Will the 10 Year Health Plan really tackle the nation’s health crisis?

Andrew: Hello and welcome to The King's Fund podcast. This is the latest episode in our new series, examining health and care policy reform. We are going to be following all of the twists, the turns, the lumps and bumps, and the all important shifts in health and care policy over the coming months. Today you have me, Andrew McCracken, Assistant Director for External Affairs, and I am joined by Danielle Jefferies, Senior Analyst at The King's Fund.

Danielle: Hi Andrew.

Andrew: Hello. We are also joined by Sarah Arnold, Senior Policy Lead here at The King's Fund.

Sarah: Hi Andrew. Hi Danielle.

Andrew: The last time we recorded one of these podcasts, it was still in those frantic days, just after the 10 Year Health Plan had been published. Now the dust has settled slightly on that plan. Danielle and Sarah, have you had a quiet summer when it comes to health and care policy?

Sarah: Well, I think, a huge draft of things have happened really in health policy since the last podcast we did in July. In preparing for this, I wrote out a list that went over several pages, and don't worry, I'm not going to read down that whole list but in terms of both…

Andrew: Thank you on behalf of our listeners.

Sarah: So that like includes stuff like follow on from the 10 Year Plan. There's also lots going on in terms of the restructuring of NHS England, the Department of Health and ICBs, and all sorts of regulation. But I'd like to highlight two areas of progress that I think both highlight the government's priorities, but also some important questions and issues arising.

So the first one is the Neighbourhood Health Service, and that's something that saw basically immediate action after the publication of the 10 Year Plan. So, within the week in which the 10 Year Plan was published, the government announced phase one of the Neighbourhood Health Service, which is basically, they've, they've gone out to local health leaders and invited them to submit applications to be part of phase one.

The idea is 42 local areas will be selected to start rolling out the program from September. And I think the immediate action here is the government signalling that they are really prioritising this, which I definitely think is necessary to make a success of the idea because it's not a new idea, it's been happening in some communities for years, but in order to implement it across the country, it's going to need significant national attention and prioritisation.

So it's good that we're seeing that. But I do think we're already seeing the consequences of a lack of clarity on the implementation in the plan. We are hearing from some leaders that they feel confusion about the role of neighbourhoods in their existing models of care, and I also saw reports that GP leaders in one area have even advised their practices to hold off on taking part in the programs because they're feeling a lack of clarity and fear that it could jeopardise their existing contract. So, I think this is possibly a theme we'll return to but kind of the lack of clarity is definitely causing some confusion.

Andrew: Just on that point around lack of clarity, are we expecting more from the government on what, you know, how all this is actually going to be rolled out in practice?

Sarah: We definitely are. What that looks like, I think is still not fully clear. So I've heard about two potential things that may both be happening or one. One is the so-called ‘missing implementation chapter’ that was originally reported to be published in the 10 Year Plan but in the end didn't end up in the final version.

We are hearing potentially that that might be published or something like it. And the other thing is planning guidance, which NHS England typically publishes. That kind of sets out objectives and goals for local systems and the wider system each year. We are hearing that that will also be published, probably a bumper edition covering several years and possibly being a bit wider than it normally is, probably including tech as well. But again, timelines on this aren't fully confirmed.

Andrew: Okay. So, more detail perhaps to follow. And Danielle, I'm going to come to you next actually on this. So, in terms of since that 10 Year Plan was published, a bit of a sense from, from your point of view on what some of the progress has been, but maybe also some of the pressures?

Danielle: Yeah, I feel like since the 10 Year Plans come out, there's been a lot of updates on numbers and data and as an analyst, I love that. So a couple of areas of progress that we've seen particularly, focus around activity of the NHS. So yes, we've had the 10 Year Plan but over a longer term we've seen an increase in number of GP appointments, so a record number of appointments. Like 7 million more than last year. But the really important thing there is that we've also seen this translate into the GP patient survey, which came out a few weeks ago, which showed that actually, more people are finding it easy to access their GP and three quarters of people are happy with their GP experience.

So it is good to see that actually those numbers are translating to actually how people are experiencing, especially considering this is one of the key areas the government's focusing on, on that community health, that primary care health, that is actually maybe starting to make progress, particularly in some of the digital areas as well.

