Ravi Gurumurthy: Hello and welcome to the mission. My name is Ravi Gurumurthy. This is the podcast to listen to if you're interested in innovation for social good, we're talking to practitioners, academics and policymakers about how to drive social change, and what makes people organizations and systems innovative. And today, I'm really excited to have Jennifer Dixon on the mission, Jennifer is the Chief Executive of the Health Foundation. And when I said earlier that we speak to practitioners, academics, and policymakers, Jennifer's been all of those having started off life as a doctor. And the reason I really wanted to talk to Jennifer is to look backwards and forwards at NHS reform. There have been few sectors that have undergone more frenetic reform and change in the NHS over the last 30 years. And I wanted to understand what we've learned about how to drive improvement and innovation from all those attempts. Jennifer, welcome.

Jennifer Dixon: Thank you really pleased to be here.

Ravi Gurumurthy: So I said earlier on that you've looked at this issue from various different vantage points and roles. Have you learnt very different things from your role as a policymaker, or actually practicing versus being in the role that you're in now? Has your mind changed with those different perspectives?

Jennifer Dixon: Well, I think that's a really good question. Ravi, I think it's, they're a very different planes of operation in the NHS in terms of making things change. And I think probably the place to start is actually the very top, which is where I ended up as opposed to where I started. And when you think about system change, you're quite right, the NHS has, you know, had tilt to it quite a lot of change over time, really, since the 1970s, and 80s. And, you know, we really got into sort of hyperactivity territory, I think, with the 1990s and the 2000s. With the market based reforms, many of people will remember the 1991 reforms that were brought in, and really a nationalized system was then overlaid with market style incentives and regulation, and targets to match. So there's been a whole variety of different sort of national mechanisms to try to probe this enormous industry into further velocity forwards. At the same time, as looking at the other end of the telescope, there's been constant change on the ground, particularly from science and improvements in medicine, rather than changes in management or other frontline care. So it's been a very interesting combination. And I think if you look at it, I'm not sure which of those forces sort of really was the most potent. And I think there's a strong argument for saying, actually, the science was more potent than the overlaying administrative reforms. So both are important. But I think we're in a very interesting phase now where the kind of some people have unkindly called it belief free prednisone, where the ideological sort of lodestar to the NHS is sort of waned a bit. People are out of ideas, big macro ideas. And I think we're now thinking much more about technocratic change based on science and technology. And that will be the lodestar for the next 1020 years.

Ravi Gurumurthy: I mean, you brought up the question about how much does this all matter? And perhaps that's where we can start before diving into the particular approaches that were tried. Because if you look at the evidence on at the NHS, for instance, compared to other health systems, as I understand it, it comes out relatively middling, but it's also one of those health systems that isn't the best funded. And so one obvious question to ask is, to what extent as basically money and investment drive outcomes? Or does management and reform and the nature of your system really make a difference?

Jennifer Dixon: Well, money, I think, is a major active ingredients, and you're quite right, we have middling performance, because we fund the NHS in a middling kind of way, when it comes to the OECD average with respect to percentage of GDP that we spend on healthcare, and just to put that in concrete terms, you know, we're about $3,000 per year, the France is $4,000, Germany $5,000. So, you know, we're really, Switzerland, more like $11,000. So, you know, you get what you pay for, in many respects. And I think we've seen that with the pandemic, that there's been quite a lot of basic ingredients that we were missing with respect to kit people, capital, so on. And actually, the cumulative shortfall over decades of that level of funding that we've had compared to others means that we really have had long term investment which has been far lower. And again, we see that in the capital investment, we're less than half of the OECD average. So that is really really important. And actually, given that level of investment, it's not bad what we have produced. And given the fact we also have universal coverage and comprehensive benefits. So, you know, decent hospital care, decent primary care, but it's in the areas such as you know, cancer survival in some for some cancers that we lose out some deaths amenable to medical care, again, were middling. So I think I think we're not bad for what we have. And obviously, as we all know, the polls show that the public support for the NHS has never been higher, really. But, you know, the extent to which the public can compare the NHS experience with other countries is obviously going to be extremely limited. And that's where the, the proof of the pudding really is, isn't it? So I think investment is a big thing. You know, how the services run, how often it's reformed. The administrative sort of back and forth of hyperactive reforms, which distract the investments we put into technology, those are other questions that you would look at the basic management of the system is going to be very important. And that's quite a weak story, I would say in the NHS history. So investment middling science, not bad. Management, I think question mark, because of the lack of attention on it, I think as to what really makes for good management in an industry as complex and as large as the National Health Service. And I think that's where we need to focus a little bit more in the in the next period,

