12/05/2016

:00:09. > :00:13.Good afternoon. Thank you for coming to this final session of our inquiry

:00:14. > :00:16.into the Spending Review and the consequences for Health and Social

:00:17. > :00:28.Care. Let's start by introducing ourselves. David Williams, director

:00:29. > :00:31.general of Finance of the NHS group and DH. Simon Stevens, Chief

:00:32. > :00:40.Executive of NHS England. Jeremy Hunt, said Health Secretary. NHS

:00:41. > :00:44.improvement. The theme you're exploring is how clear we are about

:00:45. > :00:49.Health and Social Care and what they need going into the future, where

:00:50. > :00:54.the current efficiency can is and whether we have a coherent plan to

:00:55. > :00:58.fill that gap and the consequences of failure. Could I start by

:00:59. > :01:05.commenting on the 8.4 billion promise in the Spending Review,

:01:06. > :01:11.which is 7.6 billion, if we look at it in 15-16 prices, and also the

:01:12. > :01:13.fact it appears to have been redefined as spending on NHS

:01:14. > :01:21.England, rather than the usual baseline. It appears to us and to

:01:22. > :01:26.some of the witnesses in this inquiry that it is actually 4.5

:01:27. > :01:32.billion in new money. Could you perhaps comment on that to start

:01:33. > :01:36.with, Secretary of State? Of course. Can I thank you for very kindly

:01:37. > :01:41.moving the date of this hearing. Some of the potential dates would

:01:42. > :01:53.have been difficult. It was greatly appreciated. The main purpose of the

:01:54. > :01:59.Spending Review was to help NHS England get cracking on the

:02:00. > :02:04.five-year forward view, which is the only way, realistically, that we

:02:05. > :02:06.have a chance of transforming the service, based on fundamental

:02:07. > :02:13.principles of prevention being better than cure. It is a plan that

:02:14. > :02:20.Simon Stevens put together, which had widespread support. We were very

:02:21. > :02:25.much guided by him, as to how much he thought was necessary to get

:02:26. > :02:33.going on in the form of view. And Simon's particular priority to me,

:02:34. > :02:38.privately, and then threw me, to the Chancellor, was to front but

:02:39. > :02:43.settlement, so that the majority of money that was needed would come

:02:44. > :02:47.early to enable us to make the transformational change that has to

:02:48. > :02:53.happen. That was the process that happened. I think we ended up in a

:02:54. > :02:57.place where we are able to do that and I'm sure Simon will be able to

:02:58. > :03:02.speak to that. Part of that was predicated on there being 8 billion

:03:03. > :03:06.coming from the Government. Do you recognise the figure is actually 4.5

:03:07. > :03:14.billion in new money? Well, I recognise that we are talking about

:03:15. > :03:21.?8 billion that was needed for NHS England to deliver the forward view.

:03:22. > :03:26.We have had to make some difficult efficiency savings in the rest of

:03:27. > :03:35.the health budget. I recognise we did not protect the entire health

:03:36. > :03:40.budget but our determinant as to whether or not this was efficient

:03:41. > :03:45.was what NHS England felt they needed in order to put in place the

:03:46. > :03:49.forward view. And yes, they are making some very challenging

:03:50. > :03:53.efficiency savings in the non-NHS England part of the budget. But I

:03:54. > :04:00.think it is right that we do so for the simple reason that we are

:04:01. > :04:05.asking, as you will be asking us later, we are asking NHS providers

:04:06. > :04:10.inside the NHS budget to make very challenging efficiency assumptions.

:04:11. > :04:15.I think it is reasonable we should ask other parts of the health budget

:04:16. > :04:19.to make savings. Of course that then has a knock-on consequence for being

:04:20. > :04:23.able to deliver a forward view, such as cuts to public of England and

:04:24. > :04:27.health education England and the capital budget. Could you perhaps

:04:28. > :04:33.set out where you see now the efficiency gap to be? Do we still

:04:34. > :04:38.projected at 22 billion or has it changed as a result of some of these

:04:39. > :04:42.Spending Review settlements? Could you comment on the capital budget

:04:43. > :04:48.changes, the shifts from capital to revenue? Yes. First of all, I accept

:04:49. > :04:55.we had to make challenging decisions along capital budgets. What I would

:04:56. > :05:03.say about the other savings to the DH budget that's it outside the NHS

:05:04. > :05:07.mandate, is that just as NHS providers and just as the efficiency

:05:08. > :05:11.savings in the 22 billion, we are looking for savings that will not

:05:12. > :05:15.impact on patient care, there will in fact improve patient care, by

:05:16. > :05:18.rethinking service design and the way we spend every pound goes into

:05:19. > :05:23.the NHS. Exactly the same approach has been taken, in terms of

:05:24. > :05:28.efficiency savings in the non-NHS England part of the budget. We are

:05:29. > :05:33.looking for smarter efficiencies, not any that impact on patient care.

:05:34. > :05:37.With respect to the make-up of the total sum of the 22 billion, I think

:05:38. > :05:47.Simon Stevens has published figures today that he might elaborate on.

:05:48. > :05:54.That would be helpful to know, where you see the efficiency gap to be.

:05:55. > :06:00.Perhaps you could update us on your thoughts? Actually. Thank you. The

:06:01. > :06:05.so-called 30 billion gap that would open up by 2020 was based on the

:06:06. > :06:14.assumption that demand continued to grow at its historic rate, adjusting

:06:15. > :06:20.for an ageing population and other variables and if you compare that

:06:21. > :06:25.with other factors where you had no extra money and efficiency, that

:06:26. > :06:31.left us this gap by 2020. It is worth noting that most of the gap is

:06:32. > :06:35.not money that must be saved, it is rates of spending growth or demand

:06:36. > :06:43.that we want to try to put 18 in the car of, but which that increases. We

:06:44. > :06:45.refreshed the modelling in the Spending Review and the basis on

:06:46. > :06:51.which we did that is in the figures be provided to the committee and are

:06:52. > :06:57.publishing this afternoon. And that's confirms that in the zone of

:06:58. > :07:05.22 billion, more or less, was the right amount to be thinking about.

:07:06. > :07:10.How does that breakdown? About 6.7 billion will be delivered

:07:11. > :07:15.nationally. Through a range of measures that the NHS, the

:07:16. > :07:18.Department of Health, wider Government, will be able to take,

:07:19. > :07:26.and that leaves 14.9 billion to secure locally. Of that, when

:07:27. > :07:31.billions we already have in hand. So, that leaves just under 14

:07:32. > :07:42.billion. Of which 8.6 billion will come from the 2% efficiency and the

:07:43. > :07:46.rest from service change and the process is now under way through

:07:47. > :07:53.local planning processes, the sustainability and transformation

:07:54. > :07:56.plans being developed in 44 geographical footprints across the

:07:57. > :08:00.country. In a nutshell, although 22 billion is the number everyone

:08:01. > :08:05.focuses on, in fact, it is under 9 billion that is to come from

:08:06. > :08:10.conventional provider efficiencies and it is under 50 billion that is

:08:11. > :08:14.to come from the local health service, as against the National

:08:15. > :08:20.action we are taking. Can you say more about how it will be achieved

:08:21. > :08:24.and whether it is achievable? Yes. The 2% provider efficiencies

:08:25. > :08:30.represents change in what has happened over the last years, where

:08:31. > :08:33.cost has grown faster than provider income. I think the evidence you

:08:34. > :08:39.have fully health foundation suggests that productivity had

:08:40. > :08:44.decreased for reasons we know about and can discuss. We need to do 180

:08:45. > :08:50.degrees are mad. That is also central and essential to being able

:08:51. > :08:57.to put the health service on the treachery we needed to be on for the

:08:58. > :09:00.next four years. Monitor of NHS improvement has produced a detailed

:09:01. > :09:05.working as to why a efficiency requirement is stretching, but not

:09:06. > :09:12.unreasonable, to think about for providers over the next five years.

:09:13. > :09:21.That was published in February. We show that this afternoon. Above ands

:09:22. > :09:28.that, locally, in 44 different geographies, local authorities,

:09:29. > :09:32.CCGs, provider trusts, the community sector, are coming together and

:09:33. > :09:36.saying, we can see where they need to get to by 2020. What was on the

:09:37. > :09:41.big changes that frankly we're known about for a while haven't actually,

:09:42. > :09:44.we tend to kick the can down the road and now we have to confront

:09:45. > :09:49.those and make those choices. And they will let us know by summer

:09:50. > :09:55.break, end of June, early July, what they think that means for their own

:09:56. > :10:01.health care system. And when we have that, we can then have an aggregated

:10:02. > :10:06.national at what these figures are for the efficiency programme. Did

:10:07. > :10:14.the Department stay within its spending control limits, authorised

:10:15. > :10:20.by Parliament in 15-16? We're currently at the point where the

:10:21. > :10:25.final end your positions from both commissioners and providers are

:10:26. > :10:31.being created and consolidated, so it is too early for me to give a

:10:32. > :10:37.definitive outturn for health as a whole. That will come out when we

:10:38. > :10:42.publish our annual report in accounts and we plan to do that this

:10:43. > :10:46.side of the summer break, in July. There is concern that NHS

:10:47. > :10:50.improvement have said that wants me to pursue all possible and

:10:51. > :10:53.legitimate savings that can be made from reviewing balance sheet is. Is

:10:54. > :11:00.that just clever accounting that will make us break even? It is not

:11:01. > :11:06.intended to be just clever accounting. As you will know, from

:11:07. > :11:15.the 2014-15 accounts, the outturn at group level is quite tightly

:11:16. > :11:22.managed. And we are making every effort this year as well to deliver

:11:23. > :11:28.within the sums delivered by Parliament. Has been concern about

:11:29. > :11:41.the transfer of capital budgets to revenue budgets. What consequence

:11:42. > :11:47.will not have for a future finance? Well, for 15-16, topped estimates

:11:48. > :11:53.earlier this year, we have transferred around just under 1

:11:54. > :12:03.billion of capital spend into revenue. Some of that will be as a

:12:04. > :12:06.result of better estimation of the requirements of individual projects.

:12:07. > :12:14.Some is as a result of natural slippage. In capital intensive

:12:15. > :12:20.projects. And some is as a result of management action to convert

:12:21. > :12:26.spending in the spending review period, where it will need to be

:12:27. > :12:38.prioritised against other budgets for health. Clearly, there are many

:12:39. > :12:42.new models of care, which will rely on capital spending. How concerned

:12:43. > :12:46.are you that this will be achievable? Some of it is capital

:12:47. > :12:54.and some of it is revenue. On the capital point, as David says, yes,

:12:55. > :12:58.prospectively, capital has been converted into revenue to support

:12:59. > :13:02.the front loaded nature of the settlement, which we were clear we

:13:03. > :13:10.needed and that we have got. Looking out over the next five years, we

:13:11. > :13:13.will have a clearer sense of what's the reasonable capital required are,

:13:14. > :13:17.in order to deliver the kind of change programmes that the local

:13:18. > :13:22.sustainability and transformation groups come up with by the summer.

:13:23. > :13:27.One thing they are looking at is what would it take to lubricate

:13:28. > :13:31.change in my county, my geography, my part of the city? And then we

:13:32. > :13:35.will have some tough prioritisation to make. But we will be able to

:13:36. > :13:36.exemplify what the case would be for a good capital investment in some of

:13:37. > :13:48.those geographies. Will you be able to set out what

:13:49. > :13:56.needs to be done? Two things, one is the backlog,

:13:57. > :14:01.which the trusts report on anyway. The other is where there is an

:14:02. > :14:04.opportunity to invest in a new facility or a new way of delivering

:14:05. > :14:09.care, what is the kind of improvement or saving on the back of

:14:10. > :14:14.that? We have two different types of capital requirement going on in the

:14:15. > :14:19.NHS now. One is dealing with the fact that some facilities are old

:14:20. > :14:24.and will at some point need replacing, sooner rather than later.

:14:25. > :14:29.Another set of issues is that we can see in some places, if you could

:14:30. > :14:35.invest in a new way of delivering services, you could save on running

:14:36. > :14:40.costs. We want to distil both types of proposition and see what that

:14:41. > :14:45.looks like for the NHS as a whole. RE confident the capital budget will

:14:46. > :14:48.work? I cannot answer that question until

:14:49. > :14:55.we see the answers to the questions I described.

:14:56. > :14:59.On productivity, we want to increase productivity if we are going to do

:15:00. > :15:03.efficiency savings. Is there not a risk that, I did very capital,

:15:04. > :15:12.because the evidence seems to suggest you have a higher capital,

:15:13. > :15:17.would get better productivity, do we need to improve it?

:15:18. > :15:22.It is interesting. In some cases, yes, you can see people on multiple

:15:23. > :15:27.sides in old facilities with heavy running costs as a consequence. The

:15:28. > :15:34.Lincolnshire trust for example, where Lincoln County and others,

:15:35. > :15:40.they clearly need capital, as do other places. Some could run a more

:15:41. > :15:45.efficient show. On the other hand, you have places saying the reason

:15:46. > :15:48.why costs are higher is because you have a shiny new hospital and it

:15:49. > :15:54.costs more because new hospitals cost more than old hospitals in the

:15:55. > :16:02.NHS, so you have to pass through these arguments forensically.

:16:03. > :16:06.I will come back and talk about the gap, but to put that aside, talking

:16:07. > :16:13.about the total settlement, could you talk about how you are confident

:16:14. > :16:18.that a sufficient to not only maintain and improve the services as

:16:19. > :16:26.they are, but also do some of the things which are more recent

:16:27. > :16:32.ambitions, including helping with mental health?

:16:33. > :16:38.So we set out five criteria that we wanted to think about where the

:16:39. > :16:45.settlement would be workable for the NHS, and one was that the pacing of

:16:46. > :16:52.the new things had to correspond to the profile of the money available

:16:53. > :16:55.to fund them. For a number of these, whereas there are things that... If

:16:56. > :17:00.money were no object, we would love to do some things but we will have

:17:01. > :17:06.to face ourselves over three, four, five years. A number of the headline

:17:07. > :17:11.directives, including mental health and primary care, they are looking

:17:12. > :17:14.at 2020. And a lot of the improvement will have to occur at

:17:15. > :17:22.the back end and not the front end of that period. If you take the

:17:23. > :17:27.specific issues of mental health, what we said to the independent task

:17:28. > :17:33.force was, come up with your best buy list that is affordable and

:17:34. > :17:39.deliverable. Given all the other pressures that will be on the NHS

:17:40. > :17:47.budget. That is what they have done. The package of spending in 2020...

