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Q&A Webinar: The Evolving NHS Landscape in England – From Policy to Practice

• Petauri Evidence • Season 8 • Episode 5

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In this NHS Whispers live Q&A webinar, Katie Mulholland (Senior Consultant, UK Market Access, Petauri Evidence) speaks to:
 - Sarah Everest Ford (Programme Director, Health and Care Partnership)
 - Patrick McGee (Deputy Programme Director for Pathology, Lancashire & South Cumbria)
 - Prof. Phil Richardson (Former Dorset ICS System Commissioning Director; now Chief Innovation Officer, Petauri Evidence)

Together, they explore the implications of changing NHS structure and policy, and what this means for your market access, stakeholder engagement, and product innovation strategies.

This episode was first broadcast as a live webinar on 19th September 2025. Some to the topics discussed may evolve over time. This session was shaped by your questions. Key themes included:
 - Evolving NHS structures, policies, and practices – and what this means for industry
 - Strategic commissioning: where will it happen, and who will lead it?
- The 10 Year Plan and its implications for innovation and access
 - How industry can adapt to new engagement models and financial constraints
 - What the shift to integrated neighbourhoods means for product rollout and service design

Learn more at: https://petauri.com/insights/evolving-nhs-landscape-policy-to-practice/

For support with navigating the evolving NHS and launching new medicines and products in England, please email evidence@petauri.com. 

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- [Announcer] Welcome to this Petauri Evidence webinar. At Petauri Evidence, we deliver market access and HEOR support throughout the product lifecycle to bring new treatments to patients across global markets. Follow us on LinkedIn for more great content from our team. We hope you enjoy the discussion.- Welcome, everyone, to our third live Q&A session in this NHS Whispers webinar series. In this series, we've been following the evolving structure of the NHS, which is now obviously shaped by the new 10-year plan. And exploring your questions around what these changes really mean, what's happening on the ground, and what you need to consider in the coming weeks and months in terms of your market access strategies. I'm Katie Mulholland, part of the UK Market Access team at Petauri Evidence, a global market access and HEOR consultancy within the Petauri platform. For those of you who may not know, we specialise in supporting biopharma companies across the full spectrum of market access strategy with particular expertise in UK launches, navigating NHS dynamics. Our work is deeply informed by our in-house experience and enriched by our network of NHS partners as well. We provide really valuable insights through advisory boards, strategic input and feedback on value propositions and messaging, just as a few examples. We're delighted to welcome our guests for today's session. And we're really looking forward to a lively and insightful discussion again, and hopefully you'll all find it helpful. Firstly, we have Sarah Everest Ford. So Sarah is currently working as a Programme Director in a Health and Care Partnership leading a number of transformation programmes including neighbourhood health and integration. And her background is varied from starting as a children's nurse over 25 years ago to the last 10 years where Sarah's worked in a number of senior roles in commissioning, business development and strategy. So welcome, Sarah. Next we have Paddy McGee. So Paddy joined the NHS to do the NHS graduate scheme, and has been in various operational and commissioning roles since. Most recently he's been Head of Strategy and Planning in the NHS Greater Manchester ICB. And he's currently the Deputy Programme Director for LSE Pathology. So welcome, Paddy. And then finally we have our own Phil Richardson, who I'll be posing questions to you as well today. So Phil was the former Dorset ICS System Lead, and he's got loads of experience in the changing NHS landscape having led the formation of one of the first ICSs. We've had a really fantastic turnout so far for this series, and we've had a lot of listeners submitting questions for our previous Q&A sessions. And thank you so much to those of you who've submitted questions for today's session as well. Just to remind you, there is a question box for you to submit any further questions too throughout the session. So please just check that you can see this. And do use it. We'll try and come to any other questions that you may have submitted at the end. If we don't get to your questions during the session, we'll follow up via email after just to make sure that you do have an answer. So I think that brings us to our questions. So to start, we've had quite a few questions have come in around the ongoing structural changes. The first question, Sarah, I'm going to come to you first. And the first question is,"Are the ICB in NHS England redundancies really going to happen, and what is driving this decision?"- Thanks, Katie. Great first question. I think it all comes down to who is going to pay. I know there's lots of conversations taking place at the moment between NHSE and central government. I know locally, the ICB that I work with, I've got some real financial challenges and don't have the money to pay for the redundancies in year. I know other ICBs are looking at splitting the redundancy costs across more than one year. So I think there's some real conversations happening about the actual money side. But I think more importantly, for me, it's that human perspective. We're talking about people's lives. A lot of my colleagues from the ICB, they went through a restructure last year. I think they lost about 25 to 30% of the workforce through that. And again is now looking at another 50% and then 50% effect going out into providers. I just think it's a lot for people to be dealing with, and it's really interesting that I think there's a real lack of interest in the media, I think, because it's generally seen as managers and not so much frontline staff. And I think it's just really tough for people. People might be left with a job, they might not be, it might be a different role to the one they want to do. Thinking about kind of strategic commissioner, a lot of my colleagues have spent the last sort of five, 10 years working in a much more integrated way and collaborative way with providers and what the strategic commissioner role will look like going forward I think is is a bit unknown. It's been really disruptive. I think it impacts decision-making, and I think what is it actually sort of costing from a human and an economic perspective.