found an awful lot of people felt helpless. And whether it's junior GPs who who want to go to Australia, you know, you know, TikTok and and and Instagram is full of people venting and and and saying how frustrated they are, and and that's really worrying. It it really is. But part of the solutions is making sure those solutions are crafted in the open. They're transparent.
Steve Podmore:
12:58
They're thoroughly stress tested. For people to have overall involvement gives them buy in. And that could be something simple like voting on an idea and listening to that idea, or it could be something significant like fully costing and formulating a proposal, it should be fairly and properly evaluated and in the context of the bigger system. Generally, those things are happening in dark rooms, there's not that much transparency. I think key to actually fixing this, if it's possible to fix it, you know, is figuring out where those problems are and listening to the solutions wherever they are.
Steve Podmore:
13:48
And and and I'm sure in your many years of service, you'll have found an awful lot of incredible solutions by the people who are at the conference. Absolutely.
Sir David Haslam:
13:59
There's wonderful care and wonderful things being delivered all across the NHS, but the trouble is they don't become generalized, they become localized. There's a terrible tendency sort of if not invented here, things tend not to get used in quite the same way. Often also it's just people don't know about them or people immodestly don't share them because they don't think they're that big enough a deal. You you can have, I mean, really simple things, really simple things like district nurses who who visit people in their own home, need sometimes in some areas to get a dressing they then have to contact the general practitioner, the general practitioner then has to write a prescription, the prescription has to go to the pharmacy, the pharmacy has to collect the create the prescription, the nurse then has to collect it and take it back to the patient. Now that is bonkers.
Sir David Haslam:
14:53
It's completely bonkers, but it's norm in so many areas, could be solved by ensuring the district nurse has sufficient dressings. It might mean things have to come out of a different budget, but isn't that what management is for? It's to try and sort that sort of thing out. Now that might sound really trivial, but actually multiplied up by the workforce that's the fourth biggest workforce in the world, then start looking at
Steve Podmore:
15:17
these things. All these things add up. So that brings on a very interesting question of what is leadership in this context, because an awful lot of leadership is leadership out of fear, and it's applying a set of rules, and it's not sticking your head above the parapet and wanting it to be, you know, for fear of it being shot off. And the reality is risks need to be taken. If there's no risks, whether that's the leader that would sanction that that, budget diversion or whatever it might be.
Steve Podmore:
16:01
Someone's going to take a risk, and if you avoid risk at all costs, it increases the overall risk. So I guess, how do you get leadership on every level that's fit for modern times? That's really yeah. Which includes that flexibility. That's such an easy question to answer in
Sir David Haslam:
16:20
a minute, Steve. I mean, it's I think a lot a lot of it comes down to tone. It comes down to one of the one of the problems that we've struggled with, and again, this has been the the metrics used to measure quality activity across the health service were brought in for very good reasons to try and ensure that people really did deliver, but over and over again we've got to the situation of the cliche goes in healthcare hitting the target and missing the point. So you manage to deliver the numbers that you have to deliver in terms of work done, but somehow nobody's happy in the entire scenario. We see that sort of thing over and over again.
Sir David Haslam:
17:12
So I think personally you have to free up local delivery systems. You I don't think you can begin to run something the the size of the NHS on a national basis. The trouble is the trouble is if you try and break it up into smaller units that might function more efficiently, then you get newspaper headlines about postcode prescribing or post post postcode postcode variability. How is it that in in Southampton you can have this and in Winchester you can't? That's a scandal.
Sir David Haslam:
17:42
But if you really want to deliver what's needed for a local local area, you have to have those differences, and we have to understand that. But politically Can I
Steve Podmore:
17:51
just throw this in? So I hate to talk about Rudy Giuliani, but I remember a number of years ago, he wrote a rather good book on leadership, I love it. And this was before, you know, his sort of, you know say again?
Sir David Haslam:
18:06
I have it on my shelves, and I think what happened to Rudy Giuliani in the in the Trump years has been a tragedy because that that was a great book.