We also saw people finding it easier to access GPs through their websites and the app as well. So positive story. Although on the other hand, we also heard about increases in activity in elective care. So the government saying they've had an extra four and a half million appointments, they've met their sort of manifesto pledges to do extra NHS appointments, but at the same time, is that translating in the same way to improved access in the way that the GP survey showed?

And so that one's a bit more questionable. Maybe a bit more pressure there to actually work out if these, this increase in appointments is making an impact on people when there's still 6 million people waiting for elective care. And yes, we've seen the waiting list come down very slowly over the last six months, but we've heard the government or NHS England themselves say there's still a lot to do in order to make their pledges, to get the waiting list down.

And they're doing stuff to try and help the public know and be transparent about what the waiting list is looking like. So they're creating dashboards, they’re going to create league tables to try and help the public understand how the waiting list is changing, but, actually, is that going to make a difference to someone on the waiting list, waiting for their op for six months plus?

Andrew: It's really useful to get that update on how different services are performing at the moment and how patients might be experiencing that. I wanted to rewind to what you said just then about the GP patient survey. Partly because it's so nice to hear some positive news in health and care and it sounds like we had some quite good results in the GP patient survey.

My question is, to what extent can the current government and its reform agenda take credit for that as well as some of the other things you ran through? To what extent do we see the effect of these reforms come through already, Danielle?

Danielle: Yeah, it's nice to be positive. I think to give credit to the government, there is something about steadying the ship as they took over government.

So I think they should be given credit for actually, making some of this progress and not making things worse. So I think yes, we can say the government has done some of that but also you also need to think about the longer term context. So it feels like a long time ago, but we're still in post-pandemic recovery, some of that is just picking up activity as we head out of a very tough period and five years doesn't sound long, but it is a reasonable amount of time to still be recovering from the pandemic. So yes and no.

Andrew: You said there about steadying the ship. One thing that we should just briefly touch on. Of course, when the current government came to power, they swiftly came to a resolution with the British Medical Association about resident doctors pay. But 12 months on industrial action is back. And since we last recorded the podcast, resident doctors have been out on strike. Danielle, we've just had the latest data on the impact of that strike. Do you want to run us through what you make of what we've seen there from that data?

Danielle: Yeah, so I think definitely pausing or stopping those strikes when they first came to government did have an impact. So we know recently from data that since the beginning of the industrial action, we've had more than 1.7 million appointments rescheduled because of industrial action.

It was a huge impact, huge impact on waiting lists, huge impact on patients having their appointments rescheduled. So actually, stopping those initially will have helped the elected waiting list come down. The fact that they're starting up again will cause concern for the government because if they're going to… their main target, their main mission is to get their elective waiting list down. This will have a huge impact on that if they're going to continue to go on in the next coming months.

Andrew: Yeah. The other stat that's on my mind when it comes to the strikes is just that really interesting drop off in public support for the industrial action. So I think I saw that back end of last year or autumn last year, public support was around 44 per cent but that's now dropped down to more like 26 per cent. So an interesting shift for the public there when it comes to industrial action as well.

Sarah, I wanted to just come back to you actually to do a little bit of looking forward. So, what are you expecting out of government and in terms of health and care policy reform in the coming weeks and months?

Sarah: Well, I guess beyond the stuff that we talked about earlier in terms of like probably some really big, either implementation plan or planning guidance, that actually provides kind of quite broad clarity on a range of different areas.

I think what we're hearing is that there's quite a lot of stuff going on in the background in terms of thinking about the legislation that's needed to underpin a lot of this stuff. So, we know that the 10 Year Plan and subsequent Dash Review set out the abolition of Healthwatch and the creation of a new director of patient experience.

Sarah: We are hearing that right now, the focus of the department right now, on thinking about what that would look like, is actually thinking through the legislation required to dismantle Healthwatch, because it's a statutory body and it's not just Healthwatch dismantling that's going to require legislation, a lot of changes to do with ICBs and NHS England is also requiring legislation. I know there's a big scramble to think about what's going to be in the NHS Bill, we're expecting a new one at some point next year or possibly the year after. So, it's not that we're necessarily going to hear loads of changes kind of immediately, but there's a lot of work going on in the background to underpin a lot of this stuff.

