Speaking ahead of last month's decision by the boards of NHS Providers and NHS Confederation to approve a merger, Elkeles said there were ‘two big drivers' behind the move. 

The first is strategic. ‘With the collapse of NHSE into DHSC, we think there is a really big need for a membership body to be the conduit or the voice that can speak for the NHS to the Government because NHSE used to partly be able to do that and now they won't be able to,' Elkeles said. 

And the NHS Providers boss added the direction of travel of the 10-Year Health Plan of integrated care and fewer ICBs meant there was a ‘convergence of the type of the care model we are trying to deliver'. 

As a result, Elkeles said a separation of the commissioner view and the provider view through the two organisations felt like a ‘conversation from quite a lot of years ago now'. 

‘There aren't actually that many things where either the commissioner or the delivery mechanism of the NHS are not aligned,' the chief executive noted. 

The second ‘material' reason driving this is financial. ‘These are very strained times. Lots and lots of our members are saying they can only afford one membership fee,' Elkeles said. 

Which means that both organisations face ‘huge' financial pressures with an expected combined deficit of £2.5m as we go into 2026/27.

‘The plan is to eliminate that deficit and achieve breakeven in 2027/28,' Elkeles noted.  ‘To do this we need to reduce our costs through reducing head count and to do that we are aiming to restructure in quarter four of this year as far as practical.

‘We haven't yet fully worked out what we can save in non-pay and what we need to save in pay yet. We are doing that piece of work. 

‘The areas we are looking at for savings are primarily in the areas where we're basically duplicating efforts, which broadly you can call the English membership offer, where we're saying that's where the savings need to come from.' 

The NHS Providers boss said everyone should be in the same organisation in January in order to launch a new membership offer in April. 

In the intervening months, between November and March, Elkeles said there would be a gradual convergence of the organisations. 

In terms of leadership of the new organisation, Elkeles said a transition committee from both boards had been agreed. 

A chair and vice chair, Lord Victor Adebowale and Professor Sir Terence Stephenson,  have also been agreed with recruitment for a permanent chief executive to begin in November with the process to ‘ideally finish by Christmas'. 

Further work will also be required on creating a governance mechanism for the new organisation. 

Winter pressures 

Even as he navigates the complexities of a merger, Elkeles' day job remains dominated by the immediate realities of the NHS front line.

‘It's pretty tough out there,' the NHS Providers boss observed. 

‘There's already a lot of illness about but potentially that's a good thing to get a surge of respiratory viruses while it's still warm and people can actually be outside. The message is clear though, people and NHS staff need to go and get their flu vaccine.'

Elkeles reflected that in hindsight more coverage of the Covid vaccine would have been advisable. 

‘I don't really understand the logic as to why NHS staff aren't eligible for the Covid vaccine,' he noted. 

‘Overall, I am hopeful that this winter will be less bad, or perhaps better, than last winter.' 

The NHS Providers boss said the ambulance service was in a ‘much better place'. 

‘We've had six months of achieving less than 30 minute Category Two response and last month was only 40 seconds more than 30 minutes,' he observed. 

‘There's lots and lots of "hear and treat" work  going on in the ambulance sector, which means we take less people to hospital.'

Elkeles cited the example of University Hospitals Sussex's work with South East Coast Ambulance on a scheme that was originally used at Barts where paramedics can phone an ED consultant if they're not sure what to do with a person. 

‘They're getting 30 calls a day from paramedics and GPs,' the chief executive said. 

‘They're able to turn 15 of them around so their patient doesn't get admitted and conveyances of ambulances to their ED have gone down by 10 a day. 

‘It's a good initiative and it wasn't in place last year.' 

Elkeles added he had seen ‘lots and lots of examples' of people doing great things in urgent and emergency care. 

‘Provided that we don't have worse flu than last year, I think performance will be better,' he predicted. 

Commenting on the winter preparation work carried out by NHSE, providers and ICSs in September, Elkeles said it had been a ‘sensible thing to do'. 

‘There are lots and lots of providers involved in the delivery of urgent and emergency care and what you need in each geography, whether that's in an ICS, or hospital catchment footprint, you need plans that everyone has worked on and tested them together so you can work out where the weaknesses are and the things you need to fix,' the NHS Providers boss noted. 

Reflecting on the recent rise on elective waiting lists, Elkeles said this had come despite record levels of activity. 

‘So many people are waiting for care,' Elkeles noted. ‘Demand is really high. You can see the tail of long waiters is coming down and the surge of new people coming onto it.

‘The question is, "why is there so much demand?" to which the answer has to be, "we're not looking after people properly, so they're getting acutely unwell or getting more unwell than a GP can manage". 

‘So we have to do the left shift to prevention and the left shift to community, ideally with a good dose of digital thrown in so that we can slow down the rate of increase of referrals, because if we don't do that, we're never going to catch up on reducing the waiting list.'

But with the shift to prevention not happening overnight what would Elkeles like to see in the immediate future? 