:17:48. > :17:55.The cast will not be something with an abstract, sort of theological

:17:56. > :18:00.debate about parity as an aspiration and ambition that is, it will also

:18:01. > :18:05.be tangibly, our women with severe mental health problems at the time

:18:06. > :18:11.of pregnancy, at the moment 40,000 people or so in that situation. Of

:18:12. > :18:16.the 40,000, only 10,000 get care so do we help the other 30,000? Of the

:18:17. > :18:20.people with severe mental illness who are not getting their health

:18:21. > :18:26.needs, are we getting that I tended to? The extra 10%, who need talking

:18:27. > :18:29.therapy, will we get those? Those building blocks are scheduled over

:18:30. > :18:35.the course of five years and we will have our feet held to the fire by

:18:36. > :18:43.the chief executive of the mental health task force, and Clare

:18:44. > :18:46.Murdoch, the chief executive of one of the mental health providers, to

:18:47. > :18:51.help drive the implementation. That will involve some shift of

:18:52. > :18:57.budget into mental health. We also heard a recent, welcome announcement

:18:58. > :19:02.of an increase of ?2.4 billion for primary. Where will the money come

:19:03. > :19:07.from? How will that be allocated? Word has it come from and go to?

:19:08. > :19:13.It comes from the overall funding increase available to the NHS over

:19:14. > :19:25.the next five years. Obviously, our total on NHS England spending will

:19:26. > :19:34.grow from 100 billion to 19 in cash terms of that period.

:19:35. > :19:38.To come back to the question of the ambition efficiency ambition, and

:19:39. > :19:43.where that will come from. Could you give some insight? You said 6.7

:19:44. > :19:49.billion will come nationally. Give me some insight.

:19:50. > :19:56.This'll be a combination of various things, some of which will defer to

:19:57. > :20:02.Jeremy, and wait until the Queen's Speech in terms of income recovery.

:20:03. > :20:06.Some of which are efficiencies in the payments the NHS makes to

:20:07. > :20:12.third-party Private providers. Some of which is controlling the rate of

:20:13. > :20:18.increase in our national pay bill. Some of which is reducing the

:20:19. > :20:22.running costs of the Department of Health and its arms, legs and

:20:23. > :20:30.bodies. For the hospitals amount, which I

:20:31. > :20:31.think was 8.6 billion, with a 2% tariff.

:20:32. > :20:36.Yes. Could you explain, given the track

:20:37. > :20:42.record in recent years, being able to achieve the efficiency of 4% and

:20:43. > :20:48.struggling to do so, what makes you confident they will be able to

:20:49. > :20:56.achieve it this time? The fact is that there are two ways

:20:57. > :21:01.of thinking about this, and one is to say, because we struggled over

:21:02. > :21:09.the past few years, and it has been a struggle, the alternative... The

:21:10. > :21:12.alternative is that precisely because there is that efficiency

:21:13. > :21:16.opportunities still available to us, now is the time to take it, and I

:21:17. > :21:23.think though our backs are against the wall, which they are, we ought

:21:24. > :21:29.to focus forensically on some of the available efficiencies. Not just the

:21:30. > :21:36.clever stuff but actually some of the things available right now. We

:21:37. > :21:43.heard from witnesses earlier in the enquiry, discussing there has been a

:21:44. > :21:50.bit in staffing costs and we will have two develop on that in 2016-17.

:21:51. > :22:00.Costs have gone up from ?2.5 billion a year in 2013-14 to ?3.7 billion in

:22:01. > :22:05.2015-16. NHS improvements... And Bob will want to come into this. NHS

:22:06. > :22:09.improvements has set trusts individual targets to wind that cost

:22:10. > :22:16.growth back. Just before Bob, I think this is the

:22:17. > :22:20.$6 million question about cost reduction. What will be different

:22:21. > :22:26.this time? It also relates to the earlier question about productivity,

:22:27. > :22:33.because the two are inextricably linked. The things which are

:22:34. > :22:40.different, first of all, we have now got the programme of efficiencies

:22:41. > :22:45.for NHS providers, and there is lots more work to do. There are some very

:22:46. > :22:52.encouraging things, for example, as of this year, for the first time, 92

:22:53. > :22:57.trusts are sharing full data about the 100 products they purchased. It

:22:58. > :23:04.is completely transparent. Who is spending what? And one provider

:23:05. > :23:09.spent ?40,000 on the day they started using that system... They

:23:10. > :23:15.would have spent ?40,000 more than one of the other hospitals, and that

:23:16. > :23:22.money was saved. That is happening in a real way. Not just in a top-

:23:23. > :23:29.down way, but a programme agreed on a local level, in terms of the kind

:23:30. > :23:34.of efficiencies they would make. In terms of the question about staff

:23:35. > :23:42.productivity, we do believe that we are starting to turn the tide on the

:23:43. > :23:47.exploding agency Bill. I think it was understandable, but with the

:23:48. > :23:52.hindsight over the period I was secretary, we can see why it

:23:53. > :23:57.exploded. The big issue was staffing, and everyone wanted to

:23:58. > :24:04.make sure the awards were safely start as quickly as possible for

:24:05. > :24:09.patient safety reasons. -- wards. The consequence was the agency Bill.

:24:10. > :24:15.The latest figures suggest that the agency Bill is beginning to level

:24:16. > :24:20.out. We saved ?290 million since October compared to the trajectory

:24:21. > :24:25.of agency spent at that time. Two thirds of trusts say they are making

:24:26. > :24:30.results as a result of that. Nursing agency costs are 10% lower than they

:24:31. > :24:35.were. We start to see improvement... That will have the most direct

:24:36. > :24:42.numerical impact on staff productivity figures. But the

:24:43. > :24:45.third... Sorry, the other thing... Briefly, I think it is important

:24:46. > :24:52.that the change we have to see now is that we need NHS trusts to take a

:24:53. > :24:58.strategic approach to cost reduction, and not a hand to mouth

:24:59. > :25:04.approach. What has happened in the past is that budgets, and decisions

:25:05. > :25:08.are taken in terms of what will save money in the next 12 months. What

:25:09. > :25:15.can we afford in the next 12 months? One of the things that Sam Stevens

:25:16. > :25:21.has agreed, is that towards the end of this year we will start a process

:25:22. > :25:28.of giving people 3- year budgets, so they start to know how much business

:25:29. > :25:35.they will get, if you like, over a much longer time period. That will

:25:36. > :25:40.start people making smart decisions which improve patient care rather

:25:41. > :25:43.than impact on patient care. That is the important word about strategic

:25:44. > :25:49.reduction, things which benefit patients. The final thing which we

:25:50. > :25:52.have not touched on, because you were talking about capital

:25:53. > :25:58.budgets... Within the capital budgets allocated in the spending

:25:59. > :26:01.review, there is a ?4 billion investment in IT, which we have been

:26:02. > :26:06.very careful to protect, going forward. This is because a lot of

:26:07. > :26:14.staff productivity issues revolve around things like how much time

:26:15. > :26:19.nurses are filling out forms when someone is admitted or discharged

:26:20. > :26:24.from hospital. My concern is that hospitals have a disincentive to

:26:25. > :26:28.invest in smart IT programmes which will save staff time, because they

:26:29. > :26:36.do not see the payback for 2-3 years. What we're trying to do is

:26:37. > :26:42.have strategic long-term approaches. Can I pick up on one point? You said

:26:43. > :26:47.that the programme was really motoring on, but is it motoring on

:26:48. > :26:52.everywhere? As you know, I think as well as me,

:26:53. > :26:57.things do not tend to happen in a uniform way across the NHS, which is

:26:58. > :27:01.a huge organisation. I think the truth is there will be places where

:27:02. > :27:07.it is progressing better, and places where it is not progressing as well.

:27:08. > :27:14.We will see that, because of the new inspection regime... Totally

:27:15. > :27:21.unacceptable variations on quality, managed across the system. What are

:27:22. > :27:27.we doing to help that? NHS improvement was set up, not simply

:27:28. > :27:31.to be a merger of monitor and the other one but two represent a

:27:32. > :27:35.changing culture of the NHS when we give more productive and proactive

:27:36. > :27:41.support organisations trying to improve things like efficiency.

:27:42. > :27:48.We are putting together a programme to help trusts that are struggling

:27:49. > :27:51.to permit the efficiency programmes. Abhi on target to meet the

:27:52. > :27:58.efficiency is projected by Lord Carter? I think the... I cannot

:27:59. > :28:05.answer that question today because we are collecting monthly data as of

:28:06. > :28:10.the start of this year. Trust by trust. It will enable us to track

:28:11. > :28:15.progress in meeting those Carter objectives, and there is a time

:28:16. > :28:19.delay on the data you collect. Inevitably there is a six week lag.

:28:20. > :28:23.That is something I hope we can provide information to the committee

:28:24. > :28:27.on, but I suppose on the big picture, which is the biggest single

:28:28. > :28:33.block of efficiency saving that we need this year, the reduction in

:28:34. > :28:37.agency spend, read the objective is to get it back down to the level of

:28:38. > :28:42.a couple of years ago, which would be reducing it from around 3.7

:28:43. > :28:46.billion challenge 2.5 billion, and we are on track to do that in terms

:28:47. > :28:54.of the current trajectories, so I think there is some grounds for

:28:55. > :29:02.moderate encouragement. Thank you. So there is encouragement that, for

:29:03. > :29:06.instance, that the Carter plan is going well, but that will only go

:29:07. > :29:15.some of the way. Just to slightly revert to my question, where there

:29:16. > :29:20.is a track record of hospitals overspending, what steps are being

:29:21. > :29:25.taken to ensure that even with the programmes in place that this does

:29:26. > :29:29.not happen again and what is going to make it's different this time

:29:30. > :29:33.round? So that we do not see this continuing situation of so much NHS

:29:34. > :29:39.funding being sucked into hospitals and not going to other parts of the

:29:40. > :29:42.system like primary carers. I would like to bring bobbin because that is

:29:43. > :29:52.something NHS improvement are very focused on. Three things. And I am

:29:53. > :29:55.sure Simon will agree with me here. A much better start point of

:29:56. > :30:01.understanding between commissioners and providers about plans for the

:30:02. > :30:09.year. And we are going through that progress and finalising that now.

:30:10. > :30:16.The very focused approach to agency control that the Secretary of State

:30:17. > :30:18.and Simon set it before. The Carter opportunity, although the

:30:19. > :30:24.opportunities presented by the Carter review and how we can put

:30:25. > :30:31.that into some form of programme to take it beyond the 30 or so trusts

:30:32. > :30:36.that work with Lord Carter in coming up with these areas of work. And a

:30:37. > :30:44.recognition that this is a programme overtime, this is a programme that

:30:45. > :30:50.addresses the financial challenge of the service over the period of

:30:51. > :30:53.five-year review. Thank you. And a final question, which is going to

:30:54. > :31:00.bring in social care, but only briefly. We have been very much

:31:01. > :31:07.talking about the NHS, my experience locally in East Kent, mid Kent is

:31:08. > :31:13.that we see increasing believes chances of care for patients in

:31:14. > :31:17.hospital who we think don't need to be in and some of them could be

:31:18. > :31:24.another settings, connecting to the situation of social care budgets

:31:25. > :31:31.being very tight. We also know that this is a national picture. So to

:31:32. > :31:38.what extent do these forecasts of how the NHS will manage within the

:31:39. > :31:47.funding settlement and close the gap take into account the situation with

:31:48. > :31:51.social care? And is the social care funding and performance transparency

:31:52. > :31:57.sufficient to make this work with the NHS is that something we need to

:31:58. > :32:03.change? Maybe Simon can comment on that. I think the first point, to

:32:04. > :32:06.recognise that it is very tough in social care and they have to make

:32:07. > :32:11.some very challenging efficiencies, and the second point is that we are

:32:12. > :32:17.not an island in the NHS, so the idea that perhaps existed in some

:32:18. > :32:22.parts of the NHS which is that we could operate independently with our

:32:23. > :32:26.budgets and what happened in the social care system was a problem for

:32:27. > :32:31.the social care system and not for us, I do not think anyone buys that

:32:32. > :32:36.anywhere. We are directly affected by what happens in the social care

:32:37. > :32:39.system and our success is their success, power failure is the

:32:40. > :32:43.failure, I think that is widely understood. We have made provision

:32:44. > :32:52.in the spending review to pressure in the social care system

:32:53. > :32:58.with the introduction of the preset for social care, up to 2%, councils

:32:59. > :33:02.are able to raise, which could potentially bring in an extra ?2

:33:03. > :33:06.billion to the system and later in the spending review we are also

:33:07. > :33:13.increasingly better care fund by 1.5 billion so there is some help there,

:33:14. > :33:17.but in order to make the system work we will need to go further and find

:33:18. > :33:21.efficiencies from the integration of the health and social care system.

:33:22. > :33:26.And we have seen, starting to see I think some really interesting things

:33:27. > :33:29.happen, particularly in greater Manchester where local authorities

:33:30. > :33:34.and the local NHS are beginning to work together in ways that have

:33:35. > :33:37.never happened before. We are going to need to do all of that and it is

:33:38. > :33:45.going to be vital that we are successful. The have anything to

:33:46. > :33:48.add? Exactly, I think that, you know, it is unfinished business in

:33:49. > :33:53.terms of what the future for social care looks like, but practically it

:33:54. > :33:57.is exactly as the Health Secretary has just said, what people in the

:33:58. > :34:00.country are now doing is getting together and sing under these

:34:01. > :34:06.circumstances what are the things that we need to do the link between

:34:07. > :34:10.health and social care? Sought to link to your example, I was together

:34:11. > :34:15.last week with the chief executive of your local trusts and with one of

:34:16. > :34:18.your elected leaders from Kent County Council, talking about how

:34:19. > :34:21.the county council and the NHS locally would come together in a

:34:22. > :34:29.more joined up late to try and square the circle. Thank you. I

:34:30. > :34:37.think Paul is coming in. Thank you, gentlemen. I will be very brief. A

:34:38. > :34:42.number of issues that I wanted to cover have been addressed. Thank you

:34:43. > :34:46.for providing some further clarity on the 22 billion savings are

:34:47. > :34:52.actually coming from, other life think there is still further

:34:53. > :34:56.evidence to be provided in terms of the figure nationally, but for now I

:34:57. > :35:03.want to look at the 8.6 billion provider efficiencies of 2%. I just

:35:04. > :35:08.want to if I may refer to one of my own local health trusts. It is

:35:09. > :35:11.failing all of its targets at the moment and by the trust own

:35:12. > :35:16.admissions it is in crisis, with tempers fraying on the wards. The

:35:17. > :35:24.wards, many of the wards are found to be half the safe staffing level,

:35:25. > :35:27.and I went on, last week, met a quarter of staff privately and

:35:28. > :35:31.indeed did is patient safety walkabout last Friday in the

:35:32. > :35:35.hospital. It is absolutely crystal clear that patient safety is being

:35:36. > :35:38.compromised, I have absolutely unequivocal about that and indeed

:35:39. > :35:43.the Health Secretary may well hear more from a later this week on that

:35:44. > :35:48.same issue. Is it fair, achievable or appropriate to therefore impose

:35:49. > :35:51.arbitrary 2% savings efficiency on the hospital trust in those

:35:52. > :35:59.circumstances? And indeed others like it. The only shall I start?

