Public Accounts Committee

Oral evidence: NHS waiting times for elective and cancer care, HC 1750

Wednesday 24 April 2019

Ordered by the House of Commons to be published on 24 April 2019.

Watch the meeting

Members present: Meg Hillier (Chair); Nigel Mills; Layla Moran; Anne Marie Morris; Anne-Marie Trevelyan.

Sir Amyas Morse, Comptroller and Auditor General, Adrian Jenner, Director of Parliamentary Relations, National Audit Office, Jenny George, Director of Health Value for Money work, NAO, and Marius Gallagher, Alternate Treasury Officer of Accounts, HM Treasury, were in attendance.

Questions 1-114

Witnesses

I: Sir Chris Wormald, Permanent Secretary, Department for Health and Social Care, Simon Stevens, Chief Executive, NHS England, Ian Dalton, Chief Executive, NHS Improvement, and Professor Steve Powis, National Medical Director, NHS England.

Reports by the Comptroller and Auditor General

Progress in improving cancer services and outcomes (HC 949)

Managing the costs of clinical negligence in trusts (HC 305)

Delivering new care models through NHS Vanguards (HC 1129)

NHS financial sustainability, (HC 1867)

NHS waiting times for elective and cancer treatment (HC 1989) March 2019

Examination of witnesses

Witnesses: Sir Chris Wormald, Simon Stevens, Ian Dalton and Professor Steve Powis.

Chair: Good afternoon and welcome to the Public Accounts Committee on Wednesday 24 April 2019. We are here today to look at NHS waiting times for both elective care and cancer treatment, and we are considering the NAO’s Report on that subject. In various documents, including the NHS constitution and the NHS handbook, patients in England have their rights to certain timescales set out. They have the right to be treated within these maximum waiting times, but the NHS has failed to meet some of those standards, and that is what we are looking at today.

The 18-week elective care waiting standard was last met in February 2016, and the 62-day standard for urgent referral for suspected cancer to first treatment was last met in 2013, so it begs many questions. We know that there is important work being done by Professor Steve Powis, who is here today, on those waiting times and whether they are still the right ones. We will be probing what has happened and where we are going to go from now on.

I want to introduce our witnesses before handing over to Mr Nigel Mills. From my left to right, we have Ian Dalton, who is the Chief Executive of NHS Improvement. At some point, you will become NHSEI. Am I losing track here?

Ian Dalton: We are working together already, but we are still separate statutory entities.

Chair: So that is another issue for the change in the law, which we have discussed before. Fine.

Then we have Sir Chris Wormald, who is the Permanent Secretary at the Department of Health and Social Care; Simon Stevens, the Chief Executive of NHS England; and Professor Steve Powis, who is the National Medical Director for NHS England, and is about to publish new waiting time—

Professor Powis: We have published an interim report.

Chair: So the interim report is out. We will probably come to you, therefore, quite a bit on this. That doesn’t give you a free ride, but you don’t have to repeat the expert words of Professor Powis if he has said the right thing. I am going to hand over to Mr Nigel Mills to kick off.

Q1                Nigel Mills: As an opening question, Sir Chris, can you just tell us what has happened to the annual mandate and remit letter, which you were supposed to have sent NHS England about three weeks ago?

Sir Chris Wormald: Yes, we are supposed to have done that. Obviously, it would have been better had we met the deadline for it. It is, however, much more important that the mandate is right than that it is published on a particular day. For various reasons, which I am sure you will understand, the Government has been—what’s the right word?—slightly busy. We have not finished the process of agreeing the mandate collectively, which we will do in discussion with our colleagues at the NHS. It is not ready yet, but Ministers plan to publish it as soon as they can.

Q2                Nigel Mills: Is that in a couple of weeks?

Sir Chris Wormald: Hopefully, yes. As I say, it is much more important—the mandate is a very important document for us all—that it is exactly right. It is slightly different this year because, of course, we have the long-term plan that sets out the long-term position for the NHS, so there is agreed policy in place for everything. We now need to translate that into a series of annual mandates that make sense for everyone. It is a slightly different process that we go through, but of course it is not the case that that means that the NHS is without direction.

Q3                Nigel Mills: Or stops.

Sir Chris Wormald: Well, I don’t think 1.4 million people in the NHS wait for the mandate before deciding what to do. It is extremely important for accountability and us setting national direction, but of course in this case we have a very extensive long-term plan that is governing the relationship. So, yes, it should have been published by now, but for those reasons it has not been.

Q4                Nigel Mills: Mr Stevens, is this causing you any problems running the NHS?

Simon Stevens: No, I don’t think so.

Q5                Nigel Mills: It is that important a document that you have not noticed that it is not there.

Simon Stevens: For the reasons that Chris said. We have an agreed direction in the long-term plan that includes some specific deliverables for the coming year. We have the budget set for the next year, and we have the NHS annual planning process essentially wrapped up. For the reasons that Chris said, 2019-20 is, to some extent, a transition year into stepping into the new five-year long-term plan.

Chair: That is one way of putting a gloss on it, I suppose.

Q6                Nigel Mills: Okay. I guess we can look forward to that in a couple of weeks, then. Mr Stevens, on the topic for today, can you perhaps talk us through why you think performance against elective waiting standards has deteriorated in recent years?

Simon Stevens: The number of people being treated within the waiting times standards continues to go up, and more patients are being treated within those fast waiting times standards than ever before, but the underlying answer to your question is, I think, set out on page 34 of the NAO Report, in figure 15.

Essentially, you can see there the gap that has opened up—I might add, not just in England but in Wales, Scotland and Northern Ireland—over the last six or seven years as a result of increasing our NHS operations and activity, but demand and funding capacity not keeping up with that. Obviously we are now about to step into the next five-year period with a different settlement, and that is what the long-term plan looks forward to.

Q7                Nigel Mills: So the answer is that there is just not enough money, and that is the reason why we are not hitting the target. Is it as simple as that?

Simon Stevens: It is as set out in the NAO Report. They lay out the various factors, but essentially that is what this chart shows.

Q8                Nigel Mills: So that is your sole assessment: if there was more money, you would have met it.

Simon Stevens: No. The workforce are important questions as well. No doubt we will come on to that. Within the overall number of patients who are being referred for planned care, there is a very big increase in the number of patients being referred for a cancer check. We will come on to talk about that. Really you have to distinguish what is happening for the very big increases that we want to see, in people coming forward for cancer checks, versus the steady increase in routine waiting list operations, which need to go on alongside that.

Q9                Nigel Mills: Are you bothered? Is it something that keeps you awake at night that you are missing the 92% not waiting longer than 18 weeks target, or is it one of those silly targets that you do not really think is important?

Simon Stevens: Short waits for routine care are important on the NHS, and a lot of us have put a lot of effort down the years into removing long waits for routine care. When I started work in the NHS 31 years ago, there were 220,000 people waiting more than a year for their routine operation. Now it is under 2,000, and there has been a further significant reduction even in the course of the last year. Short waits definitely do matter.

Q10            Nigel Mills: What are you saying to CCGs and providers around the country? Are you saying, “Get this sorted and start meeting this target,” or are you saying, “Other things matter a bit more at the moment, but do your best”?

Simon Stevens: We are saying that a number of things matter, and that is what we have set out in the long-term plan: the big killers and disablers, improving our outcomes on heart disease and cancer, expanding mental health services, children’s and young people’s services, and frail older people’s services.

However, routine care for planned procedures clearly matters, so we are asking CCGs to increase the amount of funded NHS activity over the next five years. As that is matched by the expansion of the workforce, we will see more patients being treated within these short waiting time targets.

