NHS England Abolished: Lessons from Past Restructurings and Future Impact

[00:00:01] Dear listeners, welcome to Faces of Digital Health, a podcast about digital health and how healthcare systems around the world adopt technology, with me, Tjasa Zajc In March 2025, it was announced that the NHS England in the UK is going to be abolished

[00:00:26] This was a shock to some and a bit less of a surprise to many others who have known or have been working for the NHS for years Because if we look at the history, NHS is under constant restructuring In the past, for digitalisation efforts, two entities were established, NHSX and NHS Digital and were later merged into NHS England

[00:00:53] A few years ago, 200 commissioning groups were restructured into 42 integrated care systems Change is a constant in the NHS and the latest abolishment of NHS England is expected to bring some efficiency and savings into the system I spoke with Liam Cahill, founder of Together Digital Advisor to Organisations and Health Tech Advisor

[00:01:22] About the impact of the latest restructuring and the expected consequences for the future But to make things clear, we also discussed the past To explain how the NHS works and how can we interpret this move based on the past developments Enjoy the show and if you haven't yet, do check out our newsletter which you can find at fodh.substack.com

[00:01:51] All the interviews are also published in a video format So just go to YouTube and search for Faces of Digital Health if that's the format that you prefer In this particular discussion, Liam and I also shared some visual statistics When we were trying to explain the structure of the NHS budget And if you will enjoy the show, make sure to subscribe to the podcast And leave a rating or a review wherever you listen to your shows

[00:02:21] This not only helps other listeners find the show as well But it means a lot to me And it gives us the additional motivation to keep up with the show And to bring new insights to you Now let's dive in

[00:02:50] Liam, thank you so much for joining the discussion on Faces of Digital Health We're going to talk about the NHS You are someone that Jane Samaru, the founder and CEO of SOMEX says knows a lot about the NHS So I said we should talk because I want to give the audience a bit of sense of what's currently happening in the NHS

[00:03:18] It was announced that a lot of people are going to get dismissed So the money gets distributed more evenly directly to the service providers Before we really dive into what's happened now I want us to maybe explain how the NHS has been changing a lot in the last few years It went from 200 commissioning groups to 42 integrated care systems

[00:03:46] And it seems that change is something that is a constant in the NHS So how do you see this new announcement? And maybe for those that don't know it You can also describe it a little bit and add How is NHS organised in the first place? So I've been in this world for 20 years now And I think there's a lot of people at the moment who are just coming to the service And they're seeing these big changes and they're like AHH! But I think to understand the NHS

[00:04:16] And it's probably the same with any large complex system Is that it's like a string of things that have gone back and happened in the past And you mentioned the commissioning groups where there was 200 and 220 something 223 I think over the time Like that was the environment where I was actually scaling an organisation across the NHS And winning each one of those 220 commissioners At that time I saw how difficult it was to win each individual area But I guess it's interesting to look at the clinical commissioning groups

[00:04:43] Because the clinical commissioning groups were pretty much very quickly considered by everybody To be a dramatic failure There was a health secretary at the time called Andrew Lansley We can work out on how high on the geeky-o-meter we want to go, right? But there's a health secretary called Andrew Lansley Who put through a very ideological reform of the NHS And actually arguably a very stupid one, right? In which he was trying to push this dichotomous system of competition and collaboration within the same thing

[00:05:09] And trying to basically see if he could turn NHS organisations into business units And very, like, before the reforms everybody knew that it was going to be chaotic And then when we got through, it was very clear that it was a mess And there was lots of things where they were Why? What was a mess? So, firstly, the way the commissioning worked is they created these commissioning groups across the country But actually if you took all of the lines of national frameworks, they all went around them

[00:05:35] So you created local GP-led commissioning bodies that actually had no commissioning power So they didn't have commissioning power in primary They didn't have commissioning power in secondary The two biggest areas And then there was like community and mental health Where there were a few things nationally But generally that's the only place that they had money and levers For a long period, we've had a system where You've got a local system which is physically unable to actually do and change anything They've got such small amounts of money and there are so many held national frameworks