:36:00. > :36:02.Certainly any information you have about particular concern that your

:36:03. > :36:07.trust, please share with me and we will take them very seriously. I do

:36:08. > :36:13.not want to pretend that there aren't real challenges on the front

:36:14. > :36:22.line. I think, anyway, there is a sort of triple whiny of increasing

:36:23. > :36:24.demand for NHS services from an ageing population, higher

:36:25. > :36:31.expectations on what patient safety should be post-mid Staffs, and

:36:32. > :36:35.financial issues and you take them together at a financial cocktail, it

:36:36. > :36:39.is more challenging for people on the NHS front line only have ever

:36:40. > :36:43.known in their lifetimes. I think they are Hiroshi -- I think there

:36:44. > :36:48.are heroic and wonderful effort is going on across the NHS now to keep

:36:49. > :36:56.patient safety. I think the answer is that we have increased the NHS

:36:57. > :37:01.budget significantly, but given those other pressures, it is not

:37:02. > :37:05.enough to me that we can deliver safe care for patients without

:37:06. > :37:12.making efficiency savings. The only point I would make, and I appreciate

:37:13. > :37:14.that this is not always a great comfort for people who are feeling

:37:15. > :37:20.very stressed because in their day-to-day work, but if you look at

:37:21. > :37:26.the hospitals which are delivering the safest care across the world, in

:37:27. > :37:30.England and outside of England, what you find is that they are also

:37:31. > :37:37.usually the most efficient as the ones with the happiest staff. There

:37:38. > :37:43.is a mentality for completely understandable reasons, the NHS's

:37:44. > :37:48.budget has, I don't think, have been cut in its history, certainly not in

:37:49. > :37:52.any time that I can remember. It has gone up constantly saw as a system

:37:53. > :37:56.we are not used to having to make these incredibly challenging

:37:57. > :38:04.efficiency savings, at least he ran until about 2010. It is possible to

:38:05. > :38:08.reduce cost and improve the quality of care, improve the working

:38:09. > :38:13.environment for doctors and nurses, all at the same time, and there are

:38:14. > :38:15.lots and lots of examples. I think the question that would be

:38:16. > :38:20.legitimately thrown back at me for saying that comment is, yes, but

:38:21. > :38:24.that takes time and I think the challenge that people fear is do we

:38:25. > :38:29.have enough time to make these changes? And I recognise that, and

:38:30. > :38:33.that is why the role of NHS improvement, in giving trusts the

:38:34. > :38:38.support they need and what is a very challenging period, is absolutely

:38:39. > :38:42.right. That is why I specifically asked, is an arbitrary 2% savings

:38:43. > :38:47.efficiency on every trust right -- the right methodology, given that

:38:48. > :38:51.there are some trust you must take into account CDC reports, surely,

:38:52. > :38:57.challenges, pressures on those individual trusts. Mid Yorkshire's

:38:58. > :39:02.hospital trust is the third busiest AMV department in that country so,

:39:03. > :39:06.clearly, given that we are in Yorkshire and away from London, it

:39:07. > :39:10.is a significant challenge of it. Yesterday I understand there were

:39:11. > :39:16.something like, Sully, in the last month there were 937 patients who

:39:17. > :39:20.missed the fabulous at a time. I think we can all agree that this is

:39:21. > :39:29.not the sort of patient experience that we seek to deliver, any others.

:39:30. > :39:32.So is the arbitrary 2% right? I entirely recognise those challenges,

:39:33. > :39:36.but the only thing I would reassure you is that it was not an arbitrary

:39:37. > :39:41.2%. When we were having the discussions about the spending

:39:42. > :39:50.review, in the run-up to the final settlement, we did not ask ourselves

:39:51. > :39:52.how much do we need them to save, we actually, the efficiency targets

:39:53. > :39:58.previously were set at 4% and we recognise that this was too high and

:39:59. > :40:03.we had lots of discussions with representatives from the provider

:40:04. > :40:05.centre as to what they felt was a fair efficiency ask, given the

:40:06. > :40:11.pressures they were facing, and the answer came back that 2% felt their

:40:12. > :40:17.to them and indeed they welcomed it when we announced the spending

:40:18. > :40:19.review. So that was the context. But that is not to say that it is not

:40:20. > :40:23.going to be very challenging to deliver it, and I think we have to

:40:24. > :40:28.play our part in government to help them do it. I think one of the

:40:29. > :40:35.things that I have learned in my time as Health Secretary is that a

:40:36. > :40:41.model of the sort of, model of cigarettes from whatever you might

:40:42. > :40:47.call the kind of extreme advocates of the foundation trust model that

:40:48. > :40:50.is basically, create the conditions for a hospital trusts to be as

:40:51. > :40:53.independent as possible and then leave it alone. That is not

:40:54. > :40:58.sufficient in the current challenges. They do need, even the

:40:59. > :41:02.best foundation trusts one support and help from NHS improvement, from

:41:03. > :41:09.NHS England, from the Department of Health. If they are going to make

:41:10. > :41:15.those challenges. To further beef crisis from EFI can. At what cost

:41:16. > :41:21.are the 2% efficiency savings on the providers going to be met? -- to

:41:22. > :41:26.further questions from me, if I can. Does this mean that 75% of the words

:41:27. > :41:33.in my local quality will be at half the minimum safe staffing levels? --

:41:34. > :41:39.70% of the warlords in my local hospital will be at half the mound

:41:40. > :41:43.staffing levels. In do not think so and I say that with some confidence

:41:44. > :41:47.because of the new CKC inspection scheme that I introduced in the wake

:41:48. > :41:51.of mid Staffs. It is a very independent and public way of making

:41:52. > :41:57.sure that standards of safety do not go down. We have a system that I

:41:58. > :42:04.have absolutely no control over, the chief inspector of hospitals,

:42:05. > :42:08.legally has the right to form a totally independent review of safety

:42:09. > :42:12.in our hospitals. And that was not the case before. That independence

:42:13. > :42:17.means that you should have confidence that there is someone who

:42:18. > :42:22.knows what they're looking at, knows what is going on in all our trusts

:42:23. > :42:27.to try and make sure that decisions are not taken away from the

:42:28. > :42:32.patients. More broadly, in terms of the savings both nationally and

:42:33. > :42:36.perhaps more locally, how are those savings going to be monitored, and

:42:37. > :42:40.that what frequency? Because if it is annual, are we going to find out

:42:41. > :42:46.that at the end of the financial year that we are, sort of several

:42:47. > :42:48.million down on what was predicted and where would the savings come

:42:49. > :42:58.from in that environment? One of the things we decided is that

:42:59. > :43:04.where there are important efficiency savings that need to be met, we need

:43:05. > :43:13.to monitor those. It clearly does not work to have a system where you

:43:14. > :43:24.do not see those figures until substantially after. Where there are

:43:25. > :43:27.things like improvements in rosters, using agency staff, and collecting

:43:28. > :43:35.data in those areas, we would like to see we are on the right track.

:43:36. > :43:40.The first thing, I think you had Professor Jim breaks before you,

:43:41. > :43:44.talking about the efficiency programme he is driving in. The

:43:45. > :43:49.extraordinary thing is, I was talking to him recently about some

:43:50. > :43:53.of the improvements he has made two different hospitals within the same

:43:54. > :44:02.trust. He described how, frankly, even across a county, people trying

:44:03. > :44:06.to get Orthopaedics right is not consistent even within one trust.

:44:07. > :44:13.Different places are doing different things. Talking to a trust executive

:44:14. > :44:14.recently, they described how the 12th trusts that comprise the

:44:15. > :44:22.Greater Manchester arrangement are coming together to finally realise

:44:23. > :44:26.they have got to share their services and back office services.

:44:27. > :44:30.This trust and executive said they have known in their heart of hearts

:44:31. > :44:34.for years but have not got round to it, not least because, for some

:44:35. > :44:37.trusts, it would put their costs up and they have not figured out the

:44:38. > :44:47.way of sharing out the gains between them. The reality is, we are not the

:44:48. > :44:50.most, in aggregate terms, the NHS is efficient, but everywhere you look,

:44:51. > :44:57.you see improvement possibility, and that is what we have to get at. The

:44:58. > :45:01.truth is, if we do not, it would have a crowd- out on all the things

:45:02. > :45:07.we need to do in the National Health Service. Mental health and priority

:45:08. > :45:10.care... We cannot let the hospital spending be the thing that finds its

:45:11. > :45:16.own level and everything else gets squeezed. That cannot carry on.

:45:17. > :45:24.You cannot, most patient safety. I believe arbitrary spending...

:45:25. > :45:28.The 2% is not arbitrary but was based on various details and reviews

:45:29. > :45:34.NHS improvement published in February, on average 1.4% rate of

:45:35. > :45:38.efficiency and they catch up opportunity for those places that

:45:39. > :45:44.were below that. More importantly, I think it is worth saying that,

:45:45. > :45:48.although we talk about 2% tariff efficiency is at 16-17, we have

:45:49. > :45:54.increased prices for inflation for 3.1% on top of that. For the first

:45:55. > :46:02.time in a while, the tariff is going up in 16-17, not being cut. We have

:46:03. > :46:07.also put that in with this ?0.8 billion with extra support to

:46:08. > :46:11.sustainability. Bob and Jim are able to target based on the challenges

:46:12. > :46:15.facing a particular hospital. Having the conversation with the leadership

:46:16. > :46:20.of your hospital about what is a reasonable improvement for them, a

:46:21. > :46:24.reasonable goal for them both financially and with waiting times,

:46:25. > :46:29.this year they can do that on a tailor-made basis rather than as a

:46:30. > :46:38.one size fits all across the sector. Thank you. Andrea wants to come in.

:46:39. > :46:44.I will come in on the same point. I'm an advocate of patient safety. I

:46:45. > :46:48.think if you put a balanced view, regarding this particular trust,

:46:49. > :46:51.regarding the 2% of efficiency savings and also the issues they are

:46:52. > :46:56.dealing with, it is not predominantly about the savings.

:46:57. > :47:03.There are recruitment issues, as we know. There are issues with taking

:47:04. > :47:08.on too many agency staff. We also had meetings only a couple of weeks

:47:09. > :47:11.ago, and the Government was very supportive with that, so we need to

:47:12. > :47:17.make sure it is balanced. I would like to know... My sister has worked

:47:18. > :47:25.in the NHS for around 20 years and I have worked with a company that

:47:26. > :47:31.provided services to the NHS. There is a hell of a lot of problems with

:47:32. > :47:37.efficiency, as I am sure is only as good as the leadership of their

:47:38. > :47:41.trust. I personally think this 2%... Yes, how long are we going to give

:47:42. > :47:46.people without actually... Give trusts and allow them to get away

:47:47. > :47:52.with not taking control of their cost net spending? I would like to

:47:53. > :47:58.know what more can be done for those trusts who are not taking their

:47:59. > :48:00.budgets, what more can be done to penalised those trusts and Pat on

:48:01. > :48:10.the back the ones who are doing things correctly? What more can be

:48:11. > :48:20.done? So, two things, up. Firstly, being

:48:21. > :48:27.really clear about prioritisation and risk associated with

:48:28. > :48:33.organisation. And financial improvement. Also, supporting it in

:48:34. > :48:38.two ways, both targeted intervention for skills and capabilities that

:48:39. > :48:52.perhaps they do not have yet, and need to acquire, and or, arranging

:48:53. > :48:58.what I call "Bloody sessions". In these, we bring together bigger

:48:59. > :49:03.ships of organisations -- buddy sessions. We try to bring that

:49:04. > :49:12.together in a planned and supportive way to provide greater improvements

:49:13. > :49:18.across the provider overall. To start with yourself, Bob, looking

:49:19. > :49:23.at the payments system itself... Jim Mackie described it as not fit for

:49:24. > :49:29.purpose. Do you not think there is an underlying disincentive in the

:49:30. > :49:36.tariff in that a tariff awards hospital activity we are trained to

:49:37. > :49:41.get away from? Do not think that, as opposed to just tweaking it, it

:49:42. > :49:52.requires something more fundamental? The tariff function within the NHS,

:49:53. > :49:55.working with colleagues in Simon's organisations, to determine changes

:49:56. > :50:03.which need to be made to mechanisms, to enable the sort of changes we

:50:04. > :50:08.have articulated and supported. That piece of work needs to go as an

:50:09. > :50:15.enabler of change, not as a leader of change. We need to balance that

:50:16. > :50:22.with... And we have started it with some of the things that we did

:50:23. > :50:25.immediately for 16-70. Calling a halt to are changes, the

:50:26. > :50:34.consequences of which were not clear to see. -- 16-17. We want to move

:50:35. > :50:39.the mechanisms. We want to improve them and make them more fit for

:50:40. > :50:43.purpose across the range of services. The most important thing

:50:44. > :50:49.is to be clear that we understand the consequences of our changes.

:50:50. > :50:56.This is such that when they are implemented, they have the desired

:50:57. > :51:02.effect, rather than effects which... Howdy you plan to do that?

:51:03. > :51:04.We are working with our commissioning colleagues, because it

:51:05. > :51:12.is a joint responsibility to make sure we are really clear about, as

:51:13. > :51:15.we move pricing, and as we move propositions, and we, with evidence,

:51:16. > :51:21.really understand what that would mean for the organisations, and can

:51:22. > :51:27.we appropriately building a trajectory of change so that we

:51:28. > :51:31.don't destabilise it? Don't destabilise it but while we enable

:51:32. > :51:34.the necessary changes at the speed in which they need to be made to

:51:35. > :51:41.support the outcomes of the five years.