Ravi Gurumurthy: it must be very hard to actually get good quality evidence about what works in this area, because it's not like you can easily do an RCT given, you know, you're talking about whole system reforms across the whole country. But I guess we have had some variation in relatively similar context between what's happened in Wales and Scotland. And England, have we learned anything from that variation?

Jennifer Dixon: Well, actually, if you look at I've done several studies over the last 20 years, actually comparing the for the NHS is in the four countries really since 1997. And I have to confess that what you don't see is a major divergence of performance. Despite the differences in approach to running and reforming the health service in those countries. There's probably you know, that there are in some cases, you know, some countries are slightly better than others. I think there is probably a systematic lag in waiting times, addressing long waiting times, probably the other countries there have been a little bit slower. But generally, there isn't a massive difference, I would say and performance, that that one would have thought of seeing, given the heat and light that's been discussed around and the controversy around some of the reforms, particularly in England, so there hasn't been a step change. I would say, on the other hand, the other thing to remember is that the NHS in England is has less funding per capita compared to Scotland, Wales and Northern Ireland. So that has to be factored in. But nevertheless, there isn't a massive change, I think, I think the English system had better improvements on waiting times, but not so much in some of the other areas that one would want to compare like stuff like cancer survival, and treatment of other main conditions. So it's sort of on you know, it's unremarkable, I would say, and actually this. So I think there's no kind of major Nirvana with respect to the administrative sort of differences between the countries, I think, I think one, then what then has to think about what are the other changes the management and the technology that really might make a difference in the coming 10 years, then I think we should really pay more attention to them we have in the past.

Ravi Gurumurthy: If you go back to the beginning of the reform story, let's pick it up, say in the late 80s. Is it fair to say that motive sort of addressing motivation was at the heart of the reformer tense in that's prior to that, you could argue that the NHS was powered by a very strong professional ethos, it was relatively self-managed, if you like. Whereas the introduction of both sort of top-down targets like regulations and targets and inspection and waiting time targets, as well as the sort of bottom-up incentives and market reforms that were induced late in the late 80s, around the interruption of internal market purchase providers, but all that was really trying to give a stronger push and motivation to perform. And I often wonder whether that focus on motivation was really the right problem to be solving. Given that, you know, are we talking about a health service with relatively highly motivated staff for all sorts of reasons. So why was that the starting point?

Jennifer Dixon: Yeah, well, I think I would scroll back further to the 1970s. Actually, where if you think about it in the NHS, there was this sort of, as Rudolph Klein put it quite well, there was a kind of consensus that the politicians sort of decided the amount of investment in the National Health Service and the, the docs didn't question that, but we're allowed to just get on with it, and even to sort of manage the system as they saw fit. And that really came a cropper in the 1970s, with a lot, a lot greater focus on efficiency, probably because of the economic conditions at the time. So, Keith Joseph and what was called the reign of scrutinies happening across all the public sectors. So, it was felt that well, not so much motivation was the issue, it was just the orientation of the professionals towards efficiency was not as strong as it could be relative to quality of care, say. So then, of course, in the 1980s, there was a lot further attention to this. And then, you know, the Griffiths report with people brought in Griffiths was I think at the chair of Sainsbury's, a lot more private sector sort of visibility of what how the NHS was run and, and more power given to managers to look at efficiency. So in a sense to take that slightly away from the docs that weren't particularly interested in it. And then we get to 1990s, where you have the market base sort of wave of reforms that swept over the NHS, that had been sort of hitting other parts of the public sector before then. So I think it was less I think, I think the motivation of certainly the clinical staff was never really in doubt. I think it was the orientation of them. And there, in a sense, probably lack of interest in efficiency that really felt that, that really sort of product, these enormous changes. But but I think that there was also a heavy dollop of you know, the NHS was a nationalized industry, it was in the way of a lot of the kinds of reforms we saw at the time, and the NHS was just about one example, regardless of what one felt about the motivation of staff in it. But it was felt go that it because it was the public sector organization, it needed to have a kick in order to get itself into the 21st century. So in a sense, it was in the way, there was a wider contextual change, as opposed to people really pointing the figure it's saying the NHS, his staff have a problem with motivation is how I view it.

