Oral evidence: Budget and NHS long-term plan, HC 1712

Oral evidence, 28 January 2019.

Witnesses

Matt Hancock, Simon Stevens, Professor Cumming and Ian Dalton.

Chair

Good afternoon, and welcome to our second session looking at the NHS long-term plan. For those following from outside the room it is very helpful to know whom you represent. The Secretary of State and Simon Stevens are familiar to most people, but perhaps Ian could start by introducing himself and his role.

Ian Dalton

I am Ian Dalton, chief executive of NHS Improvement.

Simon Stevens

I am Simon Stevens, NHS England.

Matt Hancock

I am Matt Hancock, the Secretary of State.

Professor Cumming

I am Ian Cumming, chief executive of Health Education England.

Chair

We have a huge amount to cover, so brevity would be appreciated. Please don’t feel the need to repeat what colleagues on the panel have said if you agree with them. One thing that has come across loud and clear from our previous session is that there are still many unknowns. We do not have the workforce plan, we do not know how much funding there will be for Health Education England and we do not yet have the social care Green Paper or know how much will be in the future budget—for prevention, for example. Simon Stevens, given all those unknowns, how confident can you be that you will be able to deliver the plan?

Simon Stevens

We have been able to frame the plan knowing what NHS funding for the next five years looks like. We have taken a pragmatic approach to the phasing of the improvements we want to see, and have had the knowledge that, particularly in respect of social care, the planning assumption that we were given by the Prime Minister is that we could plan on the basis that there will be no additional pressures on the NHS as a result of social care pressures over the next five years. That is the basis on which we proceeded. The National Audit Office has had a preliminary look at the planning assumptions used for the plan and determined that they are prudent.

Chair

What is the area that you feel is most at risk?

Simon Stevens

I am sure that one of the conversations we will have today is how we make sure that we are able to expand the workforce to match the increase in funding going into the national health service. There are some detailed proposals in the long-term plan, but we have now embarked on a process with wider stakeholders to put flesh on those bones. Training expansion, return to practice, retention efforts, international recruitment and changed ways of working are all aspects that will be very important in planning the workforce we need.

Chair

For you, workforce is the area you feel most concerned about.

Simon Stevens

That is the principal question. We were able to set out the plan based on prudent assumptions about what needed to happen on workforce, but there is a big implementation process now under way that we will talk about.

Chair

One aspect of the workforce drawn to our attention last week was the bandwidth in the system in terms of management to be able to deal with it. Do you feel that will be deliverable given the management required to implement it?

Simon Stevens

We have been able to frame it as a five and 10-year view of the clinical outcomes improvement we want to see and the service changes to support it. The approach that Ian and I are taking to implementation is to set a fairly detailed implementation framework in the spring—likely to be April—when there will be an opportunity for local NHS trusts, CCGs and our partners in local authorities and the voluntary sector to work together to frame, based on their own starting points, what their implementation plan looks like. We will then bring that together in a national implementation framework after the spending review, when we will be able to feed in the answers we have had on capital investment and other matters. We will be able to stress-test the phasing of delivery against the local engagement processes that will be kicked off in April.

Chair

Ian, is there anything you want to add?

Ian Dalton

No. It sets out the key issues on workforce and talks about the implementation framework. That is fine.

Chair

The implementation framework is when we will start to see whether there is enough bandwidth in the system.

Ian Dalton

Yes.

Simon Stevens

There are certain things that we want to happen everywhere quite quickly. For example, every child with cancer will be offered a whole genome test across the NHS in England this coming year. That will happen everywhere. Other things will take much more joint work: for example, the integration of GP services and community health services, which will arise from the implementation planning that is going to be done locally.

Ian Dalton

The reality is that at the heart of the long-term plan is a series of national commitments that we want to see everywhere. There is also a recognition that there is a complex new care model. That will take time and depends on where you start from. To pick two areas, one in the far north and one in the far south, we need to understand the bandwidth and capability of change and whether we find that to be sufficiently stretching, but ultimately it has to be owned locally by the people who have to deliver the new care model. Inevitably, there is a process of implementation that has to be planned locally, and our job is to challenge that but ultimately to support it.

Chair

We will come on to various detailed aspects of the plan, but I know, Ian, that you have to leave early.

Ian Dalton

Thank you for accommodating my twin appointments with parliamentary Committees this afternoon. I appreciate that.

Chair

I want to ask you a question specifically about the workforce implementation plan. What arrangements are being made for the production of that plan? Could you quickly set that out for us?

Ian Dalton

At the moment, there are significant vacancies across the hospital and community sectors. That is not to say patients are not being cared for; shifts are being covered, but we know that the workforce will change and needs to expand to deliver the new care models in the long-term plan. You will read in the long-term plan many of the ideas about increasing supply, finding new approaches to different professional roles and helping people to work at the top of their licence. You would expect to see all of those highlighted as things we will be delivering over the next period. The challenge now is to populate that with detail and turn it into a detailed quantitative implementation plan, and to pick up on it in such a way that we do not miss 2019-20, because we have things to do in 2019-20, but set a context for planning the subsequent four years. The chair of NHS Improvement, Dido Harding, has been asked to oversee that. We have brought in a senior chief executive, Julian Hartley from Leeds Teaching Hospitals, to oversee the process. There is a series of working groups, most of which are professionally led; for instance, the chief nursing officer is overseeing the workforce needs of nursing, and Professor Stephen Powis, the national medical director, is overseeing the medical aspects. The timescale is such that by spring we will publish, alongside the implementation framework for the LTP, an interim report on the actions needed, which will specifically focus on 2019-20. Without going too far ahead of ourselves, I would be surprised if that did not concentrate on areas that included retention of staff, for instance, where we know we can do more and need to get on with it, and possibly on international recruitment. Then we will look ahead. That group will continue to engage with stakeholders so that, by the time we get to the spending review and we know the HEE budget, we will have a definitive report that gives us confidence about workforce growth over the next five years but sets it in the context of the needs of patients over the next 10 years.

Chair

One of the key questions is when you will know how much you have to spend. At what point will you know what you have to spend on workforce before you finish the workforce plan?

Ian Dalton

The key point is that there will be some material focusing on 2019-20. We know we have to expand the workforce now. For instance, we are already seeing very positive results from our retention work with 50-plus trusts. It is likely that we will want to roll that out everywhere. The full analysis will be forthcoming at the time of the spending review and will be in the final report. There will be an interim report in March and then a definitive, costed, detailed report.

Chair

The interim report will be at a stage when you do not know how much money you have to spend, and you will produce the final report afterwards.

Ian Dalton

The interim report will set out in broad terms what needs to be done, but specifically focusing on 2019-20 actions, without which we might lose the first year. It is fair to say that the analysis will then need the spending review to contribute to it, so it will come out in the autumn, after the spending review. That will be the costed, definitive set of numbers.

Chair

We will come back to that later.

Dr Whitford

Ian and Simon, what funding will there be for transformation? Funding was set aside previously for transformation and changing ways of working. You talked about new models of care, and obviously that got used up in debt. It adds up to £20 billion by 2023-24, but it is 3.4%; of itself it is not a big super-charge of money, so will there be additional transformational funds to do the changes while running the NHS?

Simon Stevens

Yes, but not in the way we have done it previously. We are earmarking a local growth fund for primary medical and community health services that will grow each year in real terms and will be worth at least £4.5 billion by the fifth year of the programme. For the first time in the history of the NHS that will mean that primary medical and community health services are growing faster than the overall NHS budget. That has not been the case over the last five years. We made a start on primary medical, but the community health services element has been squeezed. That investment guarantee provides some headroom but, rather than holding it nationally and allocating it against bids, we are making it available to local areas. They will, however, have to provide an audit trail to show that the extra investment in those services will deliver the service changes set out in the long-term plan.

Ian Dalton

There is a big focus on transformation and improvement. As we have discussed in this Committee before, it is important that we are able to put in enough resource to get the change we need. At the same time, we have been able to create a financial architecture and investment fund that will enable us to make a definitive, decisive move in parallel with that transformation, away from deficits across the trust sector, to help to ensure that the NHS remains and becomes more financially sustainable. We also have to ensure that year by year we reduce the number of trusts in deficit while improving the quality of care. Through the negotiations we have had, we have set a financial framework. We will be writing out to the NHS in even more detail in the spring; we have already given some heads up in the planning guidance that says how from 2019-20 onwards we can see both those things moving forward. It is a balance and we believe we can do both.

Dr Whitford

How do you propose that the productivity savings that are almost implicit in the plan will be made?

