After a wide-ranging career in the civil service, including a spell as John Prescott’s speechwriter, Jeremy Marlow is now focused on driving efficiency in the NHS. He speaks to Richard Vize about what Whitehall and the health service can learn from each other
Jeremy Marlow had planned to join the NHS as a doctor. Twenty-five years later he finally works for the health service as executive director of operational productivity at NHS Improvement.
“I always wanted to read medicine – I had places [to study it at university],” he says. “But my adolescence struck a bit late and when I left school I just didn’t want to do it. I didn’t want to be locked in – so you wonder why on earth I joined the civil service.”
But the pull of science still proved strong, and after a year out he took a degree in environmental science followed by a PhD at Newcastle University in paleo-oceanography – “reconstructing the oceans and climate of the past” – which provides insights into climate change.
He had been exploring postdoctoral opportunities, but chanced upon a booklet at a careers fair on the civil service Fast Stream. “I looked at some of the career descriptions of people who had gone in and thought ‘I like the look of that’,” Marlow says.
After securing a place he told the civil service he was interested in working in the Department for Environment, Food and Rural Affairs, the Home Office or the Ministry of Defence. He was posted to Defra shortly before a major climate change conference in Johannesburg – and was mortified to find himself assigned to the litter and dog fouling team, part of an interdepartmental group looking at liveability and quality of life.
“I realised this was an important agenda, and I could see why they had made it a Fast Stream post, because it was linked to Tony Blair’s passion for dealing with antisocial behaviour,” he says.
It became Marlow’s first experience of the treacherous waters of tabloid journalism, when ideas he had put together about which public servants might be given powers to issue fines prompted the Sun headline “NOW BINMEN CAN FINE YOU TOO”.
Soon afterwards he moved to the private office of deputy prime minister John Prescott, where his responsibilities included speechwriting.
“I rapidly learned that speechwriting is not primarily about forming words for ministers to speak,” Marlow says. “It is about the intellectual process of them coming to policy positions, and you are simply facilitating that by giving them the first iteration of their words. It is about what they are thinking rather than what they are saying.
“That was very much the case with Prescott. You would give him a draft and he would rewrite it with a big black pen, and you couldn’t read any of the handwriting, and eventually it was either you or the private secretary in the back of the Jag; Prescott was still doing it, and you somehow had to put this thing back together in time for when he spoke. But frankly he rarely used notes to speak anyway.”
After three years as deputy director of what later became the Ministry of Justice, working with lord chancellor Charlie Falconer to ensure the court system served the interests of victims, witnesses and defendants rather than the convenience of judges, Marlow moved to the Prime Minister’s Delivery Unit in 2006 at the heart of the New Labour government machine.
“The opportunity came up to run the home affairs team in PMDU, including aspects of counterterrorism, and I thought ‘what a dream job’. That is the best thing about the civil service – the enormous variety of jobs you can go for.”
Marlow ended up running the foreign affairs section as well.
He saw the dilemmas of counterterrorism, with billions of pounds being spent trying to ensure that something doesn’t happen. For ministers responsible for both public safety and effective use of resources, it was always a struggle to judge the success of a negative outcome.
“How do you measure nothing?” he asks. “So we were trying to think along the lines of the beautiful structure of the counter terrorism strategy CONTEST, which has stood the test of time with the four strands of prevent, protect, pursue and prepare – how are you actually trying to shift the dial in those areas?”
At that time, the big government delivery mechanism was public service agreements – PSAs – where ministers and departments made commitments to the Treasury and Downing Street on what they would achieve: “I had a fantastic PSA about preventing global conflict.”
This echoes the zeal of Blair’s controversial “kaleidoscope speech” in the aftermath of 9/11, when he made a call to reorder the pieces of the world. Trying to translate this extraordinary objective into something deliverable, Marlow found “it was fascinating to see diplomats move away from their very tactical life of ‘how do we manage this issue and how do we nudge that’ to standing back and thinking ‘what is the realistic thing we can actually change on global conflict?’ It was 2006, we had had 7/7, we were still in Iraq, so it was very real – where could Britain use its influence?”
Marlow believes there are lessons for today’s Whitehall from PSAs and the delivery unit in how to turn policy into action. “It gave everyone a common framework in which to understand what they were trying to achieve,” he says. “It put some disciplines in place, saying once you have come up with the idea, how are you going to codify that in a way which is quantifiable; if that’s where you want to get to how are you going to get there? You have to keep that discipline in place, otherwise some ideas fail to deliver because no-one thought about the execution.
“I’m afraid what I’ve seen since I joined the NHS is a bit like that. You can’t see if anyone [went] through the bother of understanding what resources were needed, how you put them in place, how you keep measuring it to demonstrate the outcome.”
His delivery unit experience has shaped Marlow’s approach to subsequent roles. During his time back at Defra as a principal private secretary, and then director of strategy, it encouraged him to “think more upstream about the political problems. I put some systems in place to help do that”.