Ravi Gurumurthy: So that yeah, incentives were needed to try and increase the quality of management and efficiency of the whole operation, rather than shift the behaviour of frontline staff. Yes. Now, when you when you look at all the different things that happened in the sort of major governments, and then under Blair, and brown, there was quite a lot of back and forth and the internal market being abolished and then reinvented, do you? Where do you come out on the effects of those different reforms? Because you could argue that there's lots of ideological noise, but the ultimate effect on patient outcomes was relatively minimal. Or you could actually argue that, you know, some of those reforms are really, really important. And without them, things would have been a lot worse. What's your basic take on that? That period, in particular, say, the 90s and early, early 2000s?

Jennifer Dixon: It was a very interesting. My, I suppose it was it was an interesting experiment that was inevitable, given the wider changes that were going on and the wider sort of ideological sort of currency of the market and how it was applying to the public sector. And in terms of whether it did what it said on the tin, I don't think it did. No, I mean, I think there were some changes, marginal changes that happened. I mean, if you look at certainly patient choice was popular. Certainly there was some marginal change with respect to outcomes with respect to waiting times. But considering the amount of investment, ideological investment, reform investment that went into this, building this whole architecture of competition between hospitals of the payment mechanisms to underpin that, giving patients more choice and information, constructing information to allow patients to choose or at least GPS to choose on their behalf. That's a lot of effort and the gains. I mean, looking at the dials of quality See that they did not speed up dramatically, nor did efficiency Mac measures either as a result of these huge changes. So yes, they were change. There were improvements. But they were. I didn't think they were particularly impressive. So, you know, I think, I think, as with every large reform it they never, it's they're difficult to evaluate. But they do not produce the they hoped for aspirational changes, I think we should be more humble in future and possibly look very sceptically in future about administration defining big reforms like this. And as I say, we're out of that period at the moment. I mean, at the moment, the only thing coming at us, I think big time is the is not an ideological form. It's a technological reform. So again, I think we should be sceptical of the gains that can be made here, and just, you know, be much more humble, but also be much more cooler and serious about evaluating them to the extent that we didn't do before,

Ravi Gurumurthy: just masking away whether there's more potential mileage in any of those approaches, particularly as, for instance data to compare and contrast patient outcomes as much richer, there may be more diversity of provisioners technology providers enter the health space and electronic data records become more used by people outside the NHS, for instance, do you think there is more market based reform that you could imagine being useful? Or do you think that the belief pre belief free pragmatism that you described before is it will prevail?

Jennifer Dixon: I think that will prevail. I mean, I don't see any ideological lodestar at the moment in either the current government or the opposition parties either. What I do see as the occupation with science with technology that preceded the pandemic, actually. So I think those are the gains that we will be wanting to make. I think there's also an increasing recognition now that healthcare is very complex, and the future is likely to be more complex with respect to people having much more complex, multi chronic disease. And it's not a simple sort of factory elective care factory, which was the preoccupation in the 1990s more because of the running sort of waiting times. So I think, I think technology is the place where people will, but they're there, I think, the changes that you suggest, but also AI in particular, could revolutionize care. But it's not just a question of the tech and the kit, it's also the question of how that interacts with the care process and with staff, and how it's how it is, how uptake is, is accelerated by good management. So I think you can't ignore the human element, even if the technological future is the is the headline. So I can't at the moment, see the ideology is, is going to be as big a steer as it was in the past, I think there's just it, there just isn't anywhere coming out of the political parties, both in Britain or elsewhere, anything that suggests there's going to be another tidal wave of something completely different.