Steve Podmore:
18:16
Unbelievable tragedy, but, you know, we take what he did in New York as as the mayor, and, there was something they used called, wasn't it? And and that's where they took the different borough chiefs and, heads of of the police force and the different and fire department, etcetera. And on a regular basis, they got them to share their best practice ideas. I think it was once a month or something. And they had a system of of capturing all their data for their crimes or fires response times, things like that.
Steve Podmore:
18:54
Essentially, they physically got these people together once a month, and they had to defend their drop in statistics or explain their their their improvements. And something about that idea struck me as as as being something that could work in an NHS context. Because when you have both transparency, whether you got, you know, comparable data and you've got competition, and and the communication process that that system, elicits, you know, it it could be something that could help people share that best practice more effectively than they're doing right now. And I think we have to look at other parts of the world for systems that have an an historic times when the systems that could be relevant and could be valuable. And I agree that the yes.
Steve Podmore:
19:45
It's difficult to run this on a national basis from purely centrally, but at the same time, if you look at some of the bottlenecks of the trust situation right now and the the the the differences, we've got to find a better a better way, a hybrid way where where best practice and excellence can be shared quickly and effectively.
Sir David Haslam:
20:05
No. I I absolutely agree, and you've reminded me something I've completely forgotten, which is nearly forty years ago, I was involved in running a series of evening meetings for general practices in the area of Cambridgeshire where I practiced all get together, different practices would get together each time in a different practice and the host practice was asked to talk about three things that they were proud of and three things that they found a real problem. And we all used to hear the proud things and say, those are great ideas, and take them away. And the things that were problems, typically, one of the group of the visitors would say, why is that a problem? Why don't you try such and such?
Sir David Haslam:
20:45
It worked an absolute dream, and it's a it's a model I need to to think about again because as I say, it was a long time ago, but it was exactly that sharing of of practice. But I think part of the the challenge has been the the I don't want to simply blame politics and politicians because we get the politicians we deserve, which is a tragic thought some of the time. But but so we guess at the moment, we've got the secretary of state talking a great deal of sense about some of his priorities. His priorities around focusing on primary care, which, as you'll know from my book, I'm I'm passionate believer in the importance of focusing on primary care, on prevention, on the potential use of tech. And that we all of those really, really important and got fantastic potential.
Sir David Haslam:
21:37
However, coming out of number 10 is the message that the one thing that really matters is the waiting lists for surgery or for being seen in hospitals. And so the metric on which everything is being determined is that one, which pretty well guarantees that none of the other three are going to at least succeed in the way that we would hope. So we've got this complete mismatch between political and and again, I understand the waiting list thing. I absolutely understand why number 10 would say, you know, we we really gotta get waiting list down. It's the thing that it matters to the population.
Sir David Haslam:
22:15
It matters to. But the more we focus on that,
Steve Podmore:
22:17
the more we So I I guess there's two words there's two words in response to what you've just said. Perverse Mhmm. Incentives. Absolutely. And and we have those all over, you know, our economies, you know, and and, all over our systems, public, private.
Steve Podmore:
22:39
But but, obviously, these political incentives, they're wanting, you know, people, special advisers will be telling him something simple, something measurable, you know, something that everyone cares about, regardless of whether it's good sense or not, whether it's congruent, whether it's aligned with the three shifts, which is what you're referring to. And I agree, you know, from a it's not I don't think those three shifts are are new, but I I do think that they're focusing on them is is But, Steve, that's the is a good strategy for sure.
Sir David Haslam:
23:15
The tragedy is not only aren't they not new, they've been said by almost every secretary of state that I've ever known, but they haven't happened Right. Because of the perverse incentives elsewhere in the system. That's where the real change is. So way, way back, prior to the Blair era, so we're talking early 90s, they were talking about a primary care led NHS, and it never became anything other than a phrase because because it's simply the focus was always on on hospital waiting times.