:51:42. > :51:48.I wanted to briefly help before Simon speaks. You are right. What we

:51:49. > :51:53.have to do is move to a system of payments and population health

:51:54. > :51:56.management, provided by a countable care organisations. It is

:51:57. > :52:00.interesting that Scotland has gone a different route, which is closer to

:52:01. > :52:05.that in some ways. Although, Scotland also, as I'm sure you will

:52:06. > :52:11.acknowledge, has its own problems of resources still being... It is a

:52:12. > :52:17.huge sector, even when you break down these barriers there is still a

:52:18. > :52:23.challenge. That is why we have... Is that not where the health service

:52:24. > :52:29.started, with health authorities area -based, but people recognise we

:52:30. > :52:32.have to find our way back? Whether you are saying we find our

:52:33. > :52:38.way back to it or whether we find a way forward to the kind of budgetary

:52:39. > :52:46.arrangements that we have in the Lancia or other places. There is an

:52:47. > :52:49.important need for focus on integration and basing budgetary

:52:50. > :52:57.decisions on prevention rather than cure. Valencia. A 44 sustainability

:52:58. > :53:02.and transformation areas that NHS England have announced, which are

:53:03. > :53:06.precisely designed to enable that... Just be very direct, with things

:53:07. > :53:09.like suspending the tariff in particular areas for particular

:53:10. > :53:17.arrangements, it is remote on the table. -- it is very much on the

:53:18. > :53:22.table. That is why we're asking areas to look at three-year budgets

:53:23. > :53:28.this year. The spending review was only announced in November and we

:53:29. > :53:31.need to deal with some stability for 16-17, but going forward towards the

:53:32. > :53:36.end of the parliament, we need to make sure the incentives are right

:53:37. > :53:43.for the tariff system. You see it moving more towards

:53:44. > :53:48.population-based, network -based rather than list tariff system?

:53:49. > :53:54.Absolutely. I agree with that completely but I

:53:55. > :53:59.think there are nuances here. Having had the privilege to spend time with

:54:00. > :54:03.you this afternoon, and wondering up the road to spend three hours with

:54:04. > :54:07.the Public Accounts Committee on the subject of these services. One of

:54:08. > :54:12.the points they will make is that it could not be moved to more tariff

:54:13. > :54:17.-based reimbursement or specialised services rather than negotiated

:54:18. > :54:22.prices where there is an overspend. The move towards a new carrot

:54:23. > :54:28.system, with give us 2100 price points compared with the ones we

:54:29. > :54:35.currently have. -- tariff system. There are pushes and pulls. London

:54:36. > :54:41.is different to Devon. In Devon, for the most part, they use the services

:54:42. > :54:45.are available in Devon. A population-based controlled total

:54:46. > :54:49.for Devon is relatively straightforward and indeed that is

:54:50. > :54:56.what we have facilitated during the course of the past year. That is

:54:57. > :55:03.part of the evident success regime which will be taken forward this

:55:04. > :55:06.year and beyond. However, in London, with three teaching hospitals and

:55:07. > :55:16.lots of cross boundary patients from Kent, Sussex, Surrey, it is much

:55:17. > :55:21.harder. You can't just have a sealed system for south-east London. First

:55:22. > :55:24.of all, there are new payment models based on different population

:55:25. > :55:33.geographies rather than just some national vault to a new status quo.

:55:34. > :55:40.Secondly, we know that, not just for this country but internationally, as

:55:41. > :55:44.Bob said, payment reform is either an inhibitor or an enabler but it is

:55:45. > :55:50.not the clinical change per se. Clinical change, it is whether teams

:55:51. > :55:55.of staff are working with patients in different ways creating holistic

:55:56. > :55:59.care. If you just do the financial engineering head of having figured

:56:00. > :56:03.out what the new team -based care processes need to look like, things

:56:04. > :56:11.could fall over. We saw that in Cambridgeshire recently, with the

:56:12. > :56:15.so-called United Care proposition. It had not done the design sitting

:56:16. > :56:19.underneath it, part of what the whole Vanguard process was supposed

:56:20. > :56:25.to do. It did not get the efficiency dividends it was supposed to

:56:26. > :56:29.produce. First, different in some parts of the country, second, you

:56:30. > :56:35.must think about the underlying care changes, not just the financials.

:56:36. > :56:37.Coming across a case where it was outreach service consultants going

:56:38. > :56:41.out into the community, setting up support services to avoid agents

:56:42. > :56:50.coming in, because that consultant is paid by the trust, eventually,

:56:51. > :56:53.because it resulted in lower income for their hospital, there is a

:56:54. > :56:58.negative feeling. We need to get rid of that feeling. Is it not also the

:56:59. > :57:11.case that the Paris I said in relation to average costs? --

:57:12. > :57:17.Harris. -- tarrif. No, because costs are not based on

:57:18. > :57:21.year by year. The opposite issue is that if we do not make these

:57:22. > :57:29.efficiencies, they get remade into these inflated prices that the

:57:30. > :57:38.tariff assumes is the efficiency... It is on a like basis.

:57:39. > :57:43.The final thing is asking, Andrea was asking about what is the

:57:44. > :57:47.punishment for trusts that don't perform. There are actually finds

:57:48. > :57:56.and systems therefore people who are not meeting the targets. Is that

:57:57. > :57:59.actually helpful if you are talking about the trust that is maybe

:58:00. > :58:00.already on its knees? That is not the approach we are taking this

:58:01. > :58:16.year. Instead NHS trusts will be an

:58:17. > :58:21.improvement and as long as they are on course for improvement then they

:58:22. > :58:25.won't get pinged. That is if they beat in agreement with NHS

:58:26. > :58:36.improvement. If they don't then they default to the standard system and

:58:37. > :58:41.that is their choice. I wanted but the impact on CSR and integrated

:58:42. > :58:46.care. We have already touched on the 2% preset and the Secretary of State

:58:47. > :58:52.has said that it would raise ?2 billion. For the benefit of the

:58:53. > :58:56.witnesses, the benefit of the 2% preset would be wiped out by the

:58:57. > :59:01.National minimum wage. Once this course has been met, will there be

:59:02. > :59:10.sufficient funding left for those who require social care? First of

:59:11. > :59:13.all, I think we should recognise that if we want to transform these

:59:14. > :59:19.social care system, the national living wage is very important

:59:20. > :59:25.because we need to attract staff into these very important roles, and

:59:26. > :59:32.the where, there are indeed now, as part of the NL double, people who

:59:33. > :59:36.are on the minimum wage and I think in many ways very undervalued for

:59:37. > :59:42.the work that they're doing and so this is going to be one of the big

:59:43. > :59:48.strategic choices that we make as a society over the next few decades.

:59:49. > :59:53.As to whether we value people in the very, very important caring roles

:59:54. > :00:00.that we are growing, and the ageing population. We have in terms of our

:00:01. > :00:02.funding for the social care system, we have taken account of the

:00:03. > :00:09.introduction of the national living wage so it is not something that we

:00:10. > :00:12.ignored when we're introducing the preset, and indeed the overall

:00:13. > :00:16.package of support local authorities are going to get in the social care

:00:17. > :00:22.system is a combination of local government settlements, the new

:00:23. > :00:26.preset, the better care fund both now and when it increases in the

:00:27. > :00:31.future and also efficiencies that we will make the health and social care

:00:32. > :00:36.integration. I don't pretend that it is not as with the NHS a very

:00:37. > :00:43.challenging cocktail of things that they need to get right, but I do

:00:44. > :00:46.know that local authorities are interested in talking about

:00:47. > :00:51.integration in a way that has never happened before and there is a real

:00:52. > :00:55.enthusiasm both for the NHS and local authorities to do this, and

:00:56. > :01:02.therefore what we have to do is support them as much as we can. On

:01:03. > :01:04.the living wage, I have seen first-hand the sort of care that

:01:05. > :01:09.carers give, and they are worth every penny. We should not

:01:10. > :01:13.undervalue them. But how concerned are you about the potential of

:01:14. > :01:18.social care providers withdrawing from the market, and then obviously

:01:19. > :01:25.having a big impact. What steps are you taking to monitor the situation?

:01:26. > :01:29.I think that is... It is a very concerning situation at the moment,

:01:30. > :01:35.I think that there are a number of social care providers who made

:01:36. > :01:42.public comments about the interest in remaining involved in the market.

:01:43. > :01:47.I think that there are probably three different currents that are

:01:48. > :01:52.going on here. The first is that we are expecting higher quality than we

:01:53. > :01:58.have expected before and we should not apologise for that. At the same

:01:59. > :02:03.time as we had the problems with mid Staffs we also have a number of very

:02:04. > :02:09.high profile examples of abuse in care homes, which I think shocked a

:02:10. > :02:11.lot of people, and we do need to be uncovered my thing about the fact

:02:12. > :02:16.that we are expecting a higher standard of care for people, -- for

:02:17. > :02:22.example for people who have dementia. Sometimes people have no

:02:23. > :02:28.family, no visitors and no capacity to express to anyone else if they

:02:29. > :02:32.are treated badly. And so these are perhaps the most vulnerable people

:02:33. > :02:37.you can imagine and so we do need to make sure that we have a system

:02:38. > :02:42.where we are colonising. So if there are people who are exiting the

:02:43. > :02:46.market because they do not like the much greater scrutiny over standards

:02:47. > :02:50.of care than that is the choice, but it is the right thing for us as a

:02:51. > :02:58.society. At the same time, I would also say that in many parts of the

:02:59. > :03:02.world, businesses, because many of these organisations are private

:03:03. > :03:05.businesses, I'm looking at the ageing population has one of the

:03:06. > :03:09.biggest commercial opportunities because this is an area that all of

:03:10. > :03:13.us are going to spend much of our money on as time goes on, but on our

:03:14. > :03:17.own care and that of our loved ones, so it is important not to take the

:03:18. > :03:22.short-sighted approach as to the opportunities in that market. But

:03:23. > :03:26.there are some things that are in doubt, which I recognise great

:03:27. > :03:31.uncertainty at the moment. There is the cross subsidy that happens in

:03:32. > :03:37.many care homes of public sector trade places with private sector

:03:38. > :03:43.paid places, or privately paid care home residents. There is the overall

:03:44. > :03:47.challenges that councils are facing with social care budgets, and I

:03:48. > :03:55.recognise that this is creating some uncertainty. But I would say that

:03:56. > :03:58.this is a sign that with the economy going for words, we will be spending

:03:59. > :04:01.more money both publicly and privately and this is one where

:04:02. > :04:07.people need to take a long-term view. You have mentioned earlier

:04:08. > :04:12.that the NHS is not an island and social care is not an island either,

:04:13. > :04:17.so what assessment has he made of the effects of the social care

:04:18. > :04:19.funding restraints that you have mentioned, particularly with local

:04:20. > :04:25.authorities on the operations and finances of the NHS during the

:04:26. > :04:30.review period? Because one has an impact on the other. The lack of

:04:31. > :04:36.easily there is a very direct operation, if people I left in

:04:37. > :04:41.hospital for longer than they should be when the medically fit for

:04:42. > :04:45.discharge, because of processes necessary to admit them into the

:04:46. > :04:53.social care system or to another part of the NHS. There is a link to

:04:54. > :04:56.a handy performance which is itself under a great deal of pressure, that

:04:57. > :05:01.is another reason why we need is to break down these budget any barriers

:05:02. > :05:05.between the NHS and the social care system. So I think that is one of

:05:06. > :05:12.the things that we need to recognise. I think we also need to

:05:13. > :05:16.recognise as well that the social care system and the NHS, if we are

:05:17. > :05:21.going to achieve these challenging efficiency savings that we have been

:05:22. > :05:29.talking about earlier, are both targeting the same set of

:05:30. > :05:32.individuals. The most voluble clients in the social care system

:05:33. > :05:34.are going to be in full-time residential care and they will

:05:35. > :05:43.remain in full-time residential care. People who are most at risk if

:05:44. > :05:49.councils get these decisions wrong are the people who are living

:05:50. > :05:53.independently but perhaps need a lot of support and perhaps are quite

:05:54. > :05:57.vulnerable, the sort of people who might have a full and need help and

:05:58. > :06:00.those people, if you need to make sure the social care system is

:06:01. > :06:04.therefore, because otherwise they are going to end up in A

:06:05. > :06:08.departments, possibly having a protracted length of stay in

:06:09. > :06:13.hospital. So there is absolutely an impact on the NHS which is why think

:06:14. > :06:16.we are having a much more serious discussion between the CCG 's and

:06:17. > :06:20.local authorities and we have had in the past. Have talked about

:06:21. > :06:26.integration and some of the new models of care for testing this out,

:06:27. > :06:30.and yet we have also heard that the better care fund has been used to

:06:31. > :06:36.equalise the preset in different areas. Despite putting money into

:06:37. > :06:39.the better care fund that also the sustainability and transformation

:06:40. > :06:43.funds being used to ease the provider deficit. Is there really a

:06:44. > :06:49.sufficient funding that is going into social care to fund these new

:06:50. > :06:57.models and the integration? I think the equalising of the preset, this

:06:58. > :07:00.is something I think is primarily about the increases in the better

:07:01. > :07:05.care fund, and I think one of the things that you have to recognise

:07:06. > :07:09.when you introduce a new situation like the preset is that council tax

:07:10. > :07:13.in somewhere like Surrey is going to be much bigger than the council tax

:07:14. > :07:18.base in somewhere like Blackpool. And yes the social care needs of

:07:19. > :07:23.Blackpool are likely to be as big as the social care needs in Surrey, and

:07:24. > :07:26.so it is fair I think if you are saying that you have the chance to

:07:27. > :07:31.raise more money from your own council backspace that you reflect

:07:32. > :07:37.that differential in the better care fund allocations. Is it going to be

:07:38. > :07:40.enough? I think this is a bit of a recurrent theme this afternoon. I

:07:41. > :07:43.think the answer is that it is not going to be enough if we do not make

:07:44. > :07:50.challenging efficiency savings that we all know we need to make. And,

:07:51. > :07:55.you know, before we beat her chest in despair at the prospect of these

:07:56. > :07:58.efficiency savings it is worth pointing out that at the start of

:07:59. > :08:03.the last parliament we have the Nicholson challenge which was about

:08:04. > :08:08.making around ?20 billion of savings and I believe the any or analysis of

:08:09. > :08:15.our success in that was that we broadly did manage to make the most

:08:16. > :08:20.of that 20 billion, so I think the NHS can do these things but we won't

:08:21. > :08:23.be able to do it by repeating the same tricks. We are able that night

:08:24. > :08:28.we were able to take certain measures last time and they will

:08:29. > :08:30.have to do things in at this time. Finally, only forecasting any

:08:31. > :08:36.financial savings from the integration of health and social

:08:37. > :08:38.care, including the devolution we are seeing particularly in

:08:39. > :08:43.Manchester during the CSR period? And if not this period, are you

:08:44. > :08:48.predicting it is the future? We are, we do believe there are savings, we

:08:49. > :08:54.are not putting a cash amount to it, except for the fact that across all

:08:55. > :08:59.of our plans we recognise that we can only make the numbers add up if

:09:00. > :09:03.we're just a man for services by getting care to people earlier, that

:09:04. > :09:07.is going to be something that will reduce long-term pressure on the

:09:08. > :09:10.social care system. The number of people in Premier full-time

:09:11. > :09:14.residential care but also the NHS, so things like the translation of

:09:15. > :09:18.general practice, of mental health care, part of the benefit of those

:09:19. > :09:24.programmes is that you slow people's descent into needing full-time

:09:25. > :09:31.residential care, which is why what the NHS does can have a big impact.

