Welcome, everyone, to today’s session of the Health and Social Care Committee’s review of the 10 year plan. My name is Paulette Hamilton and I am the acting Chair of the Committee. Could I ask the witnesses to introduce themselves, starting with you, Wes?

I am Wes Streeting, the Secretary of State for Health and Social Care.

I am Sally Warren, the director general for the 10 year plan at the Department of Health and Social Care.

I am Jim Mackey, chief exec of NHS England.

Brilliant. You have me for the first question. Wes, before I start my questions, do you want to give a bit of an overview, so that we can have a warm-up? What’s wrong with you today—are you nervous, Wes?

Well, yes—you’re in the Chair! Can I begin by thanking the Committee for all the contributions you have made to the development of the 10 year plan through your inquiries and evidence, particularly in relation to the first 1,000 days, community mental health services and healthy ageing? We are looking forward to working with the Committee in the coming months and years for you to hold us to account for the delivery of the 10 year plan, because I think it is fair to say that the reception of the plan has been extremely positive. The question everyone asks is, “But are you going to deliver?”, which, given the level of people’s trust in politics and politicians, is not a surprising question, but is one that we definitely need to answer in the affirmative. I am really proud of the way we built the 10 year plan—not just taking on board the views of the Committee, but having what I think is the biggest national conversation since the NHS was founded about its future. We received a quarter of a million responses through the Change NHS website. There were over 600 in-person events right across the country, and they involved the people working in the NHS as well as the people who use the NHS. I would like to say a big thank you to all our colleagues across the House who hosted 50 events with constituents across the country. What we found, of course, was that people are extremely anxious about the NHS and its future. They feel that sense of jeopardy, and there isn’t a single person using the NHS or working in the NHS who would say that the national health service as it is today needs to stay exactly the same and exactly where it is. Everyone can see the scale of the challenge, and people want to see the NHS fulfilling its founding promise, which was to be there for everyone when they need it, and to do so in a way that defends the equitable principle at the founding of the NHS—the principle that healthcare should be based on need and not the ability to pay. We know the challenges are going to get harder, particularly with our growing, ageing society and rising levels of chronic disease. I was struck, through the public engagement, by the extent to which the general public wanted to talk about public health and prevention—not simply the service itself—which is encouraging because we are going to need their help to create a fairer and healthier nation. We inherited record waiting lists, the lowest ever levels of patient satisfaction, and staff burned out and walking away. All those things, I think, fuel the sense of jeopardy that people feel about the NHS’s future. But there are also grounds for optimism. This country is one of the world leaders in life sciences and medical technology. We need to make sure that we are not just benefiting from that revolution, but actively driving it and making sure that those innovations are being adopted and rolled out consistently across the NHS. We know that, thanks to the decisions taken by the Chancellor, the NHS has been the relative winner at the Budget and spending review, so this is a funded plan for the next few years. That sense of medium-term certainty will help the system to deliver and design the services in a better way. The thing that is fundamentally different is how we imagine the NHS working in the future. At the moment the NHS is a very centralised top-down state bureaucracy. The future needs to be one where power is devolved, and where there is far more freedom at the frontline. We have some brilliant people working at the frontline and brilliant leadership capability throughout the NHS; we need to set them free to do the job as well as hold them to account. Finally, the most important revolution of all as far as I am concerned is the revolution needed in patient power. When Nye Bevan established the NHS in 1948, he said he wanted it to hold a megaphone up to the mouth of every patient, but the NHS that we see today is a far cry from that vision. Patient voices are too often unheard, their complaints dismissed or discouraged, and the NHS needs to move with the times. Patients need to have far more ease, convenience, choice and control over their healthcare, and that is at the centre of the plan.

Fantastic. That leads nicely to my first question. You have talked about the three shifts at the core of the plan and the long-standing ambitions but, Wes, we have seen these in multiple NHS strategies for at least the last 30 years. Why do you feel this plan will succeed when so many others have failed?

It is a very good question. You are right: the three shifts were not in themselves radical new ideas, but delivering them really would be. Why now and not before? I think there are a few things in our favour. The first is that the sense of jeopardy that the public feel about the future of the NHS is felt right through the service. We have prosecuted an argument in opposition and now in government that it is change or bust—reform or die—and I think that there is an overwhelming consensus in that direction. People in the NHS want to see it change. They know it needs to change and they are up for it. Secondly, how we do the change is as important as what the change is. If you think about some of the things contained in the plan, whether they are new models of service delivery, new commissioning arrangements, or new innovations in medical science and technology, we will succeed in delivering them only if we are doing change with people rather than to them. That is why, in terms of how we have approached some of the challenges as a Government so far and how we will deliver this plan, we will make sure that the implementation is designed with, as well as delivered with, people throughout the system. Already—Jim may want to say more about this—we have had people banging down the door since the plan was launched saying, “We’re really interested in this new model of neighbourhood health; we want to go first,” or, “We’re really interested in the reinvigorated foundation trust model. How can we have a piece of that action?”, or, “On these integrated health organisations, how can I be part of that?” And that is exciting for me because—

Wes, do you want me to bring Jim in now so that he can finish that off?

Yes, feel free.

We had a chief execs gathering on Thursday. We have created some groups to develop the next parts of the plan on neighbourhood health, integrated health organisations, the medium-term planning and financial rules, and the NHS App and so on—a handful of bits of work. There has been really strong engagement. At the last count—this is still moving—there were about 120 volunteers for chief execs and their organisations to participate and get out in front. I have just left a call with a colleague, ahead of a session later on, where, as the Secretary of State pointed out, there is a real tension between real ambition and desire to get out and start delivering this stuff at pace—a will to work in a new way—and also wanting more detail. We just have to get that balance right and hold our nerve. We will develop the detail with colleagues in the service, because that will work better and give us a better chance of success. So that is really what the next few weeks are about.

What do you feel we have learned from previous attempts at reforming that we can bring to this particular reform?

The worst thing we could do is take the plan and the end state that we are aiming towards and try to impose it all in one go now. The lesson from the Lansley reforms is that a big top-down reorganisation imposed on the system does not work. Following through the logic of some of what Andrew Lansley was saying, I can see the method in his madness, but the execution was really poor, and some of the ideas at the outset were ill conceived. I know we have taken a bit of flak for the fact that we did a big engagement exercise to build the plan, and we will take some flak for the fact we are working with people on designing implementation, but that is a far better approach than the alternatives we have seen. The other thing on that point is that with some of the models we will roll out, particularly thinking about primary care, the principle is that you set people free to lead the path to the future—to show us how the new model will work, be the early adopters and pioneers, and in doing so, inspire other people to follow. It is about doing that in a way that does not go in like a bull in a china shop, where we say to a primary care network, for example, “Although you’re working really well, you’re driving innovation, and you can demonstrate year-on-year improvements, we—the Government in Whitehall—have decided that we don’t like your model, we’re going for a different one, and we’re just go to come in like a bull in a china shop through your thing that’s working.” We are not interested in going in and bulldozing through things that are working in pursuit of the thing that we think will be the future. It is far better to let people opt to be the pioneers themselves, show how it will work in practice, and inspire other people to follow.

That is a good place to stop there. My next question relates to dentistry. Last week, Minister Kinnock told the Committee that funding for dentistry was likely to be “in the region of the current financial envelope”. Given the ambitions and plans you have to reform NHS dentistry, why have you not committed to increasing dentistry funding to pre-pandemic levels? Will you be reconsidering your decision?

I will say a few things in response to that. The first thing we could do is make sure that we are making the most of the money that is already going in. In opposition, we complained a lot about dentistry underspends. We will be looking to address that through some things we are already doing, such as the 700,000 urgent appointments that are being rolled out, but we know that fundamental contract reform is needed. There is a tension—a constant tension for me—between the level of ambition we have as a Government, the level of demand put on us by Parliament and the public, and the choices and trade-offs we face when trying to deal with an NHS that has such a breadth and depth of challenges, so—

Wes, let me stop you there, because you could talk for another five minutes, and I have not got five minutes. Will you be reconsidering—

That is why I said I was scared of you chairing this meeting.

Shut up, Wes. Will you be reconsidering that decision?

It is something we are constantly put under pressure on from Parliament and the public. We will do as much as we can, as fast as we can, on NHS dentistry.

Absolutely awesome. My final question is on palliative care, which does not feature significantly in the 10 year plan. I have noticed it has been mentioned about four times with all the experts who have trawled through it, and in the index you mention something about palliative care, but nothing was actually said on it. With all the issues we now have to address, such as inequalities—and the fact we are looking at palliative care through the 10 year plan, and in the context of the terminally ill—how are you planning to address palliative care going forward? It is becoming—I will use the words from last week—a burning platform.

Palliative care does feature, particularly in the context of neighbourhood health services. I feel very strongly, having seen palliative care in a range of settings, and frankly, in a range of quality of provision, that the principle we want to see in palliative care is the same as for the rest of the NHS, which is giving people real choice on the care they receive, when they receive it and where they receive it. For some people, that will be in hospices, and for some it will be the comfort of their home. Wherever possible, we would prefer it to be the latter, but that will not be right for everyone. We have already taken some steps in our first year, with £100 million for hospices through capital investment, which has been used to good effect to expand or modernise estates or, often, to buy the kit that is necessary to provide good hospice at home care. The £26 million children’s hospice grant has made a real difference as well.