Q11            Nigel Mills: It is just that you removed any sanctions for CCGs and other people a couple of years ago, didn’t you? Now, I think, even a mention of requirements to meet the 18-week target is not in the annual instructions you send out. Is this sending a message that, actually, this is one area that can be let slip due to other pressures, or is that not the message you intend to send?

Simon Stevens: No, the reason the fines were taken out of the system was because actually there was a different set of real-world causes that were meaning hospitals were having difficulty coping with the extra expanding services fast enough.  So just fining, on top of those real-world pressures, was not adding anything. The reality, however, I think for very long waiters we do want to send that clear signal, and that’s why there will be a shared set of financial incentives— for both for CCGs and for hospitals—for the very small number of people who wait 52 weeks.

Sir Chris Wormald: If I could add to that. We have a chart in the NAO Report that I think is very important—it is figure 8. On one level, there is almost nothing to say that is not in the NAO Report. It is a very honest account. Looking at the NHS’s performance over time, it is actually very stable, even during a period when—as we have discussed with the Committee frequently—the NHS has been under considerable pressure. That line is relatively flat. Looking at the chart below that—figure 9, which Simon has already pointed to—the NHS has dealt with very large increases in demand at the same time as it has had relatively stable performance, which does not suggest that this is something on which people have lost priority. Clearly, we are below the target and would want not to be. Given those rises in demand and the pressures we have discussed across the piece with the Committee, those two charts tell the true story.

Ian Dalton: The evidence is that, notwithstanding the changes to the financial incentives that you mentioned, there are still significant clinical and financial incentives for providers to treat elective patients. The fact that they have been treating more and more elective patients every single year justifies that statement. I do not think there is any hint that either providers, clinicians or leaders are not interested in seeing patients in the elective stream quickly, and they continue to be focused on that.

Q12            Nigel Mills: But am I right, Sir Chris, to say that under the NHS constitution patients have a legal right to be seen within 18 weeks?

Sir Chris Wormald: Not quite, no. The law requires the NHS to pursue the 92% target. Quite clearly, that does not translate exactly into an individual right, because it allows 8% not to meet the target. The NHS is required to pursue the target, but that is different from an individual right. Of course, individuals have lots of rights flowing from quality medical practice, which includes things being seen in order of medical priority, as well as the time spent in a queue. It does not translate exactly into a personal right to a particular type of service, but the law requires the NHS to pursue that target.

Q13            Nigel Mills: Is the NHS pursuing meeting this target, or pursuing trying not to get any further away from it?

Sir Chris Wormald: I will leave that for my colleagues to answer but, as the Committee knows, we ask the NHS—both collectively and individually in terms of institutions—to pursue a whole series of targets simultaneously. They have to balance their financial requirements to break even with their professional requirements to treat people in medical need, and then balance the various services that Simon has just described. So they have to make choices. More important is why I pointed to figure 8. Regardless of all those pressures, we have seen very stable NHS performance, which suggests that, collectively, people care about this target a lot, even if we are not quite getting there. A further point is again illustrated perfectly by figure 9. Simon gave you the numbers—there used to be 52-week waits, but they have come down. What you see at the end of that chart, when the 52-week waiters began to tick up again, is that there was then significant management action taken by the gentleman to my right and the gentleman to my left to ensure that that turned around again. I can remember the meeting we had on the subject. The NHS decided that it did not like the direction of that graph and that action had to be taken, and it came down again. It is not the case that we do not look and it is not the case that people do not care, but you are correct that we are continuously balancing a lot of competing priorities, all of which people care about.

Q14            Nigel Mills: There is a danger that we could trade figures in the NAO Report. Figure 20 has an expectation of performance deteriorating further and heading down towards the 80% mark in the next three or four years.

Sir Chris Wormald: I believe—my National Audit Office colleagues will correct me—that what they have done in that chart, quite correctly if I remember the one you are talking about, is simply project current demand against current performance. As Simon said, that does not take account of the additional investment. We have not mentioned the long-term plan yet, but I know you were waiting.

Chair: Bingo!

Sir Chris Wormald: Well, the Committee wanted us to do a long-term plan. Figure 20 does not take account of the extra investment, and the long-term plan sets out what the NHS wants to do around these things. This was a straight projection of current trends, as in, “If everything else remained equal and no further action was taken, this is what we would expect to happen.” We would expect the long-term plan to deliver what it says it will deliver.

Professor Powis: Nor does it take account of the redesign in the elective care pathway or various components of it that are contained within the long-term plan.

Chair: Which we are going to come on to.

Q15            Nigel Mills: So when will we get to see the 92% target being hit?

Simon Stevens: I think that is a question for Professor Powis, really. As he was just implying, between two-thirds and four-fifths of what are called the clock stops that count towards that incomplete 92% target relate to out-patients rather than in-patients. As we are looking to remove the need for perhaps up to a third of out-patient visits, even if everything else was held constant, that 92% measure would need to change. One of the things that Steve is looking at is what does the redesign of the interface between GPs, out-patients, hospital day cases and in-patients will mean for a way of tracking short waits.

Q16            Nigel Mills: You see, I am trying to get my head around whether this is still a target or not, or a measure. You are kind of telling me that there is a duty to pursue, and then when I ask whether you are actually pursuing that, I get a long-winded answer which says we think it is probably not appropriate and we should do something different. You have taken away the sanctions on people for not meeting it, and apparently that has made no difference, because everyone is still doing their best. Is this actually a target that we think is important and that we are going to meet, or is it something that reflects a pretty good aspiration that we should have a short waiting period, but actually we are not going to get back to it in the foreseeable future? What are you trying to do?

Simon Stevens: It is one way of tracking short waits, but it is not the only way, and it might not be the best way. The Scots have chosen a different way of doing it. The Welsh have chosen a different way. Northern Ireland does not have a way at all. Indeed, most other countries do not go down this path. We want short waits for routine care. It is worth remembering that the average person on a waiting list—the median patient wait is 6.7 weeks. We do actually have short waits for the vast majority of elective care. We want to not only sustain that, but improve on it.

Q17            Nigel Mills: So you think this target should go. It is meaningless, isn’t it?

Simon Stevens: That depends on what Professor Powis recommends.

Sir Chris Wormald: No. Targets, including this target, serve several purposes at once. It is very important to have targets for accountability purposes and for tracking purposes. To that extent, this target matters as much as it ever did. The advice we have from our clinical colleagues is that medical practice has moved on. As with any target, you get some dangers of perverse incentives built into the target. Therefore, periodically you have to look at the composition of the target to say, “As well as giving you an accountability measure and a transparency effect, is it also putting the right signals into the system?” Steve is proposing that we pilot a series of different things that still form the accountability function but also send a better message. Is that fair, Steve?

Professor Powis: Yes. I think it is quite fair that access standards, which is what we are discussing today, serve a variety of functions, one of which is to set a reasonable expectation for the public, organisations and politicians as to what a short waiting time should be. Secondly, they allow the ability to benchmark between health systems, and with caveats—for the reasons that Simon said—between countries.

I should say that when you look at waiting times in OECD countries, we are pretty much in the pack compared with other countries. We are performing at a very similar level now, and I think that Simon has said that that has been the story of the last 10 or 15 years—that the NHS is really catching up on those long waiters.

Standards can also be operationalised into how organisations set operational frameworks, which is important to assist clinicians in managing individual patients. So they perform a variety of functions, and sometimes they try to provide all those functions at once. Back to the original question: it is important to set a standard for our staff and organisations as to our expectations of what a reasonable waiting time is—in both cancer and elective care.

Chair: We will move on to Anne Marie Morris on much the same theme.