Andrew: Brilliant. And I know at some point in the coming months we're going to have what's called the King's Speech, where the King goes to parliament and sets out the government's legislative agenda. So expecting a fairly busy period when it comes to law-making for health and care, we've obviously got the Assisted Dying Bill that'll come back into Parliament as well, which can have a big impact for health and care services.

I'm going to move us on from thinking about progress and pressures when it comes to government reform. I actually wanted to spend a bit of time talking about some of the other areas of reform that weren't covered by the 10 Year Plan, and in particular the shift to prevention. So when that 10 Year Plan was published, there was lots of good stuff in there, but many organizations, including The King's Fund, did call into question quite whether the scale of ambition was there when it came to preventing ill health in the first place, so the public health agenda, how'd you create a healthy nation? Danielle, I wanted to come to you first on this just for a bit of a sense of I guess the state of the nation really.

Where are we when it comes to health as a country? What's the latest data showing us about the health of our population?

Danielle: I think what I would summarize is, we're in a bit, we're in a bit of a health crisis at the moment. So, if you take that a headline figure of life expectancy in the UK in recent years, it's actually been falling.

That's a real reverse of trends where we've seen gradual increases in life expectancy over the last few decades. But actually, to see it fall off should be a real worry, and particularly if you compare life expectancy in this country to other countries, we're doing a lot worse than other countries who also went through really tough pandemics so that also isn’t an excuse.

Behind that is high levels of obesity, high levels of chronic disease, increasing number of people having multi-morbidities. So it's a real issue at the moment and considering that, it's a surprise that we didn't see more on prevention in the tenure health plan.

Andrew: Can I ask you as well, because one of the, you know, the government has its health mission, this idea that it's got a certain number of missions and all government departments will be working towards achieving those missions. One of them is health, but the other is to do with, or one of the others, is to do with the economy and growing the economy. I wanted to just get an update from you on where we are when it comes to the number of people who are out of work due to ill health, which I know has been of concern to ministers.

Danielle: Yeah. That should be a real concern for the government because we know there's, I think, almost 3 million people economically inactive due to long-term sickness. And that should be really embedded in all the government doing. So, for example, if you think about the elective waiting list, a few weeks ago they released demographic breakdowns of the elective waiting list and surprisingly, but maybe not surprisingly, a huge proportion of the people on the elective waiting list are working-age adults, people who might not be going to work because they're waiting for an operation, they're waiting for treatment. So the fact that there wasn't that link up in the 10 Year Plan to, we're not just focusing on the active waiting list for the sake of it, we're focusing on getting down demand for the elective waiting list or preventing people getting there in the first place because that will also link into our aim to improve the economy as well.

Andrew: Okay so with that in mind, Sarah, I know you've been doing some work recently, in fact recently published for The Kings Fund about approaches to prevention and the different approaches that can be taken. I mean, what would you expect that a government could be doing to try and turn around some of the trends that Daniel has just talked us through?

Sarah: Yeah. I'll talk about that in just one sec, but I just really wanted to highlight just quite how shocking and terrible these statistics are. We can say things like, life expectancy is falling and healthy life expectancy, inequality is a widening, but if you actually think about what that actually means, that's representing countless avoidable tragedies for people affected by illness and death, and people who are too sick to work.That's not a condition that many people want to be in.

It’s really terrible, and I think it's something that there should be a lot more focus on. Obviously, it's very easy for us to say at a distance what we think should happen. We are not, you know, in government and the government is fighting a lot of fires but this government was elected promising a prevention-first revolution. Their manifesto talked explicitly about a cross-government approach to creating good health in the broadest sense. It was really exciting, talking about good jobs, pay, housing, transport, all the things we know that create the conditions of good health, alongside making a headline commitment to improving healthy life expectancy for all and halving the gap between the richest and poorest areas. But a year on, I certainly don't think we've seen a prevention revolution despite the fact that there's been some progress, like on the Tobacco and Vapes Bill.

So, in terms of what's actually needed, and a really important first step is that the government needs to reinvigorate the health mission. I know we've been talking about lots of strategies, lots of plans coming up, but I really think across government, 10 Year Plan for wider health, setting out a coherent vision and actionable targets, are kind of needed.