Steve Podmore:
23:51
So we'll come back to those perverse incentives in a minute, but, just for a moment, you know, just for a bit of fun, I'm gonna make you king for the for the day, for this session, and I'm gonna hand you £5,000,000,000, and I'm gonna ask you, how would
Sir David Haslam:
24:10
you allocate that? £5,000,000,000 to do what? Because if I wanted to spend 5 billions on the health of the country, I would probably put it in housing and education and possibly prisons. Now if you want me to spend it on the health service or or even more on social care, I mean, I wanted to spend 5,000,000,000, I put it on social care. If if we want to improve health, we do those first three.
Sir David Haslam:
24:36
If we want to get out of the crisis where we are at the moment, you put it on social care. Why we have this ridiculous boundary between health care and social care other than for fiscal rules? Explain
Steve Podmore:
24:50
explain that boundary and explain what social care is versus
Sir David Haslam:
24:55
I'm I'm gonna struggle because it's not a logical one. If, there are some conditions some conditions that are deemed to be health problems. Your your you've told me, Steve, about your mother's experience of of of stroke. Stroke is clearly a health problem which requires NHS input and the amount of care you receive may be variable and the amount of availability of nursing care in the home and so on may be very variable and less than one would like, but it it exists. But for some other conditions like, say, Alzheimer's, you're almost I mean, not quite on your own, but you're much less likely to receive any NHS support.
Sir David Haslam:
25:38
Now tell me why that makes any sort of sense at all. Social care doesn't just apply to the elderly and to applies to sort of younger people with various lesser abilities of one sort or another. But there is no logical boundary, but there has been boundaries drawn that says these conditions are health, these conditions are social, these we, the NHS, will look after you, these you're you're on your own sunshine. You'll have to pay for everything yourself. Now, that doesn't make any form of sense.
Sir David Haslam:
26:11
We then end up in this situation. What is it they say? Around about thirty percent of acute beds are being in hospitals are held by people who could be discharged home if there was someone to look after them. But if they go home, the what's wrong with them doesn't need NHS input, so they don't get anything, so they stay in hospital. Madness.
Sir David Haslam:
26:31
Madness. Completely the wrong place. And and and from 5,000,000,000, thank you very much. That's where I'll put that.
Steve Podmore:
26:43
I'm picking that. It's complex. Right? So I have an auntie who has she's my sole remaining auntie, and I've had quite a few, and she has Alzheimer's, dementia, and has done for maybe twelve years. She's in a home.
Steve Podmore:
27:02
She's been in a home in Bovington probably for the last six, and she's at the point where and prior to that, a couple of other homes that she was in. So she's been in homes for maybe ten years, and, you know, she's at the point she doesn't even remember the the village that they grew up in, you know, or or anybody, but she still has got her innate charm, that that she can tell anyone who comes up to her how she loves the blouse that they're wearing or whatever. But yeah. And it's complicated, and I've visiting my auntie, auntie Nora and others, You see people who who I mean, we we talk about sometimes taboo subjects not enough, and end of life care is is one of those subjects that has to be also talked about. I know it's something you're very passionate about, but what I've seen continually is people are kept alive past the point where it it it's reasonable for them to have quality of life.
Steve Podmore:
28:10
I'm not saying it in my aunties case, but I've seen it multiple times. And where does that fit in terms of is that care or is that NHS? And and that sort of endless antibiotic sort of treadmill and admission treadmill. I mean, these are sensitive subjects, so I don't want
Sir David Haslam:
28:33
to ride rough shard over people's feelings, but They're very sensitive and they're incredibly important, and I'm really clear that any improvements that we can do to end of life care, which we absolutely should do, mustn't be for financial reasons. I want to separate that completely out from the challenges for the health. It's got to be because it's the right caring thing to do for that human. You don't simply I mean, I I do not understand why so often people are rushed into hospital from care homes where people who are almost in the end stage of their life are rushed into hospital for where they die in hospital. The care home was their home home, the the the the clues in the word.