:09:32. > :09:36.You have recognised that there is a problem with the funding of social

:09:37. > :09:40.care and I welcome that and the preset, but as you have already

:09:41. > :09:45.mentioned the -- different authorities have more council tax

:09:46. > :09:55.bases, so in my part of the world a 2% preset will apply, even setting

:09:56. > :10:00.aside the minimum wage which I agree with all the reasons mentioned

:10:01. > :10:03.already, it goes nowhere near the funding required for social care. I

:10:04. > :10:07.am really concerned that there is a massive crisis situation, it is

:10:08. > :10:12.overlapping and going into the hospital system, and it is not just

:10:13. > :10:17.a mild inconvenience. Patients are really suffering in the because the

:10:18. > :10:21.discharge rate is so much slower than we would all want to see,

:10:22. > :10:29.costing misery for the patient and the family, and the backlog into

:10:30. > :10:33.A I spend time recently seen patients can be admitted, waiting

:10:34. > :10:37.for it an acute bed, and that acute bed is currently occupied by often

:10:38. > :10:41.an elderly person, who really wants to go home. And they have been

:10:42. > :10:47.medically discharged, but the social care package funding for them is

:10:48. > :10:52.just not there. The worst thing I saw was one lady who actually spent

:10:53. > :10:57.ten weeks extra in hospital, so I am just concerned to know what other

:10:58. > :11:02.action you anticipate taking, because this is a crisis situation

:11:03. > :11:11.that the 2% preset is just not going to touch. I want to be at a great

:11:12. > :11:17.that the 2% alone will not be enough, it will need to be combined

:11:18. > :11:24.with imaginative thinking. -- I want to be great. And it will lead to

:11:25. > :11:30.vision improvement at the local level. I fully accept that people

:11:31. > :11:39.are working very very hard to try and mitigate those problems. But I

:11:40. > :11:42.would also say that the variation in the efficiency of the way carers

:11:43. > :11:50.deliver is much higher than it should be, so if you take the issue

:11:51. > :11:57.of home visits for example, the issue of whether someone who does

:11:58. > :12:00.home visits is able to go directly from home to their first visit and

:12:01. > :12:04.onto the second in the third and fourth, always having to go to base

:12:05. > :12:09.first, to base at the end of the day, whether they are able to access

:12:10. > :12:13.a proper electronic health record of the patients or just their own

:12:14. > :12:17.organisations electronic health records so they are able to see what

:12:18. > :12:20.the GP records is, that is a very big advantage in terms of the

:12:21. > :12:27.quality of care that they are able to deliver. I think there are also

:12:28. > :12:30.the integration that we have NHS committee military service is doing

:12:31. > :12:34.what district nurses are doing as well, it is really important. I

:12:35. > :12:38.think the straight answer to your question is that it probably won't

:12:39. > :12:41.be possible to bridge the gap if we carry on with current working

:12:42. > :12:47.practices, we do need to rethink how we deliver health and social care in

:12:48. > :12:52.a more integrated way, what's GPs community care does is hand in glove

:12:53. > :12:53.with what the social care system is doing and that we have a holistic

:12:54. > :13:05.approach to information. I want to speak on social care

:13:06. > :13:08.before a public health. Has your department done an assessment of the

:13:09. > :13:15.cuts of the last parliament to social care, which were about 33%?

:13:16. > :13:20.You have said social care and health care needs to be more integrated and

:13:21. > :13:24.I agree but what I worry about is that, in the last Parliament, it was

:13:25. > :13:33.seen as a local government, even though there were 33% cuts, a huge

:13:34. > :13:37.cut. We know that many more elderly people, but also people who are not

:13:38. > :13:42.the poorest but were not able to receive the care they needed or had

:13:43. > :13:47.difficulty accessing its... Has your department done an assessment of the

:13:48. > :13:52.impact of those cuts and has your department done an impact assessment

:13:53. > :14:00.on the NHS as well? We are conscious of both areas. In

:14:01. > :14:09.terms of the impact on the NHS, we are conscious of the fact that

:14:10. > :14:12.dealing with the challenges in AMD departments is not going to have

:14:13. > :14:22.proper handling done with the social care system. -- A With what

:14:23. > :14:26.happened as a result of cuts to local government in the last

:14:27. > :14:30.Parliament, it varies between local authorities. All local authorities

:14:31. > :14:36.have to find efficiency savings, but you find authorities like Surrey,

:14:37. > :14:40.which actually increase the funding for social care and increase the

:14:41. > :14:47.number of people receiving help from the social care system. Councils

:14:48. > :14:53.like Milton Keynes and Kingston-upon-Hull, also did well in

:14:54. > :14:55.terms of the support they gave from the social care system. You will

:14:56. > :15:01.find other less encouraging results from other councils. There is a

:15:02. > :15:08.learning process that goes on throughout all of this. Both from

:15:09. > :15:15.the local authority partners, and tackling that issue.

:15:16. > :15:20.But 33%? We have heard evidence that this has a real impact on the

:15:21. > :15:25.delivery of care. I agree with you on some of the things you said

:15:26. > :15:30.previously, and we have to try and get savings, otherwise the budgets

:15:31. > :15:36.will keep expanding, but what I am saying is that the degree of cuts to

:15:37. > :15:40.social care in the last Parliament has caused problems that we are

:15:41. > :15:47.still suffering from. Those cuts were of a nature that a third of the

:15:48. > :15:50.budget, it goes beyond efficiency savings, for me. Of course there are

:15:51. > :15:55.always some efficiency savings but...

:15:56. > :16:01.I do not recognise the 33% figure but I will happily take that away

:16:02. > :16:05.and look at it. I do, although I was not in this job at the start of the

:16:06. > :16:11.last Parliament, I do remember that calculation is what made on the

:16:12. > :16:16.basis of what, a bit like what we were discussing earlier with the

:16:17. > :16:23.Harris, what was thought to be reasonable efficiency abridgements

:16:24. > :16:28.to ask for -- Harriss. The wonder visiting the system we have now and

:16:29. > :16:32.the system we had then. -- tariff. A much higher degree of transparency

:16:33. > :16:41.and quality of care that has been received. This is a all social care

:16:42. > :16:46.providers, CDC ratings. We are more conscious of where things happen

:16:47. > :16:49.much more quickly than they were before. We do believe there are

:16:50. > :16:53.parts of the country which have withstood the pressure of those cuts

:16:54. > :17:00.to the budget much better than others. We want to make sure that

:17:01. > :17:05.lessons are learned. A question on the subject of the cap

:17:06. > :17:10.on care costs, a couple of months after the election, in the

:17:11. > :17:16.Conservative Party manifesto, it was promised to come into force on April

:17:17. > :17:19.of this year. It is now delayed until the end of the parliament. Are

:17:20. > :17:24.you confident that is something that has been delayed, or has it been put

:17:25. > :17:31.off entirely? It is absolutely still a Government

:17:32. > :17:38.policy but the reason we... One of the reasons we decided to delay it

:17:39. > :17:43.was because the original policy was designed to create an environment

:17:44. > :17:47.where there would be an insurance market that would develop. So people

:17:48. > :17:55.who wanted to protect themselves against paying first over ?2000

:17:56. > :18:01.before you reach the cap, would be able to do that. We saw no signs of

:18:02. > :18:05.that insurance market developing so we had to rethink it. Our intention

:18:06. > :18:10.was not that everyone should have to pay ?72,000 for care, our intention

:18:11. > :18:14.was no one would have to pay anything because everyone would have

:18:15. > :18:18.insurance style arrangements for that early amount and then

:18:19. > :18:22.everything above the cap would be paid for by the state. We need to

:18:23. > :18:28.think about that. The broader point is that I would make is that I think

:18:29. > :18:35.the long-term funding over the next few decades of our own social care

:18:36. > :18:41.is something that we need to give thought to as a society. We decided

:18:42. > :18:47.after the war that it was incredibly important for us to be a society

:18:48. > :18:52.where the norm was for people to save pensions. We make some

:18:53. > :18:56.provision or people who are not able to save as much as they perhaps need

:18:57. > :19:01.to but we need to go through that same process of thinking of people's

:19:02. > :19:07.social care costs, given we are all living for much longer and the final

:19:08. > :19:11.few years of our lives are likely to need extensive social care. That

:19:12. > :19:17.period of delay gives us a chance to have that thinking done.

:19:18. > :19:21.Can I come back to one of the points you made earlier about the

:19:22. > :19:26.opportunities in the market for providing... For the providers of

:19:27. > :19:30.social care? Is that the main issue that it is not financially viable to

:19:31. > :19:38.do so? In many areas, in oral areas, it is not viable for them to come on

:19:39. > :19:44.the package of financial vision -- rural, to provide care in peoples

:19:45. > :19:50.homes in areas. Is that something that concerns you?

:19:51. > :19:54.It concerns me when people say that but all I was saying is I hope

:19:55. > :19:59.people will take a strategic view of the marketplace. Not one that is

:20:00. > :20:04.based purely on some of the short-term adjustments that are

:20:05. > :20:10.happening. I think there is a longer term change which I think people

:20:11. > :20:15.welcome, because it is what they would prefer, which is a change

:20:16. > :20:19.towards supporting people to live at home independently, rather than

:20:20. > :20:23.automatically moving into residential care.

:20:24. > :20:29.I agree but the financial package available for carers to go out and

:20:30. > :20:37.help is not viable. Do you recognise that? It is a frequent complaint I

:20:38. > :20:41.hear, as a constituency MP. Also, particularly for very vulnerable

:20:42. > :20:43.groups such as people with dementia who have problems with wondering,

:20:44. > :20:50.they cannot find anywhere to look after their loved ones under the

:20:51. > :20:55.financial care that is available. I recognise if we stick with

:20:56. > :21:01.existing models and don't make imaginative efficiency changes in

:21:02. > :21:05.the way care is delivered... If we don't integrate better with the

:21:06. > :21:09.NHS... In other words, if we take the view that we followed the same

:21:10. > :21:12.model of care that we followed in the past, at the same levels of

:21:13. > :21:19.efficiency, then it will be extremely challenging. That is why

:21:20. > :21:24.we have do do, on the NHS site, working on the NHS site, so much in

:21:25. > :21:29.our interests... We recognise that we want people

:21:30. > :21:34.looked after at home who can't be looked after at home because,

:21:35. > :21:37.financially, that care cannot be provided. Is that a scenario you

:21:38. > :21:42.recognise? The scenario I recognise is that it

:21:43. > :21:47.will be increasingly difficult if people providing those services and

:21:48. > :21:52.commissioning those services do so on exactly the same basis that they

:21:53. > :21:56.have always done. I think this is a measure where we have to be

:21:57. > :22:02.imaginative in terms of the NHS. What I am not doing is saying that

:22:03. > :22:06.there are not financial pressures and it is not very challenging, but

:22:07. > :22:13.I am saying the response to that needs to be looking for imaginative

:22:14. > :22:17.improvements in the way services are delivered and closely working with

:22:18. > :22:23.the NHS. Some big evolution deals and part of the country should make

:22:24. > :22:27.it more possible. There are lots of things. I think the evidence is

:22:28. > :22:32.there are part of the country that are managing, even despite the

:22:33. > :22:37.budgetary pressures, to sustain and improve social care services. We

:22:38. > :22:42.have to learn what we can from them. Can I ask, do you have the current

:22:43. > :22:47.cost for the delayed discharges to the NHS?

:22:48. > :22:54.I do not have a current cost. I have a figure in my mind that it is

:22:55. > :22:59.around 5000 beds on any given day but it is... I am aware of that

:23:00. > :23:04.pressure on hospitals. So it has not been costed. Bob, do

:23:05. > :23:14.you have a cost? I do not. I will say... We will give

:23:15. > :23:18.a response to the committee. One final thing, we often talk about

:23:19. > :23:21.the savings that could be achieved with integration but some witnesses

:23:22. > :23:27.to this committee say it does not save money but allows you to

:23:28. > :23:33.identify unmet needs without the liver and savings. I wonder where

:23:34. > :23:36.that leaves the assumptions of the five year for review. They have a

:23:37. > :23:42.figure on what we can actually deliver the smack -- do you have a

:23:43. > :23:50.figure on what we can actually deliver?

:23:51. > :23:53.About the nature of the so-called things... It is not that we take the

:23:54. > :23:57.number of emergency admissions happening today and cut them a

:23:58. > :24:02.certain number, although some places successfully do that, it is more

:24:03. > :24:07.that we need to see the rate of increase slow compared to what it

:24:08. > :24:18.otherwise would have been to reduce the gap in 2020. The early Vanguards

:24:19. > :24:27.are quite promising in that regard. Emergency admissions growth and the

:24:28. > :24:31.spread of emergency beds days per people living in an area, you see an

:24:32. > :24:37.enormous discretion. Opportunity is greater in some parts of the country

:24:38. > :24:41.than others. The North West and Greater Manchester have some of the

:24:42. > :24:45.highest in patient bed days per resident population for emergencies,

:24:46. > :24:55.even just for the age and deprivation of the population. I

:24:56. > :24:59.think, colleagues, you have seen they are pretty enthusiastically

:25:00. > :25:02.thinking that a combination of bringing together social care will

:25:03. > :25:10.help them manage future pressures. Thank you.

:25:11. > :25:16.I would like to add questions about public health. Mr Stevens, when you

:25:17. > :25:24.came before the committee in July of last year, you said, I quote, that

:25:25. > :25:30.for the cuts -- brother cuts to spending of public health would not

:25:31. > :25:35.be a smart approach. -- further cuts.