- Yeah, thank you. Some really good points. I don't, know Paddy, maybe you've got some other bits to add there.- I mean, firstly sort of share the sentiment with Sarah that it is difficult from a sort of human factor side. Secondly, there is obviously the impact on actual delivery. ICBs were brought about sort of two or three years ago now. And the commissioning function is not where it needs to be. So we do need to draw this sort of restructure to a close at some point. Obviously Sarah referenced that there's no confirmation of where the funding will come from at the moment. So Jim has recently said that NHSE never promised central funding for the redundancies. The current sort of projected redundancies, you know, will cost sort circa a billion quid. So there's certainly not that within any of the ICP budgets that I'm close to or aware of. So I think it is difficult. I do think it's going to happen. I think based on that central government policy, some something needs to happen. So Jim said himself a couple months ago, the NHS budget is the size of the whole GDP of Portugal. So we do need to do something to sustain and improve the provision of services. We have to act in some way. So I do think we are going to get there, and Sir Jim Mackey has a reputation for delivering what he says is going to deliver. So I do, it answer the original question, yes, I do think it will happen. How is the difficult bit.- Yeah. No, thank you. And in terms of NHS England and what might replace it and over what time period, do you have any thoughts? I'll come back to you again, Paddy, do you have any thoughts on that? Has there been any updates? Well, I can't hear you, Paddy. I don't know if that's just me or if that's others as well.- Sorry, I'm mute too myself'cause of the feedback. Can you hear me now Katie, yeah?- Yeah.- Yeah. Okay, thanks. I think Wes Streeting announced a time period of roughly two years, both for the NHSE absorption into the Department for health and also to the changes to ICSs and the changes to region. I think that two-year period will obviously depend on the previous question around the redundancies in the restructure. It will sort of depend on that I think in terms of how that new sort of centralised body will look. It will be a reabsorption of many of NHSE's functions into Department of Health. A reduction of the duplication of policy teams in both NHSE and Department for Health, and NHSE that's focused strongly on standards and major programmes of change. A much stricter performance assurance regime, which you'll have seen through the recent league tables issued by the Department for Health. We know from the NHSE model region guidance that was recently published that more authority and risk will sit with regions and ICSs and provide collaboratives. And also the other point I would make as well is that over this two-year time period, the transformation team has been appointed as the sort of NHSE exec board. But if you look at the members of that, it is very acute trust focused. So I think that potentially gives us a signal of where we are headed in the long-term. And there is perhaps a slight contradiction with the neighbourhood programme there. So I think there's still lots to work out.- Yeah, no thank you. And Sarah, I can see you were nodding along there, did you have anything else to add from your perspective?- Not really. I mean, there's been a recent new model region blueprint, which I think will guide some of this. I guess it's then how there's so much change happening at the moment in so many different places. It's how some of that is navigated and the timescales are not necessarily aligning or being pushed back. And I think it's then how that sort of all works with the new direction of travel with neighbourhoods and what's done at place and what's done at ICB, and what's done at region and what's done nationally. I think there's still a lot of unknowns in terms of how that's actually going to work in practise.- And just, I think thinking holistically, obviously we've said that change is needed, but do you think ultimately this is a real change for the better that will bring cost efficiencies and not just a reshuffle of chairs, I suppose? Phil, maybe I'll come to you first.- Thanks, Katie. Hello, everyone. I think that's a great question. If you step back from all of this, there is the, why is this happening? And there's definitely cost pressures. We've talked about cost pressures already. But there was also a sense of disconnection between what was happening at a policy level nationally in the Department of Health and how that was executed through NHS England, who then had to execute through regions, and then through ICBs, and then through trusts and then down into communities. So there's multi-layers of interpretation happening. And the action taken initially by Jim Mackey and Penny Dash coming in, which was we need to thin this out a bit so we can see things. And we need to manage costs, and we need we need to have a tighter connection to the what's happening on the front line. So that was triggered. And as Sarah's talked about already, there was already a cost cutting exercise for that'cause ICBs bloated really quickly following the CCG changes. So there was a couple of key events that happened. And then the change of governments came in. And I think they were struggling to grip what the NHS was doing and how it was managing its spend of money,'cause there was a constant flow of NHS representation back into the Treasury saying, we need more money, we need more money. But no real discernible change scene for that. So it was almost a patching up exercise, it felt. So I think the government's taking control. And if you have a look at how it's doing that, it's bringing everything into the DHSE, which is then managed centrally. It's proposing to change regions to become DHSC organisations, which brings that tetrad. So it's a bringing into the centre. And before that's happened quite, that's happened a number of times in the NHS but it's brought it into the centre of the NHS. But now the NHS itself has been brought into the centre. So there's a real collapsing of the hierarchy almost between the top and the bottom. So I think that, I think there's more to it than cost saving. There's much more about line of visibility through, and there's part of that. There's definitely going to be a cost, there's a cost piece. But I think there's also a big drive to say, well, are we spending the right money