But Wes, if we talk to the sector, they say that they have used over £70 million of that £100 million on national insurance payments, so that has left them with only about £24 million. This is what they are telling me. They have said that this is going to become a burning platform in months to come, because that money is running out, and some of the organisations are now saying that they will close in the next six months to a year if they do not get the support they need.

I have never been comfortable with the extent to which hospices are reliant on the generosity of the public through donations to fund something that I think, in today’s day and age, is an integral part of the health and social care system. What I cannot do, with the scale of the challenge that we currently stare into, and the pressures on the public finances, is commit to moving us as far down the route to state funding as I would like. In the meantime, we will continue to do everything we can through state investment. At a recent reception for Haven House children’s hospice, which serves my constituency, we had Hospice UK, Together for Short Lives and other amazing charities, and I indicated that it is worth us looking at what we can do with the sector to see whether we can leverage in more support through things like match funding and other schemes to try to get more investment into the sector. We are open to those sorts of conversations.

I know they appreciate that. When will you start considering working with the sector to look at a new strategy regarding the way forward? That was talked about last year, and the sector, like many others, do want to work with the Government to get to a point where they feel as if they are being heard and included. How long will it be before the Government really start to work with the sector? It just needs to be a few words, Wes.

We do engage with the sector, and I will certainly pick up your line in inquiry with them. The Commission on Palliative and End-of-Life Care has been established. It is independent of Government. We will be following its work carefully and looking at what it recommends.

Good afternoon, Secretary of State. I am going to stick with some of the bigger themes that we dealt with at the beginning—in fact, you have already touched on some of them. I quote: “investment has to be accompanied by reform. The NHS has to be redesigned around the needs of the patient. Local hospitals cannot be run from Whitehall. There will be a new relationship between the Department…and the NHS”. Presumably that is an underpinning principle that leads to things like the decision to abolish NHS England.

That is absolutely right. We are trying to do a few things. One is to shrink the size of the centre, make its focus more strategic, hold the system to account on outcomes, and devolve as much power, resource and responsibility to as close to the frontline and at the frontline as we possibly can. We also want to make sure that our financial flows and incentives are aligned with our public policy objectives. If there is one thing I have learned about the system, in the last few years that I have been in this portfolio, it is that money talks. If you get your incentives aligned or misaligned, you get either the desired outcomes or the completely unintended outcomes. That is why working with the system on the design of those will be really important. We also want to make sure, through the technology and innovation side, that we have a big focus on productivity. That is one of the big challenges not just for the NHS but—given the size of the NHS—for the British economy, so we are trying to make the NHS as productive as possible.

Can I try another one, which I hope you will agree is on a theme—a different one, but nevertheless still a theme? To quote: “The NHS has been too slow to change its ways of working to meet modern patient expectations for fast, convenient, 24 hour, personalised care” and, “Changes in primary care will help ease the pressure on hospitals so that they can concentrate on providing specialist care.” That, presumably, in a nutshell, is the shift from hospital to community.

I completely agree.

So my concern is that absolutely none of this is new—well-meaning, well intentioned, but not new—because the two quotes I have just given you are lifted directly from Alan Milburn’s NHS plan in the year 2000.

And that plan delivered the shortest waiting times and the highest patient satisfaction in history, so it sounds like we are on the right track. But there is lots of stuff in the plan—

Is this a “Back to the Future”? Are you Doc Brown taking us back to the year 2000 to sort out the NHS all over again?

No, I have not gone that grey in this job yet. I think we said in response to the Chair that the shifts themselves are not new. Delivering them in practice, in this NHS, really would be. Lots of things in the plan are new: models, ways of working, and approaches to innovation, adoption and roll out. There are plenty of things in there on the prevention side that are novel and innovative, as well as things that are well evidenced and need to be rolled out more consistently.

Perhaps you can help. What is the difference between community diagnostic centres, multidisciplinary GP surgeries and Darzi centres—and now your word for it, neighbourhood hubs? These things have run since the year 2000, then 2008, 2012, and now your plan. They sound like the same thing, just with different names—your name is “neighbourhood hubs”. Perhaps you can start by telling us how that is different from community diagnostic centres or Darzi centres from 2008.

Darzi centres, or polyclinics, as they were known, were effectively strangled at birth. There are still a few around, but it was a source of huge controversy at the time—for something that, as an approach, people agree is a good thing to do: neighbourhood health and population health at scale. That was certainly borne out through the consultation. Community diagnostic centres are, by definition, diagnostic centres. What neighbourhood health centres will do is bring under one roof a whole range of different services, to give patients a one-stop shop, with the principle that anything that that can be done outside a hospital setting—in communities, in neighbourhoods—should be. Hospitals should be for the most serious cases, complicated procedures and operations. What we want to see in neighbourhoods is the opportunity to get much faster access to consultations and diagnostics—to have things like blood tests and scans all under one roof. Minor injuries, urgent treatment centres—all that can be done in primary care. The reason we know that is true is that, in pockets of exceptional practice in this country, it is already happening. One of the core themes of the plan is to take the best of the NHS to the rest of the NHS.

When Tony Blair and Alan Milburn were doing this in the 2000s, as you said, and delivering the sort of healthcare you would like to see, they were increasing health spending by 6.8% year on year on health. You and Rachel Reeves have a plan to spend 2.7%, according to the last Budget. So how are you going to deliver while spending historically low figures? In fact, 2.7% is lower than the 3.5% under the last Conservative Government. I am just interested—how are you going to pay for this?

That is why investment needs to be matched with reform. The economic circumstances were very different for the last Labour Government. This is a Government who have to live within their means. However, as I have argued for some time, the NHS has become more bloated. There is waste in the NHS, and the last Government are a good case in point for why you cannot just throw money at the problem; if throwing money at the problem solved it, the last Conservative Government should have had a decent run at it. They poured quite a lot more money into our hospitals and significantly expanded staff. You would think, with the pressure hospitals are under, that would be the sensible thing, right? Except that all the causes of hospital congestion find their roots outside. People either cannot get the right primary care, cannot get access to primary care soon enough or cannot get care in the community. They end up going through the front door of a hospital, either in an emergency department or on to an elective list in a far worse condition than they would have otherwise been had someone got to them sooner. They are then stuck in a hospital bed and cannot get out because social and community-care bed capacity is not available. We are doing a system-wide approach that recognises that if you want to improve the flow of patients through hospital and everything else, from A&E waits and elective times to delayed discharge performance, you have to deal with primary care, to deal with the problems at the front door, and you have to deal with social community care, to deal with the problems at the exit door—put crudely.

The plan is, we have agreed, a set of good aims—there is nothing hugely revolutionary or radical in terms of the overarching themes. My view is that the one opportunity you have to succeed in areas where, perhaps, other Governments have only partially succeeded, is the delivery—how we do the change. But there is so little in here about how you are going to deliver. Perhaps you can tell us how to get to the end point that is in this document. If you can tell us about that, where can we see it written down? I would like assurances that it is not still only in your head.

We will keep coming back to you as a Committee as well, but this comes back to the very first line of questioning: there is a way of doing this that is the imposition of change, or a way of doing this that is about taking people with you. On everything, from the new governance arrangements for the reinvigorated foundation trust model, to how integrated health organisations will work, to how we will deliver neighbourhood health, we will be doing it with system leaders. We will set some people free to go faster than everyone else and show us what the future looks like, and others will follow.

And the Chancellor is on board with the money?

She is, yes, in the Budget and the spending review.

Good to hear it.

I know the public finances are under pressure, which is why I was sensible enough to bring the Chancellor to the launch of the plan.

Thank you for coming along, Secretary of State, Sally and Sir Jim. I would like to move on to population and public health. If we continue with the theme, Secretary of State, about money talking, could you please outline to the Committee how the finances are going to align with your sickness to prevention shift? Specifically, in 10 years’ time, what percentage change should we expect to see in these areas?

I am definitely not going to write the Budget for 10 years down the line.

But would we expect to see a change, Secretary of State, in terms of the shift from sickness to prevention and the money following it?

Over time, we want to see far less spent on the price of failure. Obesity costs the NHS £7.3 billion a year, alcohol £4.9 billion a year and tobacco still, despite all the progress we have made, £1.9 billion. Economic inactivity due to sickness costs £2 billion in the NHS and costs the economy, so you can see, right across the board, we are paying a very high price for failure. In the plan, we have set out a number of approaches, some of which you would consider conventional for public health. We also have the Tobacco and Vapes Bill going through Parliament. The impact and benefit of the policy would provide the NHS with £6.6 billion in savings. We will go further by clamping down on vaping among young people. There are also more radical approaches, such as what we have proposed to do with supermarkets to improve the nutritional value of the average shop. I do not think it has been tried anywhere else in the world. The genesis of the policy was an idea from Nesta, and we worked with Nesta to develop the policy. We have got a number of the big supermarkets on board. Taking that approach will lead to a very different sort of approach—not just from the state, but from the food and drink industry.

Okay, perhaps we will go straight to that then. A voluntary arrangement with large food companies has been tried before under a previous Administration. Prime Minister Cameron tried this and yielded very poor results. In fact, the only evidence-based increase was around the legislative food tax. How is this voluntary agreement going to be different from previous voluntary agreements?

The reporting and the target will be mandatory. We want to work with the industry to get it right; it is not in any of our interests for it to fail. But the data on the food and drink that we buy from supermarkets is already held by them—it is some of the best public health data in the world. They had already been calling on us to publish the data, so that is the bit we should look to do with them most quickly. We should then work with the industry to set a target for improving the nutritional value of the average trolley or basket.