Ravi Gurumurthy: Let's get into sort of technology and AI in a second. But before we do that, just another kind of part of the reform agenda was often the creation of organizations dedicated to driving improvement, like, you know, the NHS, university, the NHS Institute for Innovation and Improvement. I think there was the NHS modernization, agency to agency, I forget, because there were so many quangos created and abolish within sort of five or 10 years now. But the theory of change behind that, presumably it was about creating more collaboration and continuous improvements within the system. Again, just talk a little bit more about what was tried and what we learned about how to do that.

Jennifer Dixon: Yeah, I mean, I think I think putting it really simply, there's an a kind of approach to change in the National Health Service, which is prod the system as much as you can give it targets, give it hard incentives, give it regulatory incentives, to do the right thing, and it will, it will move. And then the flipside of that kind of top down prod approach, if you served, if we call it that is to try to encourage and nurture frontline change, which is not big ticket targets or products, but small incremental changes the speed of which could be speeded up through good management. So instead of so instead of a big stick, if you like, you then might have smaller changes that that together would add up to something big Then Then a big stick reform and the NHS University, which really had a very short shelf life and the modernization agency were attempts to do that. And in a sense, they were ahead of their time because the zeitgeist was still very much, you know, kick the system, and you'll get the system you want, because they won't do it by themselves. And I don't think we're in that, that that that weather system any longer. So I do think that if we were going to create something like the modernization agency, which relied upon help giving clinicians tools to speed up change in terms of developing pathways of care, developing new, safer treatments, I think that could embed itself more fully in the future that we're now about to hit with technology also aiding and data, also a dating so. So lots of small tests of change, with data to show you the output very quickly. And then to make rapid course correction, I think is the so the emphasis away from the top down and towards the bottom up, speeding up of change, I think is, so the modernizations. So those organizations, unfortunately, did have a shorter, small, small shelf life not because of that they were ineffective. It's just simply, as I said, the weather system at the time was quite hostile. And people were impatient. And I think that, that needs to be retried and regained. And there's every sign to show that that is gaining more traction now.

Ravi Gurumurthy: And if you compare how we've done it with, say, some other countries, presumably, in countries which have got big private providers, within a publicly funded system, that improvement capability happens perhaps within those chains of providers now, and they've got an incentive to perform, because they're trying to be the dominant provider, I'm just interested in whether, you know, the extent to which we should embed capability and skills improvement within those chains, versus trying to do it across whole localities and across whole systems. And the latter, I can imagine me particularly useful, given what you said earlier about the need for collaboration across multiple silos to deliver better integrated care. But it's probably harder to actually execute.

Jennifer Dixon: Yes. So I think what you're describing is do you go for do you put all your chips down on vertical integration, which means across different providers in a place? Or do you go for horizontal integration, where you're working across chains of hospitals, who are trying to improve things together through mutual aid, mutual learning, mutual investment, and I think at the moment that very, very strongly the feeling is that the move is towards play space. So it's the first it's vertical integration, simply because of the types of morbidity we now face are, you know, multiple comorbidities where people are want needed to be supported to stay out of hospital for longer, and the zeitgeist is really about independent living. And there, you just need expert collaboration across highly specialists care with primary care with community care, and indeed, third sector care as well. And that's a mere function of the that is the biggest question at the moment, I think, how do we cope with that in future, rather than the kinds of productivity enhancing collaborations across hospitals that are dealing with the end state of care if you like, or elective surgery, which are fairly simple sort of treatment pathways. So I think the biggest task is the first. So that's why the emphasis on place, and also the recognition that the NHS itself only really affects anything between 10 to 20% of population health. And that actually, there's more that can be done in a place, housing, education, alleviating poverty, the NHS has role and as an anchor institution to help to improve health more widely. So that's an extra reason for looking at place. But I think the primary reason is how to think about this whole tidal wave of chronic disease, multiple comorbidities that need to be tackled in future to help people. And this is that this is a real issue, not just for older people. We know that there's a big healthy life expectancy, the differences between rich and poor are huge. So some parts of the country people are starting to get chronic disease in their early 50s. Well before retirement age, so how do we support such people to stay and work for longer to live independent lives is a major question. And you don't do that through collaboration between hospitals to get It'll active care sources. So that's the reason I think. And that's where a lot of the tech will be, will be focused in future.