I mean, we are seeing some backsliding in this area. Even some local NHS systems are even decommissioning some of their prevention work, like tobacco control programs this year, because of the need to tackle deficits, and I think there needs to be a really strong signal from the government that that's not okay, that prevention is a really important focus alongside the other things.

I mean, in terms of other things they could do, they could make much better and bolder use of tax and regulation policy, go much further on alcohol taxation, like minimum unit pricing. At the moment, the only policy is better labelling on alcohol in terms of how much alcohol is in there, which I don't think is going to be kind of the really fundamental revolution that's needed. Also, strengthening regulation around advertising junk food, which we're seeing worrying signs of that weakening, instead of kind of banning advertising for junk food.

Instead, we currently seeing they’re consulting on companies being able to, still being able to advertise as long as they don't actually show any junk food. So McDonald's able to advertise as long as there's no burgers in their advertising, which is not very strong to be honest. So I think there's a lot more they can do, and there's also quite a lot of public support for this.

Sometimes we hear, you know about the nanny state and how people don't really want this and they don't want the government interfering in their lives. But when you actually look at polling, people are really supportive of this. People understand that actually making it easier for them to make healthier choices makes their lives easier and better.

Andrew:  Do you know what Sarah, I think that is actually a really good challenge when it comes to talking about the health of the nation. It's easy to get lost in the stats and talk about measures like life expectancy and sort of lose touch with the fact that they are people's lives. And actually the one thing that often gets me is that parents today can no longer be confident that their children will live longer lives than them. You know, which is, is totally different to the experience in the 20th century and earlier part of this century.

To play devil's advocate and to be fair to ministers, the Tobacco and Vapes Bill is ultimately going to outlaw smoking. Like, that's an absolutely massive measure.I mean, is it reasonable to think that we, that they can go further than that?

Sarah: I think it's a fair, very fair challenge and the Tobacco and Vapes Bill is a really bold measure. It was introduced by the previous government, so I would say it's a very good thing that this current government is pushing it through and not blocking it.

But at the moment, it does risk kind of, I guess, this government's record or legacy on prevention to effectively be, you know, enacting the reform of the previous government. But to be fair, I mean, we are also seeing a couple of other things. There were things in the 10 Year Plan, like new commitments on healthy food sales reporting from supermarkets. But I think the real problem is it doesn't feel like it really adds up to a coherent plan. A lot of the policies that have been announced aren't new, and there isn't significant new funding attached to this agenda beyond, and this is welcome, but a relatively modest increase in the public health grant.

I think partly that's how we're, why we're seeing some backsliding in some areas, like people places decommissioning their tobacco control programs. I think there really needs to be a strong signal that this is important. And the other thing is it can't just be looking at specific areas. Again, there needs to be a coherent plan looking at all the rafts of different determinants of health and the ways that our lives are affected, because I think we've seen a decade of kind of backsliding in a lot of those areas.

So that's why there needs to be a really strong, renewed focus. I really would not like to see another 10 years of health worsening in this country.

Danielle: I would just say completely agree and also, what I was surprised about in the 10 Year Plan and sort of slightly disappointed by, is that there's a strong focus on shiny new innovation when it comes to prevention. So things like weight loss, drugs or genomics for early intervention, which are great, which are great new ways to think about prevention, but actually what they should be focusing on, other things we know that work so things like sugar taxes, things like food regulation, these big things will have big impacts on the whole population and we know they already work so yeah. focus on the innovation but also focus on the bigger picture.

Andrew: And, and just on that, Danielle, you mentioned there are some of the tax and regulation stuff that has been so successful in the past when it comes to encouraging people to have a healthier diet. We've got this junk food advertising ban that there's been some slight tweaks to in changes and a slight delay in it coming into place.

We know that often the industry lobby can be very strong in making arguments against some of these public health measures, before they came to power Wes Streeting said that he was going to, I think it was, ‘drive over the junk food industry with a steam roller’. Is it fair to say the steam roller’s run out of steam?

Danielle: Yes. I think that's probably a good analogy compared to the size of the problem. So for example, if you think about children and obesity, a quarter of children leave primary school obese, which is a huge problem to not implement some of those headline junk food claims. At this point, it feels like a missed opportunity. If they're not going to do it now, when are they going to do it? Because this was their opportunity to make those big claims and make those big announcements.