:25:36. > :25:38.Overall it is not helpful which is why the public health programme that

:25:39. > :25:44.NHS England overseas was protected through the spending review, which

:25:45. > :25:47.was achieved for immunisation, screening programmes and so on.

:25:48. > :25:50.There are obviously pressures are showing up in the local authority

:25:51. > :25:57.part of the public health programme. There are things that Government

:25:58. > :26:02.nationally can do... To overcome some of those. Changing revelatory

:26:03. > :26:06.frameworks on things like sheltered obesity.

:26:07. > :26:19.There are some things challenging but there are some steps that can be

:26:20. > :26:22.taken without a price tag being attached.

:26:23. > :26:26.Your statement at the beginning of this session, that prevention is

:26:27. > :26:31.better than curing, and you mentioned the emphasis on that in

:26:32. > :26:36.the five-year forward view. We had written evidence and oral evidence

:26:37. > :26:43.from a number of organisations who are worried about the false economy

:26:44. > :26:49.that might be at risk of producing, with the 200 million in year

:26:50. > :26:55.estimate of public health in the last financial year, and those cuts

:26:56. > :27:01.also announced. Could you give us some more detail on where we are on

:27:02. > :27:06.that. For example, the local government Association? And I quote,

:27:07. > :27:13.fear that these cuts would lead to increased rashes on the NHS and

:27:14. > :27:20.actually that this will move us away from prevention. Can you give us

:27:21. > :27:24.your assessment? -- increased pressures.

:27:25. > :27:27.I agree with the theory, that making a cut in public health provision

:27:28. > :27:36.leads to people using hospital services more often. Public health

:27:37. > :27:39.expenditure is something important to actually having an NHS, something

:27:40. > :27:44.where we have been able to lead the world. If you look over the progress

:27:45. > :27:48.we have made in public health over the last five years, where we have

:27:49. > :27:55.had pressure on public finances, we have continued to make progress in

:27:56. > :28:03.reducing teenage smoking levels to the lowest ever. And teenage

:28:04. > :28:04.pregnancy is down and drug use is down. We have made some important

:28:05. > :28:14.progress. We took the decision during the last

:28:15. > :28:18.parliament that we would devolve significant elements of public

:28:19. > :28:22.health spending to local authorities, and we did so for a

:28:23. > :28:25.number of reasons. One of them is that local authorities are very

:28:26. > :28:29.good, sometimes better than the NHS in procuring services efficiently,

:28:30. > :28:34.they have more experience in doing that and also there were some

:28:35. > :28:39.synergies between the work that they do in public health with other works

:28:40. > :28:46.such as the working schools. -- work in schools. We were asking to talk

:28:47. > :28:53.about the project which costs an average of 3.9% around the spending

:28:54. > :28:57.review period. What we are looking for local authorities to do is to

:28:58. > :29:00.make sure that these are efficiency savings, not the kind of false

:29:01. > :29:07.economies that you're talking about. What we have in place is a very

:29:08. > :29:14.robust system of being able to transparently monitor the public

:29:15. > :29:16.health services delivered local authority by local authority, and

:29:17. > :29:23.the baseline figures for that suggests that there is in fact a big

:29:24. > :29:29.variation in cities like Sheffield and Leeds which are of similar

:29:30. > :29:34.demographics, you see a significant difference in key public health

:29:35. > :29:43.measures, so there is a lot we can learn. BELL RINGS Sorry. Do you

:29:44. > :29:46.recognise that imposing in here cuts was difficult, by local authority in

:29:47. > :29:51.Wolverhampton explained that they have already put out to tender many

:29:52. > :29:59.of these services. It is not easy at all to affect cuts to public health

:30:00. > :30:04.budget in that way. I do recognise that this is challenging, but I

:30:05. > :30:07.would also say that the kind of efficiency, we have just spent some

:30:08. > :30:10.time in the early part of the session talking about the challenges

:30:11. > :30:15.of efficiencies that the rest of the NHS are going to have to make so I

:30:16. > :30:18.do think it is reasonable that the public authorities should also make

:30:19. > :30:22.efficiency savings. But I want them to be Smart savings, not

:30:23. > :30:28.short-sighted ones. And you're confident that the .9% per annum

:30:29. > :30:35.will only be efficiency savings rather than false economies that you

:30:36. > :30:42.recognise? -- 3.9%. What we tend to get in the situations is variation

:30:43. > :30:47.in performance, but we have been very encouraged by the commitment to

:30:48. > :30:51.public health shown by local authorities, there is a huge amount

:30:52. > :30:54.of enthusiasm about the fact that the American public health budgets

:30:55. > :30:59.and we need to make sure that where it is going wrong that we bring this

:31:00. > :31:05.up through health and well-being board as quickly as possible. In the

:31:06. > :31:08.five years, not only was there an emphasis on prevention but there was

:31:09. > :31:14.this phrase that there would be a radical upgrading prevention and

:31:15. > :31:17.public health. How can local authorities deliver that if they are

:31:18. > :31:23.working on efficiency sees -- working on efficiency savings, with

:31:24. > :31:29.the 3.9%, how does this go hand-in-hand with the radical

:31:30. > :31:32.upgrade? These are the pressures you're getting at but the fact is

:31:33. > :31:38.there are a lot of things that local authorities can do using the power

:31:39. > :31:45.as the local democratic agency and we think about some of the actions

:31:46. > :31:48.being taken on obesity, on the licensing and regulatory powers of

:31:49. > :31:56.local authorities, or the ability to have an impact on school health.

:31:57. > :32:00.This is not just the conventional NHS approach to providing services,

:32:01. > :32:07.per se. And I think that if you think of it more broadly, the

:32:08. > :32:09.conversation we are having an social care, there are really quite

:32:10. > :32:13.extraordinary things that we are now going to be seen the benefit of from

:32:14. > :32:17.the health of prisons that have happened over the course of the last

:32:18. > :32:21.decade. Within the last fortnight we have seen research from Cambridge

:32:22. > :32:30.that has shown that as a result of improved cardiovascular health we

:32:31. > :32:36.have now got 210,000 people per year with a dementia diagnosis compared

:32:37. > :32:39.to 250,000, and we had not had those public and health improvements. That

:32:40. > :32:43.is 40,000 people per year who are not now as a result of dementia and

:32:44. > :32:46.meeting services from social care and the NHS and the root cause of

:32:47. > :32:55.that has been improved eating, smoking less, benefiting from drugs

:32:56. > :32:59.such as that in this. So the spill-over benefits are much wider

:33:00. > :33:03.than just the kind of conventional public health services that we tend

:33:04. > :33:10.to think about. I recognise that not one more question on public health.

:33:11. > :33:13.The ADF S actually reported in recent months that 40% of local

:33:14. > :33:18.authorities according to the research where dropping tobacco

:33:19. > :33:22.cessation services, how does that fit in with the decision -- with

:33:23. > :33:26.efficiency savings question mark this is like an attack on public

:33:27. > :33:31.health. It could be but I think you have what Peter Smith said when you

:33:32. > :33:35.wrote in Salford and interesting things, I was reading the transcript

:33:36. > :33:37.over the weekend, the active smoking cessation services is one of those

:33:38. > :33:40.where they thought that they could do a better job on efficiently than

:33:41. > :33:44.the inherent -- in the inheritance they would be taking an from the way

:33:45. > :33:47.they had been organised, but there were also some other very big

:33:48. > :33:51.changes which is happening in smoking cessation as we know, which

:33:52. > :33:57.is what will be impact of E cigarettes? And Public Health

:33:58. > :34:00.England have said that they think this is a native I percent risk

:34:01. > :34:04.reduction so I think it is clear that smoking cessation is not

:34:05. > :34:12.mission accomplished, we need to get the smoking rate down from 18.5% to

:34:13. > :34:14.13% in order to deliver on the cancer prevention programme that the

:34:15. > :34:18.cancer task force has set, but the way that we did it may be a little

:34:19. > :34:22.different than some of the clinic -based approaches that we have used,

:34:23. > :34:25.but that again, without being classy about it I think people will look at

:34:26. > :34:30.our fresh as they potentially will other aspects of locally

:34:31. > :34:34.commissioned public health programmes including health checks.

:34:35. > :34:38.That was my last question. What comes to your previous point,

:34:39. > :34:43.really, which is that deprivation is clearly one of the main areas of

:34:44. > :34:52.public health inequalities. To what extent is the Department in

:34:53. > :34:54.discussion with the Department for Communities and Local Government?

:34:55. > :34:58.Because certainly my own area will -- won any of Wolverhampton and

:34:59. > :35:02.other areas where the high levels of deprivation, we now that there have

:35:03. > :35:06.been consistent moves by this government to reduce spending and to

:35:07. > :35:10.reduce the grant given to those areas that did not have higher

:35:11. > :35:13.spending per head precisely because they have more needs and more

:35:14. > :35:18.deprivation. If this continues, what is the assessment for the Department

:35:19. > :35:24.on the impact of public health inequalities? First of all can I

:35:25. > :35:27.agree with you on the link between deprivation and risk to public

:35:28. > :35:31.health? I think that is very well documented and completely fair to

:35:32. > :35:36.say. Where I perhaps take issue with your analysis is the approach that

:35:37. > :35:41.the Department is taking to the allocations for public health, so

:35:42. > :35:48.the problem that we had is that when we separated out the public health

:35:49. > :35:53.spending from the PCT 's has existed before, we found huge variations in

:35:54. > :36:00.what had been spent on public health PCT by PCT, that there's absolutely

:36:01. > :36:06.no listen deprivation levels. They were basically quite random, it was

:36:07. > :36:10.one local NHS -- it was what the local NHS has chosen to devote

:36:11. > :36:13.resources to in the particular area. It has been quite a difficult

:36:14. > :36:16.process of trying to adjust levels of spending in different areas so

:36:17. > :36:21.they reflect local need rather than just historic levels and spend by

:36:22. > :36:24.the NHS. So that is I think probably... My question was not

:36:25. > :36:31.really about that, I should have made that clear. I welcome the move

:36:32. > :36:35.that public health teams are now in local authorities and we have spoken

:36:36. > :36:37.evidence from public health teams in different local authorities that

:36:38. > :36:40.they much prefer being in the local authority setting for a lot of

:36:41. > :36:44.different reasons. My question is about the broader spending by local

:36:45. > :36:49.government, not so much the public health part of local authorities,

:36:50. > :36:54.but overall spending by local authorities in deprived areas, which

:36:55. > :37:00.is being hit, which is higher than deprived areas and I know that often

:37:01. > :37:03.the spending per head, obviously it is higher in places like Liverpool

:37:04. > :37:08.and Birmingham and Wolverhampton precisely because there are higher

:37:09. > :37:13.levels of deprivation, but the government in the last six years is

:37:14. > :37:18.moving to the creases in spending their head in these more deprived

:37:19. > :37:22.areas, and I'm just wondering what the conversations are between the

:37:23. > :37:26.impact of the spending decisions in DC LTE and your department are,

:37:27. > :37:30.because obviously there is an impact on public health and health

:37:31. > :37:33.inequalities. Perhaps it would be helpful if I asked the community

:37:34. > :37:37.secretary Greg Clark to write to you on that very specific point, because

:37:38. > :37:43.I know that he would challenge that has been the basis on which

:37:44. > :37:45.allocations are made. What I would say, in the parallel discussions

:37:46. > :37:52.that we have had with the Department of Health, over the issue of

:37:53. > :37:56.deprivation, the way that we have tried to solve that is by making it

:37:57. > :38:01.an independent process at arms length from the list so it is

:38:02. > :38:06.decided by the NHS board and ministers don't have a say in that

:38:07. > :38:12.decision. It is one where we have had to balance the weighting given

:38:13. > :38:18.to deprivation with the weighting given to a number of other areas

:38:19. > :38:24.like deprivation, which also is determined by healthy dietary will

:38:25. > :38:28.understand. It is one where frankly transparency about the level of

:38:29. > :38:35.funding given to different areas has revealed that there is a variation,

:38:36. > :38:41.and people are on or off target relatively new to the areas and it

:38:42. > :38:48.is difficult to really move people closer to target allocations in an

:38:49. > :38:51.environment where overall spending is protected in real terms. It has

:38:52. > :38:57.gone up significantly in real terms and we have been able to move people

:38:58. > :39:03.much closer to the target is a need for demographic weighted amounts.

:39:04. > :39:12.Thank you. Turning to the issue of NHS workforce planning, and current

:39:13. > :39:15.challenges, can you explain how the CSR funding will help the NHS might

:39:16. > :39:26.available resources to the specific workforce requirement? Yes. It is

:39:27. > :39:31.quite a big topic but the sort of condensed version of it is first of

:39:32. > :39:39.all I think to acknowledge this has been a problem over decades, the

:39:40. > :39:42.matching of workforce planning to add and need. Essentially because of

:39:43. > :39:50.the time delay in training up doctors and nurses means that

:39:51. > :39:54.training, having more undergraduate medical students today might

:39:55. > :40:01.actually affect the NHS in practical senses for 5-7 years, so getting the

:40:02. > :40:11.process right at something that we urgently need to do. We have tried

:40:12. > :40:15.to strike a better balance in this latest spending review, the number

:40:16. > :40:21.of doctors in training go up already -- over this period by 11,420, the

:40:22. > :40:25.number of nurses in training will go up by at 14,000 and the potential

:40:26. > :40:29.reforms to bursaries which I know are hotly debated in parliament, but

:40:30. > :40:34.they could lead to a further increasing the number of nurses so I

:40:35. > :40:37.think it is something that we are constantly looking at the analysis

:40:38. > :40:43.around to see if we have got it right, to CF we can do it better.