Sir David Haslam:
29:29
And sometimes I think that is just down to fear. It's fear of litigation. It's fear of we didn't do everything that we possibly could. It's fear that the relatives will complain. It's fear that someone will complain.
Sir David Haslam:
29:41
And that just feels we've made a misstep there. I've taken the humanity out of those last moments of life. Again, good palliative care can be fantastic, really heartwarming, if that doesn't sound a ridiculous thing to see. We're all going to die, so it's something that we should be talking about. But improving that is to try and avoid some of the overmedicalization of what is a normal step, but doing it for the right reasons, are human and humane reasons, not because we can't afford to do it in the expensive way.
Steve Podmore:
30:18
These subjects are difficult for some people to talk about. For those who are very sensitive and very emotional, it really is hard, and in a way, of our education system, you know, the the in Manchester, there is something they call it live well. It's a program to do, with health in the community and and bringing things like blood pressure assessments, and there's much that can be brought onto a community basis in order for people to live well, and it includes housing, and it includes some of the other social determinants, I think the term And that seems like it's a good model to follow. But in those community centers or religious establishments or clubs, In a way, we need to create a national health curriculum, or a local, you know, or adaptable health curriculums so these discussions can be had, and they can be less taboo. And and I think, you know, social media and and YouTube can help.
Steve Podmore:
31:27
This potentially can help, but it's one of the things that strikes me that, you know, going through it with my mom and and previously my brother, it is something that that hits you very suddenly. And all of a sudden, you've got to make difficult decisions when you're not really prepared for them. And and I think many people are in that same boat. And and the going back to care for a moment, the complexities around selling asset, paying for, you know, what what are people eligible for from their local councils? What are, what are they not?
Steve Podmore:
32:01
It it's a minefield. It's very complex, and it it doesn't feel as though it's very personalized. It it certainly doesn't feel it's very, errant in my experience.
Sir David Haslam:
32:11
It doesn't have to be this way. You know, it's quite simply we can't go on like we are because as you've said, pretty well nobody is is satisfied with the current situation. Many patients aren't. Many carers aren't. I'm not just talking about care of the elderly and so on.
Sir David Haslam:
32:28
We've we've talked about junior doctors, senior doctors, hospital doctors, GPs, nurses, physiotherapists, everyone's feeling this isn't right. This isn't how we want it to be. And an awful lot of that in my mind is to do with the almost the over industrialization of health. It's become more a transactional getting stuff done than doing stuff with people. And and and again, I don't wanna be cheesy about this, but the emotional relationship between carer and cared makes a difference, makes a difference to both.
Steve Podmore:
33:08
Now, ten minute appointments or fifteen minute appointments, That's a lot to build a relationship, isn't it, within a a short period of time? And and can we go back in in discussing that to that sort of 5,000,000,000 allocation? So, you know, to make the you it's it's not the end of the day yet. You still got, you know, some of it to spend. So let's go back
Sir David Haslam:
33:36
to how would you spend it? If I had to invest it in the NHS, I would very definitely invest it in primary care, and I'm not doing that simply because I worked as a general practitioner, I've worked in lots of sectors in the NHS. I'm looking at international evidence which shows that investing in primary care reduces health inequalities, improves overall health outcomes, improves satisfaction. Most of the I mean, one one of the great mysteries is is that if if you were to ask any secretary of state what you want to achieve, it would be improved outcomes, reduced inequalities. And what do they then do?
Sir David Haslam:
34:19
They put their investment elsewhere in the system, which seems to get more bangs for the bucks quickly. But investing in in in in primary care, in in high quality first contact, if that is carried out well, the overuse of the rest of the system can be avoided. Emergency admissions can be avoided. A lot of practices are now developing much more sort of social strategies within their practices as well where you you link population members who are frequently lonely. You population members.