Q18            Anne Marie Morris: I want to drill down a little more into the cancer piece. Mr Stevens, I believe that three years ago you agreed that the 62-day standard was not being met, in terms of delivery of treatment for those diagnosed with cancer, and you were going to do something about it. Frankly, however, things have not improved significantly. I know that you will tell me “more people” and “less resource” but, given how important cancer is, has been and will be in the long-term plan, surely you must also have looked at some of the systemic ways in which to deal with this problem.

Simon Stevens: Actually, I was going to say something different, which is that rather than this just being about the number of people within a 62-day period, the underlying thing that the health service is trying to get right is to reduce deaths from cancer and to improve the likelihood of surviving cancer. On both fronts, over the last three years, we have seen significant progress—7,000 more people now surviving their cancer for more than a year than would have been the case three years ago, and the fastest improvement in breast cancer mortality in Europe over the last five years, such that we are now better than France, Germany or the European average. All of this has been happening while at the same time—in fact, because—we have been actively soliciting people to come forward to get their cancer checks. The fact that there is pressure on the waiting times is a result of the extra screening and check-ups that directly help explain the improvements in survival.

Q19            Anne Marie Morris: That does not change the fact that you are still not meeting the target, or that you must have anticipated—surely—that if you encourage people to come forward to be tested earlier and more quickly, inevitably that will put pressure on the system. None the less, you still stuck by that target—

Simon Stevens: Not quite. We have actually been more successful than we expected in getting people to come forward and to have their cancer checks. For the first time, this past year, we have gone through the 2 million mark of people having their cancer check-ups. That is up by quarter of a million, even over the course of the last year.

The most important thing is the at-risk population who are getting checked. You could have a higher proportion of people seen within 62 days if a smaller proportion of people came forward to get checked, but that has been at the root of our lag in the outcomes measures on cancer. Actually, back in 2015, the Independent Cancer Taskforce that I commissioned under Sir Harpal Kumar—at the time, he was at Cancer Research UK—said that this is what we should be doing, moving to a focus on the proportion of patients diagnosed at stages 1 and 2, and that as a result we would see the benefits in survival gain.

At that time, the commission recommended that we needed to test new diagnostic models, which we have been doing, and that we should move over to a new target measurement set from 2020, which again Steve Powis’s review is set to confirm.

Q20            Anne Marie Morris: I totally accept the benefit of and the progress on early diagnosis—gold star—but, Professor Powis, can you explain what could be done to the targets to make them more fit for purpose? As Mr Stevens said, it is also about managing patient expectation and, I suspect, about delivering value for money with what we have in the system. Having a target that you never expect to meet does not make any sense. Could you shed some light on that?

Professor Powis: The general approach to the review of standards has been based on a number of principles regarding what matters to patients, improving outcomes, patient experience, ensuring that patients get the right services and ensuring that standards support the model of care that we have developed over the last decade and are set to develop further. There are two core principles—if you read the report you will see it is set out in this way. First, what is the model of patient care that we have set in place and the long-term plan we will develop? Secondly, how have the current targets performed and do we know what works well and what does not?

As Simon said, for cancer our focus over the next 10 years is on earlier diagnosis. There is no doubt that when it comes to key outcomes—one and five-year survival—it is important to diagnose cancer at stage 1 or stage 2. At the moment we diagnose about 52% of patients at those stages. The aspiration in the long-term plan is to get that to three in four—75%. We want a set of standards that aligns with that direction. That is why setting a standard for making a faster diagnosis is the direction of travel that the taskforce recommended and I reaffirmed in the interim standards report.

Q21            Anne Marie Morris: What about the other target, which is about, having been diagnosed, getting treated?

Professor Powis: It is correct that we should focus on faster diagnosis, but we also need to start treatment quickly. This is not an either/or, but a both-and.

Q22            Anne Marie Morris: But if you are strapped for cash and people, given the importance of cancer in the 10-year plan, do you not have to shift resources such that, if you believe that 60 days is right, you can meet it? Setting a target that you know you cannot meet makes no sense.

Professor Powis: Cancer remains a priority in the long-term plan. Supporting priorities such as diagnostics is a key component: the long-term plan commitment to more MRI and CT scans, and the commitments we have already made to radiotherapy. There is investment and there will be further investment. I am sure we will have discussions as part of capital settlements in the CRS about capital requirements to support that.

Q23            Anne Marie Morris: Are you happy that the 62 figure is deliverable?

Professor Powis: I am happy that we need to keep that target. There are some nuances in the way it is described, but the standards review recommends a faster diagnosis standard at four weeks. The offer becomes that we will give you a diagnosis whether or not you have cancer within four weeks; then, there will be a period of 31 days to treatment. That is, in essence, 62 days.

Q24            Anne Marie Morris: And your expectation is that the extra funding you will get will enable you to do that. Is that right?

Professor Powis: There will be extra investment that we have been putting in already and that we will put in as part of the long-term plan, and there will need to be a discussion about capital. There are some other nuances in the interim report, which we can discuss in detail, but it may be that for certain cancers, we need to think about that particular 62-day target. The prostate cancer pathway, which is a complex pathway with many different treatment options where some cancers can be slow-growing, is one that we are particularly looking at because it is quite right to ask whether there is a one-size-fits-all. The next part of the review, when it comes to cancer, will start to look at those questions in a little bit more detail and will get to the heart of it.

For the moment, the interim report has recommended that, as the taskforce recommended a few years ago, we should move to a faster diagnosis standard. For 2019-20 we are focused on collecting the data and piloting what that would look like with our cancer centres. If that goes well, that standard will be introduced from April next year. Meanwhile, keep the 62-day standard but also do further work to make sure we have the one-size-fits-all right.

Q25            Layla Moran: Professor Powis, I wonder if you, in your interim reports, have seen any mismatches between the needs of the trust and the central commissioning? Diagnostics are a specialist commissioning endeavour done centrally, not by the CCGs—correct?

Professor Powis: That was not specifically something we looked at in the review, but you are quite right that diagnostics is an important component, both in the cancer pathways and in the elective pathway. That is why, in the long-term plan, there is a clear commitment that we need to look further at diagnostics. Of the diagnostics that we use, CT scanning, MRI scanning and ultrasound would be some of the key diagnostics, but it is not just those and we need to continue to invest in diagnostics and also to transform our diagnostic services.

An increasingly key diagnostic service in cancer will be genetics, because one of the great advances that we have seen over the last decade is our ability to identify the abnormalities in DNA—the coding material in cells that produces the abnormal proteins that cause cancer—so we can now identify exactly the changes and mutations in individual cells in individual cancers that will allow us to make a better prognosis and a better diagnosis, and to fashion treatment better. As I am sure you will know, we have spent the last few years working on reconfiguring our genetic services, so that I believe we, as a country, will have the premier genetic services among our peers. That will put us in a great place diagnostically to drive the next round of advances in cancer treatment.

Q26            Layla Moran: Would you agree, though, that those sorts of decisions need to be done hand in hand with the trusts and the local CCGs?

Professor Powis: Yes, of course, because in all this, there is a combination between local investment at a trust level around equipment and so on, between commissioners who commission and pay for that, and national strategy. That, again, is why we work with cancer alliances in cancer, so that national policy can be translated locally, and it is why the next phase of the long-term plan will be for local healthcare economies to translate national policy into what it means for patients locally. That is something we are currently seeing.

Q27            Layla Moran: I ask these questions because we have a specific issue to do with the Churchill Hospital in Oxford. I appreciate that we did not necessarily say and you may not know the ins and outs, but Mr Stevens, does it worry you that Bruno Holthof, who is the head of OUH trusts, has said that the potential change of the contract, and giving it to InHealth, would actually compromise patient safety and quality of service? We have subsequently found out that they were not consulted, and nor was the local CCG, on that change. What happened there? Is that common?

