NHS sees patients as an inconvenience, says new boss

Telegraph

2 days ago

The NHS sees patients as an 'inconvenience' and has 'built mechanisms to keep them away', its new boss has said.
Sir Jim Mackey said the health service was too often 'deaf' to criticism, 'wasted a lot of money' and deployed far too many 'fossilised' ways of working that had not changed since the foundation of the NHS in 1948.
In his first interview since becoming head of the NHS, Sir Jim told The Telegraph the health service had 'made it really hard' for patients to get the care they needed.
'It feels like we've built mechanisms to keep the public away because it's an inconvenience,' he said, warning that too many patients were left 'ringing a number no one ever answers'.
Next week, the Government will publish a 10-year health plan that promises three major shifts in the way the NHS operates – from hospital to community; from analogue to digital; and from treating sickness to prevention.
There will be far more 'neighbourhood health', with NHS and private companies working for it to offer more care locally, including increasing the use of high street services.
A revamped NHS app will provide a new front door to the health service, with AI used to assess symptoms and direct patients to the right care, and users able to use the app to book appointments, contact medical teams and compare hospital outcomes.
The plan will also set out reforms to put the focus of the health service on the experience of patients.
The Telegraph can reveal that this will include trialling 'patient power payments', with hospitals only getting the full payment for treatment if the patient is satisfied.
The reforms are also set to change the way A&E departments are funded, with payment dependent on cutting long waits and shifting more care out of hospital.
Sir Jim, who ran the NHS's most successful hospital for 20 years, said he was driven by the poor experiences of his own family at the hands of the health service.
He was just starting a career in hospital management when his dying father suffered terrible care at the hands of the NHS.
That was in the 1990s; but the new head of the NHS says since then, far too little has changed.
'We've made it really hard, and we've probably all been on the end of it. You've got a relative in hospital, so you're ringing a number on a ward that no one ever answers. The ward clerk only works nine to five or they're busy doing other stuff; the GP practice scramble every morning.'
'It feels like we've built mechanisms to keep the public away because it's an inconvenience.'
He goes further, warning that failing to listen to public frustration could mean the end of a publicly funded state health service: 'If we lose the population, we've lost the NHS.'
The candour is startling; not least because it's Sir Jim's first interview since being appointed to overhaul an organisation long accused of a culture of denial.
It's 8am on the seventh floor of Wellington House, NHS England's headquarters near Waterloo, and the 58-year-old has been up for hours.
Sir Jim, who was knighted in 2019 for services to health care, has been appointed to lead the NHS in somewhat unusual circumstances.
On the day Labour won the general election, last July, Wes Streeting, incoming Health Secretary, declared the health service 'broken'.
It seemed inevitable that NHS England, the world's biggest quango, which had been created under his predecessors, was for the chop.
But it wasn't until February that Amanda Pritchard, its beleaguered chief executive, stood down, with Sir Jim, a long-time hospital boss, quickly announced as her interim replacement.
Within weeks, at the suggestion of Sir Jim, NHS England, with more than 13,000 staff, had announced cuts of 50 per cent. But just days later, Sir Keir Starmer announced that the organisation would be axed entirely, with functions subsumed into the Department of Health.
Sir Jim is leading the process, while preparing to implement the 10-year health plan, due to be launched next week, which is intended to radically reform and save the NHS.
It's probably a good thing, then, that the 58-year-old likes getting up at 5am, and describes himself as 'really competitive'.
Personal mission
But more than that, the softly spoken Geordie, born in Hebburn, South Tyneside, suggests he has been driven by his own personal experiences of the NHS, and has seen too often the failure of the organisation to listen to those it serves.
The NHS leader attended the local comprehensive and Durham New College, qualifying as an accountant, before he joined the NHS in 1990.
He has stuck with it ever since, including 20 years as chief executive of Northumbria Healthcare NHS foundation trust from 2003 to 2023.
The hospital trust became the most successful in the country, with by far the highest ratings, in what watchdogs described as a 'remarkable' first for the NHS.
It also embarked on radical reforms, taking over community and GP services, in a model of integrated care that next week's plan will encourage the best foundation trusts to follow.