[00:06:04] They couldn't actually change anything in primary They couldn't get these divisions to work together because they didn't hold the pen So in essence, the system was too fragmented And I think it's also worth mentioning that there are around 200 Or a bit more than 200 NHS trusts in the NHS Just so we have that idea on what it means to have 200 commissioning groups and why 200? Yeah, yeah I don't think it was necessarily always coterminous with them

[00:06:33] But yeah, they're like, there would have been a bit around hospital centres So at that time basically what the vision for CCGs was They created an economic model to try and have parameters it would fit within But actually what they wanted to do is to let a thousand flowers bloom And to see if GPs would just take control of their local area So they went up into these senior positions, they left primary care to run these systems Only to realise that they didn't, they were tiny organisations and didn't actually have any leverage

[00:06:59] And as a systems thinker, levers is how we change systems, it's how we affect change And so effectively they were arguably powerless systems What can we learn from that experience according to your observation So we know what healthcare systems should do So I think like the changes in the NHS has been like this long drawn out hokey-cokey Or like a design thinking exercise where everyone's diverging, converging, going wrong And I think if we come on to talk about national bodies in a bit

[00:07:29] We've had that same kind of expand and contract thing It's parties coming in and turning the dial up and down Like I think the first lesson that we can probably learn is that for realistic change, for actual change to happen You've got to have systems that actually have genuine levers and have the freedom to do that And even with the new system, some of the challenges that we've had is That they haven't necessarily had lots of levers in order to make changes Because you know, for those who aren't following the news in the UK at the moment

[00:07:56] We've very much got this almost doge-like narrative that's come out Where we're saying, cutting red take, we're bashing bureaucracy We're taking down the gatekeepers of middle management Who are too inclined to say no rather than yes And it's very easy, and for media it's very easy to say that But I think generally if you look at the levers in the system What we've had is also a number of problems Like that's not incorrect And I think we're at an age of institutional bureaucracy being less and less viable

[00:08:26] Like the world's changing And the more complexity that we've had The more that health has changed over the last couple of decades Has helped to prove that as well But I guess it's very easy It's very easy to create a system to give it a mandate And then to take all of its power away And I think this is probably as we look forward Going to be one of the biggest lessons that we can learn If you really want to affect change, you've got to set a big paradigm, big mission You've got to try and get people to believe in it

[00:08:55] But if you immediately tell them Weirdly, I teach this to the military in terms of disruption in systems as well If you immediately tell them That they don't have the levers and the tools to do it Then it's inevitably down the line going to become Something that gets saved Where the scapegoats in order to say where it went wrong Unfortunately that's governmental quite often It's easy to be critical in retrospect I think it's admirable though

[00:09:23] When you think about the new things that the NHS is trying When it comes to the reorganization So we mentioned that then The system got consolidated into 42 integrated care systems To work more towards the integrated care There's also four NHS bodies inside the NHS The NHS England, NHS Scotland, NHS Wales And NHS Northern Ireland This is also something that people usually

[00:09:52] Outside of the UK don't think about It's not just one NHS So that's why it's worth understanding What does it mean when the government now said That the NHS England is getting cancelled Yeah, as the name suggests NHS England Has its purview over the NHS in England And if we take Health and Social Care Northern Ireland, Wales and Scotland They tend to act as quite centralized systems actually Generally they're led by

[00:10:20] Traditionally led by governments on the left Or sub-governance, devolved governments on the left For these systems you tend to have about Six to eight sort of local health boards Which are actually a lot further down the line Although there's a number of lessons that they've struggled with too But I guess when we We, and I don't want to in any way Sound like I'm dismissing Wales and Scotland and Northern Ireland But the vast majority of the UK population lives in England And the vast majority of care and expense and so on happens in England So traditionally because of the devolved weird UK nature