Simon Stevens: I think the same happened there as happened everywhere else in England, which is that an assessment was made, which had been engaged on publicly. A decision was made and, I think, the process kicked off two years ago in 2017. To cut to the chase, my understanding is that the provider of PET-CT and the hospital have agreed to work together so that services will be maintained on the Churchill Hospital site. In addition, people living in Swindon and Milton Keynes will get a new local service at the Great Western Hospital in Swindon and at the Milton Keynes hospital, rather than having to make the trip to Oxford.

Q28            Layla Moran: Absolutely, but it strikes me that that was after a big public outcry of patient groups. We have had consultant radiologists come to us and whistleblow as a result. That is what caused the ruckus in the first place. Do you not think, Mr Stevens, that you need to create a commissioning pathway that includes, as standard, the trusts, the clinicians and the frontline service users of those services, to avoid that kind of thing happening in future?

Simon Stevens: We do think that would, in future, be desirable, which is why, when asked to make recommendations on changes to the legislative arrangements in the NHS, we have come forward and suggested that, among other things—

Q29            Layla Moran: So we would need a legislative change that you cannot institute now—

Simon Stevens: Section 75 of the 2012 Act should be amended, or in fact scrapped, because that plus the Public Contracts Regulations 2015 were what led us to need to re-procure those services.

Q30            Layla Moran: Can that not be changed with guidance from now?

Simon Stevens: It is not guidance; it is the law. It is a combination of UK and European Union law.

Chair: Which we have touched on, and we can touch on again.

Q31            Anne Marie Morris: Mr Stevens, given what Professor Powis said, and the expectation that you will have the resource and therefore that the 62 figure can stand as a target, when can we expect it to be met?

Simon Stevens: The process we are kicking off now for the implementation of the long-term plan is that between pretty much now and the autumn every part of the country will be shaping their own implementation plan for the improvements in cancer and other services that are set out in that long-term plan.

Q32            Anne Marie Morris: But surely you have a global plan, which effectively you are then looking at implementing locally. You must have thought in your own mind when you might be able—

Simon Stevens: Well, we have different starting points in different parts of the country. Perhaps we will talk about that. We have to sync up two different things. We have to sync up the capacity expansion, including the HEE workforce plan for cancer and the extra number of people working in diagnostics, with the continuing increase we expect and want to see in the number of people coming forward on to that urgent-referral, 62-day pathway.

To put this into context, if we go back to 2010, for every one person being treated on that 62-day pathway, we had 10 people who were being checked up at the start of that process. Now for every one person who is on that pathway, we have 14 people who are being checked up at the start. That is putting a lot of extra pressure on to the diagnostic element, particularly endoscopy, as well as radiology, imaging and other parts of the service. All of that has to come together, to be able to show what the sequence of improvement looks like.

Q33            Anne Marie Morris: So, Mr Stevens, even today you cannot give me a date by when this will be fixed.

Simon Stevens: What I would say is that that was something that Stephen Powis and Mike Richards, who we had before you last time—

Anne Marie Morris: They are going to tell you how, but you must be putting together a business case, which must make some assumptions.

Simon Stevens: We want to know how before we declare a date. One of the things Professor Sir Mike Richards is doing—as well as the screening review, which he talked to you about last time—is looking at cancer diagnostic capacity, and the speed of expansion there will shape the phasing of the improvements we want to see.

Q34            Anne Marie Morris: When can you give us a date?

Simon Stevens: If you remember, he said he was going to do an interim report within the next month to six weeks, and a final report in the summer, plus the local LTP plans in the autumn—that is when we will have this. But in the meantime, let us just remember, important thought this is, particularly for patient experience—

Q35            Anne Marie Morris: Mr Stevens, we have limited time. I appreciate what you are saying, but I think that you are telling me that by December I should be very concerned if you have not yet come back to us in writing or otherwise to set out by when you expect that 62-day target to be met. I think that is what you are telling me, given the timelines.

Simon Stevens: Yes.

Anne Marie Morris: Excellent.

Q36            Chair: On these changes to waiting time standards, will they be subject to consultation?

Simon Stevens: They will be subject to consultation if they involve a change to the national patient entitlements, and they are obviously being subject to testing and engagement through the process that Steve is leading. But in the case of the cancer standards, the principle change to the 28-day standard, complementing the current 62-day standard, was already set out in the cancer taskforce, so there are not proposed to be significant—

Q37            Chair: There is a little confusion, because our colleagues the MPs for Brighton Pavilion (Caroline Lucas) and for Redcar (Anna Turley) have asked questions in the House about this. I look to Sir Chris, as it is his Minister who responded. They asked if the waiting time standards in the NHS constitution handbook will be subject to consultation. There are subtleties here. Stephen Hammond, the Minister, responded that “There is no requirement to hold a consultation to make changes to the handbook” and that “changes to the NHS Constitution will be consulted on as is legally required.” What does that actually mean in reality?

Sir Chris Wormald: I need to check exactly what the law says about what is consultable on. I am sure that that answer was correct. But it is important to remember that there are two stages to this. At the moment we have a set of proposals that the NHS has made, which it is testing. The Government have neither accepted nor rejected those.

Simon Stevens: But it was the Prime Minister who asked us to do it, so we are following the Prime Minister’s request.

Q38            Chair: So you are hoping that they will just say yes.

Sir Chris Wormald: We asked for these processes going forward. The NHS is testing what the changes should be. It will then come back to the Government and say, “These are the changes that need to be made to those things,” and then there is a Government decision about whether to adopt the changes that the NHS is proposing. As throughout this process, we want to act on proposals made by the NHS. Those would be consulted and discussed in the way that they normally are. I need to check exactly what is required for which process. I am sure that answer—

Q39            Chair: It would be very helpful if you could come back to clarify, because there has been quite a bit of toing and froing. Those are two of the Members who have asked about this. It would be helpful to know.

Sir Chris Wormald: Yes, but of course, as Simon said, the process of testing also includes consultation, because we are trying things out with the public as we go, as it were. So, I think the idea is that this is a much more iterative process than the classic, “Here’s a proposal”—

Q40            Chair: Which may make sense, but it would be helpful to know, nevertheless—

Sir Chris Wormald: I will set out exactly what we are legally required to do in—

Q41            Chair: What the requirements are, and what the opportunities are—

Simon Stevens: Healthwatch has obviously got an important role to play here, and Healthwatch—having engaged with its local healthwatches across the country—has come forward and specifically asked the Government to back the process that Professor Steve Powis is leading around all the patient-focused targets—

Q42            Chair: And no doubt there will be specialist medical charities and so on that will have some input. I assume, Professor Powis, you have been talking to some of them as part of this process—

Professor Powis: Yes. So, Healthwatch has been involved, the Patients Association is now involved, and we have been talking to charities, royal colleges, etc. So, as Chris or maybe Simon has said, there is a process of engagement with professional colleagues and patient groups and charities, which is in advance of any legal consultation that might or might not be required.

Q43            Chair: So, the idea is that if you get that right, the consultation will be quick, because everyone will have been part of the agreement of it.

Professor Powis: Yes. The idea is to engage, to ensure that we have taken account of all views and we have an inclusive process. So, Healthwatch—

Q44            Chair: You look puzzled. It’s just that often in Government the discussions are not had before the thing is finally unveiled, and then they are surprised when the consultation throws up problems. But it sounds like you are doing it the right way round—

Professor Powis: The testing process is really important, because in all other things that we do in medicine we take best practice, we seek to learn from it and improve upon it, and we test to see if those improvements are right. And there is no reason why we should not do that with a set of access standards: take what is best practice, seek to improve upon it, and test whether that is the case. And if we do that correctly, then it provides a body of evidence that the people can get behind and support.