in the right way in the right places? And I think that ties in to the 10-year plan, which probably be talking about later. So it feels like it's a good idea. But as in all these things, is there really a clear plan in the way that people who want to execute can execute against it? And the answer is clearly no. We've already touched on different organisations will be moving at different speeds with the different priorities. So there is that element. And then there's a constant overlaying of new models of care and new structures, and everybody really likes to go to, unpicking what the new structure is as opposed to, actually what is the right thing to do and can we not just get on and do that? And of course in the meantime, while all of the, all of the, if we just use the chairs thing you mentioned, will the chairs have been moving around? And I don't think it is a case of the chairs being moving around. But while all that activity's happening, the flow in the front door's continuing to grow, it's continuing to build. And the longer people wait for things, the worse they get. So not only is it is the flow continuing, but the stacking up of the flow is causing the overall acuity to rise. So the longer we wait, the worse it gets really. And I think that's why certainly Penny Dash when she came in, wanted it all to be done by October. And then there's just the practicality of how you move all these massive things around in a tight timeframe.- Yeah, thank you, Phil. I don't know, Sarah or Paddy, just from your perspectives, if you have anything else to add or if you agree that this is actually a good change that's happening, it's just a matter of how and when.- Yeah, I mean, I don't disagree with anything that Phil said, and I do think that the NHS does need to change. I think, you know, you mentioned about rising acuity, and I think rising costs and expectations from the public. But I think the bit for me is that the, after any period of change in the NHS, and I think I've done over 25 years now and have no idea how many different restructures or reorganisation there's been in that time. But it is never given the period of time to stabilise. And with that, you know, anybody that works in sort change management, you have to have an embedding and stabilisation period. And it feels like a new government comes in or there's some change in minister and it's reorganised and you kind of start the cycle again. And I think that makes it really difficult for the people working within the NHS as well. And I think that's probably, you know, one of the reasons why people get frustrated and leave. And I think the fact that we have a government NHS plan rather than a kind of a cross-party or a single NHS plan that is for 10 years and stays for 10 years will continually have this change and the change that can't be sustained. And I think it's how we get past some of that. So I absolutely do think change does need to happen. And we can't stand still, but it has to be the right change for both patients and the workforce and it has to be given that chance to embed.- Yeah, no, thank you. Very good points. And just one other, I guess structural question. Do you know if we've identified any of the initial integrated health organisation foundation trusts and how their effectiveness will be measured? Sarah, I'll ask you that question.- Yeah, I think it's a work in progress. I think are starting to see some areas being identified. But I think for me again, it's what does it actually mean for patients as a result? You know, we've talked, Phil just talked about different changes and there just seems to be a lot happening at once. A lot of different terminology or the same terminology being used as different things. Where I work, we're part of one of the wave ones for the National Neighbourhood Health Implementation Programme, and the different acronyms and names that are coming out as part of the Neighbourhood Health agenda, kind of like Single Neighbourhood Provider, Multi-Neighborhood Provider. How does that fit with kind of like the AIHO structure? I mean, we love a three-letter acronym in the NHS, don't we? It seems to be. If it's not three letters, it can't be an acronym. But I think, again, coming back to the NHS, how the NHS needs to change and not change for change shake, change sake, I can't speak, and the structural side versus people working differently I think is all the stuff we need to work through. But one thing I do believe, I think fundamentally, if we don't sort out the funding flows then it doesn't matter what organisations we have, you know, we want more care out in the community, but if it's sat within the IHA or the acute, how do we do some of that? And I think that's going to be a real challenge moving forward. And I think we kind of need to establish some of that to help the new models work and not just focus on organisational form,'cause it's, you know, fundamentally about people.- Yeah, no thank you. And, Paddy, I'll come to you. Just in terms of national policy, how can national policy interact and inform the current NHS restructure?- I suppose national policy is obviously driving the direction of travel with the 10-year health plan, life science strategy, certainly overarching sort of priorities for prevention efficiency, which we've spoken a lot about this morning so far. Digital transformation. So the restructures being shaped around those priorities,(clearing throat) excuse me, as well as things like access to ED and access to general practise, and even dentistry, which we know is a challenge in some areas. We've discussed how NHSE is being slimmed down and absorbed into, or their functions being absorbed into the Department for Health, consolidating the assurance and procurement processes, which I know we'll talk about at some point in this session. And really aiming to produce that duplication and variation. The next bit as well. I know there's questions around national policy, but equally then it's the translation into regional delivery, I suppose. And that's where national have asked ICBs to develop and embed five-year planning frameworks aligned to that 10-year health plan. So the 10-year health plan is, you know, the plan, the strategy, and then it's how we going to deliver that over five-year cycles refreshed annually. So I think that's the sort of next steps.- Yeah, no, that makes complete sense. Sarah, do you have any other points to add there?