Ian Dalton

They are implicit. One of the key tests was a minimum of 1.1% productivity. That sits in a context. We have to thank the NHS for being probably one of the most efficient and productive healthcare systems in the world. The Office for National Statistics recently noted that 2016-17 data suggested that the NHS was delivering productivity of 3% compared with about 0.6% for the UK economy as a whole, so the NHS is productive. It delivered £3.2 billion of efficiency savings in 2017-18 and is looking to deliver £3.4 billion of efficiency savings this year. We have a series of 10 areas listed in the long-term plan, all of which we have started work on and are delivering savings. Those will need to be driven hard across all 230 organisations to ensure that we deliver at least 1.1%. This is one of the times when we have a good track record, but every penny we deliver over and above the 1.1% is further investment in patient care. We are asking trusts in deficit to do an extra half per cent, at least. We will help them with that to reduce the number of deficits over the next five years ultimately to zero. In addition, if patches can go further, there are further reinvestment opportunities. Productivity is hard-wired into the implementation of the plan, building on the successes we have had over the past couple of years.

Dr Whitford

Will the revised standards coming out of the clinical standards review be as challenging as previously? In particular, people are concerned about a change to the four-hour A&E target, which is not a target in A&E itself, but measures that flow through acute services.

Simon Stevens

I do not think we want to prejudge what the national medical director, Professor Stephen Powis, comes forward with in March. We are trying to do several things at once. The first is that we want to lock in short waits for emergency and urgent care as well as for planned and routine care. Equally, Steve Powis is telling us that we need to reflect changes in clinical practice. Since the administrative targets were promulgated, in some cases 15 years ago, the practice of medicine in relation to sepsis, strokes and heart attacks has changed, meaning that the golden hour requires a very early clinical focus on those rather than an average across a four-hour experience for a whole variety of patients. At the other end of the spectrum, there is the move laid out in the long-term plan, as you know very well, Dr Whitford, to same day emergency care, where many patients will be on a pathway where they get appropriate medical treatment that avoids the need for overnight hospital admission. Therefore, three hours 59 minutes is not a clinically relevant bifurcation point to decide whether or not they have to be admitted. Those are some of the considerations Professor Powis and colleagues have to take into account. They will make their recommendations and we will field-test them across the health service for the first half of next year, before they are implemented.

Dr Whitford

But the aim is to implement things that are more clinically relevant rather than move the standard because we are not meeting it.

Simon Stevens

Precisely.

Dr Whitford

Can I ask about clinical standards? Obviously, the golden hour and the acute waiting time is important; other waiting times are often less clinically important to outcome but are obviously important for the convenience of the patient. Ian, what are the standards regarding how patients are treated for particular cancers and diseases if what you want is to drive up the quality of treatment they actually get?

Ian Dalton

Professor Powis’s review will look not only at the existing targets for elective and emergency care, important though they are, but at important areas such as mental health, where we have been making a big investment push and we need to do more. The long-term plan sets out the extra investment in quite a high degree of detail. We want some standards against which to measure the responsiveness of mental health services and, to pick up your very important point, Dr Whitford, the cancer targets we need going forward. In particular, we have a big aspiration in the long-term plan for more rapid diagnosis, which contributes to positive outcomes. We will be looking at where Professor Powis goes on that and what we need to do, given that we have already committed to tightening up the diagnosis standard from 2020 so that people get more rapid diagnosis of their cancers, and then more rapid decision making and treatment can ultimately ensue. Building on Simon’s point, this is a clinically‑led review, taking into account the views of the experts, who will then advise us on the way we hold the NHS to account for both prompt and high-quality treatment. That process is the right way to proceed.

Dr Whitford

I am talking about clinical standards as opposed to waiting times, regardless of whether it is for cancer. Those have largely disappeared across England. Obviously, the getting it right first time programme is bringing them back. Having led on that in Scotland, I know that it is treatment that changes outcomes.

Ian Dalton

Sorry, I misunderstood the question. Let me strongly clarify the answer. The getting it right first time programme, which is a major clinically-led change programme that started in orthopaedics, has rolled out through surgery and is now rolling out through medical specialties. It will go on to look at mental health, community services and, potentially, primary care. It is led by Professor Tim Briggs and has already identified best practice and the ways of tackling the variation that we know exists in clinical standards across all healthcare systems. We are no exception to that. There have already been significant improvements in, say, orthopaedic care that we can point to directly as a result. We are completely committed, as part of the LTP implementation, to that work rolling out across all specialties and informing what actually happens to patients. The reasons for that are twofold. The first is that it identifies fundamentally the way the experts tell us is the best way to care for our patients. As somebody who has worked in the NHS on and off since 1984, that is motivating for me, as it is for others. Every healthcare system has variations. Making sure we minimise them and deliver in other specialties the kinds of benefits we are already seeing in orthopaedics would be helpful. The second point, which is linked to the question on efficiency that you asked, even if it is not driven by that, is that often better care is more efficient care as well. That is a critical part of our change model. It is already delivering results, and we are completely committed to driving it hard over the next five years.

Dr Whitford

I totally agree that proper clinical audit, not just of the surgical components but of whole pathways, through peer review, can drive up performance year on year.

Ian Dalton

Undoubtedly.

Dr Whitford

I led on that in Scotland.

Ian Dalton

Yes.

Dr Whitford

The president of the Royal College of Ophthalmologists has raised concern that the national ophthalmology database is going to lose its funding in August. It has run for nine years and has reduced complications by 30%, and suddenly it is losing its funding. That does not really fit with the approach of looking at outcomes, quality and risk stratification within groups of patients with common conditions.

Simon Stevens

I am very happy to get Stephen Powis to have a look at that and be in direct touch with the president of the college. As a general point, though, the clinical audit programmes across England have been a huge success over many years, but sometimes there is frustration that the pace of adoption of the revealed need for improved practice has been rather slow, and the year-by-year improvements might be a percentage point or two instead of much bigger steps. Part of the conversation is simply about having stand-alone individual specialty-based audits. That has to be hard-wired into a quality improvement process that is mainstreamed across all hospitals, and indeed the primary and hospital interface. Building on what Ian just said, part of that is what we are doing in the long-term plan, because it was developed with clinical groups and a number of patient groups, such as the British Heart Foundation, the Stroke Association and Diabetes UK, which have a strong focus on clinical quality improvement. We have a number of specific improvements in the plan that we will implement and track.

Dr Whitford

Do you not think there is a danger, if there is not acceptance of audit as an integral part of care, which we tried to develop, that that is what will bite the dust when funding is tight?

Simon Stevens

We are spending millions of pounds a year funding those audit programmes. Professor Powis will look at the specific one on the eye audit that you mentioned, but across the piece NHS England is allocating millions of pounds to fund the audits led by the royal colleges.

Dr Whitford

You do not think they will be under threat when funding starts to get tight.

Simon Stevens

I do not want to comment on that specifically. I will get Professor Powis to do that.

Dr Whitford

Perhaps I might ask the Secretary of State about opening up genome analysis of healthy people to 5 million. My understanding is that, of the initial 100,000 tests, one in five were found to have something abnormal. Is that not going to suddenly dump 1 million worried well patients into the NHS? Is that not a concern you would have?

Matt Hancock

No. The proposal is that, having achieved the goal of 100,000 whole genome sequences in December last year, which is a world-leading effort, we now have a goal of 1 million whole genome sequencing as part of a wider ambition and expectation that there will be 5 million partial genome sequencing. Partial sequencing is much cheaper and is targeted at specific areas of concern where a presentation is made of a particular risk or concern. The million is split into two. We already have a biobank of consented clinical records, and the genomes of those on the biobank will be sequenced, which will provide an internationally significant research bank for the link between clinical and research data and genomic data. The other half a million will come through those who need NHS treatment and whose whole genome sequence is part of that treatment. For instance, there is early evidence from a trial at Addenbrooke’s, where they regularly sequence the whole genome of children who have conditions, that it changes the clinical pathway and treatment of those children in around three quarters of cases, so it is very positive.

Dr Whitford

There is no issue about using it, particularly in childhood cancer, which Simon referred to. In the article you are quoted as saying that healthy people would be able to pay a few hundred pounds to have their genomes sequenced, and they would get the result. Anyone in primary care knows that when people go privately to get a whole-body scan, they turn up at their GP saying, “What does this mean?” Surely, bringing the worried well to look at their genomes completely out of context is going to add enormous pressure without our having solved the basic needs of the NHS first.

Matt Hancock

It needs to be done in context.

Dr Whitford

This talked about healthy people—healthy volunteers.

Matt Hancock

Yes, but healthy people who have their genomes sequenced can find problems they did not know previously existed.

Dr Whitford

It is one in five within the 100,000.

Matt Hancock

That allows them to change behaviour, have preventive treatment or otherwise take action that can reduce the long-term pressure. The key is that it has to be done properly and carefully in the correct context, as you described it, to make sure it is done properly, but ultimately it will reduce demand by supporting the prevention of illness.

Dr Whitford

I am not necessarily convinced of that. Their first stop will be going to their GP to ask them to interpret what it means and, depending on how quickly it is done, that could put in a huge additional burden of worried well in a relatively short period.

Matt Hancock

Not necessarily. You refer to it being done out of context.

Dr Whitford

They are not ill; they are not doing it because they have an illness.

Matt Hancock

If part of the package that is put together to allow for this is to include counselling and appropriate understanding of the results, you can get the upsides while mitigating those concerns.

Chair

Have you looked at the possible widening of health inequalities as a result of the tests?