[00:10:50] That we're a country of countries The NHS in England So the Department of Health and these changes Are very much happening to NHS England But actually if you look at the political landscape We can probably see that this will have knock-on effects in the other devolved nations as well Although we're always slightly careful in the UK Because the more that we try and run those countries from London The more likely it is that people will start pushing back and saying we want independence

[00:11:17] And there's always that kind of balance in the UK of Scotland wanting to leave and become its own sovereign state So what do you expect of this change? So what I heard you say is that the reason this matters is because it's going to affect a lot of people When I first saw the news Because I immediately thought

[00:11:40] Only somebody that doesn't understand the complexity of healthcare would dismantle an organisation that employs 10,000 people But then I heard that a lot of people in the UK are actually welcoming this change So what's your opinion? And what are the realistic expectations do you think people can have around this? Yeah, okay We know as Einstein said that the definition of madness is trying to do the same thing over and over again And expect different results

[00:12:09] I think if we look at where we are in the world And I think in the UK We have the far right on the fringes Trying to nip at the heels of the government Labour was hoping to have two terms And now it's very possible in this world that we're in at the moment That they could be having to do a lot in one term We've also got a number of other economic challenges that come from this Because you can't separate the plans for the health system around this But I think in terms of these changes Look, I'm very sensitive to the fact that there's a lot of good people who are going to lose their jobs

[00:12:37] I've got lots of friends in NHS England who I work with But I'm going to be entirely honest Like I've been a special advisor for NHS England I've worked with them very closely And I've built a national organisation I know that area very well I know all of the different tiers pretty well in different senses For various reasons, NHS England has largely been an ineffective organisation We've had plan after plan and strategy after strategy and thing after thing Getting started and stopped and created and trashed And people come and people go And I've seen this first-hand year after year

[00:13:06] And I think as a result of this We've constantly had uncertainty about what's wanted at the centre And what the plan is and the strategy And whilst we are a devolved system that we have integrated care boards That are effectively autonomous unless they're financially failing Which most of them are Then the centre plays a varying role in that And so I'll be entirely honest I feel that we need to devolve

[00:13:33] And I feel that we need to stop over Like I agree with the red tape and the governance on this one And I can see why a lot of people will have concern about the system And of course the job losses But at the same time It's not an effective It hasn't been an effective organisation for many years If you count on your hand The amount of serious successes and impact it's made Given the cost of it I think it's quite exciting Like the one thing that I'll add is that

[00:14:02] We are two months away from the strategy coming So this has been handled really badly That what we've got is a load of major Like generally create a strategy in the need of the actions Whereas in the UK we've got all of these actions With a lot of political narrative But there's a lot of question marks And anybody who knows about the NHS Will have to conclude and finish their statement But the devil's in the detail It depends what's in the strategy Because like I've got a lot of hope I've got a lot of fear around what's going to happen

[00:14:31] Because everybody I talk to It's up in the Department of Health There's a small team of people who are writing a strategy And there could be really exciting things in it There's a lot of ideas that are really exciting If you're working around pushing power downwards Driving accountability Working more closely with local populations And not up to this bureaucratic centre At the same time It could be I suppose the analogy I've been using quite a lot Is that it could be that we slash and expect That's going to create the benefits And that our vision for the NHS Is we talk about all the things we want The juiciest cake

[00:15:01] With all the juiciest cherries on The Michelin star level But then we suck off the bakers And the cake itself Is supposed to be calorie free and that it's just a pipe dream. We're all asking that question at the moment around, so what? Like, what's the detail around this? Do you know how much money is expected to be saved with this approach? I'm just looking at some of the data that I could find,

[00:15:28] and it says, so the independent published some data that the central admin cost is £3.2 billion, £2 of the total NHS budget. I don't know what's your insight. So the first thing that we, like, in terms of savings, the NHS has a budget it sets every year, and every single year it overspends by around, this year it's projected to be £6.6 billion, right?