- Yeah, I think Paddy is absolutely right. I guess the other bit for me is it's not one way. So how can we take what's happening locally, that local experience innovation to inform national policy? I know, so through the wave one National Neighbourhood Programme. It's that collective learning and then that informing direction of travel. And I think it's how we continue to do some of that. I think policy gives us the framework but then it's how the providers, councils, architecture organisations, community and industry really make it happen. So I think it's how we connect some of that together.- Yeah, no, thank you. That makes sense. And I guess one of the big topics that's been raised always being discussed from the 10-year plan is the move to a single national formulary. And we've had quite a few questions around that. And I guess a broad question first is how could that possibly work? Paddy, maybe I'll come to you.- Yeah, I think first we have to learn from others. Yes, it can definitely work.(clears throat) Excuse me, sorry. It can definitely work'cause it does elsewhere. Wales and Scotland already use, not quite a single national formulary, but centralised approaches, albeit their geographies is obviously a bit smaller than England, but they already do it. Australia and NZ do it there. There are examples across the world of where single national formularies work. So I don't think it's something that we should disregard based on their fairly positive experience, showed national consistency around equity and purchasing power for the centre. The difficult balance obviously is that the strong central governance, which is required, and balancing that with the local flexibility to reflect not only like the specific needs of a population, which will naturally be different from Northeast North Cumbria to Northwest London for example. But also the supply chain vulnerability that, you know, you can expect. And I know lots of sort of stakeholders across the system are quite worried about that bit. So I think we can expect some form of flexibility in the design. Obviously that single nationalised increases risk if there are supply chain shocks. So I do think there'll have to be some flexibility around local stock and supply and how you may have sort of approved products that maybe aren't first on the list. But this is the national direction, I think you can see from the Drug Tariff Guidance that's come out as well, this is where we are going as an NHS. You can see that the NHS, for a couple of years now at least, has been trying to consolidate sort of large procurement of things like equipment and consumables through NHS supply chain. It is very much an approach to start to consolidate, centralise and go in that sort of single fashion. As far as I'm aware, there's not yet an explicit sort of document as to how we'll approach that, but I'm sure that will come. But yes, it definitely can work.- Yeah, no, thank you. In terms of how it might evolve, obviously there's a two-year target for it to happen within or the move to happen within, do you think that it's going to be evolving, more of an evolving process? Do you think it's realistic that everything gets sorted within in the two years, or actually it might be more of an evolution over the 10 years of the 10-year plan? And we also had a question around whether you think it will likely be molecule or brand based? Sarah, maybe I can come to you.- Yeah, I mean, I think it's going to evolve. I don't think anything moves massively quickly in the NHS isn't the set target of a timeframe, and it's going to evolve. I don't think it's something that's going to be static. And I guess in terms of the areas of focus, it might be more on high volume, high costs to start with where variation create creates inequity in waste and as that sort of real world data can be built up and outcomes and then the formulary could be expanded and refined, yeah, I think it'll be quite an evolving process.- Yeah, no, that makes sense. And just in terms for those products that are included on tariff or national frameworks, do you have any thoughts on how it would change the process of getting onto either of these?- I think tariffs, national frameworks, reimbursement as a whole, I would look to the Drug Tariff Guidance and the processes that they've outlined there in terms of how you get onto a framework if you are initially refused from a framework, how you then get back on, I think the Drug Tariff Guidance is a good example of how the NHS are going to procure full stop going forward. Again, it will evolve, but the sort of the principles, I would say, will be applied generally.- Yeah, no, thank you. I've got a few questions now just around budgets and the balance of short-term costs and longer term benefits. Phil, I might come to you first. From your perspective, how do the one, three and five-year budgets link into a shift to prevention?- This has been a perennial challenge. I remember 10 years, a director of Public Health saying to me,"We could massively change cardiovascular disease if we started 10 years ago." And I think that the prevention agenda in the main gets a bit overshadowed by an acute hospital agenda. And I think there is a real willingness now to want to move that because at the end of the day, if we can stop things happening, or we can catch things early, or we can help people navigate issues in an earlier stage way, then the downstream costs are massively affected by that, as is the workforce pressure, as is the operational pressure. So I think, I think without saying it wasn't serious before, I think there's a really serious effort now to do something about prevention. But we've got to move away from prevention being a sort of a worthiness that, you know, everybody needs to eat well, drink well, exercise more. And that sort of only appeals as a message to the people who we eat well, drink well, exercise more. And I think we need to move into a holistic prevention model, which is how do we help communities? And the neighbourhoods approach is absolutely aimed at supporting that and enabling it, but there's got to be a real sense of priority that cascades down to, for it to be taken seriously in a day-to-day conversation.'Cause things like prevention as a concept, everybody does intellectually noting that's a really great idea. We should definitely do prevention. Then there's a lot of workup models which says this is how we could do prevention. And there's a lot of epidemiological modelling, there's a lot of public health modelling, there's a lot of things which say, look how much we could help if we did do this. And then suddenly you've got a queue of people with a need for some urgent treatment. And well, we'll just see those people first and then we'll get onto prevention. And of course the queue of people never stops. So that whole prevention thing changes. But if I have a look at the director generals that are being appointed at the national level in the DHSC, there's some very serious players in there who could help shift the agenda from an acute medicine model into a prevention model. But it's a huge ask, and our day-to-day operational teams are not set up to do that. So it's a big thing to do and it's a big shift in what work type has done. And there needs to be a bigger emphasis on decision-making at a senior level that can carry a prevention discussion and decision over and above a public health input. So it needs to be as part of the core mechanism, I think.