I agree that public health data are good, but I am sure you are aware that, in socioeconomically deprived areas, a substantive number of our population do not access their food and nutrition through supermarkets. How will that particular initiative therefore address those inequalities? If it does not, how will you look at the nutrition of people in what we call food deserts, where they access their foods through smaller shops and so on?

Some 85% of our shops come from supermarkets. I take the point you are making about the exceptions in some of the areas with the highest levels of deprivation, but I do not think that we should let the perfect be the enemy of the good—

I agree, Secretary of State, but in terms of proportionate universalism, if you are going to put your investment into a place where it would make a substantive difference, do you not agree that you would put it into the most deprived areas to see the improvement? I think that is your aim in your 10 year strategy.

That is why, in a speech in Blackpool recently, I announced our determination to change our funding formula for investment in public health: to target those areas with the highest level of need and deprivation. We will take a similar approach to reform of the Carr-Hill formula for general practice. It is a disgrace, frankly, that for someone who lives in the poorest community in the country, there will be about 300 more patients per head than in the most affluent—the inverse care law writ large. The supermarkets thing is significant because by setting the target in the way that we will, and actually giving industry the freedom to innovate, I think we will see things like loss leaders and price promotions on the healthiest products. I think we will see supermarkets thinking more creatively and ethically about their marketing practices and the layouts of their shops. The wonderful thing about the approach that we are proposing, if we get it right, is that it will lead to less nanny-statism, ironically, rather than having the Secretary of State trying to dictate price points, promotions, location of chocolate in the supermarkets and anything else that I might be tempted to meddle in to make the nation healthier. If supermarkets are driving towards the goal of more nutritious sales, they will know their customers best and what works well in terms of nudging people in the right direction. That is why I think that this sort of partnership approach is the third way between nanny-statism and being very directional, on one hand, and just taking a step back and being completely laissez-faire about it, on the other.

Okay. I look forward to seeing how the choice architecture improves our lives. The data so far do not back that up, but I very much hope that you are correct. May I go to something that is perhaps more directional, which is alcohol? You mentioned the cost of alcohol to the national health service and to people’s lives. Why, in this 10 year strategy, are we not making a commitment to set a minimum unit price when the available evidence shows that it is an effective way of reducing harmful alcohol intake?

I know that there is a loud campaign in favour of minimum unit pricing. It is not something the Government have chosen to proceed with at this time. I am sure there will be healthy debate on it in Parliament. What we are proposing to do is to give the consumer more health information. It is a bit daft that you can get more nutritional information about a can of fizzy drink or a packet of crisps on the shelf in the supermarket, than you can for the number of calories in a pint versus a gin and tonic, or a gin and slim versus a glass of wine—we do not make that information available to consumers. I think we really ought to. We need to go further on tackling what I would describe as problem drinking—4% of people drink as much as 30% of the alcohol consumed each year. They do that with serious consequences for their own health, sometimes to the detriment of their lives. That is the issue that, with the whole sector, we need to have a more focused approach to tackling.

I look forward to that robust debate on minimum unit pricing. Moving on to something else on our legislative agenda, could you explain why the junk food advertising ban before the watershed is being delayed?

It is coming in from the new year. There were perfectly reasonable, legitimate concerns about going as fast as we were proposing to.

What were they?

The readiness of the industry to comply and the way in which the regulations would potentially be subject to misinterpretation. It is fair to say that the industry know that it is coming. It is definitely happening—there is no wriggling out of it. You will see widespread compliance in the run-up to Christmas. There was a reasonable debate about brand advertising versus product advertising. We wanted to work through those issues with people so that the law actually works in practice rather than catching people with unintended consequences of laws. That is the only reason for that delay. But you should still see widespread compliance.

Okay. Can you explain the branding issue? Is the argument from the industry that, while they cannot show the food product per se, they should be allowed to advertise their brand?

In a nutshell.

Do you have a sense of where that is going to land yet?

We will keep you updated.

My final question is about the health mission. It is great that the national health service is going to be a national health service again. However, I know that you are all too aware that health in and of itself should be a mission across all the directorates and in local authorities. The health mission has gone quite quiet. Is it still alive? If so, how is it shaping the broader health prevention agenda with the 10 year strategy? If it has died a death, who is now shaping this important issue across the relevant directorates, and how?

It is still very much alive. One of the things that is working really well in the health mission is the way in which we are galvanising other Government Departments behind the focus on public health and prevention. The policy I mentioned on supermarkets, for example, would not have been possible without the joint working between my Department and DEFRA and the support of Steve Reed, the Environment Secretary. Similarly, the work that Lisa Nandy is doing to try to reorientate our cultural and sporting offer to underserved working class communities with high levels of deprivation and need across the country is very much aligned with the health mission. There is also Bridget Phillipson’s work on not just expanding free school meals and breakfast clubs, but making sure that they are nutritional, and the school sports work we are doing in partnership with DFE and DCMS on making sure that we have qualified PE teachers, upskilling, and education on PE and games in our schools—all really important stuff. There is a whole load of stuff just like that coming together under the health mission. But we are also looking—

Are housing and air quality there and alive?

Yes. One of the exciting things about the Deputy Prime Minister’s commitment to build 1.5 million new homes is that one of the biggest challenges we see is the number of children living in temporary bed-and-breakfast accommodation without decent space to live, learn and play. They are often in accommodation that does not even have basic cooking facilities, so takeaway is the only option. We as a Government are committed to tackling all those things—all the social determinants of ill health. The Government cannot do this alone. We need to work with business, civil society, the private sector and the voluntary sector to bring all this to life, and that is exactly what we are doing. The supermarkets policy is a good example of working with the private sector. We have an exciting collaboration coming out tomorrow to get more young people physically active and engaged to tackle the issue of obesity among primary-aged children. You can expect much more of this sort of stuff coming out of Government in partnership with business and civil society.

Great. The public health workforce is a key part of this. I appreciate that they do not all sit in the national health system; they sit in local authorities and in different places. I note that there is not yet a specific plan around the public health workforce per se. Presumably that will be looked at in partnership with local authorities.

Yes; especially as a former cabinet member for health and wellbeing in local government, I very much see DPHs and the public health teams as part of our team. We are also improving all the time the relationships between my Department, directors of adult social services, directors of public health and elected members. One of the things that I am committed to doing with the LGA, as part of the delivery of the 10 year plan, is making sure that we have much stronger institutional relationships, not just between Whitehall and communities across the country but across communities between the NHS, local government, social care and the voluntary sector.

Yes, I think the out-of-home sector has a role to play, and I think you are right; that is potentially the way in which we can help to improve the picture in the SME part of the sector. Government—rightly, in my view—takes a much more cautious approach when it comes to regulation of small businesses, and we recognise that asking people to do things such as calorie labelling on menus, or other changes to how their businesses run, comes at a cost. For some businesses, that is complexity that they cannot afford. Especially with the pressures on our high streets and on the economy, we do not want to make life harder for small businesses. I enjoy a takeaway as much as anyone else, so, on all these things, I am not coming at it from the point of view of being the fun police—as one or two drivers to my house would attest to after dropping off my takeaways. But those sorts of platforms, such as Uber Eats and Deliveroo, do have a lot of really valuable information about their customers’ eating habits, and about the food that is being sold through their partners in the sector. I think it is fair to say that they have a different starting point from the supermarkets, but we are absolutely committed to working with the out-of-home sector.

Oh, loads of stuff. Even on prevention, we went in asking questions very much about the NHS, and while I know that the public do care about health and wellbeing more generally, we did not expect the visceral reaction we got from people. They were saying, “If you’re not doing public health and you’re not doing prevention, then this plan is not going to work.” There was a real awareness on that and pressure from the public, which I think is important, especially in a political context where we are often told that doing stuff on public health gets resistance from the public. Actually, a lot of what we heard was, “Help us to make healthier choices. Help us to make easier choices. Help to make activity more affordable.” The other thing that we learned was on the technology side of things, both from the public and staff. People instinctively get it, particularly among the NHS staff; a lot of them are scientists, so they are really excited. They are aware of and enthusiastic about AI, machine learning, data, genomics and all the other stuff that will completely change the paradigm of health in this country and around the world this century. However, what they were also often saying to me—directly, as well as through the engagement exercise we did—was, “It’s all very exciting, but I can’t even get my machine to turn on reliably in the morning, and I’m using seven different passwords to log on to deal with a single patient.” What we learned there is that, if you get the basics right, you will get a lot of trust for the stuff that follows. I am amazed that this has not made more front pages or grabbed headlines—I cannot believe that our commitment in 2026-27 to give all staff a single login to deal with the seven passwords issue has not been greeted with the same level of fanfare as some of the other ideas in the 10 year plan. In all seriousness, though, it is actually really important, because of what it will prove to staff. To the point that Joe and the Chair were asking about, a lot of people out there are willing us to succeed, but are still sceptical about whether some of these things are going to happen. So the more we can prove, and the more quickly, the more momentum we will build behind the plan.

I am pleased to report that the BMA has taken up my offer of meeting this week. We will be meeting to see if we can find a way to avert strike action. I have to be clear with the Committee, as I was with the House last week, that there is no more room for manoeuvre on pay, but there are lots of other things that we can and should do that would lead to material improvements in the lives of resident doctors, now and into the future, including on progression. However, these things are always choices and trade-offs. Lots of things that resident doctors are asking for, like doctor unemployment or progression into speciality posts—both of which I agree with them on—cost money. Many of the other things that we want to do in the NHS cost money. That is why going on strike, having received a 28.9% pay increase, is not only unreasonable and unnecessary, given the progress that we have been making on pay and other issues, but self-defeating, because it will come at a cost to the things that we want to invest in to improve the NHS. At a time when the NHS is moving in the right direction—when waiting lists are falling, GP numbers are going up and people are feeling a sense of cautious optimism about the NHS’s future—I think it would be a catastrophic mistake for the BMA to throw all of that progress into reverse by walking out on strike. The public do not support it, and even a majority of resident doctors did not vote for it, so I hope that when we meet, we can see a way through this that avoids the misery that will be inflicted on not just patients—most importantly—but other NHS staff and the future of the NHS.