Matt Hancock

There is also the ability to save people’s lives. You have to look at both.

Dr Williams

Secretary of State, that would be screening of healthy people. Would the National Screening Committee have a role to play before something like that was rolled out?

Matt Hancock

We need to take a broader look at the whole approach to screening. The Mike Richards review of cancer screening is mostly because the process of delivering screening has been imperfect and has had problems. We need to make sure that the way it is organised is good. We also have health checks for healthy adults aged between 40 and 75, and there are questions about whether they are being delivered locally and differently in different places.

Dr Williams

My question was specific to the proposal for genomic screening of 1 million healthy people. Will the National Screening Committee have a role to play before that is rolled out?

Matt Hancock

Potentially. That idea has been brought up and is being discussed. The reason I answered the way I did is that there is a whole different series of actions that are broadly in the preventive space. Some are called screening, with a capital S, and are done by the NHS; others are done by Public Health England and others are done by local authorities. The genomics are new and not yet operational. At the moment, some of them are done through contracts. One is done through a Capita contract; others are done directly. They all need to be looked at in the round to make sure there is a strong clinical basis behind them.

Dr Williams

I think we would take reassurance if the National Screening Committee looked at genomics first.

Chair

We have a huge amount to get through. One further aspect of funding is the huge maintenance backlog. We have been given evidence that it is around £6 billion, of which over £1 billion is high risk and over £2 billion is significant risk. In itself, that is starting to have an impact on local services. My local hospital has two theatres out of action—it had three out of action until recently—because of inadequate extraction systems. Are you able to give the Committee an assurance that we will make progress on tackling the maintenance backlog as it affects the estate and equipment?

Ian Dalton

We discussed this the last time I was before the Committee. We have seen a rise in maintenance backlog of a couple of billion over the last couple of years. The UK is spending a smaller proportion of its health expenditure on capital than an OECD mean by quite a significant amount. Those two factors are potentially linked. It will be important to support the implementation of the long-term plan so that we can both ensure that current facilities are fit for purpose in 2019 and over the next five years, and that we have sufficient access to capital, from whatever source, to invest in the new services we will need to deliver the new care model. That would include new services in the community, for instance, for people who otherwise would have been cared for in hospital. At the moment, we can clearly reference the additional £3.5 billion that the Government put in and has now been committed. The question is whether we can we go further and bite into that and, at the same time, develop a range of new hospitals and facilities while also addressing the backlog, given the ageing estate and a rising backlog. That is something we will have to discuss when we see the capital settlement we get as part of the spending review. As I mentioned last time, my perspective is that a significant build-up of capital demands has grown over the past few years and has resulted in ageing facilities. That is both buildings and some forms of equipment, like scanners, so there is more to do.

Chair

Secretary of State, are we going to see more of the capital to revenue transfers that we have seen over the last four years?

Matt Hancock

I very much hope to avoid that. The fact that we have a five-year cash settlement means that the NHS can now plan its revenue budget over those five years. That planning is under way. It is already set out for 2019-20, and after that we will have a settlement for the last four years of the five-year cash settlement that is agreed.

Chair

The plans for the Naylor review were dependent on private finance of £2.8 billion. I understand that has now been ruled out, so will there be a gap?

Matt Hancock

We will need to address that in the spending review. There is not much more we can say before the spending review. The fact is that the collapse of some of the PFI projects has added to pressures on the capital budget, because we had to bring two hospital building projects on to the balance sheet this year. That was necessary to get the hospitals finished in Liverpool and Birmingham. They are absolutely critical hospitals and they will be brilliant when they are completed. They will be completed because we are now paying for them directly from the NHS capital budget.

Mr Bradshaw

Mr Stevens, how will your ability to deliver the plan be affected by Brexit, if it happens?

Simon Stevens

We have been able to frame the plan in the knowledge of the referendum result and the Brexit planning that is under way. As we have discussed before, we now have revenue certainty for five years. We have, therefore, been able to be pragmatic in the way we have thought about the improvements we will see. As you know, there is a lot of work under way on operational contingency planning, depending on the precise scenarios that face us. There is a set of issues around workforce that we are preparing for very carefully, and then there are broad consequences around research collaborations and so on. Frankly, the situation has not changed relative to our previous discussions as far as the Brexit aspects of delivering the long-term plan are concerned.

Mr Bradshaw

When you came before us before Christmas, before the Prime Minister called the vote on her deal, you were very clear that the contingency plans that you had ready to go would have to be activated by Christmas or early January if there wasn’t a deal. As we all know, there wasn’t a deal and there still isn’t. Have those plans been activated, and could you tell us what they involve?

Simon Stevens

They have. In the first instance, they involve the work that the Department of Health and Social Care is leading with the medicines and devices supply chains to size buffer stocks and ensure that the Department for Transport knows the contingency requirements of the NHS. In addition, we have been looking at the non-clinical supply requirements for the health sector and making sure they are factored into the transport logistics that would be needed in a no-deal scenario. As both Matt and I have said, provided everybody does what they are supposed to do, particularly the transport infrastructure—we are completely reliant on the Department for Transport infrastructure—we expect the availability of those supplies to continue.

Mr Bradshaw

The supermarkets have made it quite plain today that, in the event of a crash-out no deal there will be a serious shortage of vital foodstuffs, and prices will go up. Why should we expect any difference when it comes to vital medicines and medical equipment?

Simon Stevens

I believe that planning for food supply is being led by DEFRA. The Department of Health is working closely with other parts of Government, but as far as the NHS is concerned, obviously we have a different set of supply chains, with the pharmaceutical industry, devices and other medical supplies. We are having very detailed company-specific and product-specific conversations about uninterrupted flows.

Mr Bradshaw

The pharmaceutical industry has been quite clear with us in the past that, in the event of a crash-out no-deal Brexit, there would be problems. They and you rely on the same transport routes in and out of the country as the people who provide our food, so I do not understand why it is all so rosy when it comes to medicines and medical equipment compared with food.

Matt Hancock

Medicines will be prioritised in the event of a no-deal Brexit.

Mr Bradshaw

Medicines will be prioritised over vital food.

Matt Hancock

Medicines of course will be prioritised. We have been through detailed line-by-line analysis of the 12,000 medicines licensed in the UK. We had our latest meeting on it this morning—the three of us were there—in order to ensure that there is a plan for continuity of supply for all medicines in the event of a no-deal Brexit. The pharmaceutical industry has risen to the challenge and done its duty thus far. A lot more work still needs to be done in the remaining time, but we have the time necessary to do what we need to do.

Mr Bradshaw

By your answer, you seem to imply that it will not be possible in a crash-out Brexit to guarantee both medicines and food, and that, with your colleagues in DEFRA, you have prioritised medicines over food.

Matt Hancock

Of course medicines should get priority over food, but, as Simon says, the amount of work going into no-deal planning for medicines is very significant. For food, the lead is DEFRA. The explanation in terms of food is that the proportion of food that is imported is much smaller than for medicines. For imported medicines, about half have some touch point with the EU, in terms of the number of medicines, not necessarily by volume. Just over half have some touch point with the EU and, therefore, we need a plan to mitigate the challenges in the event of significant disruptions at the border. That is the work we are undertaking.

Mr Bradshaw

Your former ministerial colleague Ben Gummer said today that it is impossible to have all the necessary legislation in place, whether or not there is a deal for us to leave at the end of March, to deal with all of the contingencies. Is he right?

Matt Hancock

No.

Mr Bradshaw

So, in spite of the quagmire in both Houses of Parliament, when it comes to the statutory instruments, you are confident that you will get all the legislation through both Houses of Parliament by the end of March to deal with the contingencies of a crash-out no-deal Brexit.

Matt Hancock

We have a clear plan to ensure that all the legislation that the Department of Health and Social Care needs will get through.

Mr Bradshaw

You might have a plan, but it is not happening in reality.

Matt Hancock

Yes, it is. We have taken a number of SIs through in the past couple of weeks.

Mr Bradshaw

You are on schedule to get them all through in time, are you?

Matt Hancock

Yes.

Mr Bradshaw

In that case, why did you say to Andrew Marr yesterday that you may have to consider curfews, martial law and emergency legislation to deal with some of these contingencies?

Matt Hancock

I did not.

Mr Bradshaw

When he asked you what you meant by emergency legislation to deal with these contingencies if you did not get legislation through, you said, “I wouldn’t put the stress on that, but you’re looking at all options.” That does not sound to me as if you are exactly ruling out martial law and curfews.

Matt Hancock

There is no such thing as martial law in the UK; there is the Civil Contingencies Act. In the Department for Health we look at that Act. It is an option all the time for all sorts of considerations. We are always planning for things that we do not want to happen; that is part of the nature of a health department. As I said yesterday, it is on the statute book but it is not what we are planning to use.

Mr Bradshaw

It does not really matter what you call it; it is what it would mean in effect. What would those emergency measures be under the civil contingencies legislation? What sort of things were you talking about?