Q45            Chair: It is touching, Professor Powis, that that is so normal in your line of work, but I am afraid to say that as we sit here it is not normal practice—

Sir Chris Wormald: You touched on an important point. This is an experiment in doing policy differently, rather than—

Q46            Chair: The Public Accounts Committee fainted en masse!

Sir Chris Wormald: As you know, the normal policy process is that the Government publish—

Chair: You don’t need to tell us; we know.

Sir Chris Wormald: Here, we ask the NHS to come forward with proposals—

Chair: That is why we are so busy.

Sir Chris Wormald: And the Government take the decision at the end of the process of the NHS developing the proposals to come forward, obviously in discussion, but it is doing policy the other way round—

Chair: There you go, Professor Powis: you probably didn’t realise you were breaking such new ground.

Professor Powis: I would volunteer to do more for you, but I’m busy.

Q47            Anne Marie Morris: Mr Stevens, you said, “Well, we will come to variation later, won’t we?” Correct. So, have you begun to really understand and sort out that variation issue, both in terms of variation in outcome and variation in access?

Simon Stevens: Variation in cancer survival has been decreasing over recent years, and if you look at the difference—

Q48            Anne Marie Morris: But across the different parts of the country it is different.

Simon Stevens: No, sure, but if you look, say, at the difference in one-year cancer survival between different CCGs, that has narrowed by about a third over the last 15 years.

Q49            Anne Marie Morris: What do you put that down to?

Simon Stevens: I put that down to greater standardisation of cancer pathways, and the work that was done on the prior and current cancer plans, as evidenced by the fact that we are seeing these significant improvements in outcomes.

Q50            Anne Marie Morris: So when do you think that gap will become zero, so that you actually have equality of outcomes across—?

Simon Stevens: We want to continue to see that narrow. We want to see it narrow from an individual point of view, in terms of health inequalities reduction, and some of that—in terms of the differences in death rates—is obviously not just a function of how well the NHS provides treatment services.

Anne Marie Morris: Indeed.

Simon Stevens: In some analyses, up to half of the difference in class-based life expectancy in this country is explained by differential smoking rates, but there are a lot of other variables that compound and cluster around that. So, there is a big piece of work to get serious about reducing risk factors for health inequalities as well as differences in the clinical quality of care and integration of pathways that exist in different places.

Q51            Anne Marie Morris: What about the access bit, because older people were thought to be the group that was least well served? I think that the last time we talked about this, you weren’t quite sure—

Simon Stevens: No, I do not think that those data have been substantiated more recently. If you go back to what has been happening on demand for routine services, the NAO Report says a significant proportion of that increase is not explained just by the fact that there are more retirees. That’s right, but your likelihood of getting an NHS-funded hip or knee replacement or cataract removal has obviously increased very substantially over the past 15 years. In the case of a number of those procedures it is going to need to continue to increase, given how important those operations are.

Q52            Anne Marie Morris: In terms of access, you are reasonably happy that, whatever the demographic, whatever the age profile, there is equal access for all.

Simon Stevens: No, not at the moment.

Q53            Anne Marie Morris: There will be, by when?

Simon Stevens: The NHS atlas of variation has pointed this out. One of the measures we will be using over the implementation of the long-term plan will be a narrowing of some of those gaps. The combination of our right care programme and the GIRFT programme that we have discussed before is all about taking out those unjustifiable differences in access and clinical practice.

Q54            Anne Marie Morris: And you reckon that, by the time you have executed that plan, you will have a much better handle on why. Because if you don’t understand the why, you won’t be able to fix it.

Simon Stevens: We do understand quite a bit about why. Partly it is different availability of staffing; partly it is different practice patterns in different parts of the country that may be explained by more services being provided, say, in primary or community services than being referred to hospital. That will show up as a difference in the access rate.

If we succeed, as we intend to, in expanding, for example, the number of direct access physio clinics across the country, so that you can go straight to a physio without having to be routed by your GP—and physio has got a hugely important role, given the importance of musculoskeletal illness as part of the overall disease burden—that will reduce the number of people who show up in an out-patient orthopaedic department, and it will appear, therefore, that there is a lower access to orthopaedic services in that geography. We have got to strip all of that out, but there is too much variation in healthcare in every industrialised country, including this one.

Q55            Anne Marie Morris: Okay. In terms of cancer, which is not quite the same as orthopaedics, because people generally die from cancer—they don’t generally die from broken bones, although I guess they can—that seems to me something quite specific in terms of access.

Simon Stevens: Orthopaedics is actually very important. A fractured neck of femur has a mortality rate for older people. As part of the disease burden, musculoskeletal is one of the biggest disease burdens in the country. Orthopaedic surgeons, therapists and others do a fantastic job and we are going to need more of their services.

Q56            Anne Marie Morris: Totally right, but what about cancer?

Simon Stevens: Yes, what about cancer?

Anne Marie Morris: Which is where we were. We weren’t on orthopaedics.

Simon Stevens: What was your question? Sorry.

Anne Marie Morris: Access. How are you going to improve access for cancer patients, not for orthopaedics?

Professor Powis: One of the things that a set of standards does, as I said earlier, is it drives a view around how you operationalise the standards, how organisations take those standards and deliver them in practice. What you find sitting underneath those cancer standards, through our cancer alliances, is a huge amount of work on time pathways, on standardised pathways of care, that different specialists in different cancer areas are working on.

That sort of guideline development, that sort of collaborative working, starts to generate a standardised set of pathways, measures, for patients, throughout the country. A benefit of having standards is that it drives greater adherence to guidelines and standardisation. What I see when I go round cancer centres round the country is my colleagues working very hard to improve the timeliness of treatment and to ensure that patients move through to diagnosis and treatment as fast as possible.

That comes through taking those standards, sitting down together in multi-professional groups with operational managers, and working through how best you do that. There is a whole host of benefits to standards, as I said earlier, that go beyond simply a measure that sets expectations. It drives good practice.

As Simon has also said, our GIRFT and right care programmes are all aimed at ensuring that good, standardised, internationally best practice is delivered in all locations throughout the country. That is a challenge for all healthcare systems, to ensure that is done, and I think we do that pretty well here, actually.

Anne Marie Morris: Let us round off this section by talking a little about these targets, because Sir Chris talked about it being about accountability, but I think it is clear it is also about public assurance. In a sense, what you measure, by and large, gets done, and so is something that gives patients assurance, as well as ensuring that the system is held accountable.

Given that that is the case, and you have talked about how you are going to change the targets, and given how important that is, in the signal that they send and the accountability, how are you going to make those changes in such a way that we still have hard-and-fast targets, we are still accountable, you cannot fudge progress, and we have measures that the public can truly feel comfortable that you will meet? You have talked about a number of ways of redefining and splitting up the targets.

Professor Powis: For cancer specifically, as we have discussed, the key change that we are promoting, and that we will test this year, is the move to a faster diagnosis standard. That is a standard that says that within 28 days of referral you, as a patient, will be given the diagnosis that you have cancer—as Simon said, that is in about 7% or 8% of those patients referred—or you do not have cancer.

That is really important, for a number of reasons. First, it is important because we know that getting a diagnosis quickly and at an earlier stage has a very positive effect on long-term outcomes. Secondly, we know that cancer is one of the most worrying diagnoses that you can have hanging over you, so speed of getting that diagnosis is important for those reasons as well. Thirdly, it sets an operational standard that means that my professional colleagues and organisations and operational managers can coalesce around designing pathways of care—obviously, in out-patients, diagnostics that achieve that target.

As I said earlier, the key task for this year—2019-20—is to start the collection of data, to start to test how that faster diagnosis standard would work in practice, and then, if all goes well, to introduce that standard as a key cancer standard next year. We are proposing a change in the standard as the taskforce recommended, which is to put the focus on a rapid diagnosis, for all the reasons I have just said.