I should probably bring in Jim as well on operational planning, but I will just say a couple of things. We can mitigate the impact of strikes—and we will—but what we cannot do is promise that there will be no consequences, no delay and no further suffering. There are lots of people whose procedures are scheduled over that weekend period, and in the period subsequently where the NHS has to recover from the industrial action, who will see their operations and appointments delayed. I have a relative in that position; my family is currently dreading what I fear is an inevitable phone call saying that there is going to be a delay to their procedure. I think it is an unconscionable thing to do to the public, not least given the 28.9% pay rise. The other thing that I have found shockingly irresponsible about the BMA’s position is that their leaders seem to be telling their members not to inform their trusts or employers if they are going out on strike. I might not agree with the BMA’s strike action, but I accept that they have a right to strike and that they have followed the rules in order to go on strike. What I cannot fathom is how any doctor would in good conscience make it harder for managers to ensure that we have safe staffing levels, and make it harder for other staff who are going to be turning up to work that day, not least the staff who have not had a high-percentage pay rise, many of whom are paid less than resident doctors. I think that the BMA’s approach to this, from start to finish, has been completely wrong. It started off a year ago with an incoming Government that had an enormous amount of good will towards it and an enormous amount of sympathy for the arguments it was making, and that worked quickly to resolve those strikes, with not just a deal to end them, but the opening up of a partnership in which we could work together to improve the NHS. Instead of working in partnership, the BMA has chosen confrontation. It is not too late, even at this late stage, for us to get back on the path that I wanted us to be on, working together and driving real improvements for resident doctors and patients, but that is going to require a different mindset. The Government have changed; the policy has changed. It is time for the BMA’s tactics to change. The idea that doctors would go on strike without informing their employer, not allowing planning for safe staffing, is unconscionable. I urge resident doctors who are taking part in strike action to do the right thing, as I am sure many of them will.

No, carry on.

I lived through the last few rounds of this as a trust chief exec. First, to reiterate what the Secretary of State said, everybody respects the right to strike but this is hugely disruptive, and much more disruptive than we have been able to describe so far. I have worked with older consultant colleagues at the end of a week when they have worked very long hours, through the night, to keep the service going. I have met with families who have had diagnostic processes cancelled three or four times because of strikes. I do not accept the narrow definition of what is technically necessary; it is not that straightforward, and we will not accept that kind of process this time. I really hope that this is avoidable, but we cannot allow it to play out in the way that it did last time. It had a huge impact on people’s lives, including colleagues working in the service. It is very hard to quantify the impact of the cancellation and disruption of clinical pathways. Let us not get too focused on the impact on the elective list; a whole range of other disruption comes with this that we must avoid at all costs.

Good afternoon, Secretary of State. Unfortunately, I shall continue some of that line of questioning. Can I characterise your view on the strikes as being that the strikes prior to the general election were reasonable, whereas those after the general election were unreasonable? Just a yes or no, please.

I felt that the previous Government were unreasonable by refusing to sit down and negotiate with the BMA for extended periods of time.

Is that a yes?

I think that the strikes before the general election were avoidable.

What do you think has changed the BMA from a reasonable organisation to an unreasonable one?

I did not say that the BMA was entirely reasonable throughout the entire period. That would be out of keeping with its history.

What have you done or not done, Secretary of State, that has made the BMA come to this point of view?

As far as I am concerned, we have done the right thing. When we came in, the strikes had been ongoing for a considerable period of time, at great cost to the taxpayer and to patients. We recognised the arguments that the BMA had been making about pay erosion, and about the conditions that resident doctors were working in, and we recognised the pressure that they were feeling as doctors at a particularly early stage in their careers. I was proud of the deal that we did last year, and of the decision that we took this year to implement the recommendation of the pay review body. Taken together, that is a 28.9% pay increase. I would have expected, not unreasonably, that the BMA and resident doctors would think, “Okay, we might not have got everything we asked for, but we’ve moved considerably in the right direction, and this is a Government we can do business with, as other trade unions do.” The Labour party is used to dealing with trade unions; our history is anchored in the trade union movement. We do not always agree with trade unions, even those affiliated with the Labour party, but we understand the value of trade unionism, and the importance of deals and bargaining. However, I do not see a reasonable trade union partner in the RDC section of the BMA, at this time. I hope that will change.

But is that not part of the problem, Secretary of State? You gave them a massively inflation-busting pay rise and asked no increase in productivity or efficiency from them, so they have essentially just come back for more. Do you accept no responsibility whatsoever for the position that we are now in?

First, I do not hold resident doctors responsible for the productivity challenges we have in the NHS; many aspects of the way they are treated at work are fundamentally unproductive. I do not regret the deal we struck with resident doctors, but I do regret that they are in danger of squandering the opportunity of partnership in favour of a more adversarial approach that is unnecessary and, I fear, will prove self-defeating. If these strikes go ahead, with the financial costs entailed, not to mention the misery inflicted on patients, we will have to find that money from somewhere, and that will come at the expense of things that they value.

I think you have made that point clearly, Secretary of State, and I suggest that we all agree with that point of view. In December 2023, you noted that the then Government were giving a higher pay rise to doctors than to nurses. You said it was “completely wrong”, “a slap in the face to nurses”, and fundamentally unfair. If the nurses went on strike, would they be being reasonable or unreasonable?

I hope that we are not going to get to that position with nurses, not least because we have a reasonable dialogue and relationship with the Royal College of Nursing, Unison and others—

I hope we do not get there either, but if we do, Secretary of State, would they be being reasonable or unreasonable, given your previous comments on the issue?

We are working with those unions on “Agenda for Change” pay structure reform. That is what we have agreed to do. So long as we fulfil our end of the bargain, everyone will be happy and we can move forward, building on that progress. If this Government broke our commitments to nurses and “Agenda for Change” staff, I think they would be rightly and justifiably angry, which is why we are not going to do that.

Given that, as the Committee heard some months ago from the then CFO of NHS England, most of the amount of money put in in the last Budget was eaten up by pay rises, inflation, drug costs and so on, and there is therefore not a vast amount of money left, will you commit to having no above-inflation increases for any health staff during this Parliament?

First, we have an independent pay review body process. I think that process is working largely well. I recognise that trade unions have a number of criticisms about the way the process works, and I am always happy to talk to them about how the process could be better. For example, the criticism that the PRBs reported far too late in the year was not just a frustration felt by unions, but by me too, which is why I submitted evidence earlier—

I suppose what I am trying to get to, Secretary of State, is what your view on this is. I understand the processes, but what is your view? Do you think that public sector NHS staff should get an above-inflation increase over the next few years, or not?

We always take into account the recommendations of the pay review body. I would say to NHS staff that the best way for us to deal with the pay erosion they have suffered over many years, and to make sure that we have a competitive rate of pay for NHS staff and a decent standard of living for all our staff, is to make sure that we are going as hard and as fast as we can on reform and productivity. That is why we have had to make some decisions on things such as the abolition of NHS England and bringing ICBs and systems back to balance, which at the moment are causing considerable pain and anxiety for people involved in that decision-making process. That is why we have to make some of those choices—

I do not mean to cut you off, but we only have a small amount of time, and I want to ask you about one other subject. The Darzi report, which you commissioned, said that “the dire state of social care” is among the reasons that the NHS is in “critical condition”. You said, at the Labour party conference, “There is no solution to the crisis in the NHS that doesn’t include a solution for social care.”

I completely agree with myself.

So why has there been pretty much no inclusion of social care in the 10 year plan?

I don’t quite accept that characterisation. Social care features in so far as it impacts on the NHS. We envisage social care being part of the neighbourhood health ecosystem. Much of the care delivered in people’s homes will involve partnership with social care. In fact, we want to upskill the social care workforce to be able to undertake certain health tasks that we think, under proper training, they could undertake. That would have to be supported with better pay. On delayed discharges, there is a really big role for social care to play, and I would expect NHS organisations to look, when commissioning intermediate care accommodation for admission avoidance and accelerated discharge, to be buying more capacity with and through social care. That is how social care features in the 10 year plan, but of course there is the Casey commission. Report 1 is out next year, and the second report will be out subsequent to that and will set out the long-term direction.

That brings me nicely on to what Age UK has said, which is that “delaying the process of comprehensive social care reform will only make it harder to restore the NHS…to health in this Parliament, or even the next”. Don’t you accept that, as Age UK seems to be suggesting, kicking social care to the end of this Parliament and increasing national insurance contributions for the vast proportion of the social care sector are actually hindering social care and therefore will have an impact on how deliverable your 10 year plan is?

I don’t agree we have kicked the can down. Since coming into government—we have only been in a year—we have increased the spending power in social care significantly. We have delivered the biggest expansion of carer’s allowance since the 1970s, and a big increase in the disabled facilities grant. We have legislated for fair pay agreements, and the Deputy Prime Minister and I will be setting out shortly how they will work in practice and how we are going to roll them out. That is quite major improvement.