Ravi Gurumurthy: And to achieve those outcomes, the collaboration has to go well beyond the NHS, it has to be into not just social care, but housing, welfare to work, education even is that on the agenda when we talk about a place based approach? Well, that's

Jennifer Dixon: certainly what's being discussed around the country. And that's in a sense, part of the logic behind developing these ICs is integrated care systems in a place. It's also the logic of some of the big metro Mayor areas as well. So Greater Manchester is a really good case in point where they are really collaborating across the 10 local authorities there and the whole network of the NHS in order to achieve some goals, which are a to do with health to do with, you know, improving living conditions, too. And the NHS has a role as a major employer in that area. In some parts of the country's country, the NHS is the major employer. So what can the NHS do beyond simple role in care, as well as integrating across primary and community care and social care? What can it do as an employer? What can it do as a major holder of assets of land of buildings, of moral heft in an area to work with local authorities to try to improve material living conditions, which are injuring health? So I think I think this this kind of place based approach, this kind of vertical integration, as I've described it, is if anything, that's the kind of weather system where we're now in, and then just stretching beyond health, which I'll stretch it because it's out of my out of my paygrade is what is really how you then think that local governments should develop and what powers it should have to be able to affect merit material conditions in future hand in hand with the NHS in a local place. And then that gets into what is the constitutional reform within England going to look like in future which at the moment, it's quite murky? Because there's no doubt that the, that it's local authorities that really have a material impact on health far more than national government, you could argue so what how do we think about this, particularly with the levelling up agenda, just getting into completely different territory for a minute, but that's But nevertheless, final word on the NHS there is the NHS has got to stretch into this territory, but it's also got to stick to the knitting, not least in this recovery period, where everyone's looking to it to make sure that it does deliver effective elective care at a reasonable waiting time. So, you know, that's got to happen to so. So it's, there's a lot on I would say,

Ravi Gurumurthy: I guess the other the other big push historically has been around more patient involvement and patient empowerment. So for instance, personal health budgets, and, you know, expert patients playing a role, how far, you know, what, what's been tried and what's worked in the past, and where is this agenda likely to go? Because it feels still like this. This is we're at the tip of the iceberg.

Jennifer Dixon: Yes, I mean, this is an area where I'm not particularly expert. But I have to say that if you look at the big sweep of changes over the NHS over the last, say, 3040 years, the biggest factor that seems to be shaping the NHS apart from science is the political agenda. It isn't really the clinical agenda, nor is it the patient agenda, despite efforts to try to, you know, to change that for the patients, and there, as you say, there have been various initiatives over time better ways of getting patient and public opinion into decision making into the National Health Service at different parts of the system. The whole business of personal budgets, as you say, which have been really excellent, to give more power to individuals. It at the moment, it is still not a major force, I would say as forceful as it could be to drive change. But I am wondering, in future, if we are getting down to the more, you know, the front line being that the place where the focus of changes is now sitting as opposed to an administrative government lead reform. Some of the speed at which technology and change can happen will be at the speed that patients wanted to happen. And indeed, we've seen that patients can lead change in certain areas, for example, in patients who are you know, the classic case of HIV Of course, with patient groups, but also when some paediatric groups were in die beaters and asthma, for example, the parents are way ahead and patients of the clinicians and actually can do more things. So I think there could be an emphasis on that whether or not it's going to how potent force it will be with respect to change is a is a is questionable, I think. But it is certainly the right thing to do. And of course, going back to what we said before, if, if you really want to try to improve independence of individuals, so that don't have to, to interact with the formal healthcare system in future, then you are going to have to start working with patients much more carefully to understand what helps them achieve the independence that they want.