Matt Hancock

We are not planning to use that legislation, but it is on the statute book. That was what I said yesterday and it is what I repeat today. I can see what you are trying to encourage me to say, but we have planning for a no-deal Brexit.

Mr Bradshaw

I am just seeking clarity on behalf of a very worried public in this country about what on earth you are going to do in the event of these things happening. You may not like to think they are very likely, but at the Committee we have spoken repeatedly to experts from the medicines industry, who are responsible for supplying medicines and medical equipment to the public, who think it is perfectly possible they will happen.

Matt Hancock

I am giving you the absolute assurance that, if everybody does what they need to do, the continuity of supply of medicines will be in place no matter what the Brexit scenario.

Mr Bradshaw

Mr Stevens, would it make your life easier if Parliament ruled out no deal tomorrow?

Simon Stevens

That is a discussion we have had before. I repeat what I said in response to the same question last time. The NHS is here to provide care for patients when they need it and we would not seek to trespass on Parliament’s territory, which is to answer that question.

Chair

We come to Andrew and an examination of the shift from hospitals to primary and community care.

Andrew Selous

I want to start by asking what lessons have been learned from the 2016 general practice forward view in terms of the GP workforce, because that plan committed to 5,000 extra GPs by 2020. On current numbers, it does not look as if we will get there, so what have we learned? I have the 2016 review before me. It was very positive and upbeat, but we have not achieved it in this absolutely critical area, so what are we going to do differently?

Matt Hancock

Maybe I should give an overview and then I am sure that both Simon and Ian and maybe Ian Cumming will want to add something. There is a clear need for greater provision of primary care, and that is at the core of the long-term plan. It is a core part of the prevention agenda, and it is very important. The provision of primary care is changing to make sure that it is delivered by a broader range of practitioners, not just GPs but others who can provide the services and healthcare people need in primary care, whether that is a physio or a nurse in certain circumstances, and the GP where that is necessary, and a stronger link to community services. To deliver that, we clearly need more people and use of technology, and to make sure that the provision is fair across the country. Within that, we have been successful in the target for hiring more health professionals other than GPs. We have been successful in getting the number of GPs in training up to record levels; in fact, we overshot the target for GPs in training. The problem has been that the number of GPs either retiring or going part time has been higher than was expected at the time of the five year forward view, and we have a whole load of work to try to change that.

Andrew Selous

GPs leaving in their mid-50s because they are hit by some of the implications of the current pension scheme is something that the Department has been exercised about for a while. In the survey information you get back from GPs who are retiring early, is that a significant issue and, if so, have you made any headway with the Treasury?

Matt Hancock

As you know, and as reported in the magazine Pulse, I have been in conversation with the Chancellor about that particular issue. It is not the only issue, but it is one.

Andrew Selous

On international recruitment, what sort of numbers are you looking at? The 10 year forward view still commits to 5,000 extra GPs, but it just says as soon as possible, rather than by 2020.

Matt Hancock

Yes.

Andrew Selous

As you say, 3,400 medical students are going into general practice this year, following 3,100 last year, so that is excellent. But the net figure, as I understand it, in terms of full-time GPs, was minus nearly 1,800 between 2015 and 2018. What sort of scale of international recruitment are we looking at for GPs specifically, to get up to the 5,000 figure?

Matt Hancock

We have a stated target only for the overall figure, because how we achieve that depends on the level of success in retention of GPs. Ian has been leading the charge on international recruitment.

Ian Dalton

Simon, one for you I think.

Simon Stevens

Sure. We have been working on recruitment from the EU, obviously, but have been ramping up in recent months the offer in Australia as well, working with Ian Cumming and NHS Employers. All this needs to be seen in the context of some very big changes that are about to be introduced across general practice. I do not want to prejudge the announcements that we hope to make shortly, but we have been in discussion with the BMA around a new GP contract to give life to the primary care network, to have practices working together as described in detail in the long-term plan. That will provide much more opportunity for mutual support between practices so that practices that individually are struggling will get extra staff and support from other practices in their area, linked to community nurses, serving a 30,000 to 50,000 population. That is backed by their share of the extra £4.5 billion for primary medical and community health services. We are hopeful that that package will send a clear signal to precisely the people you are talking about—the very hard-working GP partner in their late 50s or 60s who thinks, “Shall I stick around for another five years or shall I head off?” There are issues around pensions, but if people can see that the cavalry is arriving, that will supplement the good news you described—the extra GP training that is coming into the system as well.

Andrew Selous

On the training point, there seems to be a little bit of confusion about the Health Education England training budget, whether it will be subsumed into a departmental budget and quite what that would mean in terms of placements for doctors and other health professionals developing training practices and so on.

Matt Hancock

Could you explain what the confusion is a bit more? It is news to us.

Andrew Selous

I have a brief from the Royal College of GPs. They are concerned about what is going to happen to the education and training budget—a point I raised in Prime Minister’s questions a couple of weeks ago. They do not feel that they have clarity on how it is going to be increased, and what place it will have as part of the long-term plan, particularly to support GPs through the mix of other clinicians around them, and in making their own working lives more significant. That is a key part to go alongside the new contract; it is separate from the new contract, as I understand it. I understand from the Royal College of GPs that that is the issue they are most exercised about.

Matt Hancock

The training budget and the Health Education England budget will, of course, be set in the spending review. It is not going to be subsumed into the Department at all; in fact, quite the contrary. As Secretary of State, the HEE reports directly to me formally and by statute, but I am very clear that I want Ian and his team to report to the NHS and deliver on the business needs of the NHS. The plan will then come to me to make sure that it is entirely tied into the delivery of the long-term plan for the NHS. Of course, the quantum will be set in the spending review, but the structure and how we deliver it is very clear.

Professor Cumming

Specifically in terms of numbers, we had a record number of GP trainees recruited last year, and it is our intention to go for a similar record number and beat the target again this year. We have factored that forward in our budgetary expenditure over years to come. Yes, we will look as part of the spending review to attract additional income to be able to fund that, but we are certainly not reducing it.

Andrew Selous

I am raising a slightly different point. The issue that current GPs are concerned about is the training budget for practice nurses, physios and all the rest of the team in primary care. They do not think that is there. They say it is critical to help them do their job, and the fact that it is not there is quite a big part of why so many are leaving, and why the net figures are down.

Professor Cumming

This is investment in lifelong learning and continuing professional development. Over the last few years, that budget has reduced in real terms. We have, however, increased it by 50% from last year to this year, and we are seeking to put more resource into it next year. Just last week, we agreed to put £22 million into funding community education hubs, which allow education and training to be delivered for groups of GP practices around particular localities. It is much harder delivering education in the community than it is in a hospital, for example, where you have everybody working in the same place. Bringing GP practices and community providers together in a hub for ongoing education, training and development, which we have committed to fund, allows the community workforce to have access to the same level of education and training as their hospital counterparts.

Andrew Selous

It was put to me by someone pretty senior in the health world last week that some GPs quite simply get bored with their work. We are talking about the brightest 1% educationally of the population; anyone who is in medical school is in that category. Hospitals can seem more exciting and, sometimes, the pure repetition of the work can sometimes be a reason why they leave.

Matt Hancock

I don’t know what your Chair thinks about this question.

Andrew Selous

Indeed. I rest my case, looking at the career choices of two of our distinguished colleagues either side of me. But it is a serious point. We are not a dictatorship; we cannot force people to do any job in the NHS. People have to enjoy doing their work.

Simon Stevens

That absolutely could be said of being a dermatologist, an ENT surgeon or a gastroenterologist. What we need is flexibility over the course of professional careers. Medicine is constantly changing—that is certainly true for general practice—but the specialty of generalism is increasingly important in an era of multimorbidity. The flexibility of primary care, in that practices can develop and expand their services, is in some ways far greater than an individual consultant would have in a hospital setting. The fact is that people are increasingly choosing to combine their clinical sessions with other work as GPs, whether it is leading the redesign of services, or the big change programme that we are going to unleash for out-patients, which will change the interface between specialists and general practice, supporting teaching and research in primary care as well. That concludes my advertorial for general practice in the national health service.

Matt Hancock

We are going to see an unparalleled level of excitement in primary care over the next 10 years, heralded by the long-term plan. If you are a GP, no longer is the partnership model the only way forward. Primary care networks will allow GPs to be leaders of their profession in their locality and, with a whole range of other care providers working in their team, I can see it being far more dynamic.

Simon Stevens

Which is why young doctors are voting—

Matt Hancock

With their feet—

Simon Stevens

And in increasing numbers, to sign up for general practice education.

Andrew Selous

Can I get a question in edgeways on the back of your enthusiasm, which is wonderful to behold? I hear what you say; it is a very good story, and I am encouraged by it, but by when will we have a net increase in the GP workforce? The current figure is, unfortunately, heading down. You say as soon as possible, but—

Matt Hancock

That is just what I was going to say, yes.

Andrew Selous

But would either of you like to mention a date as to when we will have a net increase?