- Yeah, no, thank you. I don't know, Paddy, from your perspective, is there anything else that you think?- I think Phil's covered it in the main. I think the time length of budgets is part of it. So clearly if we have such a short-term focus on sort of realising efficiency, for example, in short-term outcomes, which we very much are in the NHS and particularly at the moment with the big drive on reducing spend, we're very short-term focused. Now, clearly that's not an environment that encourages a long-term proactive prevention approach to sort of supporting healthy populations. The main crux of the issue is less so that though, that's again a key part of it, but is what Phil was referring to in terms of where the money goes. And it's essentially unrealistic to ask acute trusts, ops people to focus primarily on prevention, because if I'm to do that and I'm senior manager on call tonight, there'll be 120 people in the ED, seven-hour waiting list as a minimum. So it's how am I supposed to transact prevention when I've got a lot of reaction to do?- Yeah, and I suppose, do you have any thoughts, Sarah, maybe, on what potential solutions could be to overcoming the barrier of the short-term challenges and costs versus long-term benefits?- Well, that's a very big question. (laughs) I think it's, (laughs) I think it's a really important challenge to discuss. I think Paddy was just alluding to, the NHS is often forced into those short-term decisions because of immediate pressures. And we do know the real value of investing longer term around health and prevention. I don't think it's one thing I think Paddy start to touch on it, I think around the funding and where the funding goes. We have to be investing in communities if we want to really focus on prevention and early prevention. The challenge is the financial return won't happen for several years. Could be even generational, particularly when there's some deep rooted health inequalities and health challenges. I know locally, we've made the decision to really invest some of our health inequalities grant and things like customer and community first approach, because we do know that if we invest now it's that longer term return, but it's how we demonstrate the impact along the way. And that can be a real challenge. And I think linked to that, something about how we really measure the value. If we're only counting today's savings, we miss the wider economic and patient-person impact. You know, using measures that capture things like avoided admission, improved independence, or even people's ability to stay in work really helps demonstrate that bigger picture, which I think quite often we view it through the single NHS lens. I mean, we've done some really great work. I say we, my team have done some really great work around the Know Your Numbers campaign over the last sort of week or so, and that's about pressing checking blood pressure checks. And that is a really good way to be able to demonstrate just by doing those checks now, the savings that that has in the longer term and some really good evidence about that. And I think it's how we can do more of that how can we build the evidence to demonstrate that the savings will come in the long term. It's that age old thing of trying to prove something that's not going to happen, if that makes sense. And then I think, yeah, we've got to be able to align policy with the financial flows. As I said, we need to get more money out into communities, very much that population health approach and moving away from those single year cycles. Paddy touched on it, you know, it's starting to happen. The annual planning from NHSE and ICB is earlier this year. And it does include that sort of short, medium and long-term as well as the short-term. And I think if we can give providers longer contracts, then they have the ability to be more creative and innovative. And I think it's fundamentally about seeing patients as people and not seeing it as today's cost or balance sheet. And I think if we can get some of that right, the economics and the patient outcomes will align. We just need to start trading today against tomorrow. I think that's one of the biggest challenges in how the NHS currently operates.- Yeah, no, thank you. And I suppose just in terms of industry and how they might be able to support, Phil, I'll come to you for your thoughts. Do you have any ideas for how the NHS and pharma or wider industry could work together to deal with the management of long-term conditions when budgets are so short-term currently?- Yeah, thanks, Katie. I'd like to sort of join the two conversations together for me. I think there is a bit which is, where prevention plays a key role in long-term conditions and then there is long-term condition management, but it's actually all on the same continuum really,'cause a number of long-term conditions actually start with a preventable start or at least an ability to reduce the impact at the start. And an example that might help with that is the recent session bringing together the, bringing together the cancer alliances and industry joining that conversation to say how can we detect cancer earlier, right up to the point is what are the new things we should be looking for as opposed to the more traditional biomedical type markers? And what was really cool about that is it had organisations in the room who have a quite large proportion of their business on dealing with the later stage cancer challenges. And they were in the room actively engaging, trying to diagnose it earlier. So moving into that early diagnosis stroke prevention space. And I think if I connect that then with the prevention agenda, I think there's a real role for industry just to work in collaboration with some of the teams who are leading on how do we get prevention engaged in the community, how can we support long-term hospital engagement? I think there's a real opportunity to do that. And that would help catalyse the importance of this by starting to demonstrate some of the evidence that Sarah's just touched on