Ravi Gurumurthy: So if we're doing this podcast in another 30 years, what will we be looking back on in terms of the things that change the NHS? In contrast to what we've we're talking about now, you talked about science and technology being the big driver?

Jennifer Dixon: Yes, I mean, 30 years is a difficult life span, isn't it? I mean, more like 10 years, I mean, I think, I think that technology is going to be and information in particular, virtual AI, will be supporting us making all sorts of decisions, home based clinical and specialist advice through the, through an online system. Wellbeing advice, tailor made to individuals, devices that can test basic parameters of our health regularly. Robots that will support us in different ways at home, I see that as being and then of course, the big thing is trying to understand the role of big technology companies and, and how they develop their products and, and how that will be regulated, I see those. And then, of course, all sorts of, you know, quantum, quantum computing speed up all of this dramatically, so that we can access much more information and much more quickly, tailor made. So I think that is going to change more than anything, I would say. And I think we'll look back over the political attempts to change services through the kinds of reforms we've seen is really very old, old fashioned, very 20th century, and very lumbering, and Ill focus. And I think we'll be surprised at what we did. And

Ravi Gurumurthy: it will break down all the traditional boundaries that we see between patients and dots are public and private home and care. And it'll be sort of doubly lot of transparency and data that we that we can use in that process. I'm interested in in, you know, the NHS has record in applying technology is not the best. How do we make sure that this story happens in 10 years rather than 30? And without lots of sort of big expensive failures?

Jennifer Dixon: Yes, that's a really good question. I mean, I think I think very approximately, that the, you know, in the next few years, the big issue for the NHS is how it even articulates the kinds of technologies that it needs, as opposed to the ones that science gives it is a big question. So how do we focus the scientific and entrepreneurial community on some of the big questions that are facing the NHS as opposed to the ones that the innovators want to solve on? And I recognize that's a controversial statement, because some people think that you can't actually guide innovation, but you can actually you can have the big challenge prizes, you can articulate the needs more. So I think that's one proximal area. I think, I think the NHS has just got to be much more clever at the way that it spots, new innovations coming out of the big sources of technological development in the way that I don't think it does at the moment. So what's our horizon scanning system looking like? What kinds of debates and discussions are we having with big technology companies? Do we understand what AI can do in future do we understand what quantum technologies can do? What are we facing? I don't see that level and I should be in my position seeing those kinds of debates, but I'm not seeing them enough. So I think we've got to we've got to get much smarter in this in this area. And think about it more comprehensively them than we are. So I that's a very sort of high level statement. But I think I think it comes down to something as basic as that.

Ravi Gurumurthy: And given the structure of the NHS. Do you see that as a What does The advantages and disadvantages of that, as we, as we take advantage of these different opportunities, for instance, it strikes me as difficult for the NHS typically to do lots of experimentation and trial and error and have a diversity of different approaches and see what works because it feels more monolithic than that. On the other hand, given the concern about patient data, for instance, I can imagine in a more privatized system that many other countries have, that is going to be a massive concern, whereas the NHS has quite a big advantage in terms of the trust that it has with the public.

Jennifer Dixon: Yes, I mean, I think the NHS should, I think it needs to sort of, in a sense, realize that there's a balance here, on the one hand, the size can really help, it can help to stimulate challenge funds, it can help to, you know, the data helps the fact that we have got data on every single person in the country, in one way or another. And that could be used to in the construction of artificial intelligence to evaluate the impact of certain changes. So I think I think there's heft on one side that it can recognize, on the other hand, that we, if we are moving forwards, and we don't know what the future holds, then we have got to construct ourselves in a way that tests rapidly, certain new developments. And again, that is something we can do if we wanted to. And, and there are signs, you know, with recent policies that actually that message is getting through, for example, 20 years ago, if we decided to have integrated care systems in the National Health Service, we'd be doing it all overnight. Now. The reform isn't so prescriptive, you know, there are broad guidelines, but then people can then figure it out locally as to what certain aspects can be tailored locally. So I think the same will be true with technologies, we just need rapid test sites. And I think, again, that's an area where we should be thinking about the science and technology evaluation, R&D, funds that underpin the NHS and how those can be better harnessed than they are at the moment, and then strategy joined up to try to test some of the most promising technologies. And so and to do it rapidly and quickly. So there's that there's a lot to be done, I think, joining the NHS with the R&D side, and the horizon scanning side that we haven't really focused on too much in in the past that that needs to really be beefed up.