Simon Stevens

We are seeing a couple of things happening. First, we see the upturn in the number of new doctors coming into general practice and, of course, we have an increase in the overall number of doctors coming through. To that extent, with the expanding number of medical school places, we are able to sustain the enthusiasm for general practice and deal with some of the factors that mean there is early retirement. Within the next several years, we hope to see that corner turn, but I do not want to make spurious predictions, because that is not the kind of fact-based evidence you expect.

Chair

I do not agree with the stereotype of general practice either, but you would expect me to say that.

Johnny Mercer

All of that sounds fantastic, but in Plymouth we still have a GP shortage, of 30 GPs. What are you going to do to try to attract GPs into areas where, for one reason for another, they may not want to go? There may be factors specific to a community that make it very difficult to recruit GPs. We have just been on a massive recruiting surge and we got two, which does not scratch the surface of the problem. You have just clearly advertised how important GPs are to access to health and the NHS as it stands. What are you doing to encourage them to come to specific areas and cities like mine?

Professor Cumming

There is a direct correlation between where people train and where they end up working, so the first thing we need to do is to attract more trainees into areas where we need to recruit more staff. That is why with the allocation of new medical school places we specifically went to parts of the country where we were under-doctored, because we know that there is a correlation between medical school and postgraduate training and consultant or GP contracts. There are other things we can do. One of the more successful schemes that we have piloted was to offer people an additional year of training after they become a qualified GP to gain extra clinical expertise in an area that may interest them, such as psychiatry, care of the elderly or whatever it may be. We have co-funded that in return for people taking a job in a part of the country where it is particularly hard to recruit. They may come to your constituency, where they would work as a GP, but, for a day a week, we would fund them to go into the local hospital or work with some of the specialists in the area to gain extra knowledge and expertise, which they would continue to be able to practise for the rest of their career. Those are just two examples of things that are having a real impact on some of the hard-to-recruit areas.

Johnny Mercer

Is there anything else? That is good, and the number of places is great. We have 40 new places at Plymouth University, and in eight years’ time we will see the benefit. What are we doing to alleviate the challenge that directly impacts getting more GPs into Plymouth at the moment?

Professor Cumming

Prior to last year, we had 3,250 GP training places in the country. We have increased that, because we were able to over-recruit. We have gone out and identified an extra 220 training places. Those people will then move through to the second year, and we hope that we will be able to over-recruit again this year. By putting those training places where we have particular shortages of GPs, we start to feed the pipeline. There is no solution through the training pipeline to this happening overnight, because we need to build people and they need to go through their three-year training. The other options are around what we can do to attract people. You mentioned the expansion at your local medical school; colleagues in some of the new medical schools have been saying that, simply by expanding the medical school and creating teaching jobs, they have been able to attract doctors to the area who want to be involved in teaching as well as in delivering services.

Johnny Mercer

With all that money going into projects like that, in the short term, why don’t you just pay them a bit more? Why not incentivise them through their pay packets to go to some of the really difficult areas to try to get a handle on what some people would perceive as almost a crisis level of GPs?

Professor Cumming

In some training posts—bearing in mind that we are responsible for the training side—we have incentivised GP trainees to go to areas where they have never had a trainee before. That has been very successful, and we will continue to do it.

Johnny Mercer

Simon, are you thinking of rolling that out further across GP practices?

Simon Stevens

We are. By definition, this is to some extent a zero-sum game within a given supply, but we want to improve the fairness of the distribution of GPs across the country. As Ian has just said, we have been offering £20,000 bursaries for trainees to work in practices that have historically had difficulty in filling places, which has been very successful in the parts of the country where it has been tried. We are looking to expand that, yes.

Johnny Mercer

Okay.

Simon Stevens

I take that as a bid for Plymouth.

Johnny Mercer

Thank you. Excellent.

Chair

You also wanted to ask about mental health.

Johnny Mercer

I do. On the issues around mental health that have been brought up by the plan, it sounds fantastic—lots of money, a long-term plan with a strategic direction of change. But those going through the system, such as constituents I had coming in this weekend, say, “This all sounds great, but my son has schizophrenia and is still on the waiting list.” The CAMHS list is still at 12 to 16 weeks, and 32 weeks in some areas. How will NHS users see a fundamental change in their experiences of going through the system? Up here, we are very good at saying that we will put billions of pounds into this and do X, Y and Z. But what is your plan actually going to mean for Mr and Mrs Smith, who struggle to get their son mental health treatment in some of our poorest communities in this country?

Simon Stevens

It is going to mean another 345,000 children and young people getting the services they need over the next five years. That ties right back to the question we began with, which is the phasing of workforce expansions, with extra trainees, including the psychologists and counsellors who are needed to do that expansion. We are doing work with schools to see whether more schools-based support reduces the feed-through into the need for specialist CAMHS services. That will not be the case for conditions such as schizophrenia, where, obviously, there is the early intervention for psychosis service, which we have begun implementing. Meeting the waiting times that we have initially set for that across the country will be very important. There is a big programme for the expansion of children and young people’s mental health services, but there are some things we do not know. We do not know, frankly, what the right balance should be between schools-based support versus specialist CAMHS services, which is why we are testing the new models in between a fifth and a quarter of the country to answer that question.

Matt Hancock

There is another change that we are bringing in that has come to me through my own constituency cases. When children become adults, with the current gap between CAMHS and adult mental health services, children who have access to CAMHS lose access to mental health services because they reach their 18th birthday. That is clearly wrong, so changing the pathway for those already in CAMHS to continue to get access up to 25 is a very important part of the change in mental health provision.

Johnny Mercer

You are testing mental health support in schools. What is that actually going to look like? Are you looking to do it in a quarter of the country at the moment?

Simon Stevens

Yes, between a fifth and a quarter. The mental health prevalence survey published in November is the most recent authoritative look at how much mental illness, stress and other mental health problems there are among children and young people, and what the service availability looks like in the round. What it said, roughly speaking, was that about a third of young people with mental health distress were getting support from schools, counsellors or other non-NHS services, about a third were getting support from specialist NHS services and about a third were not getting any support at all. We obviously want to make sure that the third of people who are not getting support, but would like it, get it. We are testing what proportion of that third should be getting it through counselling or schools-based support versus specialist mental health support.

Johnny Mercer

In gathering that evidence, have you looked at other countries that face similar challenges? Have you looked at some of the work they have done in Trieste in Italy, or in any other places where they are looking at how to cross-pollinate support from schools into communities and so on?

Simon Stevens

We have, and it was instrumental in shaping the Green Paper proposals. As you know, there is something called the international mental health benchmarking service, which looks at different service structures. There is obviously a lot of research literature that has been developed in young people’s mental health services as well, and we have been working closely with the Royal College of Psychiatrists, the Royal College of Paediatrics and Child Health and various children’s organisations, as well as the Children’s Commissioner, on what the package of support should be.

Johnny Mercer

How would you judge, if you were sitting here in five years’ time, what success looked like? With mental health, more people become aware of it, and so on, and it is about getting a handle on the problem. We hear about the massive growth in mental health problems, and we try to get a balance of whether that is about more awareness or more people actually presenting. We were sitting here a year ago, and you mentioned that we were going from meeting one in four to one in three mental health needs. What would progress in five years look like?

Simon Stevens

To underline the point, that one in three is one in three getting NHS support. It does not mean that the other two thirds of people are getting no support at all; it means that half of the two thirds—the one third, as it were, who are not getting looked after by the NHS—are getting some other support. The straightforward answer to the question is that, over the coming five or, certainly, 10 years, everybody who needs specialist NHS support should be getting it, but exactly what the balance looks like between NHS support and other support will arise from the pilots. In the meantime, we want to use the pilots to test how quickly we can introduce waiting-time standards; for routine services, we will test a four-week waiting time, but we will have a more fast-track waiting time for the most urgent cases. We have begun with eating disorders, where we are doing well with service expansion. In a nutshell, we will have appropriate services, some of which may be specialist NHS but some may not. The balance is right, and everybody who needs access will be able to get it, and there will be clear waiting-time standards for doing so. That is what success will look like over the next five and 10 years.

Johnny Mercer

We have talked before about having a dashboard where you can see how much CCGs commit to mental health and so on. Is there any way to make that information public so that individuals suffering from a mental health problem have confidence that they will be treated? For a lot of them, the difficulty is in coming forward. If the service is not there, it compounds the difficulty. Is there any way of making it public, whereby if you come forward with a mental health problem around depression in Plymouth you are likely to get treated in X number of weeks?

Simon Stevens

There is. That is exactly what we are going to do. The mental health dashboard will get more specific around children and young people’s mental health services. The new news in the long-term plan is that, as well as saying that overall mental health spending has to grow faster than the NHS budget, within mental health spending children and young people’s services have to grow even faster. We will have an audit trail and transparency on that, which we have not had before.

Johnny Mercer

I am talking literally about the measurability of that, because people have become cynical about hearing—

Simon Stevens

Yes, we do not just want to track the pound notes; we want to track the services.