because that's one of the challenges:

how do we see our return on effort? And one of the big challenges with funding is that, so something like 75% of funding is people related. So if industry can provide some people related horsepower into the mix, then the funding requirements suddenly a very different profile. And if that can work in a collaborative way as a joined up team, which I've seen work really effectively and it can be focused on prevention in a therapeutic area or comorbid area that the organisation is familiar with, then that could start to unlock some real benefit, and it could start to unlock it earlier. But the funding for long-term conditions has been a perennial problem. And what typically happens is they end up in a primary care space with quite a bit of the time doing routine follow-ups, diagnostic rechecking. And some of the interventions from a digital point of view can really help that. So wearables and remote monitoring are a key part. So we need to think about the answer may not be a medical answer, it could be a broader answer by bringing together some technology, some data and collaborative working with industry and others.- Thank you. And that actually really nicely brings me onto my next question, which is all about how we're going to be adopting innovative technologies. Obviously now more than ever, there's more and more coming through. And one of the key targets within the 10-year plan has been around introducing efficiencies through automation and AI as well. Just the first question just around budgets, efficiencies that need to be made. Obviously ICBs are needing to cut costs and it's just a question around how the 2% efficiency mandate will likely affect the adoption of new innovative technologies. Paddy, maybe I can come to you first with that.- Yeah, so I actually think it's more like 3% or quite a bit more in some cases where there are already significant deficits. Obviously that poses a real tension for boards where the NHS urgently needs innovation to drive the productivity, prevention, population health agenda that we've spoken about. But again it's balanced against that sort of blunt cost cutting pressure that potentially crowds out that investment or at least that intention to invest. We've spoken a lot already around the mandate that pushes ICBs to towards those short-term cash release and savings rather than the long-term transformation, which can make it a little bit harder to fund upfront costs for new technologies 'cause of that short-term focus, which is where I think industry, so it needs to frame frame technologies as not really just nice to have, but as efficiency enablers and things that will introduce at least partially a short-term benefit. I think industry needs to help the NHS achieve that short-term benefit whilst also focusing on the long term. Now, that's not always possible but it probably does need to be the focus. Any business cases need to be absolutely robust that are able to realise something within sort of an in-year benefit with potentially I think flexible commercial models around risk share and stage payments and sort of partnerships. So I think that the efficiency mandate doesn't necessarily stifle innovation, but it does raise the bar for business cases. Only those solutions that directly release cash, save staff time, and by staff I mean in the main, I mean, you know, clinical time, or demonstrably reduce demand will make it through. And those that don't tick two or three of those boxes will probably struggle. I think the last point I'll make, Katie, is just that we've also got the health innovation networks as well, which are in place to support the adoption of innovative technologies. So whilst there are cuts at the centre and regionally and in ICBs, hopefully the health innovation networks will be able to balance that in some way.- Yeah, no, great. Thank you. Sarah, do you have anything else to add from your perspective?- That's very comprehensive, Paddy. I think just to add, I guess, it's balancing the longer term impact versus that short term. And I think we're good at in the NHS of looking for quick, I like to call 'em quick wins. And I think when there's money to be saved or there's an efficiency mandate, it is the quick wins that get the attention, but actually all the quick wins often do is just put a bit of a stick in pasta row there. It might make a a short-term impact, but we want to make real long-lasting change, it's about how those innovative technologies that can do that around the things that Paddy has just described. And I think it'd also add into that is improving patient outcomes as being a top priority as well. But yeah, I think it's not focusing on the quick wins but looking at at the longer term impact, and being able to demonstrate those savings and improvements along the way, but that not being the first focus.- Yeah, thank you-- Katie. Katie, can I just sort of jump in? Sorry, didn't need to get across here. But I think the important thing here is, say there's a bit of a smoke and mirrors conversation often happens around savings. So if I just comes back to my commissioner role, we would often be given a business case would say you do a thousand of these a month, we'll save a pound on each case. That means you've got a thousand pounds worth of savings. Then you think, well, no, not really because we'll still be doing a thousand, we'll be using your new technology or solution which will be costing us more and I can't get the pound out, I can't find a way of getting the pound out to give it to somebody else. So I think there needs to be bit of an asset test on savings. It is what is actually cashable? Will I have cash in my hand at the end of the business case that I didn't have before? And in a lot of cases, you can't. And even if it's like clinical savings. So we had examples such as physiotherapy which said, well, we could provide apps that people can use at home, which will mean they can do physiotherapy activities by following the app as opposed to having a physiotherapist show them how to do the activity. And you think, well, that all sounds very interesting. So that will save 20% of your physiotherapy costs, but I'm not really going to reduce my physiotherapy workforce by 20%,'cause those physiotherapists are also deployed in other things, which would then be a hundred percent stopping that activity. And 20% of the physios, we can't really take a, you know, 20% of a person away 'cause they're working full time and they allocate their time in different ways. So something about cost saving where, and, you know, I thought about earlier, 70% plus of the costs of people costs. Then you need to make some fundamental decisions about what the purpose of your case is. Is it to allow deployment of staff into a wider range of activities? And if it is, where are they going exactly and is that where they're going, is it efficient where they're going because you could just waste money doing that? Or can you show direct cashable savings? And I think there's quite a lot that sits in that precision around commissioning decisions, which could release cash right now, but you would change your workforce structure.