:40:44. > :40:48.But I think perhaps the best example of how we got it wrong, and I think

:40:49. > :40:54.in fairness though one could have seen this coming, was that following

:40:55. > :40:58.mid-Staffs we had a huge demand for nursing staff and the result was

:40:59. > :41:01.this mushrooming of the agency Bill and that of course is incredibly

:41:02. > :41:06.wasteful in terms of the NHS budget and that is what we need to try and

:41:07. > :41:11.avoid. To return to a couple of points, we acknowledge that the

:41:12. > :41:17.actual use of agency service staff as well as having a detrimental

:41:18. > :41:22.effect on the morale of the core staff, I have heard this first-hand

:41:23. > :41:26.by the hospital wards and in A that the staff resent that less

:41:27. > :41:31.qualified, less experienced staff are actually paid at quite a higher

:41:32. > :41:36.level than some very experienced senior, particularly in terms of

:41:37. > :41:41.basic staff. I absolutely agree with that and I think it is completely

:41:42. > :41:46.poisonous at a ward level if you have a doctor who is being paid

:41:47. > :41:53.three -- seen ?1000 for one shift in the nursery is being paid ?2200 for

:41:54. > :42:00.one shift, and it is very unfair if two nurses in the same trust do the

:42:01. > :42:03.same work but one of them is choosing to have a full-time

:42:04. > :42:06.contract for three days per week and then work through an agency being

:42:07. > :42:11.sent to the same hospital for another two days per week and

:42:12. > :42:15.twisting the salary and another nurse is on a five-day contract and

:42:16. > :42:22.I think that the strongest critic of this has actually been the chief

:42:23. > :42:25.inspector of hospitals, because his point about agency staff is that you

:42:26. > :42:30.don't get the continuity of care. It is not that they are not often very

:42:31. > :42:35.hard-working individuals but you know once you have 18, you know each

:42:36. > :42:41.other, and not the patient, then you can be much more confident in

:42:42. > :42:49.continuity of care. So that is why from April I think, NHS improvement

:42:50. > :42:56.issued guidelines that asks all trusts not to move towards a system

:42:57. > :43:00.where no one can actually be paid more working as an agency staff or

:43:01. > :43:04.as a locum doctor and they would be paid where they working at a

:43:05. > :43:10.standard NHS full-time contract rates.

:43:11. > :43:18.The controls have been put into control out paid agencies also what

:43:19. > :43:22.agencies pay to their staff. That will take time to work through the

:43:23. > :43:27.system, and will not be overnight, because we have to think about

:43:28. > :43:30.patient safety and it is a big change.

:43:31. > :43:33.I accept what you are saying about long-term planning solutions as

:43:34. > :43:39.well, that you do not fix things overnight but need to train more

:43:40. > :43:42.nurses, more doctors, for things going for it. It could be five to

:43:43. > :43:50.ten years before we have the benefit. Would you accept that the

:43:51. > :43:53.move for nurses will have a detrimental effect for recruitment

:43:54. > :44:00.of people who would have been interested in a career in nursing

:44:01. > :44:04.and are now rethinking that? Some health professionals have given

:44:05. > :44:09.evidence that at Salford, a nurse was worried about the effect that

:44:10. > :44:13.would have. We had a debate about this in

:44:14. > :44:17.Parliament last week. The Government 's strong view, which I accept you

:44:18. > :44:20.will not subscribe to, is these changes will lead to an increase in

:44:21. > :44:26.the number of nurses going into training. They are fairer for nurses

:44:27. > :44:34.going into training and they will allow greater financial support to

:44:35. > :44:37.nurses who go into training, RBS on a loan basis. I recognise point was

:44:38. > :44:45.made several times during the debate. -- however on a loan basis.

:44:46. > :44:50.Nurse trainees are not identical to other undergraduates, particularly

:44:51. > :44:55.in that you get more mature students going into nursing than in regular

:44:56. > :45:01.undergraduate degrees. We need to monitor that closely but overall the

:45:02. > :45:05.lesson of the reforms made to tuition fees at the start of the

:45:06. > :45:10.last parliament is that this can be a beneficial way of increasing the

:45:11. > :45:13.number of places, and increasing the number of people from poorer

:45:14. > :45:20.backgrounds. One other point I would make is that, coupled with these

:45:21. > :45:22.changes, we are making some very profound and important changes that

:45:23. > :45:30.open up the nursing market to health care professionals, without them

:45:31. > :45:35.needing to go through a process of a full-time degree at a university in

:45:36. > :45:39.order to become a nurse. We are creating a lot of opportunities for

:45:40. > :45:43.people experienced in health care to move into nursing on an accelerated

:45:44. > :45:49.basis. One more point. I'm unfortunately

:45:50. > :45:57.missed the debate last week, but I fail to see the logic that... That

:45:58. > :46:05.with drawing the bursary will make nursing a more attractive career

:46:06. > :46:08.option. It will actually decreased numbers, won't it?

:46:09. > :46:14.There is an issue about equity. Whether we should be paying the

:46:15. > :46:19.nurse bursaries to people who may actually end up getting a lower

:46:20. > :46:23.salary than nurses themselves get. If we are going to have a public

:46:24. > :46:28.subsidy, I think the most beneficial thing is that this subsidy goes into

:46:29. > :46:34.increasing the number of training places we have. We are confident

:46:35. > :46:37.that, given the experience from the last Parliament, it will not be

:46:38. > :46:42.detrimental. At the moment, our system is that I believe it is two

:46:43. > :46:47.in three of the people who apply for a nursing degree can't actually get

:46:48. > :46:54.onto it, because we do not have enough nursing training places

:46:55. > :46:57.available. We wish to do with that, given the current financial

:46:58. > :47:03.circumstances, this was the only way to deal with it.

:47:04. > :47:07.Following on from that, you have exercised caution in shifting away

:47:08. > :47:11.from a Harris system because of the danger of destabilising the system.

:47:12. > :47:19.Making a sudden change away from nurse bursaries. -- tariff. Is there

:47:20. > :47:25.a case for a parallel system such as in Bolton at the trust where you

:47:26. > :47:32.have bursaries creating a longside in places available through the

:47:33. > :47:38.conventional route? There is clear evidence that the workforce is a

:47:39. > :47:45.mature student workforce. Is there any concern on your part that there

:47:46. > :47:48.may be a destabilising effect? I understand the logic of your point

:47:49. > :47:53.but given the judgment and the difficult judgment we must make,

:47:54. > :47:59.there is an urgent need to increase the number of nurse training places.

:48:00. > :48:05.One of the reasons for the agency staff bill that we talked about

:48:06. > :48:08.extensively earlier in the session is we have not got a big enough

:48:09. > :48:13.number of nurses coming onto the market.

:48:14. > :48:15.Did you not have a double system where you increase the number of

:48:16. > :48:19.courses available with the student loan? That was hugely

:48:20. > :48:27.oversubscribed, the course in Bolton. To have a dual system we

:48:28. > :48:33.retain some bursaries for some with a degree for example?

:48:34. > :48:38.Our policy response to that is to try and find other ways to make sure

:48:39. > :48:45.we are creating ways for mature people to go into nursing. Some of

:48:46. > :48:50.the things we have talked about but also to make sure the financial

:48:51. > :48:55.package is sufficiently attractive to mature students who do not have

:48:56. > :49:01.that negatively affect... We have to make a judgment and, for me, the

:49:02. > :49:07.urgent need is to make sure that we have the right amount of supply of

:49:08. > :49:11.new nurses going into the market. There is this time lag before nurses

:49:12. > :49:18.actually come out qualified and ready to train others.

:49:19. > :49:24.Could you set out what the cost would be to the NHS of a standard

:49:25. > :49:27.system where somebody takes a loan out and pays tuition fees, and the

:49:28. > :49:33.cost of somebody training through the bursary route? If there is not a

:49:34. > :49:36.huge extra cost if people are paying tuition fees and taking out a loan,

:49:37. > :49:40.what would be the problem with introducing that in parallel, to

:49:41. > :49:44.increase the number of training places for people who cannot afford

:49:45. > :49:49.the funding during the current bursary system?

:49:50. > :49:53.Let me get the details you asked for. What I would make in terms of

:49:54. > :50:03.money is that the agency staff bill has gone up for the NHS from 2.5

:50:04. > :50:08.billion to 3.7 billion, we think, over the last three years. There is

:50:09. > :50:13.a huge cost to the NHS of not training the number of nurses we

:50:14. > :50:16.need. Or policy priority is to make sure...

:50:17. > :50:22.Indeed, it is just whether or not you could achieve that by other

:50:23. > :50:26.ends, as well. By introducing this alongside. My point is, was

:50:27. > :50:35.withdrawing bursaries a cost saving measure? I understand it will save a

:50:36. > :50:38.considerable amount for the budget but not within this Parliament.

:50:39. > :50:42.Of course it saves money but, combined with the other measures we

:50:43. > :50:47.take in terms of the support we are putting in place to the loan system,

:50:48. > :50:53.and the new ways into nursing we are announcing. We are confident we will

:50:54. > :50:57.be able to do what we have achieved in other parts of the higher

:50:58. > :51:01.education sector, which is a package which increases the of people from

:51:02. > :51:07.disadvantaged backgrounds into nursing, and we want to increase the

:51:08. > :51:14.number who go into nursing full stop.

:51:15. > :51:18.Just look at the seven-day services, which was a big manifesto

:51:19. > :51:26.commitment, both in hospitals and with GPs. I'm sure you have seen

:51:27. > :51:30.both the on Friday of the paper and the comments of Professor Rothwell

:51:31. > :51:36.this morning, that suggest we now have a almost two to one ratio of

:51:37. > :51:40.papers that do not show a weekend effect, as those that do. Do you not

:51:41. > :51:45.think that the first thing that is required is to actually gather

:51:46. > :51:47.proper evidence as to whether it exists and what because of it might

:51:48. > :51:53.be? I think we have that evidence. We

:51:54. > :51:59.have actually had eight studies in the last six years...

:52:00. > :52:03.But there are 19 studies that say there is no weekend effect and they

:52:04. > :52:13.can to be methodologically more details. -- they tend to be.

:52:14. > :52:17.Let's look at this paper, because the interesting thing about that

:52:18. > :52:24.study is it does conclude that there is a weekend effect and what they

:52:25. > :52:30.say... The quote is, hospital staff appear

:52:31. > :52:33.to apply a more stringent admission threshold at weekends to patients

:52:34. > :52:40.seeking emergency care in A They are stating that they believe that

:52:41. > :52:44.we do not offer the same standard of care at weekends as we offer in the

:52:45. > :52:50.week, because you can be sick with the same illness and the same level,

:52:51. > :52:53.and you would be admitted on a weekday but not admitted on a

:52:54. > :52:57.weekend. That is what we want to change. We want to be able to

:52:58. > :53:00.promise everyone they will get the same high care every day of the

:53:01. > :53:03.week. Speaking to the authors of the

:53:04. > :53:08.paper, they found people admitted to get a test who actually had a low

:53:09. > :53:13.risk, and if it was on a weekend, they would simply be brought back

:53:14. > :53:19.during routine hours for that test. Whereas, people who were ill and

:53:20. > :53:25.were admitted, they were admitted. The same numbers, with 12.5 million

:53:26. > :53:30.who came to 80, but no increased death rate and actually fractionally

:53:31. > :53:33.fewer deaths at weekends of people admitted at weekends. The main thing

:53:34. > :53:38.is this lower denominator of admissions. If we expand, and say,

:53:39. > :53:42.OK, everything every day, is there not the danger that, in actual fact,

:53:43. > :53:46.we will admit more people, so the ratio will look better, but the

:53:47. > :53:51.exact same numbers of people will die. We will not have prevented any

:53:52. > :53:57.death, just have made our mortality rate look better.

:53:58. > :54:02.We can get into discussions about the differences but I think the most

:54:03. > :54:09.copper heads of study was the one last September, which was a huge...

:54:10. > :54:13.-- comprehensive study. It is the same dataset. They

:54:14. > :54:19.included all the A attendances. And they include in that paper that

:54:20. > :54:22.there is a weekend effect. They include led conclude that the

:54:23. > :54:26.standard of care at weekends is different because you have to be

:54:27. > :54:33.more ill to get a decision to admit you. That is a big reason why we

:54:34. > :54:36.should have a seven-day NHS because we do not believe there should be a

:54:37. > :54:41.difference in the criteria for admission at the weekend as in the

:54:42. > :54:46.week. The broader point I would make with these papers is that there are,

:54:47. > :54:53.I think, internationally 15 studies that showed there is a weekend

:54:54. > :54:59.effect, if you include the one we referred to, that makes 16 studies.

:55:00. > :55:05.We now have evidence across emergency surgery, across cancer,

:55:06. > :55:11.across a whole range of different illnesses and situations...

:55:12. > :55:15.Yet, if you look at liver transplants, and bleeds, you do not

:55:16. > :55:22.find that at all. Really the only way to know a death was avoidable or

:55:23. > :55:30.the treatment of a patient was sub optimal, is to review the case. So

:55:31. > :55:33.the people who do these studies would tell you there are different

:55:34. > :55:36.ways of doing this, but I will make the point that I am not an academic

:55:37. > :55:40.but the mistake for a Health Secretary is to look at the

:55:41. > :55:47.overwhelming amount of evidence there is of a weekend effect and

:55:48. > :55:51.decide to get off the hook by disputing the methodology.

:55:52. > :55:54.I think it is clear, if you look at the big studies...

:55:55. > :55:58.The methodology is important. This is numerical that you have different

:55:59. > :56:02.numbers of people admitted on different days, because there is not

:56:03. > :56:10.any routine services. You do not have extra deaths in Best paper,

:56:11. > :56:12.using the same dataset. Therefore, is it is not beholden on the

:56:13. > :56:19.secretary of state to actually know what the problem is before you spend

:56:20. > :56:23.volumes actually fixing it. The one you are quoting here, which

:56:24. > :56:28.I looked at as well over the weekend. I am quoting its now, that

:56:29. > :56:34.the weekend effect was only apparent in subset of patients admitted to

:56:35. > :56:36.hospital, and admissions on Sundays, Saturdays and Mondays are associated

:56:37. > :56:42.with higher mortality compared to Wednesday.

:56:43. > :56:48.Mortality rate, not mortality. I quote directly. Higher mortality

:56:49. > :56:53.than those admitted to A The fundamental point is, what is the

:56:54. > :56:59.appropriate standard of care for any emergency inpatient on a week day?

:57:00. > :57:05.-- weekend? Back in 2012, it was said that there are at least four

:57:06. > :57:09.things that emergency patients on a weekend, just as on a weekday,

:57:10. > :57:14.should expect, and one is that they should get an assessment of their

:57:15. > :57:19.need and treatment a senior doctor within 14 hours at the latest. The

:57:20. > :57:26.second is there needs to be diagnostic back-up available on a

:57:27. > :57:29.weekend, including CT scan, MRI and other processes.

:57:30. > :57:34.And you think that is not available? The third is there should be a

:57:35. > :57:39.consultant directed to treatment is available for emergency patients on

:57:40. > :57:43.a weekend, including on critical care, dementia, radiology and

:57:44. > :57:50.surgery. Fourthly there should be ongoing review for patients.