Johnny Mercer

No, you do not want to track the pound notes, but you want to see a distinguishable difference, if you live in one of our most deprived communities. People see all the millions of pounds being thrown at it, but you should speak to Mrs Miggins down the road, whose son has just waited for 12 weeks for CAMHS, and wants to know whether there is a place that tells them that the wait in Plymouth is five weeks.

Simon Stevens

Yes, it will be the mental health dashboard, which will publish those data.

Matt Hancock

You cannot manage what you cannot measure. In the big picture, one reason why in the past we have seen more rapid increases in funding go to, say, A&E compared with mental health services, has been that that is where the targets were. Having transparent, clear targets that the local NHS, national leaders and indeed politicians are held accountable for is a very important part of getting this right.

Chair

We are running very behind. We have a lot to get through, but before we leave communities I want to raise the question of dentistry, which is absent from the 10-year plan. I had an email from one of my constituents who was told that no practices in Devon and Cornwall were taking on new NHS patients, including children. That is clearly a desperate situation. Can you update us on what is going to happen on dentistry? Why is it not in the 10-year plan?

Simon Stevens

Dentistry is referenced in the NHS plan in various places.

Chair

But it does not really feature significantly, does it, as the rest of the health system does?

Simon Stevens

Some people have said that 133 pages is already quite long. We do reference dentistry. The fact is that the availability of dental services has been either stable or slightly improving. When you ask people whether they have been able to get NHS dentistry, at the England level that has remained a solid result. There are parts of the country where pressures arise, so our local teams have to use their flexibility to go and commission alternatives. That is not the same as saying that you need to throw up in the air the whole of dentistry across England to solve some of the particular pressure points.

Chair

We have been talking about access to primary care in Plymouth. If there are entire areas of the country where people are being told that there are no dental practices taking on NHS patients, what is going to be done through the NHS long-term plan to address that?

Simon Stevens

Our local teams will certainly look at that. People can phone NHS 111 and get advice on the nearest dentist that would accept patients. If there are particular geographies that you want to raise—

Chair

The particular geography is Devon and Cornwall. That is quite a large particular geography, isn’t it?

Simon Stevens

Let us take a look at it and compare notes on the actuality.

Chair

We can correspond separately about that.

Rosie Cooper

Does the Department of Health in any of its guises have access to any of the dentists’ patient lists? I was told that you guys had cured this, so I am testing it. When dentists in my area said that they were going to go private and were not taking on more patients, and that the patients had to go private or find another dentist, the Department of Health in any of its guises could not write to those patients because they did not know who they were, unless the dentist gave you the list.

Matt Hancock

I would not expect the Department to have individual data about where everybody’s dentist is.

Rosie Cooper

If you wanted to access a dentist’s patient list, could you do so? If the Department of Health wanted to try to contact a dentist’s patients, for whatever reason, could you if the dentist did not give you that list?

Matt Hancock

I would not expect those data to be held within the Department, because dentists’ contracts are held by the NHS.

Simon Stevens

And I do not know the answer to your question, Rosie, so let me find out. I am sure you will have investigated thoroughly, as you always do, but let me get back to you.

Rosie Cooper

The question I leave in the air is that, if you ever needed to make any changes or do anything to contact those patients, you cannot. Ergo, you are at a serious disadvantage.

Simon Stevens

Let’s find out specifically what the situation is in respect of dental lists and patients as against general medical practice. I’ll get back to you.

Dr Williams

I have a quick specific question, following Johnny’s questions around mental health. There are some great things in the plan about perinatal mental health treatments. There is still an issue with identification of perinatal mental health problems, which the plan does not say anything about. Survey data suggest that half of women with perinatal mental health problems do not have them identified. Is there anything that can be done about that?

Simon Stevens

As you know, Paul, the initial focus of the expansion of perinatal services has been on women experiencing maternity-related psychosis or severe mental illness. To expand services, we need to layer some of them into general maternity services. Part of the question is about whether there are cross-training opportunities for midwives, as well as specialist support. In the parts of the country that have begun the more general perinatal expansion, that is what they are doing. I am racking my memory, but I think Plymouth, although Johnny is not here to hear it, is an example of a service that has done well in that. The need is acknowledged, and part of the perinatal expansion has to address it.

Matt Hancock

There are also examples where the midwifery team and the community trust have linked together well, and it is all part of a more integrated service provision. In Medway, for instance, there is that integration, meaning that the follow-up through midwifery and health visitors also has a mental health aspect in spotting postnatal depression and signposting treatment. There are examples of good practice that I am sure could be spread more broadly.

Dr Williams

I have a few questions about the system that is going to deliver the plan. How important is it to the delivery of the plan that the current STPs become ICSs—integrated care systems—by 2021?

Simon Stevens

We think it is important. As you say, that is why we have declared our hand: every part of the health service should be operating in that way, with our partners in local government and the voluntary sector, having a shared approach to improvement for a whole population, rather than each individual institution or each part of the health service just ploughing its own furrow. We know enough now about what works and how to get there, based on the fifth or so of the country that is doing it, to be clear that that is what needs to happen everywhere.

Dr Williams

Why aren’t you planning to make ICSs legal entities? Why will the CCG continue to be the legal entity, rather than an ICS?

Simon Stevens

CCGs will continue to be the legal entity while the law remains as it is. We have proposed some possibilities for Parliament and the Government’s consideration. One discussion to be had at that point is what clarity there needs to be for the new integrated providers we are proposing on their ability to work jointly on planning and funding. It is perfectly coherent to have a situation where you have a CCG per ICS. You still need a bit of grit in the oyster. For example, if you are trying to move money to support additional mental health services, rather than just continuing to reproduce the status quo, it requires you to be able to stand back from day-to-day service delivery and make those judgments. That is one of the questions we will want to test with you and colleagues as part of the legislative proposals.

Dr Williams

It is not quite the end of purchaser-provider split, but a change in the relationship.

Matt Hancock

That’s right. Commissioning remains important, because you need to get value for money and to be able to make changes based on an objective assessment of what is needed outwith the provider delivering those services. Whether that is done by a CCG, which has essentially the same geographic boundary, or through the commissioning of a whole area, including primary care, by NHS England, the question is where exactly to put the commissioning relationship. It has to be somewhere, otherwise you are just giving an area a large amount of money and saying, “Do your best.” The key is how to get the best integration you can while retaining the accountability and constructive challenge that comes from a good commissioning relationship.

Dr Williams

You talk about accountability and constructive challenge. Does that include a bit of competition, Simon?

Simon Stevens

Between whom for what?

Dr Williams

I do not know. What is the role for competition in this new NHS?

Simon Stevens

We have just completed a successful procurement for biosimilar medicines, which involved a competitive procurement process between different pharmaceutical companies. I think we will continue to want to use vehicles such as that. However, that is not the same as saying that, if in a local area you are trying to get GPs and community nurses working together, the GPs should be there in perpetuity, and every three years you should be breaking up the team as you think again about how integration works. We are proposing that the NHS, subject to best value tests, should have the flexibility to determine how to drive efficiency while getting integration, rather than having a more mechanical, reflexive process.

Dr Williams

I will try to interpret that. Will there still be a role for non-NHS bodies in delivering NHS care?

Simon Stevens

I do not think we are suggesting that we should retreat from the idea that patients should still have choice for the aspects of care where they have had choice for more than a decade, but there are ways of doing that which are not the inflexible, periodic transactional procurement processes that currently operate through the system.

Rosie Cooper

There are people who think that the move towards simplification actually makes privatisation of the health service more rather than less likely. In response to your questions to Paul, you have both been dancing around that, so I thought I would ask the question that most of the public will be thinking about. People will say that it makes it more likely that bits will be privatised, and others will say not. I am going to ask you the reverse of that question: how can you assure them, and what work have you done to ensure that that work continues really to be done by the NHS, or is the NHS just going to become a badge?

Simon Stevens

No. The answer to the question is that you as a Committee looked at this question very carefully last summer, and you made some recommendations as to how we could ensure that there was appropriate public provision and accountability. In the light of that, we went away and kicked the tyres and we have come back and said that we agree. Here is the proposal. We are suggesting that the integrated care should be from public providers. Frankly, it would be a strange situation if, having been accused of one thing, when we come forward and respond very concretely to those concerns, people do a 180 degree turn and say, “That’s exactly what we were worried about in the first place,” when it is the precise opposite of what they were previously critical of.

Rosie Cooper

Simon, I absolutely appreciate that. But having done that, can you express, and enable people to understand, that you have put something in place, whatever it is, that will assure them that this is not likely to happen? I am giving you the floor to say that this is so much more not likely to happen, instead of just giving blanket reassurances that, depending on their original belief, people either do or do not believe.

Simon Stevens

That is the key: some beliefs are not shakeable by any empirical evidence. We have put this on the table in black and white in chapter 7 of the long-term plan and, frankly, the reporting of it has confirmed that what you say is what we are proposing.

Matt Hancock

I am going to be much more concrete. There is no privatisation of the NHS on my watch, and the integrated care contracts will go to public sector bodies to deliver the NHS in public hands.

Rosie Cooper

Voila.