Ravi Gurumurthy: And is one of the other benefits of sort of belief free preferences, and which is not the most strong rallying call, but it's got a lot of advantages is the lack of antipathy or conflict between, say, doctors and practitioners and governments? So is this a world where you can imagine the medical profession being leaders and not ending up in sort of big ideological struggles?

Jennifer Dixon: Yeah, I mean, I think, that the medics just have a different kind of value set. Sorry, what's the worst possible best way of putting this, I don't see, I see that the medics and the clinical professionals would respond really well to a new landscape that would give them more agency. And allow them to be able to test change more rapidly and learn from the results, and learn from the results from other test sites more rapidly. That's the way they go on. I mean, the medics are very hung up over randomized control trials as the pinnacle of evaluative sort of prowess. And I think that given the kinds of changes that we that are now ahead of us, which are to do with the pathways of care, not just the medical treatments, then that may lend itself to different forms of evaluation that the medics may be less comfortable with, but over time could develop. And this is where my organization spent a lot of time trying to think about this, what's called quality improvement methodology, which is basically trying to improve services as opposed to medical treatments. And to do so iteratively with small tests of change Plan, Do Study Act cycles, which are rapid, and to make small steps rapidly and then have rapid course correction, which is very different from the three year randomized control trial that might be there might be used to with respect to testing of drugs or other treatments. So I think it's that kind of new rapid change, sort of psychosis that needs to be sort of trained more systematically as part of medical training and indeed nursing training that would stand us in good stead as we get into this new world where we are testing more technological change. At the front line. So I think that that that's part of science, that's part of it's an analytical approach, as opposed to an ideological approach, which I think would go down really well.

Ravi Gurumurthy: But are you saying that that's currently not a core part of medical training or even the sort of identity of the profession?

Jennifer Dixon: It's, begun to enter medical training, it's not yet as valued because of the exactly as you say, it's not part of your core identity, which is still very much science and capitalist science largely, and were the fruits of your labour or to, you know, to discover the best new treatment for something or, you know, well, when a Nobel Prize, or, you know, being a member of the Academy of Medical Science, it isn't to produce a really good service necessarily. I mean, for some clinicians, sure, that's the case. But that the lodestar is still towards science, which is slightly, which runs slightly counter to what we're talking about. So I think, I think we need to beef up this part of the clinical training, and indeed, managerial training as well, to understand that the way forwards is to have rapid tests of change of the type I mentioned. And it's not to control everything, if you're a manager, and as a clinician, it's not to, to, to subject everything to a randomized control trial, otherwise, you don't change anything to see or to me, and then to see it as part of the day job that that your day job is twofold. One is to do the care. The other is to improve it, as Don Berwick said. So I think I think there's a lot of work to be done there, I think. And then we can then sort of have a hope of having a platform to speed up the velocity of change through tech,

Ravi Gurumurthy: you mentioned challenge prizes as being a kind of valuable way stimulating innovation and accelerating it. I'm interested in well, two things. One, are there particular areas that you feel challenged prizes should could be used to drive change? And also, how do you actually execute those? Well, how do you make them fulfil the promise that you've outlined? Yeah,