[00:15:55] So we've got this 200, so arguably it's £200 million, right? So if you look at integrated care boards, I think the general spend is about £150 mil, £1 million, sorry, I'm more able to speak into an international audience, £150 million, and if you cut that in half, then arguably that would be around about £75, £80 million. Aha, there we go. Just so we can imagine a little bit easier, yeah. Oh, that's perfect. Yeah, so if we take that,

[00:16:22] the government is seeking to half the spend within the centre, but obviously in the centre, like, some of these jobs will carry over to the Department of Health. So arguably if you took that £3.2 billion, put it in half, and then maybe did some reductions in Department of Health, you'd be maybe talking a couple of billion pounds. So we're still about £4 to £5 billion short of the overall target. Yeah, yeah, yeah. What do you think, you know,

[00:16:51] is going to happen with people that are now going to lose their jobs? Because I'm thinking a lot of, I can see that I saw when I was working still in healthcare IT that sometimes people from the clinical practice that were working on digitalisation projects would move into the NHS. So I think this is an opportunity for them to go back because when it comes to digitalisation and implementation, you need people who know how to do that.

[00:17:19] And those are usually clinical people that go from clinical practice and get upskilled specifically for implementation of an EPR, of an EPMA, or something else. Yeah, like I think those who are clinical by background, like there will need to be clinical roles that continue. Can't imagine that any of the areas would even dare to not have clinical roles in them. And also a number of clinicians such as national clinical directors and stuff like that tend to have part-time jobs because they work in clinical practice as well.

[00:17:49] So the challenge I think is, like when we've had previous reorganisations, what we had is people have just moved from place to place and there's usually somewhere else that they go. And I'm cautious about how I say this because I know people who are working in NHSN might be listening to this, although I think it's probably best to speak the truth in this. This is, I suppose, an attack and reduction on non-clinical mid-tier jobs. And over the last couple of months, we've had pushes around reduction in admin staff.

[00:18:18] They're the ones I worry about most because they're going to be the ones who really struggle to find jobs. If you're a senior leader who has years of experience and you've been national director, you're going to find it easier than someone who's got an admin role. But I suppose if we take these, like the local system is reducing, trusts, so the local hospitals, are being asked to reduce. The national system, the NHS England is being abolished, the Department of Health is being reduced, so there's going to be a sort of smaller core thing. The health tech industry in the UK is on its knees. Why?

[00:18:47] And because the NHS has been so ineffective for years, because we've had this sort of hierarchy devolved system, so generally the view in the UK is that the health tech system is really struggling. There's a lot of companies that have left the UK. There's a lot... Like the NHS is a wonderfully attractive system. It's really attractive for many reasons. But we don't have... If you look, for example, at DIGA in Germany, although obviously that's got its prime problems, we've never had anything like that emerge.

[00:19:15] We had plans come about a year ago, and that's all been trashed with the new government coming in, as far as we know. So generally the NHS is like this confusing, hyper-localised system, and because we've had austerity and productivity pushed down from the previous government, it's been really challenging for there to be any money towards digital. So I think through various forms of mismanagement, we've not managed to create a really secure and viable health tech industry. Like it is possible in the UK, but it's not seen as attractive by... There's a lot of investors

[00:19:44] that are all pushing companies to leave the UK at the moment. Do you think that the hospital tenders are also going to change? Because health tech providers sell to hospitals, and hospitals are the ones that do tender processes, that want to test the solutions before they sign longer-term contracts. And I also recently spoke with the CEO of the Cleveland Clinic London, which is not part of the NHS, but I thought it was really interesting when he mentioned that

[00:20:13] Cleveland Clinic in the US is doing a year-long pilot with five ambient solutions, and after that year, they're going to decide what to take. And he also urged everyone when it comes to AI to really be mindful, to do pilots, to be careful, to be slow in essence, when it comes to deciding what you're going to buy, which is understandable from the clinical and hospital perspective, but like from the health tech and vendor perspective, it's just a nightmare. Yeah.