Andrew: Okay. I'm going to move us on from looking at what the government has or hasn't done to looking ahead to the future because we have had a question come in from one of our listeners.

This question comes in from Lord Bethell. People may remember, Lord Bethell is a former health minister in the previous Conservative government but is also a very strong advocate when it comes to public health and improving the health of the nation. Now, Lord Bethell asks us, based on current plans, things like the 10 Year Plan and based on existing trajectories from the likes of the OBR, what do we calculate will be the change in our national health by the time of the next election? Danielle, do you want to take that one?

Danielle: Yeah, that's an interesting question. I think to see changes in five years is very ambitious, particularly when it comes to prevention and life expectancy. Those things change very slowly over time. But that doesn't mean you couldn't see big changes if the government goes full on with their prevention agenda and actually makes some big changes. So things like cardiovascular disease, in 20 years we saw cardiovascular disease, mortality halve. Those kind of things are completely preventable; you can do things very easily at a national level to reduce cardiovascular disease, which will have an impact on widespread mortality and morbidity across the country. O as well, things like the health of children and young people. In five years, you could change a whole generation's health environments and habits and when it comes to being healthy by doing things like the smoking ban, by doing things like reducing levels of obesity. So there is lots that could happen in five years.

Andrew: I'm going to push you on this one, Danielle. So that's a lot of what could happen based on what you've seen so far. Is it going to happen by the time of the next election, which we'd expect in around 2029?

Danielle: I think based on what they've said so far, it doesn't feel like we’ll make much progress. They definitely have the ambition to make progress, but whether that will be reality, I'm sceptical of.

Andrew: I'm going to ask you the same question, Sarah, and I might already know the answer, but are you feeling optimistic on this front?

Sarah: I mean, I feel like I'm a naturally, quite a pessimistic person personally. Unfortunately.

Andrew: That's not true. But I mean,

Sarah: In some senses, I guess, I mean, I think the area, an area that we've been looking at particularly recently at The King's Fund is child health, and that's an area I think that I am particularly concerned about. There was a report by the Royal College of Paediatrics and Children's Health, done in 2018 but I don't think there's been significant change since then in terms of outcomes, that found that England had poorer health outcomes than average across comparable countries in nearly all areas studied and the rate of improvement was much slower. And that meant that unless current trends improve, England was likely to fall further behind other wealthy countries on children's health. And that's sort of what we've been seeing most shockingly, to me at the time, they predicted that infant mortality rates could be 80% higher by 2030. So I mean really, really shocking.

And I don't think that can be reversed without a prevention revolution. We're not convinced that current plans will be sufficient. And also, I mean, the government's fiscal watchdog, the OBR has also been looking at kind of long-term health projections. They're also pretty negative. And I don't see that they will be turned around.

Andrew: Okay, so in answer to Lord Bethell’s question, not a whole lot of optimism coming from you both today but thank you and thank you to Lord Bethell for the question.

I’m just going to move us onto a slightly different topic, and that is adult social care. So, you know, a lot of what we discussed here and a lot of what we discussed last time in the podcast was about the 10 Year Plan.

A massive moment but by the government's own admission, largely focused on the NHS and less so on social care. We know that the government has established the Casey Commission to come up with recommendations for how to improve social care, starting with a report in 2026 and then a final report in 2028 on more fundamental reform of social care.

But since we last recorded the podcast, we've had some new data on the social care workforce. Danielle, did you want to tell us what we've, what we've seen in that latest data?

Danielle: Yeah, so recently Skills for Care published their data on vacancies, and there's a slight positive story, the vacancies go down. But when you start to look into it, you actually realize the vacancies have already gone down because of international recruitment, which is shortly going to change and there's going to be less of a focus on international recruitment. And if you look at the data, British recruitment has actually fallen in recent years. So if we were relying on the fact that we're trying to increase the number of social care staff from British applicants, you're going to be in a real trouble, especially when we've not got any more clarity on the fair pay agreement for social care staff.

That's still unclear how we're going to attract more people into the social care workforce, particularly the younger generation. So there's still a lot of unanswered questions about how are we going to sustain low levels of vacancies.

Andrew: You, you were so close to giving me some positive news there, Danielle, then you took it away at the last minute.

