This has been your first week as Chief Executive of the Nuffield Trust. What attracted you to the organisation?
It was the opportunity to be part of an organisation that has the potential to influence and to do that at such a significant time for health and social care services. The Nuffield Trust has a distinct, respected and trusted voice. I wanted to be part of that.
I've spent my whole career – whether that's as a clinical psychologist, leading an economic development agency, running a charity, or leading an NHS trust – trying to make stuff better for patients, citizens and staff in an area that I care about deeply, which is health and social care. This is another place for me to do that.
How would you describe the general health of the NHS and social care in England in 2023?
There isn't a simple answer to a very complicated set of organisations that make up the NHS and social care, and those organisations it works so closely with such as voluntary and community sector partners.
If I was forced, I would say the NHS and social care is a bit tired. On a good day, it's wonderful, extraordinary, life-saving, thrilling, brilliant, innovative and creative. But on a bad day, it's exhausted, lost its way, over-complicated, miserable, angry, and it's having a bit of a trauma.
It has parts that are thriving and in the best of health, and it has parts that are falling apart, but there isn't an easy answer. If you think you have an easy answer to this question, you are more likely to think of easy solutions – and there isn’t one answer and there aren’t easy solutions.
What do you believe is the role of a think tank in 2023 and why are you so committed to an evidence-based organisation?
Facts matter. I'm not over experts. I love an expert. And I love facts. Instinct is great and experience matters, but shining a light on issues and the cool, calm collection of evidence can be transformative.
Throughout my career – as a clinician, a manager and a leader – I have looked for things that challenge me to think differently, which hold a mirror up and go “but this is what was happening… you thought it was this, but when we looked at it, this is actually what's going on”.
The role of a think tank is to look – in as neutral and unbiased a way as possible, both on its own and in partnership with others – at what is really going on, and feed that back in a way that can be understood and taken on board by people making decisions and by people within services. The purpose of this independent think tank is to provide evidence for better health and social care in the UK and to ensure that evidence is utilised to make things better.
What opportunities do you think there are for the Nuffield Trust to make things better and to inform policy change?
There's no point producing policy or research if people aren't there willing to listen to it – it just goes to the wind. I have seen this time and time again in my career. Research can be incredibly enlightening, but it’s only transformative if the conditions to act on it are also there. So to me, the most important thing is that we have impact. To do that, you've got to be doing work in the right areas, and people have got to be there ready to listen.
The Nuffield Trust does outstanding work – many people know that. The opportunity at the moment is to work in partnership with others and have a strong voice. There are many tribes and many languages spoken across health and social care and it’s important for the Trust to be fluent in them all to influence and effect change.
Ultimately, I'm an optimist. While there are people who want easy “unicorn” solutions that generally don’t exist, many people across services and government do want to listen. I do think people are trying to look for solutions and are working to make things better.
The political landscape in this country has changed a lot in recent years and there's another general election around the corner. What do you think is needed to make the right kind of policy change in this country?
It needs people who are committed to doing the right things in policy terms that are often perceived as boring, often perceived as hard, often long term, and often may not be eye-catching. They may not give a sparkle to your policy, but they are the systematic, long-term, embedded changes that you need to make consistently, whether those are changes that genuinely allow staff to work fluidly across sectors, or real investment in modern digital that allows all systems to talk to each other – I could go on. Ideally, the biggest change would be a cross-party, long-term agreement on what should happen, so that health and social care stops being over-politicised by any political party, and policies that support health and wellbeing are implemented systematically.
What is it about health and care do you wish that people at the top of government understood?
I have encountered brilliant people working in local, devolved and national government, and I don’t think understanding per se is the issue. It can be a problem, but can also be rectified. Taking people out to services is essential, and real meetings with people working in services are crucial. It is often what governments choose to do with their understanding that is the main issue.