[00:20:41] To which many of the CIOs would say, keeping your business afloat isn't our problem, keeping patients safe is, right? As they would always say. I think the hospitals are probably going to be the least affected group on this. I think also, if we look at the way that the top team is changing in England, in the NHS in England as well, like they've just announced their top team and it's all chief executives of hospitals. Like yesterday, they announced a load of them. With the exception of the chief financial officer, all of the main jobs are currently working as CEOs of hospitals.

[00:21:10] I think the writing's on the wall that the hospital is going to become ever more powerful and is going to reach more into other areas in the community. And I think the hospitals are, if you go to an area like Cambridge and Peter, sort of Cambridge or Oxford, where the big academic institutes are, they already have huge amounts of control and leverage over their local system because they're so powerful and dominant. And I think that will give us a direction of travel. So I think in terms of the tenders and process, like again, with hospitals, it's always been a hyper-localised process. It's always been hyper-localised. Generally, you go to them,

[00:21:39] you have to win them and then they say, what frameworks are you on? Are you on this framework? Are you on G Cloud? And so on. And so that's a secondary thing rather than a primary thing. And I think a lot of folks who are coming to the UK go, what do we need to get on so we can be bought? Whereas to be honest, it's who do we need to convince and then how do we make sure that we're on something that they can use? So I think that's probably less of a thing. Although I'm also hearing rumours that there are proposals and plans to do a more centralised procurement function. But again, since they're getting rid of everybody, how do they do that?

[00:22:09] What do you think about the current landscape for healthcare tech providers? You mentioned that it's quite a struggle for them to work with the NHS. In one of the podcasts you did in the past, what I thought was really interesting was the challenge of sustainable healthcare business models and the fact that companies, even with software, are going from

[00:22:38] one-time procurement to subscription models. But the funding that hospitals get for that is not designed in a way that it would support sustainable financing of these solutions. So for example, you get a pocket of money, you spend that money on a specific software solution, but that also means that after five years when that subscription needs to be continued, you're going to have a problem because then you need

[00:23:07] to find another pocket of money. So where do you see the changes in that regard and how can health tech companies be sustainable in this uncertain time? Yeah, like I had a big discussion with a number of sort of the, I suppose, the thinking leaders in this community. I think we're all pretty much of agreement that, look, like, if we just step back and look at any health system, right, the digitization that's going to happen in our society is not us just adding stuff. No society can afford that no matter where they are. Like,

[00:23:36] and there has to be a point where we shift to make sure that is about shifting business as usual change. And it has to be that. It has to be doing good work to say, this is how you currently work. If you use us, then you can save money, you can be more efficient, you can improve your productivity. I think if I'm honest, like, we've had a number of years, particularly since COVID, where we had a lot of companies that came in with investors that thought that they were going to get rapid returns and that everything was game for opening. And I think there's been a narrative that's almost been driven by,

[00:24:05] when I said that the NHS is on its knees, that the UK health tech industry is on its knees, I think part of the problem is it's on its knees because a lot of companies have blamed the NHS, a lot of investors have blamed the NHS. But actually, like, you know, I work with lots of, I've worked with 60 companies and many of whom I've helped to get contracts, but that's because and if I'm honest, many of the companies that I've seen over the years

[00:24:35] have done a slither of that, they haven't done enough. So I think I'm actually really, generally, whilst we've got lots of change, I'm really positive about the ability to make case to organisations because I think that they know that change needs to happen. But it's not a drop in, stick one person, tell them about your product and then suddenly everyone buys you. If that's the strategy and I did an intervention with someone I met the other day, oh yeah, we'll think about strategy in the future. We don't, their strategy was who can we talk to? That's not a strategy, that's winging it. Like, I think the NHS