- Yeah, some great points, Phil. Thank you. I've just got another question around actually implementing some of these innovations."How will the NHS ensure that AI and clinical informatics are safely integrated into everyday practise without adding to the digital burden?" Sarah, maybe I can come to you.- Yeah, thanks, Katie. I mean, I think this is really, really important. I love tech, especially AI. It makes my job easier, it makes me more time efficient. But I'm not necessarily certain that the whole workforce feel the same. I think we've got a bit of a skills gap challenge. I think we've got some people who embrace technology and want to use it more. And then we've also got people who aren't that interested. And I think if we also then play into the mix around sort of health inequalities, I heard the other day I think it was 10 million people in the country don't have the skills to be able to use new technologies, and 3 million, I think it's about 3 million that don't have access to the data or the digital tools. So I think exclusion is a real challenge. There's a big push through the 10-year plan from analogue to digital and using the NHS app, which I, you know, think is great and we need to use that more and it needs to be built so it has more capability, but we need to be really mindful that there's a real risk around inequalities. And what we don't inadvertently want to do is make that inequality gap wider, both digital exclusion for our communities but also for our workforce. We need to make sure that proper training is in place so it's not seen, I think Phil talked earlier a little bit about the challenge between managing crisis on the day versus is prevention. And we need to make sure that this is not seen as something extra like I think prevention can often be, it's like how can the technology be absolutely making people's jobs easier and making sure that we've got people with the right skills and that we're providing opportunities for people in communities who don't have access and don't have the skills not to be digitally excluded and widening that gap.- Yeah, thank you. And I don't know if you've got any thoughts on how industry might be able to support and show their ability to actually support the changes that are going on.- I think-- Sorry, Sarah. You go and then I'll come onto Paddy as well.- Yeah, I think for me this is is where industry can provide support, whether that's in kind or whether that's resource around digital initiatives. And then we've been looking at some things recently'cause we've got a real challenge with inequalities where I work, and people being digitally excluded. And actually if we're working with industry or we're working with a local business, how can they support through that kind of social value agenda in terms of helping us fill some of those gaps that we've got. Particularly as we've talked a lot today about funding being a challenge.- Thank you. Paddy, do you have any other thoughts?- I think Sarah's covered it mostly. I think, I would reflect on my previous point slightly, is if you want adoption in the NHS then it needs to be safe as a bare minimum. So you need to be able to prove that, and obviously there's various, you know, sort of regulatory frameworks that should ensure that. But it also does need to de deliver value both in the short-term and the long-term and save time for staff, particularly clinicians. I think the other point I would make, and it's I think easily forgotten is the integration with existing systems. So if I was to bring in automation into pathology or diagnostics, for example, I would have to make sure that my product integrated seamlessly with various different types of RIS/PACS, various different types of LIMS, various different types of order comms, potentially. Certainly various different types of EPRs. You know, potentially different types of GP, management systems, different types of patient administration system. I could go on. And I do think that is a key challenge. So if you want fast adoption in the NHS, make sure that you are at least integratable, for want of a better phrase, with some of the big players in the APR space and the LIMS space, and the RIS/PACS space. Or otherwise you might have a very good AI product, but it's of absolutely no use.- Yeah, no, thank you. And just on the topic of industry again, is there an appetite for strategic partnerships with industry across NHS? And if so, what type of initiatives would add most value, do you think? Paddy, I'll come to you again for that.- Yeah, so I think the appetite is sort of selective, I would say. NHS leaders at the moment are under extreme financial pressures. Extreme workforce pressures that does vary by system and by provider. So partnership has to mean help solving system problems. Not just commercial engagement or a long-term partnership that delivers value financially for the supplier. There obviously needs to be benefit and kind there. I think the NHS has has demonstrated largely its open to strategic partnerships, particularly at the centre. I think industry needs to keep in mind when engaging the sort of NHS and the wider public sector that actually a lot of people that have worked that work in the NHS have only ever worked in the NHS and worked in the NHS for 20 to 30 years and are actually instinctively suspicious of industry. So I do think there's a barrier to get past there in terms of engagement. So, and that's my point in terms of the appetite can vary. But that appetite will be strongest where industry co-invest, share risk, bring capability that the NHS doesn't have internally. I think in terms of where initiatives would add most value, one of the key things we've spoken about today, prevention, community care. We've also spoken about workforce productivity, digital transformation, supply, resilience and sustainability. So I think there's various things there. The other final point I'll make is that, and I think most most colleagues know this, but pathway focused things, models of care focused solutions that Phil was referring to right at the start. Not just single independent products to be added to a formulary or a framework for reimbursement. Things that actually solve pathway problems, from the GP to the hospital and back out.