But when asked how the NHS needs to change in order to deliver for patients, Sir Jim's story becomes much more personal; about how his own family's experience at the hands of the NHS, and the failure of the service to listen to its patients has driven him.
'My dad died in a hospital where the local folklore was terrible about the hospital, but the hospital was deaf to it and didn't know what was actually being said.
'I wasn't long into the NHS, it was a long time ago now, and I felt really powerless. I found out too late that the clinical community knew the guy who looked after him wasn't as good as I would have wanted him to be. I'll carry that for the rest of my life.'
His elderly mother's experience and later death also informed him: 'All their friends knew which ward not to go into.'
It happened during 'a very complicated point just after Covid' in 2022.
He is at pains to praise the staff involved, but clear that there is 'a hell of a lot of learning' from the way that the system failed her – the inconsistency of care over seven days, with a lack of weekend services, and a 'disjoint' between different services.
'It's our job to bring those experiences back and think about, what do I do about that here? How are we going to sort it out? How do we avoid it happening?'
The emphasis on the experience of the patient can be seen throughout Sir Jim's career.
As chief executive at Northumbria, he created a 'patient experience programme' that aimed to learn from industry in getting a far deeper level of insight into how the population was being served.
Some of it was trial and error – he is deeply sceptical about the tendency of the NHS to embark on 'engagement' processes that have a predestined outcome and 'destroy' any public faith.
He wants to see more use of big data to shape NHS services, built on patient satisfaction.
But sometimes it comes down to 'having a chat with a few old people about what they were really bothered about', he said.
He added that as a trust chief executive, he tried to take every opportunity to act on feedback, read every email and spoke to every family that approached him.
One of his deepest concerns is that far from responding to the public it should serve, the NHS has instead constructed walls to lock them out; the 8am scramble for a GP appointment, 'that heart-sink moment, someone's got to sit by the phone, they've got to ring forever, don't get through and then have to do it all again tomorrow'.
Equally, he is concerned where practices have tried to force patients to make online requests, even if they are unable, warning that efforts to modernise the NHS must not find new ways to lock people out.
'It feels like we've built mechanisms to keep the public away because it's an inconvenience. We've got to somehow reorient it; think about how do we find people who need us, how do we stop thinking 'it's going to be a pain in the arse if you turn up because I'm quite busy' and instead think about how do we find out what you need and get it sorted.'
Earlier this month, health was the winner in the spending review, with a record £29 billion annual cash injection. The total NHS budget will be £232 billion by the end of this parliament.
But one of Sir Jim's biggest fears is waste; he said the NHS generally performs best when money is tight: 'There's got to be some tension in it, otherwise we'll waste money,' he added, bluntly.
'There is a strong argument that we have wasted a lot of money in the last few years, we haven't spent it as wisely as we could have done.'
Critics have argued that the increase – which amounts to a real-terms 3 per cent a year for the NHS – is not enough.
But Sir Jim warned: 'I think we have to understand where we are as an economy. There is a reality about what the country can afford.'
Noting that NHS turnover is about the same size as the GDP of Portugal, he said: 'It's bloody massive, it's more than £200 billion quid. We all know and experience waste.'
Sir Jim seems visibly appalled by the bureaucratic empire the NHS has created.
'Most NHS organisations are massive,' he said: 'It's hard for people outside the NHS to get their head around.'
NHS England, which has 13,500 staff, and the Department of Health and Social Care, with more than 4,000 staff, will see numbers halved. So too will 42 integrated care boards, which employ around 25,000 people.
'We definitely got very complicated and very expensive in our operating model, our corporate overhead,' he said, with far too many layers of oversight.
'It takes forever. It costs a fortune. We need to 'delayer it' because it's expensive, it slows decision-making down, it de-powers people who need to make decisions and need the service to move more quickly and more in a more agile fashion.'
He described deep frustrations as a hospital trust chief executive at the sharp end of it, recalling thinking: 'I just don't know how to get that decision made any more.'
Public confidence in the NHS has slumped to rock bottom since the pandemic, with just 21 per cent of people expressing satisfaction last year.
However, Sir Jim said the health service was heading into trouble long before.