Q57            Anne Marie Morris: Is that changing it and removing others? Is that an addition or an exchange?

Professor Powis: The proposal is also to simplify by removing the two-week targets that we have and to go to a diagnostic standard. The offer becomes: we will give you a diagnosis within 28 days. At the moment, a lot of the two-week offers are: we will see you at a first appointment within two weeks. We want to change that to: we will provide you with a diagnosis within four weeks. For all the reasons that I have said, we think it is better linked to long-term outcomes. It is what people want. They want to know whether they have cancer or not, and it allows us to design those pathways of care.

Simon Stevens: Being purist about this as well, for all the epidemiologists who will be studying the transcript of this Committee, we get the fact that cancer mortality is important as well as survival. We understand survivorship bias. That is why we are focusing particularly on early diagnosis and survival in colorectal and lung cancer, and other cancers for which there is a strong evidence base that early treatment makes a difference to mortality, as well as to survival.

Chair: It’s important that that is on the record. Thank you.

Q58            Nigel Mills: May I rewind a few minutes, Mr Stevens, to when I think you quoted the NAO Report, which set out that an increasing and an ageing population is not the main driver of an increase in elective referrals. What do you think is driving the number of elective referrals?

Simon Stevens: The first thing to say is that the growth in GP referrals has been very successfully moderated over the last couple of years as a result of the work that GPs and, increasingly, primary care networks have been doing. Over the past 12 months, GP referrals have gone up by only 0.4%, which is about a quarter of the medium-term trend rate. It is half of the needs-adjusted rate that you would expect. A lot of that extra service is being managed in primary care, despite all the pressures that GPs and community nurses are under.

Having said that, as I said earlier, part of what is happening here is that the NHS is expanding the number of cataract operations, knee replacements, hip replacements and so on, and we are constantly pushing the boundaries of medical science. Even this week we have talked about pioneering brain surgery that allows deaf children to hear for the first time being made available across the NHS. These are the auditory brainstem implants now being offered in London and Manchester. We see a steady drip-feed of these continuing innovations as medicine advances.

Sir Chris Wormald: We have done some work looking across at the drivers of demand across the world, and we have had some very interesting discussions with the NAO about this. It basically falls into three categories. The first is demography. The second is technology—in other words, things that couldn’t previously be treated. The third is variously called “the income effect”, “public policy” or “raised expectations”—in other words, we are deciding in one way or another to do more. The average is somewhere around 4% across the OECD, in terms of the demand for healthcare. It is basically a combination of those three. There is a lot of demography in there, but it is by no means the only cause.

Ian Dalton: Just to add to that and put some numbers on it, our analysts would suggest that about 45% of the growth in in-patient treatment is driven directly by demography and an ageing population. It is a success that people are living longer and therefore potentially need more treatment. That is a good thing, but it will likely continue. That is about 45% of the growth in in-patients. It is a little bit less—about 25%—of out-patient growth.

Sir Chris Wormald: Of course, all three of those drivers of demand are good things. Those are the things we want to have. They are difficult to pay for, but nevertheless they are societal goods.

Chair: We have covered that a lot in many of our hearings.

Q59            Nigel Mills: Do we think we know, then, what is driving the increase? Do we think it has bottomed out where it is and now we can deal with it, or do we still not really know?

Sir Chris Wormald: It depends. I am sure my colleagues will add to this. We understand it at the level that I described it. We know that it is those three categories, and we roughly know their proportions. I am not sure we would know it at a sort of granular level for a particular set of conditions, unless Steve knows otherwise. There would be a different balance of those factors in each medical pathway, and what you do about it is slightly different in each of those pathways.

It is true—as I say, the Comptroller and I have discussed this—that this is much less researched internationally than the classic supply of health questions. It is my personal view that an awful lot of the challenges of health going forward will be in the understanding of those demand drivers and then what you do about them, as opposed to the things we have researched in the past, which is what the next treatment is. Do you agree with that, Steve?

Professor Powis: Yes. I think we see variation in referrals for a number of reasons. As Ian said, demographics, age and population growth is one part of that. As we said earlier, we have a number of programmes that are aimed at understanding and reducing unwarranted variation where appropriate. We talked about GIRFT—the getting it right first time programme—and the RightCare programme. Another programme that the board of NHS England approved and we consulted on last year is our evidence-based interventions programme. We worked with the royal colleges, other professional groups and specialist societies to ensure that there is consistent implementation of NICE guidance.

We are actually quite good at issuing guidance, through either NICE or specialist societies, on what a standard of care should be for a particular procedure. We still find, as do other healthcare economies, that there is variation in how that is used. I know that the point of view of members of the public is, “Why is this procedure, and not that procedure, in this part of the country?” Taking into account that it is absolutely the role of local healthcare commissioners to ensure they provide the care that is required for their particular populations, we want to ensure that we address the issue of unwarranted variation through those programmes.

When you start to drill down into those individual conditions, you see a lot of reasons why that variation occurs. We are focused on programmes of work that will ensure that there is a consistency, rather than analysing to death why the variation occurs. That is the point of those programmes.

Simon Stevens: Notwithstanding the variation at any moment in time, looking out over five or 10 years, in every industrialised country we should expect that medicine and healthcare will be able to do more. That will be a very good thing. Think back to last autumn, when we were the first health service in Europe to fund the new CAR-T cancer therapies. We are going to see a lot more personalised therapies, including for rare conditions. That is going to be a huge benefit to humanity, including patients in this country.

Q60            Nigel Mills: The reason I asked the question is that when you tell us you have a long-term plan for the NHS, presumably you need to be able to model what the demand will be for certain services so you can have the staff, the resources, the wards and the beds, or whatever you need, in the right places to deliver that demand. Do you understand how much you are going to need of certain key services, or is this just a bit of a finger-in-the-air hope that, “We’ll just add units as and when we need them”? Is there any more science you can get to for that?

Simon Stevens: We have a base case so-called activity model for what we think will be the increased services needed in different parts of the system over the next five years, but there are some known unknowns in that. One of them will be the interface with social care. The Government have wisely committed to ensuring that there are no additional pressures flowing into the NHS from adult social care over the next five years, so that is the planning assumption that we have used there, which obviously affects the number of older people who will end up in hospital—

Q61            Chair: You present that optimistically, which suggests to me that it is your “get out of jail free” card when it does not work as smoothly as you just outlined.

Simon Stevens: We do not want to be doing anything rear-view mirror; we want to be going into this full speed ahead from the get-go. That is one of our known unknowns.

Q62            Anne Marie Morris: You make it sound like we are not integrating social care and health. I thought we were. You are talking about taking pressure off you by sorting out social care. Isn’t that a joint responsibility now?

Simon Stevens: Yes, that is what I said. I said our planning assumption is that that will happen in the way that it has been promised.

Sir Chris Wormald: Simon is simply restating the existing Government commitment.

Q63            Chair: Just to remind Mr Stevens that is what he is doing—just in case you were not aware that is what you were supposed to be doing.

Sir Chris Wormald: If I can come back to Mr Mills’s question, I will give you the answer that my Chief Scientist, Professor Chris Whitty, gives to that. There is a set of things in the future of health that are actually quite easy to predict. The demographic changes are very baked in across the whole world and are very predictable, so that element of how demand will change we can predict really quite precisely. The technological changes we cannot, for obvious reasons. There will be transformative technologies. Whether it is AI, genomes, quantum or whatever, there will undoubtedly be changes.

