The inimitable health commentator interviewed the health and social care secretary at the end of January. Lyn Whitfield went to hear them discuss politics, NHS priorities, and what Hancock’s obvious interest in technology is likely to mean in health and care.
On the bio page of his Academy of Fab Stuff website, Roy Lilley describes himself as an ‘NHS writer, broadcaster, commentator and conference speaker’. Which hardly captures his rambunctious style.
Building on his 1990s experience as the chair of a learning disabilities trust (when he was a keen advocate of the Conservative internal market reforms) and chair of his local health authority (a model to which he now advocates a return) he has become something akin to a political commentator or sketch writer on health and care issues.
Lilley runs a well-read newsletter four days a week and hosts regular live Health Chats sponsored by electronic patient record provider IMS MAXIMS. Last up in the Health Chat hotseat was Matt Hancock, who took over from long-serving health and social care secretary Jeremy Hunt in a Brexit-related reshuffle last summer.
Lilley started by asking Hancock what had got him into politics. Or, as he put it: “You went to a posh school, two universities (Exeter College Oxford, to study PPE, and Christ’s College, Cambridge, to study economics). Couldn’t you have got a proper job?”
Hancock looked a bit taken aback; but used the opportunity to tell one of his favourite stories, about growing up in a household dominated by his parents’ business, which built software to attach addresses to postcodes and to look up postcodes from addresses.
“I hope we saved everybody here some time on your Christmas shopping,” he joked to his audience at the Royal Society of Medicine. “If you used a postcode look-up, that was us.”
Answering Lilley’s implied question, he went on: “There was a moment, in the 1990s recession, when a big client could not pay the bills, and we nearly went under. I became interested in small business and enterprise and… how a decent, small business… could go to the wall because of factors outside its control. That injustice stayed with me.”
Plans for the NHS
Hancock did a stint at the Bank of England before being elected to the utterly safe Conservative seat of West Suffolk in 2010. A series of ministerial jobs saw him become minister for digital and then secretary of state for culture, media and sport just a few months before the call came for his current job.
“So,” Lilley asked, “what did you think, because there was a secretary of state who let slip an expletive” (John Reid, when asked to take over from Alan Milburn in 2003, famously responded: “Oh fuck, not health”). Hancock looked slightly taken aback by that, as well.
“There was nothing like that,” he insisted. “The over-riding sensation was one of duty, and duty of care for the NHS. I am not a politician with a focused view of what should happen with the NHS. It has always been there for me and my family, so I want to get it right.”
There have been suggestions that Hancock is a bit more ideological on health than this suggests. When he was appointed, the Independent noted that one of his donors is the chair of the Institute for Economic Affairs, which has no time for the NHS and wants it privatised.
Asked about this, Hancock insisted that there was no link between himself and the IEA, and it was anyway not relevant because: “I love the NHS.” Certainly, his early priorities for the service – prevention, workforce and technology – don’t feel particularly ideological.
Nor has he had much impact on the current blueprint for health and care, the NHS Long Term Plan, beyond a chapter on “digital first” primary care and creating a level-playing field for practice-based digital offers and new entrants such as GP at Hand (which he has backed heavily).
Although the plan was well in hand by the time he was appointed, it was launched by its main architect, NHS England chief executive Simon Stevens, alongside prime minister Theresa May; who found the money for it to mark NHS70, in a move of which the IEA did not approve.
Three priorities: prevention, workforce and technology
Asked how he came up with his priorities, Hancock said he had been influenced by the NHS’ chief medical officer, Dame Sally Davies, who, “on day one” went into his office and said: “we need to get ahead of the demand curve” by acting on prevention.
His interest in workforce, he said, came from his time as a constituency MP, “because I know from working with the NHS locally that the people in it do an amazing job, but they do not always feel valued, and I wanted to change that.”
And, although it didn’t come up in the Health Chat, Hancock has said frequently that his interest in technology was sparked by a nightshift with the London Ambulance Service and Chelsea and Westminster Hospital.
In a Facebook post that was later turned into an official government press release, Hancock wrote that he was shocked by “the lack of national interoperability standards” that mean “systems just can’t talk to each other” so “people are forced to revert to pen and paper.”
He subsequently published a tech vision promising IT built on cloud-first and internet-first principles, and technical standards to make systems easier to upgrade and plug and play with third-party add-ons.
Health tech interoperability
Lilley has some familiarity with NHS IT issues, not least because of IMS MAXIMS’ support. The company is a founder-member of INTEROPen, an industry-focused group working on interoperability standards, and released its code as openMAXIMS when open source was (briefly) a government policy imperative.