I just wanted to focus on one thing you said there actually about the fair pay agreement. So this is, you know, one of the major, more tangible of this government's reforms when it comes to social care, that they want to set a new, higher specific minimum wage for people working in social care to attract more domestic workers, homegrown workers, into the social care sector.

But what we've seen in recent weeks and months is that the government has withdrawn what was called the Care Visa. So that was a special route that the previous government had put in place to make it easier for overseas workers to come to Britain to work in social care and to plug some of those vacancies and gaps in rotas that we saw in social care.

Phenomenally successful policy but has ran up against the other big debate, which is immigration, which has obviously been a major topic for newspapers and broadcasters over the summer so far. So the government is betting that its fair pay agreement will attract more domestic workers into social care.

But we don't think that fair pay agreement is, well, it certainly hasn't even been written into law yet. The legislation is still going through Parliament, and even when it does get into law, it's not going to be implemented until probably around 2027. And crucially, it's not clear where there is going to be additional funding to pay for those increased wages.

So question marks when it comes to social care recruitment there. I'm going to move us on to a totally different topic.

I now want to bring it back to what we are hearing from people who are working in the health and care system. So from the leaders and staff across health and care that we're talking to week in, week out, what we hearing about these reforms and how they're landing with those who ultimately are going to be implementing them.

And I wanted to start with you first on this one, Sarah.

Sarah: So in terms of what people are thinking and feeling, I think it's pretty mixed. This is a little bit anecdotal but some of my friends who are frontline staff really feel disengaged. They're just trying to get on with their jobs or are focusing on the current pay and working conditions rather than the big sweeping changes, which is completely understandable. At a more leadership level, I do think some health care leaders are really trying to see, are managing actually, to see these changes as an opportunity. But on the flip side, we're also hearing leaders are facing really significant tensions between keeping the show on the road and maintaining care quality, alongside financial constraints. And leaders are concerned about supporting their teams themselves and each other through change and uncertainty when being pulled in all sorts of different directions, when sometimes they don't even face clarity on their own jobs and they're trying to lead through change. So I do think it's really tough for many, basically. Change is never easy and this really feels like change under some quite extreme pressure.

Andrew: Yeah. I mean, building on what you said there, what I picked up was a real willingness that people want these reforms to work. It was sort of the depths of of, of how bad it can go, people really want there to be change, but maybe that uncertainty about exactly how any of this is, is going to translate. I mean, Danielle, coming to you, what are you hearing from the people that you are talking to about these reforms and how they might be landing?

Danielle: So similar kind of feeling from people I've been talking to. It feels like this is a really tough time to be a leader in the health and care sector.

Some people don't know which office they'll be in, who they're going to be sitting next to, or even if they'll have a job next week, let alone what the NHS will look like in five year’s time. So with the fact that there's mergers, funding cuts, there's people not knowing what their role will be very soon. It doesn't feel like there's strong foundations for a big set of reforms to be implemented.

It feels like people need more breathing space to actually take on this change and implement it with the passion that they actually do have to create a better health system for people.

Andrew: Breathing space. Breathing space. As we start to, although it's hot now, look into winter coming by, I imagine that breathing space is going to be in short supply.

Danielle: Yeah, winter will come very quickly and all the usual pressures of increasing demand and hand and do of delays and ambulance call outs will quickly pick up very soon, which is just another layer of pressure for people.

Andrew: Okay, so a busy few weeks and months ahead for health and care reform. It's also going to be a busy few weeks and months for us at The Kings Fund.

On the 9th of September, we've got our 10 Year Plan conference where we'll be talking about lots of the themes that we've covered in this podcast with fantastic experts. And then on the 17th of September, we've also got our prevention conference so again, some of the themes we've covered in this podcast.

But I'm very pleased and proud to say that for that conference we're going to be joined by all four Chief Medical officers of the UK. So we are going to be getting a rounded view of what's going on when it comes to health in England, Wales, Scotland, and Northern Ireland. As ever, keep an eye out on The King's Fund blog for our latest research and analysis, but for now, I'm going to say thank you to Danielle.

Sarah: Thanks Andrew.

Andrew: And thank you to Sarah.

Sarah: Thanks for having me.

Andrew: And special thanks to Sarah Murphy, who is this episode's producer and also to Bespoken Media who edited this podcast. Thanks for joining us. We look forward to having you here next time.

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