[00:25:05] is very possible, but that kind of needs us to raise our game and I think this is where I think there's a lot of agreement amongst the players who've been around for a while that that means that hard work has to take place and I think that investors and those who are funding these businesses need to say we're going to win this by inches and we're going to have to invest a lot and front load a lot to get this to happen. But, like, I scaled a business to 100% of the NHS and that was through diligent, hard work and absolutely committing to understanding the system

[00:25:34] and there's no shortcuts. There was no just have a chat with people. It took us eight years to get to 100%, but we did and we did that because we lived and breathed fitting into that system. That's just what we did. Yeah, I suppose it depends on what expectation comes and I think the investor community obviously plays a really big role in this as well. I'm worried I didn't answer your question around the financial model side of things. I spoke a bit more around the culture and practice side. Do you want me to answer that one? Yes, absolutely. Cool. Because I was just looking at how much the NHS spends

[00:26:04] and the UK spends in 2022, it spends 11.3% of GDP on healthcare and what I continuously wonder when it comes to technology is that we keep claiming that technology is going to save money to the system but if you look at the business models and the cost for software it's just yeah, IT budget needs to increase and I see an increasing cost. So what are your

[00:26:33] observations in that sense and how do you see that promises around the return on investment and actual results go together? Yeah, and it's a difficult balance, right? Two sides that want to have their cake and eat it because I think it comes down to who's taking and holding the risk. Does a tech company go, here's some stuff we've done and you take all the risk you pay all the money and we'll hope that the outcomes come in the future or is it a system that says we want you to take all the risk and to do this? Now, one of the things that has been emerging

[00:27:02] over the last few years look at that still not as bad as the US, right? It's insane and our outcomes are still better than the US, right? Oh, you're muted. Sorry and yeah and this is definitely not I would say the right figure I'm pretty sure that the US is now at more like 20%, 18 to 20 than 16 but anyway let's say it says OECD stats

[00:27:31] so we will trust the OECD but go ahead, go ahead we got distracted. I just can't look at that model and not think that people who don't have a good income in the US and get cancer are very possible they're possibly going to be dragged into poverty and I'm so proud of the fact that even though we've got a challenge system that doesn't happen here and I'm just really scared that's where we're going to lead if we don't get things right which is a total shift away from what the question was like one of the things that's really interesting

[00:28:00] is that over time there's been something called the NHS payment scheme and it doesn't apply to everywhere because I think what we've had is obviously we've had a pandemic which has thrown a few things up different kinds of payment models with their providers right so obviously you've got local system and the different providers you might have two acute hospitals you might have a community provider and a mental health provider and increasingly

[00:28:30] the NHS payment scheme means finally these local areas have commissioning power in order to say we're going to pay you a little bit for activity we're going to pay you for KPIs for key performance and the things that are improvements and actually we're going to pay you based on value and so on and what I think is really interesting is it's quite clear that over time and like NICE for example have just started changing their model to think about value although it might be a bit ahead of the game it might create some problems because they're thinking too far at the moment but like that actually

[00:29:00] the ideal reality over the next three to five years is that this scheme starts to lead to folks going we'll pay and we'll share the gains or we'll do it based on performance and targets and we've got the data and digital infrastructure in order to properly measure that because actually realistically why like philosophically if I'm paying my taxes why does the NHS go to a hospital and say we'll pay you for on performance and they go to a tech provider and say we'll just

[00:29:30] give you a flat fee you don't share any of the risk and so I'm really curious and like the investor and investment community is not not my area but I'm really curious about how how that works in the UK because I heard recently about some American provider that came over and said basically we'll only charge you if you achieve these things we'll take on the risk and we'll come and do this and I think particularly some of the big tech firms that kind of come in and start being able to get coverage and almost monopolize the