It’s not really the fundamental reform that you were talking about a few minutes ago.

I’m not pretending for a moment it’s a panacea, but those are meaningful, demonstrable steps in the right direction, and there is more to come.

I will leave that there, because I am sure the Chair wants me to finish. This will be the final question from me. There are a number of health-related concerns in my constituency of Farnham and Bordon. Will you be willing to come and meet some of the doctors and patients in my constituency to hear their concerns?

If the diary allows.

I’ll take that as a maybe.

Secretary of State, Jim and Sally, thank you very much for coming today. The plan has been a fascinating read and also a nice read in large print, which makes a change for a Government document; it actually makes it easier to read. I want to talk a little bit about equality, particularly race inequalities, and about inequity, which of course is different from inequality. It is excellent that the 10 year plan references inequalities and to see the determination to improve matters there, but it says relatively little when it comes to ethnic or race inequalities. You will be aware that as a Committee we have been looking at this. The work we have been doing on maternal health shows quite serious differences. More black women die in childbirth. As the 10 year health plan references, more black children—at least twice as many—die in childbirth. There are lots of examples like that. Do you think that there should be more, in the implementation plan that you are bringing out, about tackling racial inequality and, in particular, structural racism in the NHS than there is in the 10 year plan itself?

Yes. Unfortunately, this is a huge issue in the NHS at every level. If you look at the experiences of black and Asian staff—if you look at the experiences of black and Asian patients, even adjusting for class inequalities and social determinants, we are seeing unequal outcomes for patients. We are seeing bullying of staff, which, when you think about how long we have had black and Asian staff in the NHS—since the beginning of the NHS—I think is just completely intolerable. We don’t have enough black and Asian faces on executive and non-executive boards across the NHS. And that culture flows right down. In the work that I have been doing on maternity—obviously, the black maternal mortality gap has been well publicised and should be no less shocking to us now that we have become used to those statistics. But what I was really, really shocked by, in talking to some of the victims of NHS maternity scandals, was the patients who described—patients and survivors, I should say—being described as a kind of problem. One woman told me that she had been told, “Well, I thought you were a strong black woman,” as an excuse for the fact she had not received enough pain relief. There were Asian women described as divas. So yes, there are health inequalities that need to be tackled. Some of that is about public policy, and some of it is about social determinants. There are also wider inequalities and things like genetics, dispositions to certain diseases and all the rest of it. We have to deal with that using good science and good-quality care, but that does not explain the overt as well as unintended or unconscious racism that we see in the NHS.

It is very interesting that you talk about that within the NHS. I have been looking at the figures for the published staff surveys for 150 NHS organisations over the last few years, and they are quite shocking. The figures for 2022 on whether you feel that you have had fair career progression, whether you have been discriminated against by patients or other members of the public, and whether you have been discriminated against by other members of staff have got worse in the last two years. Jim, is this something that you recognise? Do you have ideas about how you want to tackle it?

Yes, absolutely. This will be something we really want to elevate in the next phase, from a staff satisfaction perspective as well as a patient satisfaction perspective. We want to try to get behind these metrics and understand what is driving concerns in how people feel they are treated.

Given the fact that the figures have got a bit worse over the last two years—actually, all the time we have been looking at it; over a number of years, they get a little worse each year—do you think the NHS does not have an idea about how to tackle it? If so, what do you think it could do differently?

I think pockets of the NHS have. There is evidence of organisations being very systematic about understanding the data and tailoring it to local actions that address the specific issues. There is evidence that that has worked. It has not worked across the board, and we will absolutely be trying to do that and scale that across the NHS.

I see Sally nodding vigorously. Maybe she could come in.

Particularly when it comes to workforce race equality, there are good examples of local trusts tackling and making improvements on two or three metrics, but they have not been able to shift that to improvement across all the metrics, so there is a task for us nationally to help to share best practice. Some of that is about networks. Some of it is about leadership programmes. There is lots of activity that has been proven to work; it is just about how we scale that across all our local trusts.

I would just add, briefly, that this is where we need to reform our approach to diversity, equality and inclusion. There is a school of thought that says that anything that is spent on DEI is dead-weight cost and wasteful—that we should get it out of the NHS. Actually, as we can see through the black maternal mortality gap, or in other areas, like mental health, inequality can be a matter of life and death. It should be the NHS’s core business to tackle health inequalities. I think we therefore need to both reform our approach to equality, diversity and inclusion in the NHS, and hold people to account for outcomes, not just inputs, workshops, posters and all manner of other things that people are doing. It should not be the case, in this decade of the 21st century, that black women are three or four times more likely to die in childbirth than white women, or that black men are twice as likely to die of prostate cancer than white men.

Absolutely. Obviously, it is just simply wrong, cruel and poor. It is also expensive. This is an area that the NHS Race and Health Observatory has been looking at: the economic cost of racism. For example, in maternity care—we have spoken about black women being three times as likely to die in childbirth—£1.6 billion compensation is paid out for maternity-related cases every year. In mental health, black men are three times as likely to be detained under the Mental Health Act, or eight times as likely to get a community treatment order. This will cost the NHS some £11,000 to £12,000 a year; a white person is costing £5,000 a year. I do not think it is intrinsically the colour of the skin that makes people behave differently; it is the way people are treated that is costing the NHS a lot of money. On workforce, bullying and harassment costs £2.3 billion—a huge amount of money—and again, that is a particular issue if you are from a black and minority ethnic background. There are all sorts of other areas. The NHS 10 year plan talks about allocating NHS money more effectively “to better maximise”—a split infinitive, but it is in the paper—“return”. Is part of better maximising return doing a proper analysis of the economic cost of structural racism in the NHS?

Yes. When you illustrate the cost to the economy as a whole, that can be really helpful in terms of elevating something as a priority and demonstrating the impact that it would have if we solved x problem on the cost to the economy, but I think even more powerfully, in an NHS context, we can demonstrate the actual cash price of failure. You just did it in maternity. It is shocking that we are spending more on maternity claims than we are on maternity service improvements. It is a no-brainer to me that we need to shift a number of these things in the right direction, not least because it is better value for money, but most importantly of all, because everyone in our country, whoever they are, whatever their background, deserves access to high-quality, safe care where they feel safe and respected. That should be a service that is available to everyone, and the people working in the service should also feel that they are able to bring their whole selves to work and they should not be discriminated against because of who they are.

So you will be looking at the actual costs that you could save at the same time by dealing with racism because it is iniquitous? No matter what other parties on the right of us say about not tackling diversity issues, it is clearly highly inefficient because it costs the NHS a lot of money, taking a very stark view, at a time when we have been left with empty cupboards wherever we look. You are going to have another look at the Carr-Hill deprivation formula, and that could lead to a different approach towards deprivation. Is that going to be on the basis of geographical deprivation? Are you also going to take racial issues into account? Some of the challenges facing ethnic minorities obviously often come from poorer communities and are spread around the country; they are not just in specific areas. Will race equity be part of your Carr-Hill review?

We are going to consult on Carr-Hill. It is a reasonable thing for people to ask us to look at, and we will take it into consideration.

Will you take that into consideration?

The real thing we are driving at is to make sure that the level of resource going into general practice is able to meet the needs of the local population. You have got to take into account a whole range of demographic pressures and societal conditions on the health need and demand.

We have also said that we are going to ask the advisory committee on resource allocation to look again at our overall formulas for allocations to integrated care boards. We want to look at a whole host of factors that can drive health needs. Some of that will be geography, and some of it will be economic circumstances, but there will be a lot around coastal communities, for example—we know that there is higher health need; we know that there will be different health need from different ethnic communities—so we want to look at the best possible evidence base to have a new formula that reflects current and future need for health.

No doubt we can come back and discuss whether we think your approach is right. Obviously, it is a necessary thing. I have a final quick question on a slightly different thing: neighbourhoods. Who is going to lead these locally? It could be GPs. It could be hospitals. It could be NHS trusts. It could be private companies. Yes? All those are possibilities?

In terms of neighbourhood health services, we would anticipate that these would be mainly NHS organisations, but you could imagine, with some of the things that we want to achieve, that we will be working with companies like Boots and Specsavers to deliver a greater range of services as well.

But led by the NHS?

Yes, always led by the NHS.

That is going to require extra resource for whoever is doing it. Running a neighbourhood health service is quite a management job. Is extra resource going to be given to whoever is actually managing it, whichever part of the NHS they are doing it from, or are they going to be expected to manage and set up these new neighbourhood centres within the existing budgets?

There are two different things. There is neighbourhood health, in terms of leadership of the needs of the local population, and then there are neighbourhood health centres. In terms of neighbourhood health models, of course, any new provider organisation would obviously be commissioned and established with a level of management resource to be able to undertake the duties that they are taking on. On neighbourhood health centres, we have done two things. The first is that we have got the largest capital allocation the NHS has ever had. That gets us some of the way in terms of meeting the capital needs and pressures on the NHS, but we need to go further. The Darzi commission identified undercapitalisation of about £37 billion. With the best will in the world, even if the Chancellor is able to find more public resources available for us, I do not think we can anticipate over the course of this spending review or over the course of this Parliament that it would be sufficient to deal with all of that undercapitalisation that Darzi diagnosed, so we need to look at alternative private investment options. That was in the Government’s infrastructure plan as far as neighbourhood health is concerned. We are treading cautiously. Proud though I am of the record of the last Labour Government and what it did for waiting times and patient satisfaction, PFI led to large costs and in some cases very poor value—

Very poor contract management.