Sir David Haslam:
34:54
I'm talking about humans. What a
Steve Podmore:
34:56
dreadful piece of cliche that was. Talking about human citizens, getting them to to just link together in a social way, and and In your book, you talk about this concept of medicine being developed for loneliness, which is like a crazy a crazy concept. I I mean, to
Sir David Haslam:
35:16
be honest, the current focus on obesity as being a problem that we have to treat with as many drugs as we possibly can, in the short term, I absolutely get that. Obesity is a massive problem for the health service in every sense in terms of heart disease and cancer and arthritis and all the rest. Diabetes is a huge problem, but surely the way to tackle this is around diet and lifestyle, and I'm talking about the food industry more than anything, And yet, we're now pouring the the Tony Blair Institute today as we're recording has said we should be pretty well sending on demand drugs to obese patients. They don't need to see their doctor. It just yes.
Sir David Haslam:
36:05
Short term, fantastic. Long term, madness.
Steve Podmore:
36:11
The irony is it's like a sticking plaster over an open festering wound. It's, yeah, you gotta get to the root cause of it. When you look at outcomes and measurable outcomes, I think the you know, you can track first of all, big pharma and big agriculture, they're two big questions, and we talk about perverse incentives. So, yeah, I mean, I know from the book, talked about your brother and your father, they would not have passed so early had some of the medications been around that are around now. And you also mentioned that you're not anti the pharmaceutical industry.
Steve Podmore:
36:52
I'm not sure where you stand on the food industry, but from my perspective, we're doing an awful lot to destroy our soil and to keep people addicted both with pharma and with food. And we need to to have a a planet that's sustainable and and and intelligent. We have to to really, rethink a a a great deal of how we live. And and I'll rephrase that. I don't know.
Steve Podmore:
37:22
I think a lot of that thinking has been done, but it needs to it scaled and and and become mainstream. But if you look at finance that plows into that farmer and finance that plows into those food industries, they push the extremes of behavioral science to sell and market things to people that are not always good for them. Yet they still use these serotonin inducing mechanisms to satiate people's appetites. I think it's
Sir David Haslam:
38:02
it's it's pretty pretty clear that a lot of the activities of the food industry over the last decades have been very similar to the tobacco industry in the 1950s when the problems of smoking were becoming medically apparent, and yet all the research as much research as possible could be buried. I I I find it deeply, deeply disturbing.
Steve Podmore:
38:28
If we go back to the per perverse incentives, you know, we how do we hold them to account, and how do we give people better choices? You know, when we spoke previously, you talked about, how the trend of obesity and and all of the all of the issues, it wasn't the same when you were a young boy, and and you think something's happened.
Sir David Haslam:
38:56
Well, I mean, classically, whenever you start talking about obesity, there was a letter in the Times a couple of days ago saying for heaven's sake, all people need to do is exercise more and eat a bit less and we don't need to worry about all this stuff. Now I'm always struck by photographs of the Woodstock festival, that's my generation's first festival. All the photographs of all the people in that, you could see their ribs. Everybody. They were all today's metrics, we would call them skinny.
Sir David Haslam:
39:27
I do not believe all the subsequent generations have just lost willpower and are just lazy and don't I don't think there was anything superior about my generation who was skinny at that age. I think the food we were eating was different at that age, and I think if if you look look at what's happened to the just go down any high street and see the average size of the average person, you realize something really quite dramatic has happened. Very taken by Chris Van Tulligan's book ultra high processed food, there's some really interesting work he talks about in that, but whatever the cause is, there's no doubt it's a societal thing, not just individuals being greedy and gluttonous and lazy, which some people would like to say. I cannot accept that. I don't think whole society has changed like that, but food industries certainly changed like that.