'We ran into Covid in bad shape. All of the key metrics are telling us we're in trouble, patient and staff experience, performance, statistics, financial position, going into Covid. We had that huge amount of public support in that first period. Then if we're honest, that disconnect with the population has just grown and grown.'
He believes the goodwill of the public was squandered, suggesting that the NHS took it for granted.
Failing to listen to public frustrations could mean the end of a national health service, he warned.
In particular he highlighted maternity failings – where a national investigation is about to start. He said: 'I think it's behavioural, I think it's cultural. I think it's about how we listen to people and not desensitising; not thinking we know best when mothers know best – listening to them and families and building the service around them.
'The big worry is, if we don't grab that, and we don't deal with it with pace, we'll lose the population. If we lose the population, we've lost the NHS. For me, it's straightforward. The two things are completely dependent on each other.'
Dwindling confidence in the NHS has been fuelled by worse access to services through the pandemic, and too slow a recovery since, allowing waiting lists to grow, he suggested.
Swathes of activity were stopped during the pandemic, with more surgery stopped than in almost any European nation.
'Really difficult game'
Sir Jim was on calls with healthcare chief executives across Europe and the United States at the time, and was well aware that other systems had paused far less activity – and sprang back much more quickly.
'We curtailed access much longer than other systems. So we were building up more of a problem than others were. There were a lot of other developed systems that were more agile and opened up more discerningly than we did.
'A lot of us operationally felt that we had people chomping at the bit, we knew we could do it safely but we couldn't in the circumstance… it was well-motivated, but we created more of a problem at that point.'
Even in 2021, by now on secondment as NHS England's elective adviser, Sir Jim felt that hospitals were playing 'a really difficult game' with far reduced capacity, thanks to infection control practices brought in during the first lockdown, which were still in place some 18 months later.
By 2022 the NHS was heading into strikes, with junior doctors, consultants and nurses all joining industrial action.
Perhaps little surprise then, that productivity has tanked, despite record funding, with a sharp fall in the number of patients per medic in clinics and theatre lists.
Last autumn, an investigation of the NHS by Lord Ara Darzi found that while hospital staff numbers had risen by 17 per cent since 2019, productivity was at least 11.4 per cent lower.
'There's a straightforward argument on productivity and recovery that says, whatever the reasons are, we're actually not seeing as many patients as we were then.'
'Fossilised' ways of working
He goes on to suggest that the latest generation of medics may not be used to the workload that came before the pandemic: 'There's a lot of clinicians now who've only worked in a post-Covid environment... they never experienced the busy consulting in 2017 when we had 30 per cent more people on the list than we do now. That's a harder thing to change, because that's what they've come into… it's hard when you've got a big backlog.'
However, Sir Jim suggested it was not just about speeding up; but rather about bringing an end to outdated practices.
He warned that the NHS has too many 'fossilised' ways of working, some of which have barely moved on since 1948.
Sir Jim said getting care out of hospitals into local neighbourhood centres is crucial, in order to tackle waste, and make care more convenient.
'There's so much to go at. There's so much to change in a short space of time.'
Top of his list is reform of hospital appointments, which see millions of people routinely called back for checks that very few need.
'Outpatients is glaringly obvious. Of 130 million outpatients a year, about 85 million or so are follow-ups,' he said, saying it feels 'wrong' that the NHS diverts so much resource to follow-ups, at the expense of those waiting for diagnosis and treatment.
The NHS spends more on hospital outpatients than on the whole of the GP primary care system, he said.
Revamped NHS app
The 10-year plan will pledge an overhaul of such systems, giving patients more direct access to medical teams, so they can seek help when it is needed, instead of being repeatedly summoned.
A massively revamped NHS app will be key to 'liberating' the patient, Mr Streeting has said, giving a new front door to the health service, with AI used to direct patients to the right care, and users able to compare hospitals by outcomes, waiting times and patient satisfaction.
Under the plans, the app will also be a route to contact medical teams and book appointments.
It's a revolution Sir Jim has long been calling for, back in 2021, when appointed elective adviser to NHS England, warning of too many 'pointless' appointments.