And poor contract management, so we need to make sure we learn those lessons and get this absolutely right.

Just to add to that, from a management leadership point of view, what we have been trying to do, as the Secretary State said, is shift the leadership focus up through the chain into the centre and more local. So there may be some additional management resource, short term, to help develop neighbourhoods, but the idea is that it will be more productive management over time locally rather than through an oversight and assurance process.

To follow up on that question, I want to ask about capital spending in the health service as part of the 10 year plan. In terms of the NHS neighbourhood hubs, will there be any specific capital investment to enable the roll-out of neighbourhood hubs, or is this solely leaning on a future—

We have committed during this Parliament to 40 to 50 neighbourhood health centres that we think we can roll out during that period. If we are able to leverage in more external investment, obviously our capability and capacity to do more will be better.

That is without private sector investment, the 40 to 50?

Yes.

Fantastic. And there will be specific capital funding available centrally to enable—it will not just be local systems.

Yes.

On the PPPs and learning the lessons of PFIs, which you touched on slightly, what will be the assurance process of local agreements? Will the Department provide very clear guidance to avoid the contracting mistakes that we saw under PFI?

Yes. We will be setting out clear rules and frameworks that people can work within, specifically addressing the issues from the past. Over time, we will set out model contracts, model approaches and those sorts of things, so that we do not replicate things all the time. That will be developed over the summer. Also, as well as PPP or traditional capital, a lot of people are finding that there is a really good council facility, or an already quite new health centre that could be reallocated and redeveloped as part of this thing. What we want to try and do is nurture all these things at the same time, as long as it delivers on the principles and the outcomes we expect.

The plan talks about private financing of revenue-generating assets: car parks or energy facilities. Should we expect increasing patient charges for car parks, food and other associated goods to enable this capital investment? Are you confident that patient charging through these other routes—

We will not shift the cost on to patients. But this is a really important thing to open up. There is an awful lot of commercial appetite out there in the NHS for the development of, say, pharmaceutical production. Laundry services is one of the things that was being explored in the north-east before I came to do this job. There is an awful lot of stuff where there is a potential market opportunity that was previously constrained under the old rules, and now is possible under these rules.

We have seen strategic health authorities and PCTs become CCGs and ICSs and then ICBs. Now we have got ICBs plus ICOs. Do you think the structures are suitably different to drive different outcomes? Are the fundamental issues about financial flows and incentives for prevention significant enough? Do you feel that the roles of public health and social care are strong enough in the new structures?

Throughout this discussion we have gone back through history to various points when we have tried some of this in different ways, and it has either worked or has not worked, or has worked for short periods. There are really strong common principles—financial incentives, a devolved system, a clear rules-based system—but also the clarity that you have to work with local partners, whoever those local partners are. And sometimes there is a really strong voluntary sector or independent sector, or you have a specific housing issue or social justice issue.

There is always public health and there is always social care. What would make them work with—

They should absolutely be at the table and be key partners in all this.

Is that different from PCTs, or ICBs through ICPs?

In some of those previous incarnations, the involvement meant representation on a board or in some form of governance system. We are trying to say here, “Work with partners actively. Don’t just address it in the governance system.”

What does that mean? To me, that sounds quite similar to a person on a board. How will it look different from a person on a board?

I am talking about operational, clinical and social care colleagues—practical people on the ground working within a set of rules.

They will have to work together operationally and in terms of—

It is about working at every level. My point is that it is not done when you have appointed somebody to a board; this has to work right the way through the system, and be less bothered about who works for who, but more about what they are delivering for people.

In terms of the development of neighbourhood health and care plans, I want to see people work together to develop them and sign them off together in a spirit of partnership. I think it is fair to say, having sat in different parts of this system over the years, that the NHS always feels like the big beast at the table. Some NHS organisations are better at partnering with their voluntary sector and local government partners than others. Close working, mutual respect and partnership should be the norm, not the exception.

I certainly agree with that. In terms of patient power payments, on financial incentives, what would stop sink hospitals or sink services developing under patient power payments? Those are services that are already struggling financially, and patients then move their care or seek to move their patient power payments to bigger, more successful trusts. How does that go with the spirit of ensuring areas of deprivation get better services, not worse services?

The first thing to say is we will trial this approach initially, because it has never been done before, and with something like this, we would not want to just roll it out across the NHS without making sure there are not unintended consequences. The purpose behind it is to give the patient real bite in the system. At the moment, it is extremely easy to dismiss and ignore patient complaints and concerns. I have seen that in the most egregious cases of families who have been failed in the most appalling way in maternity services and mental health services. I have spent a lot of time in the last year meeting with people I would characterise as victims of the NHS.

Sorry to interrupt, but time is short. Is a payment penalty enough to change that, or is it a change of leadership, a change of culture, or investment?

Ultimately, in terms of performance improvement, it is a range of levers and a range of consequences.

Can you guarantee there will not be sink hospitals and sink services that see their funding slashed further—or are struggling, potentially in maternity services?

The money is not pulled away completely; it will go into a patient improvement fund, and everyone from ICBs to NHS regions has oversight of services and financial performance, as well as quality and safety. There are checks and balances in place. What this will enable us to do, if it works as I intend, is to allow patients to hit NHS providers where it hurts, because money talks in this system. In doing so, that will send a signal up to us, if we are spotting that a whole number of patients in a particular part of the country are exercising that right to withhold payment for a particular service and putting it into a more general pot. I must say, that is not my big fear with this system; my fear is that it will be a bit like someone who gets a ropey Uber driver who has taken them round the wrong route, but they think, “If I give them anything less than five stars, I will get them in trouble,” so they give them a five-star rating. There is more likely to be that kind of kindness bias in this system than the opposite, but we will see, and that is why I want to trial it. I want to give patients more genuine power, choice, convenience and ease in this system. Those are all sorts of things that patients will get through the app. They will feel an improvement to their experience. I also want to give patients more bite.

On the app, a huge amount relies on digital transformation driving productivity improvements. The 10 year plan talks about bringing the NHS into the digital age. Who will be accountable for the digital transformation, and who will lead it? Will the functions that were NHS Digital in NHS England transition to the Department? Will resources be the same for that function?

We are working through that. The current plan is that those functions will transfer to the DHSC.

Will they be equally resourced as they are now?

Everything is subject to the cost reduction that has already been announced.

How will we do more—how will we drive a digital NHS—if fewer staff are working in digital functions? We have heard that ICBs are also reducing headcounts by 50%. Providers are often discussed as potential leaders of digital transformation, but many are being pushed to deliver more frontline staffing, and digital is not usually considered frontline staffing. I think the Business and Trade Committee recently had a session about NHS Digital, and around 3% of staff in the whole health service are in digital functions. Will that 3% across central, regional and local systems go up or stay the same?

Everything will have to be challenged. There is no part of the health service that we can say is absolutely, 100% protected from a cost-saving point of view, given the overall position. We want to be sensitive, understand need and not shrink something when it will disable capability and capacity going forward. We also know that there is huge variation right across the system in what people are currently investing in. The short answer is that we can say neither that it is a straight 50% everywhere, nor that those things are completely protected, because it is much more complicated than that.

Some £10 billion has been allocated specifically to tech in the spending review.

That is really welcome, but in terms of delivering capital investment, if staff in the NHS are cut dramatically at all levels, are you not worried that, to roll out that capital spending, we might see more reliance on poor private sector contracting for digital products and the failed IT projects of old?

I would not anticipate staff in this area being cut dramatically in the way that you suggest. Jim is absolutely right: in terms of the design of the new organisation, we want to reduce overall headcount by 50%, but that is not the same as taking 50% out of every team and function. This area is absolutely critical from the point of view of health security, system delivery and future transformation.

I want you to succeed. I want this to succeed. The values are unarguable. The shifts make a lot of sense—no one would argue with the suggestion that we need to shift from prevention to sickness. Therefore, we want the process to succeed. In the case of shifting from hospital to community, the question is: how? It is like changing the wheels on a moving bus. How can you do that when, at present, there are the pervasive problems of corridor care, ambulances queuing and avoidable deaths in emergency departments as a result of the pressures at that level? How can you take resources away—which is, in effect, what you are proposing—while making sure that the services are stable enough? Don’t you need to double run to a certain extent?

The two problems you have described are inextricably linked. Over time, we will drive the left shift in terms of not just transfer of resources, but transfer of responsibilities. Lots of things, from diagnostic tests and scans to minor injuries and urgent treatment, can and should be done in primary and community care, as far as I am concerned. There are also areas where we can and should make savings in hospital care, particularly out-patient appointments. We want to significantly reduce the pointless activity that takes place in out-patient appointments and deliver more out-patient care where it is needed to make sure that it is delivered close to people’s homes, or indeed in people's homes, which would be easier and more convenient. We are only a year in, but we have already started to signal what that shift looks like. With £889 million into the GP contract and the employment of an additional 1,900 GPs, we are beginning that left shift. It is going to take time, and one of the virtues of having a 10 year plan is that you do these things in a managed and orderly way, rather than a disruptive, or, worse still, a self-defeating or destructive kind of way.

And you believe that that is possible in relation to the emergency entrance into the hospital, which is the one that I was referring to? Are you content that it can be managed and that you can get on top of this crisis at the same time as doing everything else? We have to call it a crisis, and it is still a crisis. It is not your fault; you have inherited it—it is a difficult one to overcome.