Jennifer Dixon: I mean, the kinds of challenging areas, I think it to be very broad, I think, to new technologies that can help people stay independent for longer. So I would try to, if I were the NHS try to funnel them less towards the science end of the spectrum that can change treatments, which are very important, but more towards changing the shape of care, so that people can be supported at home more safely, more effectively, and to build their confidence. That's the kind of thing. So that's one set of challenge funds, I think that would be useful. And then the other set, I think, would be in more productivity enhancing technologies, where, you know, maybe they're more straightforward, but that, that they can be done faster and quicker and leaner with less labour. And those aren't necessarily the kind of challenge prizes you see in in healthcare generally, which may be towards the challenge to treat a disease better, which are very important, but I would say these other two are also critically important. As for how to run them, well, I that's not an area I'm particularly expert in. But, so I can't really I can't really say I'd really defer to others. But I do think the most important thing is to is to try to articulate the kinds of questions for which we need answers, and then to put some money behind them. And there, I think the NHS is better on in some areas, which is the treatment side than it is on others, which is the kind of productivity enhancing or independence enhancing kind of technologies that we're going to need so I think that's how I'd I put it, if you look back at the industrial strategy, a lot of the challenge prizes there were to do with healthy aging, and a lot of that, again, was to do with treatment. And so, again, I would try and push it upstream a bit and say actually, this is about independent living.

Ravi Gurumurthy: Jen, that's incredible we've covered so much ground, it's really interesting conversation. Can I just end by just asking you about the lessons you would give other sectors because new public management Quasar market forms, many of the things that we've talked about today have been inflicted on sectors in education, social care, etc. And the NHS has gone through probably more reformed in any other context and is now Coming into a slightly different space. What? What lessons would you give to people outside your field? About, you know what you've learned over this period?

Jennifer Dixon: Yeah. You know, that's such a good question. I was reflecting the other day that, you know, 30 years ago, 25 years ago, you couldn't move when you went to conferences about policy and change in the NHS without everybody mentioning the word competition. It was absolutely everywhere. And then, and then I would say scroll forwards about 15 years, and nobody mentions the competition word at all. It's really, really interesting. And you're left thinking, all that energy and thought that went into those reforms that were constructed on the ethos of competition, market style incentives were terribly well. Meaning. And, you know, I think they were they were definitely worth trying. But when you look back at them, what my overwhelming feeling is, is was this really a fad? You know, where did this come from? Was it just a wind that would just was just blowing, and it was, was it just an AB reaction to what came before because what came before was so different, it was just heavy, nationalization, and, you know, top down sort of public sector management. And so the, I think the real message, when I look back over this is, is to be very, very sceptical of other kind of fashion, what could be a fashion? And just to not to be a resistor, but to question everything, and to look at the evidence as well. And to look at the arguments for the evidence. So that's probably the biggest thing I would say, looking back. And for sure, you know, what, what if what affects the NHS affects the other parts of the public sector to equal degree, it's the same kind of weather system, which is infecting? I mean, just, you know, it's like, it is like a virus, just, you know, probably coined the phrase at the time. So I think we're all subject to this. I'm sure you were having I think I was, too.

Ravi Gurumurthy: Yeah, I mean, my reflection on this is that when you're in government, firstly, you pull the levers that are easy for you to pull at that time, and frankly, negotiating a target with the Treasury or creating inspect, yes, and those are easier levers to do than the sort of more adaptive constant learning and iteration that you've been talking about. But the other thing, my other function was, when went, I went briefly to work in local governments. And what really struck me was the all these things that we'd we were thought were incredibly important, like targets, or incentive mechanisms, when you actually get down to the frontline, and even closer to the actual practitioners. What seems really important and is going to drive behaviour, when you're in Whitehall, actually, often, when you get down to closer to it doesn't really actually shape things as much as you think. Yes. And that's so important. It's just much less important. It's just more simple.

Jennifer Dixon: Yes. And even just the last thing, I mean, if you look at the academics who've spent the most time looking at the impact of competition on hospitals, if you ask them well, how is that? How is competition among hospitals meant to influence the behaviour of the clinicians inside, you know, the surgeons and the physicians? There's no clear answer. It's almost as if it kind of hits the wall of the hospital. And then and then the theory of change is to kind of build a fine. So I think I think the bottom line here is humility, and question everything, I think, when it comes to these big changes, and that includes the one ahead of us, which is technology, and the value of collaboration in a place also has to be treated sceptically, I think. So that's, that's probably the sober bottom line of the last year's

Ravi Gurumurthy: Great, innovation and healthy scepticism a good way to end. Jennifer, thank you so much for being on the mission.

Jennifer Dixon: Really great pleasure. Thank you, Ravi