He moved from Defra to the Department of Health in 2015 as director of productivity and efficiency, where he worked with Lord Carter on implementing the recommendations of his NHS efficiency review.
When he was asked to go to health Marlow says he “got the bug really quickly”. He is fascinated by the chasm between the simplicity of the objective – put the right interventions in place to keep and make people healthy – and the complexity of the delivery. He is now continuing the efficiency work as executive director of operational productivity at NHS Improvement. “I feel quite passionately that I am part of the NHS,” he says.
Marlow says he has spent most of the last 18 months trying to understand how the NHS is wired, “because, crikey, what a pickle... ”
NHS Improvement’s mission is to support trusts in delivering safe, high quality care within their financial targets. Marlow says his organisation is careful not to take responsibility for delivery away from trust chief executives and boards: “A great expression of my boss, Jim Mackey, is ‘we’re not taking the keys’. We are here to support but we are not taking overall responsibility.”
Marlow’s work is built around Lord Carter’s review of operational productivity in non-specialist acute hospitals – acute care accounts for half England’s £120bn NHS budget. The final report, published in 2016, focused on driving down “unwarranted variation” – unacceptable shortfalls in productivity compared with other hospitals. Whenever a clinician is asked to work differently the reply is “show me the evidence”. Now they have it.
For example, the staff sickness rates in the worst trusts are more than double the best, estate running costs per square metre vary from £105 to £970, and some trusts are paying twice as much for prosthetic hips – one of which was installed in Marlow last year, he reveals.
“Prescott would rewrite draft speeches with a big black pen, and you couldn’t read any of the handwriting. Somehow you had to put this thing back together, but frankly he rarely used notes to speak anyway”
On the back of all this information, Marlow’s team has constructed a “model hospital” exemplifying how a good one should perform. Each hospital is then given a tailored report explaining how their performance compares with the model.
“I have to have the data,” he says. “I don’t want to wait until after the event and something goes wrong and either a trust reports a massive deficit or, God forbid, has a major safety incident. I want to know that I can see as much data as those trusts can, to know where things might be going wrong.
“This fantastic tool, Model Hospital, tries to do that – to give them and us a clear line of sight into what’s going on. It’s an online portal where we continue to crunch as much data in real time as possible.”
NHS Improvement tries to persuade senior doctors that they are essentially part of a production line, in order to apply the same techniques as any other production line to drive out wasted time and effort. Marlow says that routine healthcare “is actually quite a linear process, especially in hospitals, and if you can understand it and make it lean, and find the most efficient way of doing it, you can give really good outcomes”.
His current work reminds him of reforming criminal justice: “The system in which [professionals] work does not have to be complete anarchy and chaos. When you get these extremely bright people like judges and clinicians to look at the whole system and what they do, they then start to look at other people and say ‘hang on, that variation isn’t warranted’. No, it isn’t.”
But he also believes policymakers need to listen more to experts: “You must have them there at the outset of policymaking. You can create the most beautifully crafted pieces of work, but the more professional the industry sector in which you are working the more dangerous and totally disconnected from it you can be.
“Working with the judiciary was a classic,” he says. “There is no way you can work out the best way to transform the efficiency of how cases go through the court – so you can spend less on legal aid and give people less anxiety – unless you work with the judiciary, because they manage the system. It was fantastic building the relationships with the judiciary there, and I’ve done exactly the same here with the medical profession and the nursing profession.”
NHS Improvement is appointing clinical leads for each major specialty to assess the data on their colleagues and “play back to them their performance compared with their peers, sometimes right down to the surgical team level”.
Marlow says it is essential doctors hear the results from other doctors, not people like him, “otherwise they’ll just come out with some long Latin word to explain why it is isn’t possible”.
He refuses to predict whether the NHS will manage to achieve the productivity gains it needs to become financially sustainable while still providing safe, quality care. “All I’ll say is that the potential is there, and what people are doing at the moment leads me to believe that we are perfectly capable of doing it if we really want to,” he says.
“The system in which professionals work does not have to be complete chaos. When you get extremely bright people like judges and clinicians to look at the whole system and what they do, they start to see variations that aren’t warranted”
He adds Whitehall can learn “a huge amount” from NHS Improvement’s work on gripping the data to drive improvement.
“I often have visitors here, or I take our work out to other bits of Whitehall. They are pretty blown away by what we have done with the data, not only because we’ve done some crunching but because we’ve pushed that back out in a really accessible way to the people whose data it is. That creates a really virtuous circle because they start to care about their data.”
Originally on secondment from DH, Marlow has now “cut the chain” and become an NHS employee. As to his next career move, he says he may well end up back in Whitehall, but then adds that “running a trust would be fascinating”.
“Some of these trusts are enormous, with a turnover of more than £1 billion – bigger than some parts of government but with direct operational responsibilities. They are like multinationals in some regards. And then you get international leading brands such as Great Ormond Street, the Royal Brompton. Running one of those would be amazing.”