There are lots of people who are presenting in emergency care who do not require emergency care. I do not criticise those patients, because often it is the only place that they feel they can access. But there are lots of things that the NHS is doing that, if rolled out consistently, would make a massive difference. For example, “hear and treat” services—so that when people are phoning up for an ambulance they are being triaged on the phone. As I saw with Jim’s predecessor, Amanda Pritchard, up in the north-east on Teesside, instead of waiting hours for an ambulance that, when it turns up, has staff who are probably a little bit grumpy, even if they do not show it, because they think, “You didn’t need to see me; someone else could have done this,” they had a community response car out from the community-based team. It was much faster, so it was a better experience for patients and a better use of taxpayer money. The more that we can get people the right care, in the right place, at the right time, the less likely they are to unnecessarily and avoidably call on emergency services. That then frees up those emergency services to do the things that only they can do. Finally, since you mentioned corridor care, I wanted to inform the Committee that we are shortly going to be publishing data on the number of corridor care beds. I think sunlight is the best disinfectant; we have to be honest about the scale of the challenge, so that you can hold me to account for improving the situation, and I can hold the system to account.

That is helpful, and we will monitor that as time goes on. Moving on, you mentioned that patients can be treated egregiously—I think that was the term that you used—and that you had dealt with a number of those cases. Looking at chapter 7 of the document, to what extent do you think there needs to be more in relation to mandated safe staffing levels? For example, we know that beneath all of the heat and fury of the Mid Staffs inquiry reports were chronic unsafe staffing levels in many of those contexts. To what extent do you think there needs to be established, mandated, registered clinician staffing levels?

I will say a few things and then bring in Jim and Sally as well. First, when it comes to thinking about quality and safety, Mid Staffs looms large in my mind, as do the lessons of that inquiry. As do the conversations that I have had with a significant number of families over the last 12 months, which have been far and away the best and worst meetings I have sat through—they were the best in terms of the insight, and the worst in terms of how harrowing and distressing some of the stories I have heard have been. There are lots of tools available to us that we did not have when we were last in Government, in terms of the quality of the data available and how we can use that to give much better early warnings for where things are going wrong or where you can see patterns in patient experience that might point to a deeper problem, so that you might want to send a team in. We are also, thanks to the work of Penny Dash, looking to streamline regulation so that the people who are regulated know the rules that they are working to, and can discharge safer care because they have got much clearer marching orders—and we can better assess their performance against those. Reforming the CQC—there are a whole number of things that we can do on quality. On safe staffing levels, it is really important that we work with the professions and look at each clinical pathway, and at what a safe staffing level means in each case. We must also recognise that those levels will not be static. There are all sorts of improvements in medical science and technology. There are a growing number of roles. We are doing a bit of first-principles thinking on that at the moment, and we will shortly publish the Leng review on medical associate roles. We have to make sure that we are, by all means, discussing and debating safe staffing levels, but following the evidence as we do so.

One area where I think that safe staffing is important is nursing. You mentioned that earlier, and you have heard the RCN talking about nurses’ pay and conditions today. I know that Sally comes from a nursing background. Very often people go into nursing, commit their whole careers to it, and finish on band 5, which at the top of the spine can be £37,000. Someone who has committed their lives to that profession can end up at that level. Do you think that is sufficient? The majority of nurses end up in that situation. In chapter 7, you talk about how to recruit, but retaining nurses is the big problem. They are leaving in their droves, and no wonder.

Yes, that is right. I am anxious about this. I do not think that our nursing profession has received the level of respect and support to which it is entitled. Unless we give nurses better job security and job satisfaction, and unless they feel genuinely recognised and rewarded for their work, we end up in the worst of all worlds: investing a lot in their training and then losing all that knowledge and experience when they go elsewhere. The chief nursing officer for England is working with the professions to develop a strategy that will make nursing and midwifery modern careers of choice, to address the decline in applications to education programmes. We have committed to RCN, Unison and others that we will reform the “Agenda for Change” structure—I think that would make a real difference. We also want opportunities such as consultant nurses, and nurses as leaders in their own right. I think that the future for the profession is bright but, as with most things in this job, July 2024 was not necessarily where I would have wanted to start from.

Of course. That is all in the report.

Andrew, it is 3.37 pm; you have one minute.

Okay. I have a final question. In the social care contracts for my area, both the NHS and the local authority are proposing to pay social care workers £12.79 an hour, irrespective of whether they work on a holiday, during unsocial hours or anything else. The national living wage is £12.21.

Andrew, ask your question.

How can we possibly fill those contracts when the service itself is not prepared to pay for it?

That is the thing that unites the employers, the trade unions and the local authorities. Unless we pay our care staff better, and build a genuine social care profession, we will fail to recruit and retain the brilliant people we need. That is why fair pay agreements were introduced in the Employment Rights Bill in our first 100 days. That Bill is making its way through Parliament. The Deputy Prime Minister and I will shortly set out how fair pay agreements will work in practice, and the funding attached to that—

That is a good place to stop, please, Wes.

I am going to ask about the career progression of doctors, and training routes. In 2012, 66% of doctors who completed foundation training—F2—would go straight on to a specialty training programme. That has shifted: now it is 22%. Obviously, that is a huge shift in the medical workforce, some of which is driven by the fact that we do not have enough training places. You have said you are going to get 1,000 new training places over three years. Is that enough?

Yes. If I can go further, I would like to. Notwithstanding the fact that I do not agree with the BMA about the timing or the necessity of its proposed strike action, I absolutely share not just the concern but the anger and frustration I hear from resident doctors. As I have said to many of them, the best pay rise they can get is going from being a resident doctor to a consultant. If we can deal with the bottlenecks issue, that will be better for them, for patients and for the NHS, because we need more of that clinical leadership capability.

We are now also seeing a massive increase in the number of doctors going on to SAS and LE contracts. Is the answer to that a more formal role for SAS and LE doctors, or is it to get training sorted and other routes on to the medical register?

I think you are right. We have our workforce plan, which we are currently developing in the light of the 10 year plan. The previous workforce plan was just not in the right place. A number of its assumptions were flawed. If we continue the rate of growth that the long-term workforce plan had assumed, then by the end of the century 100% of our population would need to work in the NHS. I think we can all agree that is implausible—I almost said something else. We are therefore developing a workforce plan that aligns with the strategic direction set out by the 10 year plan. That also offers us an opportunity to deal with some of these thorny issues that just have not been dealt with and have led to resentment in the profession.

I get that, but I am trying to work out what our doctor population looks like. We all know that resident doctors deliver most of the care, as do SAS and LE doctors, so what does it look like? Are we going to have a greater proportion of SAS and LE doctors, or are we going to get the SAS and LE doctors into formal programmes through to being at a higher level of training?

You are tempting me to pre-empt the workforce plan. Those are exactly the sorts of questions that we need to address—the size, shape, capacity and capability of the future workforce.

There was a brief mention in the 10 year plan about simplifying routes for SAS and LE doctors on to the medical register. Last year, 276 doctors went through what used to be the CESR/CEGPR route. Is that the right kind of number, or do you think that we should make it easier for SAS doctors to become—?

We do need to make it easier and simpler. Again, that is something we will look at in the context of the workforce plan. We also need to look carefully at the diversity of the medical workforce. I do not just mean doctors. If we take medicine specifically, it is still the case that too many people who are signing on to medicine courses at university are from the background of sons and daughters of doctors. We need to make access to medicine more open to working-class students from backgrounds like mine, and not just the preserve of people who can afford it. Similarly, thinking about the broader NHS workforce, one of the great tragedies, particularly in nursing and midwifery, is a lot of people who have reached a stage in their life where they might have a career change—maybe they have been doing some caring for young or older relatives and think, “I’m now going to go into nursing or into midwifery”—are not doing it. We have to deal with some of these disincentives, because we are losing a lot of people with really valuable life experience going into a whole range of NHS professions.

Do you think part of that is some of the assumptions baked into NHS contracts? Some 60% of doctors who have just qualified are women, compared with a medical workforce where they make up about 49%, so you can tell like it has skewed younger. Is that just because it is not flexible enough?

Yes. I was thinking back to the big row that Jeremy Hunt had with the BMA over seven-day working. That argument looks so dated now because lots of people—not just in the NHS but particularly in the NHS—would like more flexible working. One of the reasons we have seen agency costs shoot up is because people have seen agency work as the only way to get a career that fits around their lives. That is worse for them, because they do not necessarily know where they are going to be working from one week to the next, and you do not build the sense of camaraderie, teamwork and relationships at work that I think we all value most of the time. It is also not great for the NHS, which ends up paying through the nose, or for patients who might not have that continuity, even in a hospital setting, where you get to know the clinical team around you. I think flexible working is a win-win. Again, in contrast to the approach we have seen in the past, I do not think this is something we need to impose; it is something we need to offer. I think we will find staff taking it up in a way that benefits them, the NHS and, most importantly, patients.

Do we need better flexible training as well? If you think about the point of life at which doctors are in specialty training, and given that the majority are women, does training need to be more flexible?

Yes, I think we need to look at that. We also need to make sure that training for all parts of the NHS workforce, in all cases, is valuable. There is a lot of complaining from NHS staff who feel they are subjected to a whole load of training that they feel is pointless. That brings to life why the idea that NHS staff are opposed to reform, or that they are somehow a problem on productivity, is nonsense. One of the things that staff really complain about, in terms of training they are subjected to that they think is pointless, is that they want to be out seeing their patients, and they know that their time away from clinical practice is valuable time. We have to make sure that we are using their time effectively and asking them to do things they genuinely need to do, or offering them development opportunities where we can, rather than subjecting people to training that they think is a pointless waste of their time.

