On 4 June, two HSJ journalists spent the day attending the regular Monday meetings chaired by health secretary Jeremy Hunt.
These long-running meetings have become notorious in the eyes of many as the prime example of Mr Hunt’s alleged “micro-management” of the NHS.
HSJ first suggested it attend the Monday meetings more than a year ago. The health secretary said “yes”, but the senior government spin doctors said “no”. As Mr Hunt got closer to breaking the record for the longest serving political boss of the NHS, he decided to ask for forgiveness rather than permission.
Therefore, on the day Norman Fowler was relegated to second place, HSJ travelled to the Department of Health and Social Care’s new Victoria Street HQ.
The subjects of the Monday meetings have changed over time, with previous line ups including, for example, regular discussions on dementia and technology.
Mondays at the DHSC now usually include sessions on: performance management; care quality and safety; mental health; transformation; social care; finance and efficiency; and workforce.
HSJ was invited to attend the first four and was asked to step outside for the social care and finance meetings. There was no workforce meeting on the day we visited. What follows is our “as it happened” report of those meetings – followed by some brief conclusions.
Meeting 1: Performance management
As HSJ waits outside the health secretary’s office, a senior civil servant remarks that today’s meeting is very different from the normal performance management sessions.
Instead of looking at the record of individual trusts and their leadership, this meeting will examine a report prepared by a distinguished former trust chief executive into how the centre scrutinises local performance. “We’ve all learned our lines” jokes another senior figure (conscious of our presence) as the call comes to enter the meeting room.
Mr Hunt arrives last, sitting in the middle at one side of an oval table, around which sat very senior representatives from most of the major NHS arms-length bodies, as well as the Department of Health and Social Care.
The health secretary is teased about his record breaking stint in the post before he introduces the report.
He says the genesis of the study was an attempt to address the concern that the job of a trust chief executive “has become so difficult that only totally exceptional people can do it”. He adds: “We need to have a job that good people are able to do.”
Running to just over 20 pages, the report is a thorough analysis of the myriad and often conflicting ways the centre keeps tabs on local organisational and system performance. It also features some pithy quotes from trust chief executives about that approach, the tone and nature of which will be familiar to anyone who reads the comments under HSJ stories about central performance management.
Six minutes in, Mr Hunt jumps straight to the report’s conclusions – which are sound, but have been well-rehearsed in leadership circles for many years.
He praises the “excellent piece of work”, but says he detected a “mismatch” between the concerns of chief executives and the conclusions. “I didn’t feel the conclusions went far enough”, he says, also noting that some of the recommendations seemed to be aimed at helping the centre get a more accurate picture of local performance rather than lightening the burden on trust chief executives.
The health secretary then drew responses from almost all present.
Much sense is talked, but again little that would surprise anyone who had been paying moderate attention to the challenges of being an NHS leader in the post-Lansley reforms world. Some hobby horses are gently cantered around the room; nobody responds directly to the challenge made over the report’s conclusions.
Summarising, the health secretary says he would like to know the answer to five questions:
- Do local NHS leaders know what is expected of them?
- Are they being supported by the centre?
- Are the goals of individual organisations and the health systems in which they operate aligned?
- How can the centre reduce the administrative burden on local leaders?
- Will local leaders be recognised and rewarded for taking on difficult jobs?
The meeting is done and dusted in under 30 minutes.
Meeting 2: Care Quality
Senior leaders from NHS Improvement, the Care Quality Commission and NHS England took their seats after lunch to discuss quality of care – an issue Mr Hunt has made a priority during his tenure.
Led by one of the NHS’s most senior medics, the discussion focused first on what were described as “challenged providers” and specifically two trusts that were at risk of deteriorating and falling into special measures.
Initially, the discussion focused on the sustainability of services and leadership challenges of the smaller trust. The solution was felt to lie with a nearby trust that was now supporting its smaller neighbour and taking on services and a leadership role. Mr Hunt seemed reassured and satisfied with the trajectory.
The larger challenged trust was described as “being on the cusp of special measures”. There was no doubt this was a trust keeping people awake at night. It had cultural issues, workforce shortages, a lack of leadership and significant demand from the local community which was using its accident and emergency “like a primary care centre”.
The trust was described as “very fragile in terms of staffing” in A&E with nursing and medical rota gaps a big factor in its inability to cope with demand.