Still, Lilley pointed out, these kinds of developments haven’t made much of an impact. “We have got this electronic tower of Babel,” he said. “Everybody talks about interoperability, but nobody understands it. The whole thing is a mess.
“Don’t we just need to shout ‘stop’ and start again. Because there isn’t really a strategy. There is your vision, but it is not a strategy.” Hancock looked positively affronted by this. “Yes, it is,” he said. “There is a plan, and anybody who does not think that is where we are going should give me a good reason or get out of the way.”
Taking his stated reasons for coming into politics at face value, Hancock’s small business perspective does seem to shape his thinking, particularly on IT.
Asked about the challenges facing health tech, most commentators would talk about the failure of the National Programme, the mismatch between the global digital exemplar programme’s single-supplier approach to addressing that failure and the tech vision’s belief in cloud.
Also legacy issues and security. Interoperability, undoubtedly. But alongside that, the need to recognise that IT projects are change management projects, the need to shift culture, and the need to address some basic organisational and commissioning blocks to adopting new ways of working.
Hancock invariably focuses on companies and contracts. At the Health Chat, when Lilley asked him: “Why is interoperability so hard?” Hancock responded: “It is because suppliers have to open up data, so other suppliers can access it if they want to.
“They do not want to do that but, in future, you will not be able to sign a contract unless you have these standards in it.” Central bodies, he said, are already acting: the GP IT Futures framework that replaces GP Systems of Choice, “requires suppliers to open up their data, and if one of those suppliers does not want to abide by that, they will be out.”
Commissioners and trusts will be required to follow suit. “Where there is a contract, we will mandate standards,” Hancock told Lilley. “We can veto [trust] spend if it is not in line with the tech vision – and that will be happening.” Indeed, he suggested, even old contracts might be changed.
Show me the money
A downside to Hancock’s buy-in to the current direction of policy is that he seems unlikely to lobby for more money, or to take bold decisions about using it. The NHS Long Term Plan was triggered by May’s announcement of an extra £20.5 billion a year for the NHS in England by 2023-4.
That increase of 2.9% in the coming year and 3.4% subsequently was significantly less than most think-tanks felt was needed; an influential report called for 4% to address acute deficits and demand and deliver some modest improvements in priority areas, such as mental health.
As Lilley pointed out: “When this audience sees politicians on television talking about £20 billion for the NHS it groans, because it knows that this comes after ten years of flatlining funding that has caused a lot of problems, and it knows that what is coming is not a bonanza and can’t do everything.”
However, Hancock insisted that “the extra £6 billion I year-one is a change in direction in the curve”, that it should be “perfectly possible” to get trust back into balance year on year, and that the five-year settlement should enable them to plan for the long-term.
The only central money available for technology is that being released by the GDE programme, the £412 million tech fund extracted by Hunt and distributed to sustainability and transformation partnerships, and £75 million for e-prescribing.
Hancock not only indicated that he wouldn’t be looking for more cash, but that he would be against distributing money centrally, on the grounds that trusts should be investing in IT that aligns with their business imperatives. “Hospitals are tech organisations. They are buildings, people and tech and the three work together.
“So, it is better for money not to come from the Department for Health and Social Care because… trusts need to spend the money where they think it makes sense for them to do that.”
The X-Men cometh
As long as any contracts they place comply with current DHSC thinking, presumably. On this point, Lilley got in a quick question about NHSX, the new unit that he is reportedly trying to create to wrest control of aspects of technology from the NHS’ central commissioning and delivery bodies.
“I have a team of technology people, so does NHS England, and then there is NHS Digital,” Hancock said. “We want to bring it together in one place, for a more cohesive approach that is close to decisions about running the NHS more broadly. Because technology needs to be seen as an integral part of running the NHS.”
A quick question about the social care paper – still out “soon”, possibly “April” – and a quick question about Brexit – happening and happening hard on 29 March unless something changes – and Hancock was done and off with a whole line of special advisors.
Lilley at least appeared to be converted. In the newsletter following the Health Chat, he said Hancock’s commitment to joining up NHS data and getting it used had been “a breath of fresh air” and he was fully behind his moves to change contracts; even if lawyers had to get involved. Indeed, he signed off, “if number 18 achieves one thing… this’ll do for me.”
The Health Chat with Matt Hancock was streamed live via Periscope and the recording is online, where it can be watched in full, for free.