[00:29:59] system because they're right they've got enough capital in order to take on that risk might become really attractive so what we might start seeing is the system goes to the provider and rather than going to the system and saying can we have some money for this technology you go to the provider and say you're probably being paid for this and we'll come in and share that risk agreement and we will be part of your approach that you're putting up what's your model okay how about if we take responsibility for this element and this means that it can be more efficient you can get more in terms of your KPIs so I can

[00:30:28] see stuff like that's going to emerge but again we've got a brand new strategy which will massively affect this and who knows whether the thing like who knows whether thinking around this is going to be good or not like whether it's going to cover this at all like it should but again we're waiting and seeing on that one in the past one thing that has happened in the NHS was also that there was this structure of two digital agencies in a way

[00:30:57] NHS Digital and NHSX and nobody really knew what the difference was so they just cancelled NHSX and now there's just NHS Digital how do you compare that structure and that decision to what's happening now yeah actually if you go if you're really going to go for digital we also had Health Education England who was responsible for digital skills training we had NHS Improvement that had a bit of a role like we had all of these bubbles of agencies sitting around just to give a bit of perspective NHS England was always the center

[00:31:27] point but then what happened was NHS Digital almost became like the tech delivery arm of it so they would do stuff around the app they'd do stuff around integration or they would at least tell us they were doing stuff around integration it's still not fixed and there'd be a number of technical activities that they would do such as email infrastructure and teams and working with Microsoft so that's what they did and then when the Health Secretary Health and Social Care Secretary Matt Hancock came in I think he was quite frustrated by the fact that he couldn't really

[00:31:57] influence thinking NHS England because NHS England had a separation between the government you can't just go and tell NHS England what to do or you couldn't and so his answer to that was to create this whole new organization called X which was supposed to be this like edgy design thinking it was like the thinking about digital arm so you've got an operational center you've got a different organization that thinks about it and a different organization that does the technical stuff I don't need

[00:32:26] to probably comment that's quite dysfunctional logical and actually so when the pandemic came I was leading part of the response to where digital could be used in medicines and I was working in X so I was drafted in and did some work in NHS X during that time to help provide responses and we were trying to interface with NHS England to say here's all of these different things that we could potentially do for vulnerable patients and stuff like that and they were like this is our plan and here's the rules and this is what we do and there was no way that we could influence us so we just ended up finding stalemates

[00:32:56] across the board and that was my personal experience and we just ended up and NHS England didn't like NHS X because they were taking response they were just doing supposedly doing duplication so we had a bunch of mergers and they brought them all back together but then actually that was a huge number of job cuts and what I know was happening in the background during this time is there was lots of political infighting and turf wars around who owns this territory and who does that and lots of job cuts and distraction which again is why the organisation struggled to get stuff done

[00:33:25] and do you think it's better now when there's just NHS digital do you think it's is it more efficient no no like pretty much since 2019 we've had distraction after distraction and new health secretary and someone changing the rules and moving stuff we've had a major reform we've had mergers we've now got a Labour government that's come in and we also had that period before an election where everyone stops doing stuff because they know a new government's coming in are they more efficient do they cost less than

[00:33:55] they did if you take consultancies out was huge spend in that area then they cost less than they did during the pandemic and maybe just before the pandemic but obviously costs skyrocketed during that period but I guess are they efficient like you've got to be able to measure the output in order to gain to measure efficiency and the reality is that the output's been bugger all so if you take the output the efficiency is probably more marginal it's a very hard organisation to measure because it's always had

[00:34:24] something it's going through which is hugely distracting and loads of change that's so it's difficult to answer that question really could it be that now people are excited just because this is a big change with the NHS England going away and there won't necessarily be as big of an impact as people might hope I think it's definitely going to be an impact

[00:34:52] I think the government wants to rule how this change happens like they don't want to give it away to another body where they're not accountable and there was an interview on Sunday with the health secretary health and social care secretary and he was like like how can I take responsibility for this if I can't actually influence anything that's happening right like accountability needs to sit with me and I need to be able to do that and some separate body is just something for people to hide behind like again it has to come back to what's