It is generally accepted that working collectively together across all organisational boundaries is where we want to get to – one team spanning health, social care, voluntary and community sector partners and others for the benefit of the citizen or the patient, accompanied by a shift to community and primary care and to prevention of ill health. But there are really crunchy things that get in the way of that, and it simply continues not to happen. For example, employment practices and different salaries, like the same person being employed at a different grade, doing the same job for different organisations. If I’m a nurse in a hospital and I really fancy that new matron job being advertised in primary care, I lose all my continuity of service if I go for it because primary care is outside the NHS.
I think people often grasp the vision, but don’t grasp how complicated the implementation of that vision is. And I think people move on too quickly from having articulated that vision to believing that it can then happen tomorrow.
What is the biggest challenge facing the NHS and social care over the next five to 10 years?
The workforce. If you had to choose one thing that’s keeping an NHS chief executive awake at night, besides safety and whether your buildings are going to fall down, it’s the staff.
What makes the health service is an engaged, active, committed, value-driven workforce that stays, which commits to the work and feels heard, understood and appreciated. Those staff want to work in brilliant buildings, with modern IT, use their training to provide excellent care, and to be paid appropriately. Understanding how to retain our staff, and then recruit both those who are already trained and also the upcoming workforce – which has very different ideas about how they want to work – is the core of what’s going to make it work. That’s going to be the case whether you're working in primary care, community care, hospital care, social care, home care or a care home.
Can anything change to help meet those challenges?
They're not easy fixes. Your workforce thrives fundamentally when there's enough of them and the system around them works.
It would nonetheless be great if we got NHS IT to work better, as it would if we got systems to talk to each other across primary care, secondary care, social care, pharmacy, dental, but people have been trying to do that for decades. If you could wave a magic wand and make those things happen, that would make lots of people happy. They’re not the shiny easy solutions and they're complicated. They've got lots of information governance complications and lots of tech complications, but they're completely solvable. And they’re one of the things that gets in the way of integration.
But fundamentally you’ve got to listen to the workforce.
Is there a particular perception about the NHS and social care that worries you?
Hospitals are amazing, extraordinary, brilliant places, but as a society we’re a bit in love with them, and I think we've got to share the love. Most health and care actually takes place outside of those hospital buildings. We need to cherish, understand and nurture everything from the community pharmacy to primary care, to district nurses, to school nurses, to health visitors, to social workers, to third-sector workers who support you when you're having a rough time, to the leisure services that actually rehabilitate you. That's where health and care really happens all the time.
Don't get me wrong, I think we need more hospital beds and our hospitals should be modern, energetic, efficient and well-run places, but the country’s mindset is a Holby City mindset, which is that the hospital is where health care takes place. You’ve got this high-tech love affair and intrigue with the fast-paced world of Holby City, and when people think of health care outside of hospital they often think of Call the Midwife, where people are still having cups of tea and riding bikes. I think that presentation continues to infiltrate what people are emotionally pulled to and relate to in health care and social care.
You worked in the NHS throughout the pandemic. What are the main things that you learnt from it?
It was such a learning experience. The first big thing I learned was that you could implement a whole new IT system in 48 hours and that the world wouldn't come to a shuddering end. You could tell people to get on to Microsoft Teams when nobody knew how to use Microsoft Teams, least of all me. I learned that you could do it, that you could implement something at scale and pace unbelievably quickly when you had one priority and one thing to do, and everybody was focused on it.
I will forever be grateful that I had part of my career in the NHS during the Covid years. It was awful, dreadful, but also an extraordinary time to be part of that.
What would you say is your biggest passion when it comes to work?
Making a difference. I want to make things better, which has been the case right through my career since I was a clinical psychologist and family therapist. I also want to make things better for the most disenfranchised and the most vulnerable person. I'm a white woman with a good salary, who has huge embedded privilege. I work hard not to see the world through my gaze alone. I'm really committed to thinking about the work I will do here as I have been in the work I have done over the years – through as many lenses as possible.
Many voices are seldom heard and seldom influence. Listening to those voices and responding has always motivated me and always will.
Stein T (2023) “Friday FAQs: Thea Stein”, Nuffield Trust Q&A