However, he is well aware that access needs to be just as good for those who cannot rely on digital access, including some of the most elderly and vulnerable.
Reforming the system means bringing far more services together, out of hospitals, in settings close to home, with multiple checks offered simultaneously.
Too many people are coming in and out of hospital for multiple interactions, often in the same week, forcing people to take a day off work and then do it all over again, just because 'we can't join the dots and do it in one go', he said.
'Too many people dying in hospital'
The NHS fails to respect what patients actually want, he suggested; then ends up paying a higher bill for it, with long stays and multiple interventions.
The simplest example is perhaps the most stark: 'We've got too many people dying in hospital when they want to die at home,' he said.
The plan will put a central focus on the experience of patients, he promised.
'Patient power payments' will be trialled in some areas, with hospitals only getting the full tariff payment for their treatment if the patient was satisfied.
When Mr Streeting unveils the final draft of the 10-year plan next week, it will have gone through so many drafts that those involved blush.
Sir Jim said he was 'genuinely a bit emotional' on reading the first draft.
'I was thinking, thank God, we are talking about things I really want to talk about.'
He praised its long-term ambition, saying the NHS has previously failed to look sufficiently ahead.
Labour's election issue
While the spending review is for three years, with a four-year plan for capital, it will look much further.
'One of our failures, I think, in the last sort of 10 years or so, has been our inability to think and plan ahead. But it generates some ambition. So you will look at it and think, 'Oh, that looks a bit frisky compared to where we are now'. That's the point. It's not saying this is all going to happen tomorrow.'
For Labour, saving the NHS is an election issue.
Sir Keir has pledged to restore the maximum wait to 18 weeks (for 92 per cent of cases) by the next election.
Does Sir Jim feel like the next election result is resting on him?
'I don't worry about that,' he said, while he insisted the waiting pledge will be delivered.
'I worry about the population. I'm really competitive. I want to deliver on everything, and in all of that, I want to deliver for the population and our staff. I want to see more pride in the NHS; I want to see more joy. I want to see more celebration of the brilliance of it all; but we've got a lot to sort out.'
That competitiveness isn't just professional. Sir Jim is a former competitive swimmer, who admitted to being 'a bit obsessive' about health and fitness, and said exercise was his first call if he is getting stressed.
Carping from the sidelines
One thing that frustrates him is critics carping from the sidelines, even before the plan is out.
'I needed to swim last night because I was wound up,' he said.
'I'm a very motivated person, right? Some would say I'm really driven, but I want to deliver. I feel the responsibility of delivering. And there's one thing about negativity that really winds me up is that kind of tone, that negativity, defeatism and cynicism when the plan isn't even locked down yet.'
Another thing that wound him up? An article in the Daily Mail in April, which dubbed him 'Sleepy Jim' after catching him snoozing on the train back up to Newcastle.
'It did irritate us,' he said. 'The day before, I worked 17 or 18 hours, even on the day of that picture. I started at five. I finished it just after seven. I've been in a health select committee for two hours in the middle.'
He was inundated with messages, unanimous in stating that the piece was 'a bloody disgrace'.
'Everybody who knows me knows I'm not sleepy, I'm not lazy. It jars, it was upsetting what it did to the family; one thing I'm not is sleepy.'
He's up at 5am every day ('I was a swimmer, my kids were swimmers, my body clock has been completely buggered up since then'); when he can, he tries to get home at a decent time to see his family.
'Heart has always been in North East'
Even when he took the top job, Sir Jim, a family man with a wife, two grown children and grandchildren, said 'my heart has always been in the North East'.
He intends to return to Newcastle upon Tyne Hospitals NHS foundation trust, where he last year became chief executive, once he has 'led the NHS through its transition from the current crisis to getting back on its feet'.
Football also keeps him going; he has previously described himself as a 'Newcastle United supporter with all the psychological scars'. Is he the Eddie Howe of the NHS, able to turn around the NHS, as much as 'Steady Eddie' has transformed Newcastle United's fortunes?
He pauses – in a notably steady way: 'The Eddie Howe of the NHS?… He's very grounded and very analytical, a decent bloke, with a good way of getting the best out of people… I think there are some commonalities.'