Steve Podmore:
40:28
We talked about the economics. We talked about my previous project or the project that's on hold, Transform Global, and the idea to to kind of create a financial institution that can get capital better deployed in a way that can, create more jobs, deliver more innovation, create more tax revenue, and and gainfully employ many, many more people than than than is the case with our concentrated capital, system. Major corporations are useful, but they don't actually, they strip out more employees than they than the the jobs that they create. Not always. There are some amazing large organizations, but, the the reality is we need to rebalance our economies.
Steve Podmore:
41:21
And if we don't do that, the poverty and the the inequity and inequalities, you know, just keep on increasing the gaps between those haves and have nots, are huge. And and so I guess my question is is the links between intelligent economics and healthy economies and a healthy population. How important is that? To your theory, something's going on. Could that be part of it?
Sir David Haslam:
41:51
Yeah. I think it's extraordinarily important. Linked to what you're saying, one of the things that always bothers me is the way that, certainly to the treasury, it looks like the NHS is always a source of demand rather than benefit. The the worry is always how much does this spend, how much does the NHS cost, rather than what benefit can a healthier workforce, a healthier nation make to our country. So it's always seen in terms of cost rather than benefit rather than investment.
Sir David Haslam:
42:27
Investing in health and improving the health I think addresses so many of the issues that you flagged out there. This widening inequality can only end in tears.
Steve Podmore:
42:45
Right. And that's where I I think, you know, in terms of, the innovation, getting innovation right the way through the country, and and and we need intelligent models of finance to help Yep. Fuel that. But we also need it in the health, you know, in the health care system, both internally and external to the NHS. So my view, one of the things we've got to do is is really have a sort of root and branch analysis of where we're overpaying for services, where we're not using intelligent energy, where we're you know, there's so much waste in the system, and often that's because many incumbents are involved.
Steve Podmore:
43:26
Now, the NHS is for sure free at the point of delivery, although we do have to pay for prescriptions, and we do have to, you know, pay for for certain other services, as you know, and and and and the like. But many of the suppliers into that system are private enterprise, aren't they? You know, and there's a big debate over, over the privatization of the the NHS, and and there's an awful lot of strong feeling quite rightly, and I write to the back of this conversation, you said, you know, you are a massive fan, and I am a massive fan. I think the principle of free and the point of service is should never be on the table. But innovation should be part of this, and and this hybrid system that we've got should be improved.
Steve Podmore:
44:22
Where do you stand on on getting innovation into this complex massive organization? I think for me,
Sir David Haslam:
44:33
fundamental principle should be who pays rather than who does. So I don't mind who does whatever is required provided the average person doesn't have to pay for it. What worries me is when the only way you can receive certain aspects of care is if you offer to pay. What worries me is seeing general medical practice, the risk of it going the way of general dental practice where theoretically there's dental availability, but for the vast majority of the population now the only way you can get timely care is to pay for it. And it would be an absolute tragedy if that happened, for general medical practice.
Sir David Haslam:
45:21
And I think if it happens, it'll happen by accident and by negligence, and, no one will claim that it was their policy, but it it it it would worry me. But in terms of the private sector being involved, I don't feel paranoid about that. I worry about, I do worry about things like aspirations to profit levels. Personally, I'm completely mystified by things like, you know, the PPE scandal in the in the in the COVID pandemic when I cannot imagine how people thought that that was a good time to make themselves rich. It's just not a thought that most of us would have crossed our minds.
Sir David Haslam:
46:02
But, yes, we need private enterprise to be able to help help us tackle some of these issues, and I have no problem with that at all as long as at the end of the day, it's not the patient who's paying.
Steve Podmore:
46:15
Agreed. And it's I I guess really competence of procurement is a major issue there, therefore, you know, within the system. And I think one of the challenges, and this often happens in government, you know, politicians are to some people's view, they're paid a lot, but to others, they're not paid so much related to their in relation to their industrial counterparts. So in in the NHS, the people who are responsible for very, very large budgets have paid, you know, relatively small amount of money compared to the pharmaceutical giants and and their executives, you know, or construction or, you know, name any vertical that supplies the NHS. And and their senior people and their salespeople are paid an awful lot to essentially sell into that system.