:57:51. > :57:56.Those for things we say represents the appropriate standard of care. As

:57:57. > :57:59.to what the outcomes are, nevertheless there seems to be wide

:58:00. > :58:03.agreement that patients are sicker so in a sense the challenge for the

:58:04. > :58:07.health services to make sure that those poor things are in place in

:58:08. > :58:13.every emergency inpatient. And to add to your question, we have

:58:14. > :58:18.hospitals to self assess against those, the first quarter of the

:58:19. > :58:23.country should be covered by those by March 17, rolling out half by

:58:24. > :58:29.March 18 and then all of the country by 2020. If we grounded in the

:58:30. > :58:34.standard of care we would expect for our mother or daughter then that is

:58:35. > :58:39.a pretty good way to try and... Is that the definition then of the

:58:40. > :58:44.seven-day services that your mini? It is. It has waxed and waned,

:58:45. > :58:48.including talking about greater convenience, talking about seeing

:58:49. > :58:52.AGP between eight in the morning and it at night. It is certainly not

:58:53. > :58:56.dermatology outpatient on a Sunday afternoon, the task in front of us

:58:57. > :59:03.is making that those four standards of care are set by medical working

:59:04. > :59:06.groups are made available to patients throughout the week. Went

:59:07. > :59:10.back and do you think that there would have been the same friction

:59:11. > :59:14.with the profession is that is all that had been stuck to as meaning by

:59:15. > :59:20.seven-day services? Because that is not what the profession feel that

:59:21. > :59:22.they are being asked to do. I have tried very hard including the

:59:23. > :59:28.statement I made to Parliament a few weeks ago to be very clear. This is

:59:29. > :59:30.not a policy about 70 elective care, it is about improving urgent and

:59:31. > :59:36.emergency care so that we are confident that we are giving the

:59:37. > :59:41.same high quality of care. I outlined the standard to Parliament

:59:42. > :59:45.that the Academy of Royal colleges talks about. When it comes to GP

:59:46. > :59:50.care we have been very clear that yes we do want people to be able to

:59:51. > :59:54.make routine appointment at the weekend, we think that is an

:59:55. > :59:58.important thing for the NHS to offer people who worked choosing the week

:59:59. > :00:03.and may not be able to take time... Till late or just Saturday mornings?

:00:04. > :00:07.We have said we would like to be able to make appointments into late

:00:08. > :00:11.in the evening and weekends but we are not asking every GP's surgery to

:00:12. > :00:16.open at weekends, we think that arrangement is something that can be

:00:17. > :00:19.done through networks of GP services, indeed 60 million people

:00:20. > :00:23.are already benefiting from those networks from the challenge fund in

:00:24. > :00:28.the last Parliament. And in fact I think the package that we outlined

:00:29. > :00:32.for general practice a couple of weeks ago shows very clearly how we

:00:33. > :00:38.are able to deliver those increases in funding going into primary care.

:00:39. > :00:43.You have not the five-year forward views of the 2.4 billion, is that

:00:44. > :00:46.then going to be on top of what was imagined? Is the extra funding going

:00:47. > :00:54.to go to provide the five-year forward view? With what is now part

:00:55. > :00:57.of the seven-day services. The 2.4 billion is a comrade of package of

:00:58. > :01:02.support for GPs including general plaque -- general practice,

:01:03. > :01:08.including practices that are under great pressure, we have identified

:01:09. > :01:13.the first 800 or so now and we are going to work with the RCGP and the

:01:14. > :01:20.general practitioners committee this year to broaden that out. We will

:01:21. > :01:24.install 3000 mental health counsellors who will be embedded in

:01:25. > :01:28.general practice, it is for additional pharmacists be funded to

:01:29. > :01:34.help primary care, so it is a range of things that is all about

:01:35. > :01:38.implementing the strength of hospital and nuclear models that are

:01:39. > :01:42.envisioned in the full review so I think the living VDP foreign view is

:01:43. > :01:47.one of the -- is one and the same of delivering that pillar of the

:01:48. > :01:51.forward view. In the pilot studies that went ahead in the extended

:01:52. > :01:54.general practice, obviously the uptake other than the Saturday

:01:55. > :02:00.morning in a lot of places was very low. When Alistair Burt was in front

:02:01. > :02:04.of the committee he described that that evidence would be taken into

:02:05. > :02:08.account, when is obviously the Prime Minister had initially said that it

:02:09. > :02:13.would exist everywhere from eight till eight, seven days per week. So

:02:14. > :02:17.which is actually going to. Have made it clear manifesto commitment

:02:18. > :02:22.that everyone in England will be able to make routine appointments

:02:23. > :02:29.eight till eight and weekends, but I think actually the evidence is quite

:02:30. > :02:35.encouraging that where patients nor about services that are available

:02:36. > :02:39.there is good take-up. But that is not to say that the take-up on a

:02:40. > :02:44.Sunday afternoon is going to be the take-up on a Saturday morning, and

:02:45. > :02:49.so that is why if you have a network year which means you are not

:02:50. > :02:52.encoding be fixed costs of requiring all GP practices to be open at

:02:53. > :02:57.weekends even though there may not be many takers at 4pm on a Sunday

:02:58. > :03:03.afternoon, but you might have a town like Macclesfield for example where

:03:04. > :03:07.there are two GP practices offering Saturday morning appointments but

:03:08. > :03:11.only one that is offering a Sunday afternoon appointment and the

:03:12. > :03:15.technological innovation that makes this a viable in a way that has not

:03:16. > :03:20.been possible before is the sharing of electronic health records. Our

:03:21. > :03:23.view is that it very much must be a personalised experience for the

:03:24. > :03:27.patient, which means that even if they are not seeing their own

:03:28. > :03:30.doctor, they are seeing a doctor who knows about them and has access to

:03:31. > :03:35.the medical record and is able to update the medical record with what

:03:36. > :03:39.happened in the consultation. Is it not the case that this is going to

:03:40. > :03:43.create more confusion for the patient out of hours in that they

:03:44. > :03:47.are not going to know where to go? At the moment if we need a pharmacy

:03:48. > :03:52.on a Sunday then you have to get the local paper or the library or the

:03:53. > :03:57.kids up. So we already have out of hours GP services, so we did not

:03:58. > :04:03.actually make sense in some way expanding then? Exactly. It would be

:04:04. > :04:05.hard to envision grating more confusion than already exists

:04:06. > :04:10.because we have this patchwork quilt of GP had a very services, walk-in

:04:11. > :04:17.centres, various places. So the whole point of this is actually to

:04:18. > :04:20.streamline and to then signal much more explicitly to patients and the

:04:21. > :04:27.public when you go for your urgent care need, what is AMD and how you

:04:28. > :04:32.access a GP appointment in places, the places within a few miles of

:04:33. > :04:34.here, CCG is already doing this very successfully, individual London

:04:35. > :04:42.boroughs, perhaps have four hubs that have those arrangements linked

:04:43. > :04:44.to the out of hours and the improved one-on-one services. Greater

:04:45. > :04:48.Manchester, one of the things I think they told you was that they

:04:49. > :04:54.had put in place a seven-day access to GP services across greater

:04:55. > :04:58.Manchester now, not five years out. But that is an offer they are making

:04:59. > :05:06.to the public across greater Manchester. If you think about the

:05:07. > :05:10.way the duty chemist works, this is an enhanced version of that using

:05:11. > :05:18.the ability to share records and appointments. And to have a

:05:19. > :05:22.streamlined way to fault of the NHS when it is a child on a Sunday

:05:23. > :05:26.afternoon because you cannot get off work when you know you should see a

:05:27. > :05:30.doctor, it must be at the weekend. That is what people put in place.

:05:31. > :05:35.Certainly when we did our visit and met primary care teams, what they

:05:36. > :05:38.said was that they felt that actually the new system was

:05:39. > :05:42.undermining out of hours, it was a doctor will actually error more

:05:43. > :05:48.doing one of the Prime Minister extra GP sessions and they pay an

:05:49. > :05:53.awful lot less in defence. So is there not the danger that yes we

:05:54. > :05:58.will start to have the access to GP for routine but out of hours GP

:05:59. > :06:03.practices may end up getting dragged down? That is why part of the

:06:04. > :06:08.reforms were introducing needs to be the proper integration of the 111

:06:09. > :06:14.service, the out of hours service and those routine weekend and

:06:15. > :06:19.evening appointments made by GPs. I think that they are, there may be --

:06:20. > :06:25.there may well be a bigger role for the 111 service to have a place

:06:26. > :06:29.where appropriate for people to go for their needs but that is one of

:06:30. > :06:33.the NES, one of the important steps that is being made, the joint

:06:34. > :06:38.commissioning of 111 hand out-of-hours services which is now

:06:39. > :06:41.happening across the country. But we must make sure that people are

:06:42. > :06:45.properly signposted because I be at the moment it is much too confusing.

:06:46. > :06:53.I totally agree with the points about the standards of care across

:06:54. > :06:56.the seven-day emergency service that a patient accesses, obviously we are

:06:57. > :07:00.not particularly going to agree on what is called the weekend effect

:07:01. > :07:05.from research, because in my impression it looks as if we have

:07:06. > :07:08.not answered what the cause is, there are paper suggesting that it

:07:09. > :07:15.is actually nursing ratios as much as access to consultants, but do you

:07:16. > :07:19.actually think that it will be cost-effective from the point of

:07:20. > :07:23.view of preventing depths when as keynote earlier in the discussion,

:07:24. > :07:28.one of the biggest things that actually causes a shortened life

:07:29. > :07:33.span is deprivation? Could we not be looking at how we spend the money

:07:34. > :07:38.perhaps better than what may be involved than what we may have is

:07:39. > :07:43.the core number of people who die does not change that much, we end up

:07:44. > :07:49.actually changing the denominator of admissions. I think that without

:07:50. > :07:54.getting into sort of my academic study versus dual academic study,

:07:55. > :08:00.debate, I think we can agree that there is a weekend effect is that we

:08:01. > :08:04.have higher Saturday mortality rates for people admitted at weekends. But

:08:05. > :08:10.there may be disagreement about is the cause. What the government was

:08:11. > :08:15.my view is that we need to look at the clinical standards that the

:08:16. > :08:18.Academy of Royal colleges recommended in 2012 as the most

:08:19. > :08:24.appropriate way of ensuring that we offer consistent care. That is

:08:25. > :08:30.something that does not just involve doctor cover, it involves diagnostic

:08:31. > :08:33.tests, some of the other standards involve the social care system and

:08:34. > :08:38.mental health and so on. Have you costed what you think it will take

:08:39. > :08:45.to change to meet those standards by 2020? Let me ask Simon to do that,

:08:46. > :08:48.but we should be clear that a seven-day service was not just in

:08:49. > :08:55.the government's manifesto commitments but also in the forward

:08:56. > :08:57.review. We Mac there will be a smartly and there will be in an

:08:58. > :09:02.affordable way of doing the since the reason for doing this as Doctor

:09:03. > :09:09.lost must David Elliott on a phased basis is precisely to figure out

:09:10. > :09:12.what is the smart most cost-effective way of doing it. The

:09:13. > :09:17.fact that a quarter of the country will be covered by the standards

:09:18. > :09:23.from next March, really very made in -- at really very modest think it'll

:09:24. > :09:29.cost of the trusts, we are going to Southampton, James Paget in Norfolk,

:09:30. > :09:36.copy and so forth. Which was indeed that it can be done but if you just

:09:37. > :09:41.think, if you plough on with a lot more consultants, senior medical

:09:42. > :09:46.staff, and other elements, that will clearly have an impact. But the NHS

:09:47. > :09:50.has an incredibly good, if proven understood track record of improving

:09:51. > :09:54.the organisation of hospital emergency services, generating

:09:55. > :10:00.patient outcome improvement on the back of it and doing so within an

:10:01. > :10:04.envelope and the two cases I would point to it would be the move to

:10:05. > :10:10.Major, centres and the move to a specialist/ service. Where those

:10:11. > :10:15.have happened we have seen huge improvement in survival and

:10:16. > :10:19.relatively modest incremental models. Similar debate happening

:10:20. > :10:24.around vascular surgery, emergency surgery around the country, as well,

:10:25. > :10:28.and part of the hospital planning process that these 44 geographical

:10:29. > :10:34.footprint are now engaged in is answering the question what is the

:10:35. > :10:37.smart way to do this for people in our area? If that has been already

:10:38. > :10:41.emerging had been emerging through dialogue, which is very much how it

:10:42. > :10:45.has been taken forward in Scotland, we really needs have all of the

:10:46. > :10:50.conflict that we currently have between the Secretary of State and

:10:51. > :10:53.both the senior and junior doctors, it has been done without changing

:10:54. > :11:01.contracts or couldn't it have been done? It has been done in very few

:11:02. > :11:07.places, and in our judgment, we talked before about the financial

:11:08. > :11:09.pressures and also the variation in quality and management across the

:11:10. > :11:15.NHS and our judgment is that it would not be possible to offer that

:11:16. > :11:21.commitment to everyone, which we need in our manifesto, without some

:11:22. > :11:29.changes and contracts. I'm -- where I would agree with you is that

:11:30. > :11:32.actually I think there has been more -- there has been too much focus on

:11:33. > :11:36.the junior doctors contracts. There are lots of other things that we

:11:37. > :11:41.need to do in terms of diagnostic tests, consultant cover, it is

:11:42. > :11:44.obviously attracting a lot of attention because of the difficulty

:11:45. > :11:47.of reaching an agreed solution with the BMA and I think it is a great

:11:48. > :11:52.shame because I actually think the evidence is that the trusts where we

:11:53. > :11:55.do have a seven-day NHS are not just trusts that are safer for patients

:11:56. > :12:00.but actually have higher morale for doctors. The help of been managed to

:12:01. > :12:04.do that on the contract as it is. In one or two places. But this is

:12:05. > :12:12.something we want to offer consistently across the NHS. We are

:12:13. > :12:16.now needing the end of the session. I would like to turn to mental

:12:17. > :12:23.health if I make and how do that is in the five-year forward view.

:12:24. > :12:27.Clearly the mental health task force was commissioned to provide a

:12:28. > :12:32.report, could I ask how many of the 15 recommendations that they have

:12:33. > :12:37.made our agreed with or supported by the government and the NHS? Shall I

:12:38. > :12:44.start? Luckily we agree with all those recommendations, and it is a

:12:45. > :12:50.very, very ambitious programme. It is an extra billion pounds going to

:12:51. > :12:54.mental health and it is also around 1 million more people being treated

:12:55. > :13:00.annually from Italy of conditions so it is a very ambitious drop. And it

:13:01. > :13:03.is something we are very much committed to.