Matt Hancock

That is what Simon was saying. Isn’t it?

Chair

Wonderful. Of course, it was what we recommended.

Matt Hancock

It was based on your recommendations. Let me be a little bit clearer about the history of how we got here. GP practices are largely private organisations; they always have been. That was a decision by Bevan, and it is how the NHS always operated. We want the possibility for primary care to lead integration in some cases where that is most appropriate. Following your analysis, which we agreed with, we have come forward with a proposal so that GPs could potentially bid in, but through an overarching body that would be a public NHS body.

Dr Williams

Simon, earlier you used the phrase, “integration of GP and community health services.” Potentially, for you, that therefore means that GP and community health services are integrated in an NHS body.

Simon Stevens

That will certainly be an option. When you see the new GP contract, with the primary care networks, you will see that it means that we will be able to continue to support practices that want to continue in their current guise, while nevertheless strengthening their joint relationships.

Dr Williams

But there will be alternative routes.

Simon Stevens

There will be alternative routes, with public accountability, to achieve integration without going through the procurement processes that have given rise to concerns in some parts of the country.

Matt Hancock

It is not just concerns; it is money going to lawyers that should be going to the NHS frontline.

Chair

That is very helpful. We were very encouraged by the response to the recommendations in our report, and it would be helpful to set out now how we are going to take those proposals forward.

Matt Hancock

I will go first on the high level. The NHS has made recommendations on changes to the law. We are open to considering them, and potentially to making Government time available for a Bill, but they very much emanate from the NHS and we want them to go forward on the basis of further work from the NHS. We would be enthusiastic if you as a Committee were heavily involved in that work, too. As to the exact process for how that occurs, I am very much in your hands in taking that forward.

Chair

We are very keen that it is an NHS-led process. Perhaps, Simon Stevens, you could set out how you envisage that.

Simon Stevens

Yes. In responding to that invitation, we will set out more detail from the NHS point of view of the proposals in the long-term plan to ensure that there is proper engagement across the health service and publicly. We will do that in February, and would then hope to have the opportunity to engage directly with you as a Committee either this or the other side of Easter. We will put the flesh on the bones of the proposals, so that people can see the detail and have a chance to contribute to it; then the NHS will say, “Here are our recommendations for Parliament and Government.”

Chair

In putting more flesh on the bones of what is in the 10-year plan, will you definitely engage with patient groups and the voluntary sector and across the NHS and local authorities?

Simon Stevens

Indeed.

Chair

It will be at that stage that, hopefully, the Committee come back to look at it.

Simon Stevens

Absolutely, as we did when forming the plan in the first place. We had patients’ organisations representing more than 3.5 million people, with over 200 engagement events and 2,500 submissions from a whole spectrum of people, for the long-term plan, and we will absolutely continue with that.

Chair

Thank you. We look forward to seeing those proposals and engaging with you on them further. Before we move on to the next section, can I touch on the issue of local system reviews? How helpful have the CQC’s local system reviews been in encouraging the sort of integrated working that we want to move towards?

Simon Stevens

The geographies chosen for those reviews were a cross-section of places that were thought to be doing quite well and those where, frankly, the opposite was the case. The CQC helpfully laid that bare, which served as a bit of a catalyst for improvement in parts of the country where it pointed to dysfunctions that existed, and produced broader lessons more widely. In their own terms they were helpful, but, by itself, just doing inspections or reviews does not constitute the change we need to see.

Chair

They were to highlight best practice and chivvy along people who were falling behind. In that case, how helpful were they in improving practice in areas that were falling behind?

Simon Stevens

They were a contribution to that. There are many other ways in which we are trying to do that as well, but they certainly were a contribution.

Chair

Right. There is some concern from the CQC that its funding for local system reviews is not going to continue. Is that the case?

Simon Stevens

The CQC has not been tasked with adding a new layer of inspection on top of the inspections it was previously doing. It was specifically commissioned by the previous Secretary of State to do those in particular geographies for a particular purpose. It was funded to do that and has done that, and we are grateful to it for doing so.

Matt Hancock

I am very open to doing further such system-wide inspections in future. I think they have been very valuable.

Chair

At the moment, they have to be directly commissioned. The CQC cannot decide to initiate them itself. Sometimes it will go into an area and see that there is a system issue; it is inspecting one part of the system, but it can see that it is a whole system issue.

Matt Hancock

Yes, but it can always come to us and have that discussion.

Chair

When the CQC comes to you and indicates that something is a more system-wide issue, will you still commission it to carry out the more system-wide cross-cutting work?

Matt Hancock

I am reluctant to answer a counterfactual, because we have not actually been asked, but I am very open to that, should the CQC do it, because I see the value that it has brought.

Chair

Can we turn to prevention and health inequalities, Paul, because Luciana is not back yet?

Dr Williams

Secretary of State, we know that there are £85 million-worth of public health cuts next financial year, and then there is the investment in the NHS. You have the health budget to play out, you are increasing the proportion of it that goes to NHS England, and there is a reduction in the proportion that goes to local authorities for public health. What is the strategy behind that?

Matt Hancock

The public health budget was set in the 2015 spending review, so the changes from this year to next year are simply that playing out. I have not made any changes to that. The thrust behind prevention is much broader than public health, although, of course, it includes public health; public health is important. What matters in public health are the outcomes, and many local authorities will argue that they have been able to put the public health money to better use because they were able to integrate it with their other services. The NHS budget is going up by £6 billion next year and I want to put the entire £148 billion of the NHS, as much as possible, as a shoulder to the wheel preventing ill health, of which public health is one part.

Dr Williams

Some clinical services are delivered through the public health budget. If somebody had a gynaecological problem caused by a non-infectious cause, that might come under gynaecology, which is keeping its funding, whereas, if it happened to be an infectious cause, it comes under sexual health, which is having a reduction in funding. What is the logic behind reducing the funding for one type of service and maintaining funding levels for another?

Matt Hancock

As I say, the funding level on the public health side was set in the 2015 spending review.

Dr Williams

Was that a mistake?

Matt Hancock

It was the right decision at the time. Now the right decision is to increase the focus on prevention right across the NHS budget. There are also potentially some structural changes around the boundary between public health and NHS-provided services.

Dr Williams

The plan talks about the NHS potentially taking responsibility for sexual health services and health visiting, taking over some of the clinical public health services.

Matt Hancock

I cannot remember exactly which paragraph that is in. Simon is looking at paragraph 2.25, or something like that.

Dr Williams

It is in the section on health inequalities.

Matt Hancock

Yes, that’s right. The plan puts forward the fact that we are going to look at the commissioning of those services. It is right that the broad public health budget is held by local authorities, because of the links to other local authority functions, not least social care, both for children and adults, and housing, which is very important. Sexual health services are at the boundary of that, as are health visitors and district nursing, which are actually much closer to the NHS. In fact, most sexual health service money that goes through the Department to local authorities gets procured back into NHS services, so it seems sensible to look at the commissioning of those services.

Dr Williams

Is it the same logic for drug and alcohol services?

Matt Hancock

Drug and alcohol services, we think, are more closely aligned with core local authority activity, so the benefits of their commissioning directly through local authorities are clearer. They are much more rarely commissioned straight back into the NHS.

Dr Williams

Watch this space for, potentially, the NHS having responsibility for health visiting, district nursing and sexual health services.

Matt Hancock

Don’t take that as necessarily the presumption. In many parts of the country, there is now joint commissioning of those services, and often that is the best way forward. Hence, instead of merely saying that we would move that back inside the NHS boundary, we are looking at the detail of how it is best commissioned.

Dr Williams

That is very sensible. Simon Stevens, what level of funding will be needed in the spending review for public health functions to ensure the success of the plan?

Simon Stevens

That is the discussion we will be having with the Government as part of the spending review process. What we have done in the long-term plan is underline the importance of the contribution that local authorities make to prevention more generally and show how the NHS will step up and do what only the NHS can do. In one or two places, there has been a bit of misunderstanding about that. The reason why we are focusing on alcohol care teams for people in touch with the NHS is not that we think it should be the totality of what drug and alcohol services look like; it is just that it is a specific touch point for the NHS. The reason we are saying that we are going to fund, as recommended by the Royal College of Physicians, the roll-out of smoking cessation services for in-patients and for mums during pregnancy and their partners is that those are touch points that the NHS has. That is without prejudice to the fact that we need wider smoking cessation, drug and alcohol services, and so forth.

Dr Williams

If public health cuts continue, will you be able to deliver the plan?

Simon Stevens

We point out specifically that, “funding and availability of these services over the next five years which will be decided in the next Spending Review directly affects demand for NHS services.” I am quoting from paragraph 2.4.

Dr Williams

I am just trying to turn that around to see whether you will be able to deliver the plan if public health cuts continue.

Simon Stevens

There are clearly implications and read-acrosses, and that is the dialogue we are having.

Dr Williams

We know that health inequalities, which narrowed in this country until about 2011 or 2012, have widened again. How much does the success of the plan depend on some of the wider Government actions to tackle poverty and inequality?