We have to be ready for the things we know are going to happen and—this comes particularly into some of the workforce, training and leadership questions we are addressing—we have to have a system that is able to respond to changes we do not know about yet, particularly technological changes. We will need medical workforces that are being trained now to use technologies that have not been invented yet. Are we creating people who are able to adapt to new technologies as they come forward? That is going to be the human resource challenge for the health service. So we are in neither of the states you describe. We have some things that are very easily predicted, for which we have to have very clear plans, and then we have to be ready for the things we cannot predict.

Ian Dalton: Taking it right down to the next five years—some of the technological changes necessarily take longer than that—and trying to answer your question directly, given that we know about the demographic change and we know that for the last few years, as we discussed at the top of this session, the demand for elective procedures has outstripped the supply, albeit both have grown and the NHS has treated more patients, what we are clear about is that in the plans that each of the health communities has to prepare across the summer to respond to the long-term plan, they have to tell us the capacity they are going to need to the treat the patients they will have. It is clear from the long-term plan that we have set out our stall that more elective surgery and more treatment will be necessary to cope with the demands from demography and the other factors that we have talked about across the next year.

Q64            Chair: What are you going to do when you know that?

Ian Dalton: It is a question of ensuring that several things are lined up. The first is the variation point we talked about—giving everybody an equal chance of accessing the services they need. The second is making sure that the capacity is in place. I am sure that we will talk about things like staffing. Although beds are not necessarily a major driver of RTT, at the margin they can have an impact on the length of individual patients’ waiting, so there is a capacity issue. There is a big capacity issue around diagnostics, which we touched on earlier. We will need significant planning—

Q65            Chair: We know those problems. What are you going to do to ensure that they have got all that? We know that NHS trusts have routinely got more demand than they were established for.

Ian Dalton: We need to draw a distinction between the years that we have come through, when we have treated more patients in the face of rising demand. We are in a different resourcing situation over the next five years, with the NHS’s new revenue settlement. That will enable us to put more resources into elective treatment than we have been able to so far. That still leaves us with all the work that we currently have under way, including the number of diagnostic staff. We will have to come back on scanners, where we clearly need some significant capital investment. England does not feature well on the OECD list of access to MRI and CT scanners, so that will be a mission for us.

Q66            Chair: This is not normally a shroud-waving Committee, but we have been reminding the NHS and the Department about the capital funding issue for some time now.

Ian Dalton: The answer to your question is that we expect each patch to undertake a proper analysis of demand and supply. We will then do our bit to help them with the capacity, including actions that are already underway—for instance, recruiting more radiologists and radiographers, who we know are important in diagnostics and imaging.

Professor Powis: As I said earlier, we need to transform elements of the elective care pathway. An awful lot of the elective care pathway in the initial stages is out-patient work. We have had the out-patient model of delivery for probably hundreds of years. You can go to hospitals not very far from here that were built over a century ago, where “Out-patients” is carved in the stone. As the Royal College of Physicians reported last autumn, it is a mode of offering treatment that needs to change radically. It needs to take account of the fact that we work differently and can use technology differently. We can see people once—we can do things on one day rather than having them come to out-patients, go for a test and then come back for the result. All those things are happening in examples across the NHS. What we need to do as part of the long-term plan—what we need to ask our local healthcare systems to do—is to ensure that we are doing that everywhere. When you start doing that, you start to release resources and impact on some of those numbers, particularly at the front end of the elective pathway.

Q67            Chair: It also sounds a bit more like the patient is at the centre.

Professor Powis: Yes, and in my experience patients do not want to go to a needless hospital appointment, particularly those who might be frail and elderly—a day at the hospital is actually a really big deal and a big disruption to their daily life. There is a win-win in this: we can produce a service that is more fit for the 21st century, more efficient and moves patients more quickly through an elective care process.

Q68            Nigel Mills: Mr Dalton, presumably you want CCGs to prepare these reports or assessments for you, but does it make sense to have 195 CCGs? Presumably they can manipulate the same level of population data and apply the same sort of demographic analysis and percentage increases to come out with a local plan. Presumably you will then audit them and say, “No, that’s not consistent with how we did the national model for the NHS 10-year plan. Go back and redo it.” Is there not some level of central help you can give to say, “Actually, we think demand for this in your demographics will go up by Y,” rather than reinventing it everywhere and arguing about it?

Ian Dalton: Two points: the first is that we are looking to STPs to be the planning cluster because, by definition, the 200-odd CCGs are quite small in their geography. We are asking for a larger plan in the footprint, which reduces the number to 42, I think, rather than nearly 200, and provides sufficient scale to look at care in the round for patients.

The second point is that we will be clear that there are some expectations around the broad demographic and other drivers that we have talked about. I think it is also fair to say—it would be wrong of us not to focus on this—that access and capacity still vary locally, as we talked about earlier. We need to understand those variations. It is the case that if you are looking at providing more diagnostic services. For instance, you need to do that in a sufficiently large but still local population to understand the variance and to be able to deal with it. The needs of different populations start from different places.

Q69            Nigel Mills: I am always intrigued by how you manage demand and capacity in the NHS. If you were running a Tesco or something, and you thought that you had more demand than you had supply, you would put a shop where you needed a new shop and would try to direct people to shop at the right shops so that you have queues in the right places. Can you do that in the NHS? Can you say, “Well, I know that in the east midlands I need a bit more hip-replacement resource. Actually, I will put it in Derby and we will move patients there until we need one in Leicester”? Is it possible to move people around in that sort of way?

Ian Dalton: It varies. Clearly, we are a national service. In terms of different services, you get different approaches. One of the things that we are looking at—we are already working hard on pathology, and we will look at imaging in the same way—is making better use of equipment and scarce staff to provide services more equitably across the country. We know that the demand for diagnostics is rising rapidly, so we are working hard with the NHS to develop 29 pathology networks, which will be critical to delivering the extra pathology tests that we will need over the next few years.

We also know that we have some significant issues on expanding imaging, as we have talked about before, so we are having a look at imaging. The aim is to use the equipment and the staff, supported by technology, more flexibly to treat more patients and to look after more patients’ needs.

On access, we also expect local areas—we have signalled this in the long-term plan—to have a look at how potentially to draw greater distinction between sites that serve emergency patients and electives. We know that the emergency patient must take clinical priority and that particularly in times of high emergency demand such as winter, sometimes elective patients have to have their procedures postponed, or cannot get access to theatres—clinically the right thing to do—but our challenge to local populations and the people planning services for them is then how we potentially move to hotter and colder sites, so that we can treat more patients. That is ultimately about making the best use of the resources that we have, which is why the planning process has to be run locally.

Q70            Nigel Mills: May I move on to something that might be of some contention? How do you understand the link between the availability of beds in hospitals and the fact that we are not hitting the waiting time targets? Is there a link between those two, or is that just a blind?

Ian Dalton: There is no direct link—this is certainly the view of our analysts—between the achievement of the 92% RTT standard and bed occupancy. If you take a time series, you will see that over some periods of time RTT rates increase at the same time as bed occupancy increases. It is therefore no surprise that when only 3.5% of RTT treatment pathways are admitted patients, the link between—

Q71            Nigel Mills: Is that admitted overnight, or in the day?

Ian Dalton: That is admitted overnight.

Q72            Nigel Mills: What is the percentage for a day patient?

Ian Dalton: I do not have that figure to hand.

Chair: They are still taking up a bed space, if they are there during the day.

Ian Dalton: They are, and they are still potentially—but the point that I am trying to make—

Q73            Chair: But the 3.5% overnight figure is a false measure, isn’t it?

Ian Dalton: No. Those are the patients who will, by definition, be more complex patients. They will stay—

Chair: They might just be having their operation later on in the day so that they cannot quite be sent home.