- Thank you. Yeah, that's a great answer with lots of good points there. I've got a final question to wrap up. But before that, we have had a couple of questions come in. The first one, they're both around a bit more of a commissioning focus. The first one is with the devolution of specialised commissioning for many areas to ICBs, what are your thoughts on this being held here? And do you think that ICBs have a plan for the management of this increased load? Don't know if anyone feels they can start off.- I think, well, so it's why I don't work in ICB at the moment. Obviously I know lots of people that do, and I was around when some of this was being spoken about. I think it depends, which I know is not a very good answer necessarily, but it would depend on the different ICBs. Some of them I know are very prepared, and those that are very prepared have already had it devolved or will have it devolve sooner than those that are less prepared. Obviously there is still the risk and I do feel like I'm banging on about it, but there is still that risk of reducing funding, but then devolving more powers. And I do think that's a difficult balance to strike. But a lot of ICBs have brought it within their exec team and appointed, you know, specialised commissioning people. The problem is, I think, capacity is one thing, capability is the other. Spec comm is something that's pretty much always been done nationally. So then to add it into systems, they may not have the capability to do it in some cases some of the talent has followed, but there's 42 ICBs at the moment, sooner there will be less. But it's whether that talent can be spread across all those different footprints, I suppose, is the challenge.- Katie, can I just-- Great, thanks-- Can I just jump in on that too?- Yeah.- As Paddy said, there's been an evolution which has been coming for a while and there've been some early adopters, and some who're really quite reluctant for the reasons Paddy said is it's a very specialist skill. It takes a huge amount of effort to do in what was seen as diluted way across a number of settings. The other challenge is practical in that it will work quite well with an ICB who delivers the tertiary services. That specialised commissioning is commissioning. Where it's more challenging is where those services are delivered in another ICB,'cause that adds another whole layer of complexity about how you manage the flow of commissioning.'Cause in real terms specialised works by being close to the providers who provide those type of services as much as it is just about the commissioning bit. So it's that connectivity and the flows of patients. So I think that's key. But I also think it's just a point of view. I think it's possible that there'll be a review of that and some of them will be recentralized. So I think there will be a period of time given which says, is this working or is it not? And what is a better way of doing it? Because having what could be at the sort of ICB cluster level, 26 people leading on a particular portfolio or specialised commissioning might not be as efficient as a smaller group looking at a bigger scale. And specialised have this challenge all the time.'Cause in the main, their flow of specialised type work, just the geography of that, doesn't line up particularly well with the ICB geographies. So I could see that being re-looked at again, but I think it'll be a while. But it's possible.- Thank you. I'm just conscious of time. We've got two minutes. What I might do is just go around very quickly and get your final thoughts. If you had one or two pieces of advice around what listeners should do to help navigate them with the changing structure of the system and everything else at the moment, what would that be? Paddy, maybe I'll come to you first.- Okay, I think I've already said it probably a couple times throughout, but to reemphasize, cash-releasing benefits, saving stuff time and performance improvement. If you're not ticking two out of three of those, you're not going to get very far in an NHS that's very focused on the short-term at the moment.- Thank you. Phil?- I would say two things. I would say understand who the stakeholders are that are important to where you can add the value. If we go back to the digital one, and I was looking at AI, I'd be looking at clinical safety officer, the clinical nursing information officer, and the chief clinical information officer as people to have a good relationship with,'cause they'll understand the practicalities of both digital and safety and clinical practise. And then the second bit, which is please don't start any conversation with my product, is it does this, my therapy area is this, and we have products that do this, because nobody knows how to connect to that problem. And it just aggravates the way Paddy was talking about earlier, that antibody levels. If you came in and said, I can see from my research that you have this challenge, you've set a programme up and actually we've got some great expertise in there and this is how we could help you solve this challenge, then I think you would be welcome with open arms and people be trying to figure out how to work with you, not whether they should work with you.- Thanks, Phil. And Sarah?- Yeah, no, I agree with Phil. I think focus on helping solve real world problems, getting to know the people and build those relationships. and I think it's probably thinking about different stakeholders to maybe ones previously. So thinking about who are the leaders in place, working directly with providers. And I think there's something important about offering something back so that social value, looking at financial initiatives into communities, and really try to understand the local problems that people want to solve. I think if you can help with some of that, then you'll be pushing against an open door.- Brilliant. Thank you so much. I think that brings us to the end of the session. Thank you to everyone who's tuned in. If we haven't got your question, we'll follow up over email or we'll signpost you in the future as well, if you have any other questions, just to someone that can help. Thank you again for joining. Have a great rest of the day.- [Announcer] Thank you for watching. If you'd like to find out more about how we can support your market access goals, get in touch today. For more market access insights, follow us on LinkedIn.