Simon Stevens

On one hand, we reference academic research suggesting that the broader determinants are part of what is putting £4.8 billion-worth of extra hospitalisation demand on the NHS. On the other hand, we have been particularly guided by the work of the “Global Burden of Disease” study, published in The Lancet, which Public Health England and others have done. That looked specifically at the drivers of changes in healthy life expectancy and pointed out that differences, particularly among older people, in cardiovascular disease and other major risk factors explain a disproportionate number of the changes in projected healthy life expectancy. That is not a phenomenon confined to the UK. It has also been the case in a number of other European countries, including some with vibrant economies even post-2008. It is fair to say that the root explanations for the change in healthy life expectancy are still being discussed by epidemiologists, but, based on what we know, we have put our chips on the board to ensure that NHS resources are allocated to high inequalities areas, and we are getting more precise about how that is done; and we are ensuring that the extra funding going in is used for evidence-based best buys that will help to reduce health inequalities in those areas and between groups.

Dr Williams

Are those evidence-based best buys going to be recommended centrally?

Simon Stevens

Yes.

Dr Williams

Are you recreating the health inequalities national support team that the last Labour Government had, which was disbanded in 2010?

Simon Stevens

I have not received a specific proposal to do that, no.

Matt Hancock

This has to be, and will be, the core business of the NHS. It is not just about having a support team; the focus on tackling inequalities is from the chief executive down.

Andrew Selous

What should we do about food manufacturers who put sugar in baby milk and baby food?

Matt Hancock

We should make sure that the prevention agenda includes not just the NHS or the public health budgets but the whole activity of the Department and the Government. There is clear action needed right across the board, as set out in both the first and second chapters of the obesity strategy.

Andrew Selous

Would the prevention agenda include things like trying to make fresh fruit and vegetables more affordable, as the chief medical officer was suggesting before Christmas?

Matt Hancock

I would love to make good food more affordable. How to do that is quite a challenge, to say the least, when most of it comes from a global market. I am a big supporter of the sugar tax that was introduced, albeit for sugary drinks. I am successfully concluding a commitment to the deputy leader of the Labour party not to drink any fizzy or sugary drinks during January, which is quite easy because I don’t at any point in the year. Clearly, there are fiscal measures that can be taken. Also, as I have discussed quite a lot, there are ways to have more targeted approaches, both within the NHS and more broadly.

Andrew Selous

There is no reason why we could not extend the sugary drinks industry levy to other projects—perhaps baby food with sugar in, or other types of confectionery, and so on—if there was good evidence, perhaps making some of the more nutritious and healthy food more affordable.

Matt Hancock

Tax is a matter for the Chancellor.

Andrew Selous

Okay. What about active travel and planning policy in terms of the reams of unhealthy takeaways near schools? We are building a lot of houses. Shouldn’t every new housing estate have a cycleway and a decent footpath to the local school? How much clout do you have as a Cabinet Minister to get those sorts of policies adopted around the Cabinet table?

Matt Hancock

Again, that is a matter for a different Department. The point about the obesity strategy is that it is a cross-Government document, so there are parts of it that I am directly responsible for, and I have discussions, in that case, with James Brokenshire and others. There are decisions for local councils. It has to be an effort across the board.

Andrew Selous

Okay.

Simon Stevens

As you know, we have been running a programme called the NHS healthy new towns programme, whereby health experts work with planning authorities and developers on designing in the kinds of initiatives that you describe, on the obesogenic environment and easy access for older people to local services. We are in discussion with the Ministry of Housing, Communities and Local Government about the extent to which that scheme could be extended more broadly for kitemarking developments as they occur right across the country.

Matt Hancock

It not just about action for Government. Action for business has a role, and for individuals. The fact that sugary sweets are so regularly given to children, not by their parents but just offered up as rewards, is extremely frustrating.

Chair

Are you going to act as a champion for health in all areas?

Matt Hancock

Yes, I am. But I hope to jump in in a way that brings people with us. You can enjoy life and be healthy at the same time; you do not have to stop doing all things that are fun—all things in moderation.

Chair

Right.

Dr Whitford

Simon, in the five year forward view, it was very much put forward that public health, prevention and social care were critical to the NHS moving forward, so how important is action on social care to the NHS long-term plan?

Simon Stevens

It is important not just for the join-up of services for older people but for the changes we need to see in support for people with learning disabilities. It is important for the special educational needs and autism services, together with education departments, and for the work we need to do more generally with local authorities. We tend to think of the social care debate as about adult social care, and within adult social care we tend to think of it principally around frail older people and the support they need. Vitally important as that is, of course, the social care agenda goes much wider. That connection is well understood. There will obviously be a process that will be kicked off with the Government’s social care Green Paper around more fundamental reform. In the meantime, over the next several years, we will continue to need proper public funding of the system as it currently exists. That is the basis on which we have set out the long-term plan.

Dr Whitford

There has been a reduction in social care funding over many years, against an ageing population. I recognise that social care is right across the age range, but the aspect putting pressure on the NHS, particularly the acute side, is the frail elderly. What will you be looking for when the Green Paper finally comes out? What would make you say, “Brilliant”?

Simon Stevens

I would distinguish between the Green Paper proposals, which, even with the best will in the world, are not going to have an impact next year, the year after and the year after that, and the work that needs to be done with the Government to size the social care funding questions that, ultimately, will have to be settled in the spending review. The Prime Minister has given the important commitment that social care will be available such that there are no additional pressures on the NHS. Now we need to work to put the practical flesh on the bones of what that commitment means.

Dr Whitford

With an ageing population, that means expanding social care, rather than it not being diminished. Is that view allowed for in the long-term plan? You will actually have expanding elderly social care.

Simon Stevens

As I say, we are planning on the basis of the important commitment that the Prime Minister made, and we will now work with the Department and Government on how to turn that commitment into the consequences that flow from it.

Matt Hancock

The commitment is that there will be no further pressure on the NHS from social care. It is actually not true to say that the amount of spending power on social care has fallen. Many councils have taken the opportunity to use the social care levy to increase their ability to fund social care locally, and we have put in more money from the centre. Nevertheless, having said all that, there are clearly pressures, which I fully acknowledge, and we are committed to ensuring that those pressures are not higher. In fact, through integrated services and integrating the social care element better, both for ensuring that people can leave hospital when they do not need to be there, and pre-emptively making sure that we get care into care homes so that people do not have to go to hospital and secondary services in the first place, we hope to be able to reduce the pressure, through organisational reform, although of course an appropriate level of funding has to go in as well.

Dr Whitford

When we look back over the last nine years, the funding through local government to social care has gone down, and that has created enormous pressure, which has all landed on the NHS.

Matt Hancock

The funding has increased in the last couple of years, although I do not have the figures.

Dr Whitford

But not to reverse to where it was in 2009, or equivalent.

Matt Hancock

There have been savings over a longer period, of course. At the same time, there are pressures on social care because of an ageing population. My point was simply that, in the last couple of years, and certainly since I have been Secretary of State, in the last six months, we have increased funding to social care in terms of spending power. But it is not just about money going in; the Green Paper will talk about both the finances and the ways we can improve delivery of services.

Dr Whitford

The Age UK estimate of people who have insufficient social care is that between 400,000 and 500,000 who require it do not have any. Is that taken into account in the equations? That is currently unmet need; it may be provided by a frail partner but there is not actually a sustainable service for those people.

Matt Hancock

The eligibility requirements and rules around social care, which were set in the Care Act 2014, are the basis on which we make all these decisions.

Dr Whitford

When do you think, Secretary of State, that the Green Paper will actually come out?

Matt Hancock

Soon. I said before April. Soon.

Dr Whitford

In all my time here, I have been hearing, “Soon.”

Luciana Berger

Perhaps you could comfort me, Secretary of State. To go back to the very important question that Dr Whitford just asked you, if there is all this additional resource going into social care, why is it that cities such as Liverpool now provide social care to 5,000 fewer people?

Matt Hancock

Well, of course demand has gone up—

Luciana Berger

No, no; 5,000 fewer people now receive social care packages in Liverpool. Why is that, if there is all this additional resource going in?

Matt Hancock

Compared with when?

Luciana Berger

Compared with 2010.

Matt Hancock

The Care Act 2014 made changes to eligibility for social care, and that is the basis on which we now provide social care.

Luciana Berger

That means that fewer people are receiving social care. Demand is going up and fewer people are receiving it, not just in Liverpool but in other places right across the country.

Matt Hancock

The provision of social care is increasing at the moment.

Luciana Berger

So more people are receiving it since when?

Matt Hancock

I do not have the figures in front of me, but the spending power on social care has gone up, certainly in the last year and I think the last two. I can write to you with the figures.

Luciana Berger

But there are obviously inflationary costs and increased wages. An increased budget does not necessarily translate into more people receiving social care. Can you give us the number of how many additional people are, as you indicated before, receiving social care support in the last either one or two years?

Matt Hancock

I can absolutely write to you with that. The provision for an increase in the social care levy, in addition to council tax, came in only after 2010, obviously.