[00:35:22] the strategy and what they actually plan to deliver right and again that leaves us in this middle ground at the moment I think there's a lot of people who are excited because they like the idea of shit getting done they like the idea of just finally there's others who are saying this is an absolute catastrophe because they think NHS England is a necessary model and actually they've only been in the system whilst NHS England's been there so it's like cutting something that's always been there out and that

[00:35:52] will create fear and of course those who've got friends and close relationships and maybe have been reliant upon NHS England are despairing because they might have lost perceived opportunities like I wouldn't go as far as saying I'm excited I'd go as far as saying I'm curious and intrigued and there's a degree of hope that actually something really good could come out of this but since I'm not in the central room it could just be a bunch of noise and hoping that cuts gets an

[00:36:21] outcome it won't it's it's definitely a big and heavy discussion but since you mentioned excitement you're reading my mind because I wanted to ask you to lighten things up what are you excited about in what you do and in what you do with the companies in what you do on the UK market what's brightening up your day after the previous things that we've discussed it's a good it's a good phase shift

[00:36:51] it's hard to go through so much geekery and it not be like a heavy damning thing so what's for dinner oh I don't I don't know whatever I'm going to go and cook when I go downstairs after what am I excited about I'm like like like it's difficult to not have a degree of nervousness and excitement but I feel that we are like what a time to be alive what a time at this moment and we can look at this in a number of

[00:37:21] areas right we are going through this huge very exciting revolution we are people like you and me are in places where we can influence this we can actually have an influence on how we shape future society this is not the slow crawl from thing to thing this is like stuff happening and you know whether you're at hymns talking about key things that's going on whether I'm in it like a few weeks I'm I'm chairing a convening session between a bunch of finance directors and tech companies to try and see how I'm excited about that because I

[00:37:50] think actually we've got over this kind of we've had this kind of collective mourning and now we've got this feeling of urgency and as someone who's been teaching about the urgency for years it's hard not to be slightly thrilled by the fact that we're here and now's the time and I can't help but being really I don't know really privileged to be in this place at this moment but at the same time there's a lot of stake right there's a huge amount that's at

[00:38:20] stake and like my mission in the world is I want to try and see how I can work with others to see how we create a positive productive human centric alternative to the Trumpian doge model and in our system right how we can positively and empathetically disrupt and change our paradigms in how we bring in how we create a whole new system of health and social care and that's super exciting yeah speeding out and looking at the

[00:38:49] bigger picture I think I'm also just like like for years like I wrote a few articles on just like the hype cycle like for year like my when I've been working with health tech companies all I've been able to do is to say this is how I see success looking it's hard work you've got to do the right stuff you've really got to embrace this and you've got to be sophisticated and I think 2021 2022 maybe even 2023 everyone was like oh yeah pots and many drop in everything and now I'm actually

[00:39:19] excited by the hard work I'm doing the real work and now that everyone's a bit more sober this like the harder the market kind of gets the more I get excited that actually people are receptive to doing really good work and I love the fact that I have longer term clients that I'm working with who are winning and we're doing the best work of our lives and it's really getting into that transformation that has to happen in the system and that's really it feels really fulfilling after years of everyone

[00:39:48] kind of being oh yeah but maybe another pot of money or dropper or something like that and seeing the system as easy I've spent 20 years in the system I know it's not easy but it's winnable it's absolutely you can absolutely make change in a system and so I like the fact that as a community that is coming because that means that I'm less compromised and more philosophically oriented and in the UK I guess as someone who's arguably seen as a well-known leader in this area it's nice that I'm getting so much better

[00:40:17] reception to what I'm advocating for too so lots to be excited about you've been listening to faces of digital health a proud member of the health podcast network if you enjoyed the show do leave a rating or a review wherever you get your podcast subscribe to the show or follow us on LinkedIn additionally check out our newsletter you can find it at fodh.substack.com that's fodh.substack.com

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