‘In the very short term, we need really good operational management at provider level, because you've got a fixed amount of capacity and you've got a huge number of patients, so you need the flow to be good and you need people to be productive,' he observed. 

The chief executive said he had seen some ‘amazing examples' of best practice such as Bradford Hospital's control centre which monitors what is going on with patients in every bed and what needs to happen next so they can be discharged as quickly as possible. 

Elkeles said a ‘big chunk' of his value was sharing best practice through having the ‘luxury and the privilege of being able to go and visit lots and lots of organisations'. 

‘That's the biggest honour of doing this job,' he reflected. 

Elkeles shares the good practice he has learnt through a weekly blog on email and social media. 

‘The readership is big and growing, and I've had loads of people come to me to say, "oh, I didn't know that about this place, and I want to find out more," ' he shared. 

NHS Providers has published a series of podcasts during the past month featuring trailblazing good practice for the 10-Year Health Plan which you can find at https://nhsproviders.org/resources/providers-deliver-10-year-health-plan-trailblazers

The right targets?

With providers coming under rigorous scrutiny through elective targets and performance measures such as league tables, I asked Elkeles if he felt they were overburdened? 

On league tables, the chief executive said more indicators were needed to give a more accurate reflection of how providers were doing.

‘There's more work to be done to get the right set of indicators and we fed this back to the centre,' Elkeles said. 

The chief executive said he was ‘hopeful' this would be taken on board although this was unlikely to happen as quickly as providers would like. 

NHS redundancies 

Commenting on the impasse between the Treasury and DHSC on who should pay the excess of £1bn bill for halving the NHS England workforce, Elkeles said: ‘I think everyone could agree that announcing that policy without having worked out how you were going to pay for the redundancies was not sensible, but we are where we are.' 

He said suggestions that NHSE could fund the move by bringing forward money meant for later in the settlement review was a ‘very pragmatic, sensible approach'. 

When asked about the impact of the impasse, Elkeles expressed his sympathy for the staff in ICBs ‘left in limbo'. 

‘For all their sakes, this needs to be resolved one way or the other soon,' he stressed. 

Autumn Budget 

Looking forward to this month's Autumn Budget, Elkeles acknowledged the current difficult spending climate but said the costs of any US trade deal on drugs or of industrial action should not be borne by the NHS 

He called on the chancellor to focus on delivering the capital reforms NHS Providers proposed in its Investing in the NHS: empowering the sector to drive productivity, renewal and growth report in October. 

‘There is a huge potential for the NHS to rejuvenate town centres by putting in high footfall services such as GP surgeries, community diagnostic centres and children's hubs and that to be financed by local authorities, who need to regenerate lots of the assets they own in towns,' he said. 

Elkeles cited Wakefield CDC, located in a former Carpetright centre in a retail park, as a ‘great example'. 

‘All that's stopping that from happening elsewhere is how we apply accounting rules, as far as we can see in the NHS,' he noted. 

‘The chancellor could unblock that and unleash a huge amount of growth and improvement to the NHS, and I think the public would notice.' 

The report also outlines ways of allowing private sector investment in the NHS without encountering the pitfalls of previous PFI contracts, including setting up an NHS Bank. 

Neighbourhood health

Turning to the goals of the 10-Year Health Plan, Elkeles said neighbourhood health driven from the centre would fail but creating ‘a permissive environment where providers are more able to work together, more easily with each other for patients' would ‘see a huge amount of change really quite quickly'. 

On the plan's goal of halving the gap in healthy life expectancy between the richest and poorest regions, Elkeles said: ‘There are some pretty awful, damning indictments of how people are living that we absolutely need to fix, because it's just it's not right and it's not fair.'

He cited an initiative in Devon where the NHS goes out to fishermen at the quayside and a health hub in Hartlepool on the ground floor of a library as trailblazing intervention examples. 

In another example from Hartlepool, PCNs in Teesside have invested GP funding in a senior mental health nurse supervised by a psychiatrist from the mental health trust who has helped bring waiting times down to less than a month. 

‘They're able to intervene much more early in someone's condition, which means referrals to secondary care have gone down by a quarter, so you've got happier patients, much happier GPs and psychiatrists, and you've got more people in work as well,' Elkeles noted. 

The opportunities and challenges posed by a shift to neighbourhood health are being addressed through a two-day simulation at the NHS Providers Annual Conference and Exhibition in Manchester this month. 

‘We wanted to make this year a learning environment as well as a conference,' Elkeles explained. 

‘We're assembling about 75 clinicians, patients and managers and we're giving them the scenario of you're a place that wants to do neighbourhood health. 

‘We've scripted all the roles with lots of inputs and they play it out in different cycles based on the decisions they make 

to see whether, at the end of the conference, neighbourhood healthcare has delivered what it promised to do in terms of the left shifts.

‘There's going to be inputs from their simulation into the main conference hall and people can go and watch it as it's playing out.

‘We're going to find out whether neighbourhood health care actually works and people are going to learn based on the interventions they make in the scenarios 

HM will be in Manchester to see how it all plays out so watch this space.