How are we going to make sure that we have people in the roles that we need for the future? Obviously, it is much easier to train a doctor into the specialties that we have at the moment and the specialties where we have more people. GP training is a particularly difficult area to train the right number in. How are we going to incentivise that and get that shift?

We need to look at all the training routes to make sure that they are relevant to what modern clinical practice will look like and the way in which these roles are going to evolve with medical science and technology. Part of the challenge with general practice and district nursing, for example, is that they have not had the best rep with medical students when thinking about where they are going, or nursing students when thinking about what they imagine their nursing career to look like, because they have been seen as on the slide or going through a bad time. If you are reading all the time in the newspapers that GPs are overworked and burned out, and you are constantly seeing GPs given a kicking because people cannot get an appointment, you are not going to think, “That’s where I want to go to work.” Similarly, with district nursing, there has been a sense for some time that that part of the profession has been on the wane. Actually, the pitch I want to make to the doctors and nurses of the future, as well as other allied health professionals, is that community neighbourhood health is where it’s at. It is where some of the most exciting medicine will be practised. It is where you can make the most difference to patients in tackling health inequalities. I think that will really speak to the values of the generation who are coming through and what they want to achieve. I hope that we will see a good deal of enthusiasm for working in general practice, or working in community teams as district nurses and in all sorts of other roles.

My final question is a bit left-field, but you said that community and neighbourhood health is where it’s at. Earlier, you said that social care will be the door out of the NHS. We have talked a bit about funding. This report is brilliant, but it is very light on social care, and it points just to the result of the upcoming Casey review. I do not feel that it quite grasps the nettle. Would you like to see it grasp the nettle more? How can we be confident that between now and the release of the Casey review, social care is going to be in a better position?

Without reeling off the list I gave earlier, I think the things we have done in the first year of this Labour Government have been significant and substantial on social care, but I recognise it is against the backdrop of much wider challenge and crisis in the social care system. What you will see next year from Casey is a set of recommendations—and effectively marching orders, because it is Louise Casey—about what we should do for the remainder of this Parliament, and then the long-term reform agenda, which I think involves a much wider national conversation about what we need from social care and how we fund it. That will come following that. It is not like there will not be other big things going on in social care between now and then. What we are doing on fair pay agreemen.ts is in itself a significant reform, but I do understand—

The thing that I don’t really know about fair pay agreements—I am not sure whether this is—

Order.

We will come back to you on that.

Thank you, and thank you, Josh. We are going to ask some snap questions, and we are looking for snap answers.

Oh no—the answers I’m least good at.

Unfortunately, I doubt you will be able to give this question a snap answer, but I look forward to you writing to me if not. Sir Jim, in an answer to me earlier, the Secretary of State suggested that he did not see it as being the role of resident doctors to be involved in productivity and efficiency. Is that your take on this, or is there a role for resident doctors, and any part of the workforce, to be part of that?

I don’t think he said that; I think he said we should not blame resident doctors for the productivity problems that the NHS has. We all have a part to play in our approach to productivity. We will look at things in the round—the workforce, technology, the estate and so on. All that is in hand, but I don’t think he actually said what you just said he said.

If I have mischaracterised him, I apologise, but specifically then, where do you see the workforce playing its role in efficiency and productivity?

We want the whole workforce to engage in the challenge that we have. We have a finite amount of money—on the edge of what the economy can afford. There has been huge growth over recent years, and we have lots of patients to treat, so we need everybody to lean in and participate in the innovation, the transformation, and the pathway changes that we all have to play a part in. It will not be possible with just the management system pushing it, or certain parts of the clinical community pushing it. We have to try to do it all together.

The best examples of improved productivity in electives, for example, have come from frontline clinical leadership. Obviously that includes resident doctors and other NHS staff. That is what gives me hope, actually, about the future. I think they are up for the challenge. They want us to take the brakes off.

Maybe you would cite the GIRFT programme as an example.

Yes, it is very good.

Another snap question. Gambling currently sits under DCMS. There is an increasing evidence base that it is incredibly harmful, particularly the more dangerous products online. What do you think about seriously putting it into the Department of Health and looking at it as an addictive, harmful agenda, as opposed to an entertainment agenda?

I think gambling is a bit like alcohol in that I do not want to stop people having a flutter, just as I do not want to stop people enjoying a pint, but in both alcohol harms and gambling harms what you see is a minority, but not insignificant number, of people who experience severe harm, and that is where we have to focus.

To press you, you would not put alcohol in DCMS. Would you transfer gambling, by the logic of your argument?

Alcohol policy straddles us and the Home Office. In terms of gambling harms, I have a line of sight into it as the Health and Social Care Secretary, but it sits with DCMS.

For now. Thank you, Secretary of State.

The Committee has looked at child vaccination rates recently. We had a tragic outbreak in the last few days around Alder Hey. The 2012 outbreak in Merseyside cost £4.4 million to treat—20 times the cost of the vaccinations that would have prevented it. The 95% WHO target has not been met. The vaccination rates between areas vary by sometimes 30%. Was it right to downgrade the 95% target? Should it be restored for the system, and are we doing enough to increase child vaccination rates?

First, no child in this country should be dying of measles. I am extremely sorry to the poor family who are now grieving the loss of a child in those circumstances, and I am sure everyone will join me in sharing condolences. This is why we have to redouble our efforts on vaccination and make the case. Some of the improvements in the 10 year plan will help—for example, having digital records of children’s health that parents can check, in the digital red book. That will be really good and will mean that, in moments such as happened over the weekend, if parents read about an awful case in the media, they can quickly log on and check whether they got that jab—“Are we up to date on our vaccinations?” We can also proactively invite people to a vaccination. We will do a lot more throughout the remainder of the year to try to improve vaccination uptake, because it saves lives.

Do we need additional investment and support to get those areas that are 30% below the highest levels of vaccination in the country up to where they should be?

We already have significant resource attached to public health information campaigns. Given the profile of the issue at the moment, I will write to the Committee to share the work we will be doing to drive up vaccination rates.

The 10 year plan has some dates by which things will happen. Are you planning to produce a single overview timetable for the implementation of all the different promises in the plan? If so, when will you produce that timetable by?

There are lots of dates throughout the plan. We can be clear about what we are doing over the next few years, because that is in the spending review period. Obviously, from one year to the next you have to revise your financial planning, but overall, we have a clear set of commitments for the next few years, which is the clear line of sight that I have in terms of the money. Beyond that, we are more into ambition territory, for no reason other than that I am reluctant to make promises, or to write cheques without knowing that I can cash them.

That is absolutely right. Could you at least pull together everything that currently has a date and produce a single timetable? It would be easier for us, and probably for everybody else out there, to deal with. Would that be possible?

It is possible.

We are planning to have the NHS produce medium-term plans in the round, starting in the autumn and completed by Christmas, ideally. That will set out how the NHS takes the plan, and all our other operational imperatives, and plans that out over a period of time.

I served on an ICB for two years. Will it be a nice, simple two-pager that we can all read, alongside the 350 pages that an ICB would usually require us to plough through?

Hopefully, yes.

Just a couple of pages. Thank you.

You’re giving us a lot of homework! [Laughter.]

You have made the patient voice a high priority, and not just in terms of patient power, as you said in your introductory remarks, but you are scrapping Healthwatch. What will you put in its place to ensure that there is an independent vehicle to make sure the patient voice can be heard?

I have a few things to say about that. First, I do not doubt for a moment that Healthwatch, and Healthwatches across the country, have produced some valuable work over their time, but we are moving into a new phase in which the patient voice should be embedded throughout the whole system. There are other national organisations in this space but, fundamentally, we want, first, to give more power to the patient. Secondly, as parliamentarians we have to stop outsourcing our job to other people. Government is doing it all the time with the proliferation of loads of arm’s length bodies, which basically says either, “This is too difficult and too controversial and we don’t want to touch it, so we’re pushing it out over there,” or, “We don’t trust ourselves as politicians so it’s going over there.” The same is true for advocacy for the public. We should not need loads of organisations to speak up on behalf of our residents and citizens. That is our job as parliamentarians, councillors and elected representatives.

My last question is about black maternal health. I am passionate about this subject, as you know, Secretary of State. The fact that black women are 3.7 times more likely to have poorer outcomes than white women is an issue out there. There is talk about a national maternity investigation. How are you hoping to address some of the issues using the 10 year plan? If the question is too much for today, I am happy for you to write in.

The first thing I want to do is reaffirm to you and to the Committee that we will have a target for improving the mortality gap, because it is so important. As you know, I am trying to reduce the number of targets overall, but this is extremely important. It is morally impossible to justify the gap. As part of the national investigation and the work of the taskforce, we are going to make sure that the inequalities side of maternity failures is absolutely integral to the work of the investigation and then the work of the taskforce. I know that we will definitely come back to this topic, but I want to reassure you and the Committee that the racial inequalities in maternity care and failures in maternity care are going to be absolutely at the heart of the agenda. If we cannot get tackling racial inequalities right on maternity, I don’t think we have a chance of doing it in the rest of the NHS.

Thank you for that. We will absolutely return to the 10 year plan in future sessions, and we hope that you, Secretary of State, and your Ministers will be able to return to the Committee to answer questions. We are also really looking forward to having Jim Mackey back in September to go through the ICB reforms and finances in more detail.

Good luck, Jim.

I think we’ve been pussycats. On that note, thank you all for coming. You have done a great job in a short space of time, as has the Committee.