What is it about your job that you feel would surprise the public?
The sheer size and complexity of Turning Point – we worked with 83,000 people last year and we employ nearly 4,000 people. Our turnover when I started 19 years ago was £28 million, whereas now it's well over £120 million.
People would also be surprised with the complexity of the clinical interventions that we make, and that we employ doctors, consultant psychiatrists, social workers, psychologists, specialist blood workers, counsellors and many others. As well as being surprised and delighted by the quality of our services, I think they would also be shocked by the depth of inequalities that we see on a daily basis.
What’s been the biggest change you’ve seen since you started working in the NHS and social care?
Inequalities are actually getting worse. It's now become the accepted face of the welfare state for people to go to foodbanks – that's different from before. And we've also now got a lack of outrage about what that means.
In terms of health policy, the 2012 Health and Social Care Act threw all the cards up in the air and was ‘Schumpeterian’ in its impact on the NHS and social care. Another big shift has been in the role of the third sector – there's been a transformation in how those services are delivered. We're not an 'add on' or a 'top up' service, we are part of an integrated pathway in many places.
If you could make one change to the NHS and social care over the next 10 years, what would it be?
We need an absolute focus on inequalities. For 70 years the life expectancy of the working classes and poor rose inexorably year on year until 2010, before we first saw a levelling off and then active life expectancy starting to drop (as did life expectancy in some cases). The NHS was started by the working classes, and the middle classes benefited as a result. Now it's become a service where the middle classes benefit but the working classes and poor don't. That's frankly unacceptable, as well as expensive.
Change from the top
If you could give Matt Hancock one piece of advice, what would it be?
The digital agenda is actually welcome, but he might be barking up the wrong tree. I'm concerned about digital companies exploiting market failure and competing with the NHS, rather than working with it. I wonder whether we have a clear enough specification about what the NHS actually wants from digital and the kind of company it wishes to work with, and he could help with that clarity. My concern is 'does the NHS understand what it needs?'
Eight million people don't have access to the kind of Wi-Fi that you need for some of the digital services that are being promoted, and even more don't have access to £600 smartphones that appear to be a prerequisite with much of what’s promoted.
What do you wish people at the top of the NHS understood?
In my six years on the board of NHS England, I think I became quite boring yet consistent in talking about health inequalities – it's the biggest danger to the future viability of the NHS. The Long Term Plan shows that some headway has been made, but there is still a long way to go. York University estimate that the cost to the NHS of people in poor places going to hospital with things that could have been dealt with in the community much earlier is about £4.8 billion a year. That means about 25% of the £20 billion new money will effectively go on 'poverty services'.
Policy in practice
What policy have you seen successfully implemented, and why did it work?
There isn't one policy that jumps out per se, and in my experience policy doesn't necessarily work like that. It's always the degrees of the curate's egg. Policy is a human construct and how successful it is comes in the learning and evaluation of it, rather than in thinking 'one leap and we're there'. It's about making sure you don't repeat mistakes, therefore ensuring better policies next time.
What policy have you seen fail, or not be as successful as first intended?
Some policies have failed partially. Successive governments have invested a huge amount of money when it comes to information technology, for instance, and we're nowhere near where we should be as a modern society in terms of accessibility, availability and appropriateness. There's lots we need to learn from previous policies, to make it more likely that the curate's egg will be more edible than less so.
What policy and/or change in behaviour are you currently trying to implement, and how’s it going?
We've started to deliver a number of healthy lifestyle and wellbeing services – health trainers, health checks, integrated healthy lifestyles – being population based in our approaches, and that's going really well. What's letting us down is the commissioning, and we'd like to help commissioners get the whole picture as we have a lot of experience.
We are also pushing the value of leadership within the business, so that it's not about having a heroic leader but having leadership throughout Turning Point – I'm really proud of my colleagues taking that on board.
The NHS is under pressure because...
Because it tries to manage demand on a uniform basis, and doesn't think how to solve a problem in response to demand in local and regional places. It's also slightly afraid to discuss the undiscussable, with inequality being the main example of that. It also needs to engage communities before co-designing accessible services, as was the case when the NHS started – it was designed by the people who actually used it.
Lord Victor Adebowale CBE is the chief executive of Turning Point.