Mr Hunt was clear he was not “quite as optimistic that this is going to sort itself out” as he was with the first trust.
The room was quick to reassure him. New leadership was being put in place and “it was important we back [them]”, he was told. The consensus was that the trust also needed to resolve longstanding “internal issues” and “get a handle on their governance” as well as work to find a better strategic position.
The meeting then turned to maternity safety and nine trusts which were thought to have a problem in this area. The secretary of state was given a whistle stop tour of each one and the actions being taken. This included the use of an £8m funding pot for training and Mr Hunt was keen to know whether it had worked.
Yes, came the reply - but one senior medic was quick to say that while there had been short term improvement the question was “are we creating sustainable changes to the culture? The test will come in time.” The statement hung in the air.
On a discussion of the wider maternity transformation work, Mr Hunt floated the idea of a dedicated fund for maternity safety and training but a senior civil servant was quick to shoot this down arguing where that happened, NHS trusts “tend to cut their own training”.
The meeting ended with the promise of an evaluation of what was working well to be presented back to Mr Hunt later in the year.
Meeting 3: Mental health
Presented with new ambitions to improve mental health, another area of Mr Hunt’s focus in recent years, the secretary of state was quick to point out to civil servants and the clinical leaders that they had missed their mark this time
Mr Hunt “cut to the chase” telling them he wanted something “tangible that would turn heads all over the world”, and singled out targets for reducing mental health illnesses in children as one he could support as there could be a clear “yes or no answer” as to whether it had been achieved.
There were big sums of money at play. £100m here, £50m there and links with the research world and global charitable trusts who could partner with the DHSC and contribute their own funds.
There was no ducking of serious issues with mention of the prejudice against people with mental health by NHS services and the unjustified mortality gap with the rest of the population.
The room had to agree on a vision and Mr Hunt was clear in inviting the experts to tell him if his ideas “were complete nonsense”.
While there appeared to be genuine discussion and debate about what could best be done to achieve a step change in mental health over a long-term period, Mr Hunt had to return to his initial point several times and warned the proposals risked “falling between two stools”.
Eventually he drew a line, asking for “a rethink” and once again reiterated his hope for something deliverable but ambitious.
The next item involved plans to boost levels of mental health research. Again, Mr Hunt had bad news for the DHSC officials, rejecting their recommended option. “It’s one of those afternoons,” he remarked dryly, revealing the Monday meetings can sometimes be a challenge for civil servants.
Mr Hunt both challenged and listened to the advice from civil servants and the clinicians. The debate was healthy but no clear outcome emerged. It ended with a clear steer from the health secretary on what he wanted to see next time around.
Meeting 4: Transformation
This meeting involved a 45-minute dash through a series of very large, very thorny issues: data sharing, genomics, artificial intelligence, and how the NHS and the country might benefit economically from advances in these areas.
Mr Hunt was joined by the influential junior minister Lord O’Shaughnessy, whose wide-ranging brief takes in technology and life sciences. The two ministers took turns to lead the conversation – in which several arm’s-length body leads and civil servants gave as good as they got.
Much of the debate involved the politicians trying to pin down specific commitments.
Mr Hunt, for example, wanted to know when the Local Health and Care Record Exemplar plan would be complete and also felt that it was important, because “of the nature of IT projects” that there was also an agreed “definition” of that completion.
Mr Hunt suggested: “Everyone in the health and care system is able to access a patient’s record on a read/write basis”.
A debate ensued about what the current level of agreed spending should be expected to deliver.
Mr Hunt changed tack and wanted to know whether the LHCREs would be integrated with the forthcoming NHS App.
The reply started: “In the long term”, which was enough for the health secretary to stage another intervention.
“I appreciate that, but I wonder if we could make this part of our short-term vision – because I think that might make the App story a much stronger story. It’s not just your GP record you’re accessing in two years, it’s your entire health and care record.”
That sparked an examination of how many NHS records would not be digitised within that timeframe – and whether it was wise to offer “piecemeal access” to patient’s data or whether it was better to wait until a more holistic experience could be offered.
The conversation moved onto payback for the investment in new technology.
DHSC officials got stuck in on when the IT funding “would pay for itself”. Here the health secretary – clearly remembering the conclusions of the report he commissioned from Bob Wachter – came to the aid of those from the ALBs attempting to explain that a simple payback equation was not the best way to judge IT investment.