Steve Podmore:
47:08
And if you look at Donald Trump and, you know, tariffs and if you look at, you know, the deals that, you know, are are being discussed probably behind closed doors, you know, we have to be very careful that that we're not the the the the confidence of those doing those deals and making those procurement decisions is up there and and able to counter those very high paid executives whose motivation is very often purely financial. Yeah. No. You make some really interesting points there and working out the the best solution to that is gonna be and where where things
Sir David Haslam:
47:48
like like AI may be able to help us in that is a way forward. The solution isn't going to be sort of matching managerial salaries in the NHS with managerial salaries in big pharma. That won't won't solve this. It this it's however much they might like it, it wouldn't be the solution.
Steve Podmore:
48:11
No. But but I do think somehow, you know, getting bonuses based upon savings or based upon, you know, I I think it's getting the incentives right. I think it's really, really important. It's important in government. It's important everywhere.
Sir David Haslam:
48:24
Absolutely. But I've never seen an incentive that didn't drive the wrong behavior somewhere along the line. So it's it's the it's those unintended consequences from incentives. When the incentive becomes the thing that drives you, you often lose the point of why the incentive was brought in and that's, as I said right at the start, that's one of the things that happened with the incentives to get people seen by anybody within forty eight hours, which was a Blair government target, destroyed continuity and that was a disaster.
Steve Podmore:
48:57
Right. Hence, you know, going back to unintended consequence or side effects, that's really the key is is is trying to get ahead and understand where those knock on effects are gonna be. And when I
Sir David Haslam:
49:09
say incentives, don't mean everyone should say go. Just remain clearly focused on the point of what you're trying to do. You know, why we're doing this? What are we trying to achieve? And that's that's that's the critical bit, and that's what I keep coming back to.
Sir David Haslam:
49:25
When you've got that clear in your mind, then it'll make life an awful lot easier.
Steve Podmore:
49:31
And just to wrap up, what do you do for fun outside of this medical world, and what gives you hope?
Sir David Haslam:
49:41
What gives me hope is my lovely family, my grandchildren are are are, you know, wonderful and give me tremendous hope for the for the future. What I do for fun, I live in rural Dorset surrounded by the most idyllic countryside, and I try and walk as much of it as I possibly can.
Steve Podmore:
50:03
Amazing. Well, one day, maybe I'll, take the drive down to Dorset or the train, and, we can do this. We can do a mark two with, with us getting some, some exercise. That might be a nice, a nice way forward. Well, so David, thank you so much.
Steve Podmore:
50:18
Well, David, I really do appreciate your your frank and and your clear views. I think there's many more questions asked than perhaps we've answered. And what I'm I'm curious to, perhaps explore with you another time and and with others is, you know, if we were to allocate capital and understanding into primary health care, which I think is the you know, my conclusion is that, yes, we can better allocate capital in the hospital system. Know, I care very much about thrombectomy and stroke, and we'll be launching a campaign around enabling thrombectomy for one hundred percent of the population. I think the return on investment for government is so high, and it has the potential to save or improve over fifty thousand lives in the next decade.
Steve Podmore:
51:23
And yet, we're only 25, 30 percent of the country is covered with the ability availability for mechanical thrombectomy. So I do think there are occasions where investment into the hospital, secondary care system is necessary, but but if we are able to redeploy understanding, perhaps using the Manchester's live well concept and rolling that out, getting that that money, I'd really want to understand how that would be better allocated, where it would go, and where there's, you know, opportunities to to create enterprise alongside the health system. So economically, it can work from the country as well. You know, the more taxes we generate, the more people employed, you know, the better for the system. So, there's lots of follow on, but but for today, thank you very, very much.
Steve Podmore:
52:18
I really appreciate it. And just the final words to yourself. Not at all.
Sir David Haslam:
52:21
It's been an absolute pleasure. Thanks very much, Steve.