“To me this is the equivalent of putting down superfast broadband”, the health secretary interjected – adding “you can find all sorts of ways of dressing this up with the most fantastic ROI, but in reality, we’ve just got to get on and do this.”
Next, the subject of language arose – with Mr Hunt wanting to dispatch “LHCRE” as a term (everyone of course pronounced it “lyrca”). He proposed “personal health care record”. When told that might sow confusion he tried again with “personal care record”. No agreement was reached.
The weightier subject of genomics produced another challenge from the health secretary.
“I wonder if we could give ourselves a private ambition by when we [could] start integrating the first genetic profile into a LHCRE, because I think there’s quite a lot of thinking we have to do as to how we would integrate it in a way that was useful for a clinician”.
Mr Hunt then suggested a deadline and a definition for what should be achieved.
The debate that followed underlined the health secretary’s point about the amount of thinking required, as it quickly became obvious that answering the question would demand a much greater understanding of the implications of genetic medicine from most around the table.
A similar debate developed around the issue of artificial intelligence and the various joint ventures – ongoing and planned – the NHS has with a range of technology businesses.
The discussion concentrated on the “rules of the road” for this process, how a world leading IT sector might be developed in the UK because of the NHS’s digital advances, and levels of public trust for data sharing which might challenge those developments.
Mr Hunt attempted to summarise by asking how the UK ranked in its efforts to exploit AI and machine learning for the benefit of healthcare.
“Everyone’s getting very excited about this”, he said. “However, we need to understand better what is going to be the USP for the NHS – and how we measure that?”
A micro-manager at work?
The evolution of the health secretary’s Monday meetings is plotted in Nick Timmins recently published history of the NHS from 2012 to the present.
Early in his tenure, the health secretary explained to Mr Timmins that he held the meetings on a Monday as that was the time least likely to be disputed by the demands of Parliament.
Later, he told the same author the meetings were important as they encourage the NHS ALBs, and NHS Improvement and NHS England especially, to establish “a common NHS position” on important issues.
He added: “On things like preparing for winter, I am not sure you can do those things, with the legal structures as they are, without having some way of bringing people together. I am quite confident that the civil service would brief any successor of mine that it is essential to have those Monday meetings.”
There is little doubt the meetings have developed from, in the words of a senior civil servant quoted by Mr Timmins, “the same old performance management” to a “more orderly sequence” in which the health secretary “might be looking at performance, but not every week, or safety and quality, but not every week, and not demanding that everything come back by next week.”
However, Mr Timmins concludes “the Secretary of State’s Monday morning meetings regularly focus on what are clearly operational issues – with Hunt demanding action, and still on occasion insisting that hospital chief executives’ heads roll.”
HSJ is under no illusion that it is possible to reach any kind of definitive conclusion about the Monday meetings from its time at the DHSC on 4 June.
Everyone HSJ spoke to on the day agreed the meetings have got more useful over time and in the words of one had “fallen into a good rhythm”.
The meetings we observed displayed very little attempt at micro-management on the part of the health secretary; but then the performance management meeting was atypical and we did not attend the “finance, efficiency and delivery” session.
As would be expected across so many meetings the quality and nature of debate varied.
The performance management meeting felt perfunctory at times, with no-one raising the obvious question: why have the many similar initiatives of the past 15 years – including the one which reported in April last year – so far failed to deliver the goods?
At other times, the meetings felt more about reassuring the health secretary than an attempt to find new solutions to long-term challenges.
More positively, it was clear that Mr Hunt’s aim to get the NHS to adopt a “common position” across the various ALBs had largely been achieved. The health secretary’s many interventions were – by and large – what any fair-minded observer would expect from someone in his position. There was a focus on getting clarity on goals and teasing out implications for patients. The level of debate was often robust and perceptive.
In general, the civil servants HSJ talked to welcome the meetings, finding them a useful frame for their work. Senior clinicians and “technicians” from the ALBs clearly enjoyed educating politicians about their areas of expertise and debating with their peers.
The ALB top brass, broadly, see the meetings as an acceptable way of maintaining a good working relationship with an increasingly knowledgeable and influential health secretary - while still sometimes resenting the time commitment it demands of them.