Ian Dalton: But typically they will be patients who stay in for more than one day—this is a one day-plus length of stay, so these patients might be having quite major procedures. The point I am making is that the evidence suggests that bed occupancy is not linked to the achievement of the RTT standard. That said, bed occupancy has been rising inexorably across the acute sector for some years. At the margin—we should not denigrate this—the emergency patient taking precedence can mean that the elective, the in-patient, does not get access to the bed or theatre and has to have a procedure postponed. That is clearly a major concern. While the RTT standard is not affected by the occupancy level in hospitals, it is fair to say that occupancy in hospitals has been rising, and that is a matter of concern.

Sir Chris Wormald: As I understand it, how busy the hospital is overall does affect the RTT rate, but not specifically bed occupancy.

Ian Dalton: Yes, the key measure would be flow, particularly the flow through the hospital, which is often reflected by the emergency care targets.

Q74            Nigel Mills: Do you think we have gone, at best, far enough or, at worst, too far in reducing the number of beds? Has it got too tight for hospitals to manage and is therefore seeping out into patients having procedures cancelled?

Ian Dalton: We use our beds reasonably efficiently. That said, there is still more efficiency to get out of our theatres and beds. We are reducing the length of stay, as you know. We have freed up more than 2,000 hospital beds by cutting length of stay, and we think there is significant further scope for cutting length of stay. There is still scope for addressing some of the significant variation in day case rates—inguinal hernia repairs vary from 41% to 92% day cases by CCG. Programmes such as the Getting It Right First Time initiative offer ways of using our beds, theatres and staff more efficiently. If you look at the next five years, those clinical improvements are the way we get the most patients treated.

Q75            Anne Marie Morris: Professor Powis made the important point that we are trapped in old ways of delivering things, and we need to look at different ways forward. The case quoted was how we might do more by using technology and how we might reduce face-to-face out-patient appointments. Mr Stevens, you have committed to reducing that by one third in the next 10 years. Mr Dalton, how will you do that? What is the plan?

Ian Dalton: Professor Powis may describe some of the clinical interactions, because clearly this is a clinically-led discussion about a change in clinical practice.

Q76            Chair: Where is the good practice?

Professor Powis: There are a variety of ways by which you could achieve the one-third reduction. One way that does not particularly use technology is to ensure that we make maximum use of what are often called one-stop clinics, which I referred to earlier, where instead of the traditional model of coming to out-patients, being asked to have some tests, coming back for the results and then getting a treatment plan, all that is done in a single visit. Increasingly, the work we have done in cancer has driven those sorts of one-stop clinics. We need to see that across all the elective care pathways.

The second way is, as we integrate primary and secondary care, to ensure that we are managing patients in the correct environment. Simon gave the example of first-contact physiotherapy, where by using a different model of care we get patients to the right person quicker and cut out process in between. The third is the use of a range of technologies that we use in our everyday life, but which we do not use when we go across the threshold of the hospital. That could be video consultation, although it does not have to be. It could be emails or texts. In many out-patient appointments what we are doing is communicating. Where a test or a physical examination is not required, it should be possible to do that interaction in another way.

Q77            Anne Marie Morris: What you are talking about is aspirational and good—gold star—but given that you have committed to reducing face-to-face by one third in 10 years, is there a concrete plan? How will you do that?

Professor Powis: We have started work with the royal colleges and with our integrated care systems. Across NHS England and NHS Improvement we have been doing work on this already, and we now need to expand it. One of the tasks is to work with our specialty colleagues in the royal colleges and others to work out what works. Every specialty is a little bit different, so what works in my specialty—kidney medicine and transplantation—might be a little different in respiratory medicine and chest. We need to look at what the opportunities are for reducing face-to-face appointments and examples of where that is working already.

The example given in the long-term plan is in my specialty, kidney medicine: in east London, my colleagues at Barts Hospital and local GPs have worked out a consultation system that does not require patients with possible kidney disease to attend hospital. It is about rolling out those models and then, as we have said, asking integrated care systems, as part of their plans over the summer, to start to lay out how they will translate those principles into their local pathways of care.

Q78            Anne Marie Morris: So how can the Committee hold you to account? How can we measure your success? Are there any staging points? Ten years is a long time, but a commitment to reduce by a third is quite a big one.

Simon Stevens: I suspect that we may be back here together before 10 years has passed.

Anne Marie Morris: I think so, Mr Stevens.

Chair: It is all right—we have a long list of things that we will be writing to your successors about, even if you are not here in 10 years.

Simon Stevens: Just to repeat what we said earlier, under the process that we are using now, having got that overarching national set of implementation frameworks, every part of the country, as Ian said, will have the chance to set out what its own trajectory looks like on those service changes. We will then bring that all together in the autumn for the national implementation plan for the long-term plan, and that is the point at which you will have the answer to your question.

Anne Marie Morris: It sounds as if at Christmas we will have a bumper session looking at all of this, which is great.

Q79            Anne-Marie Trevelyan: On reducing face-to-face appointments and helping to get better flows, one of the problems in some of my GPs’ practices is that the broadband is incredibly poor. We have drilled right down and found that it is not a lack of broadband in the town or the village; it is that the service provision in the NHS is causing endless problems. I have GPs watching little whirry things while waiting for the technological information to go through that should speed up the decisions.

I am doing a little ad hoc survey among colleagues and making them ask their GPs about this, but it strikes me as an incredibly easy thing to solve that would rapidly open up the ability of our GPs to do a great deal more. I ask you to have a look at that, because it is the NHS part of that digital service provision that is the problem.

Sir Chris Wormald: Yes, and our colleagues at NHS Digital are looking at exactly those issues. I will get you an update.

Anne-Marie Trevelyan: That would be kind. Thank you.

Q80            Chair: You might want to refer to the rural payments programme as well when you go down this route, because there are lessons to be learned. The NAO has a whole catalogue—a “How not to do it” guide, effectively—or you could read Richard Bacon’s book if you want a summary.

Sir Chris Wormald: Just to reassure you, this is a discussion that we have had quite recently with NHS Digital. I have not brought the details with me of exactly what they are doing, but I will come back to you.

Chair: It takes a brave permanent secretary, or indeed chief executive of the NHS, to take on digitisation and big IT changes.

Simon Stevens: I think you have heard Chris step forward on that one.

Q81            Chair: Pass the buck back! Anyway, Professor Powis has outlined the vision for the future that you now have to deliver.

Sir Chris Wormald: As I am sure you know, this is an agenda on which my Secretary of State is extremely keen. Indeed, we have just established a joint thing between me and Simon.

Chair: It makes being a professor of transplant surgery seem easy, doesn’t it?

Professor Powis: I don’t do the surgery; I only do the medicine.

Q82            Anne Marie Morris: Mr Stevens, I am interested in how you are looking at integrating primary and secondary care, which is absolutely the way forward. Given that many of the royal colleges have said that they recognise that they have moved towards being over-specialised in their training, and that they need to be more generalist so that they can deal with more interactions with patients, have you looked at how you might expand primary care? Rather than just having integration, could you change the skillsets of your GPs so that they could do many of the things that they used to do before, such as minor ops, which are cheaper in a primary care setting than in a secondary one? Is that on your radar, given the call from the colleges?

Simon Stevens: It definitely is. I think both the Royal College of General Practitioners and the Royal College of Physicians are fully signed up to doing what you have just said. The RCGP is working with us and with the BMA on the formation of the primary care networks over the next several months, which is backed by investment that will mean up to 22,000 more staff in practice teams across the country. It will be linked with community nursing for the first time so that we get an expanded multidisciplinary team, including therapists, social prescribers, physios, clinical pharmacists and others.

Q83            Anne Marie Morris: But will you be looking at a greater number of people who have more specialist generalist skills? The physician associates were a good example of individuals who were well qualified across a number of different specialisms and who could work in primary care or secondary care. If you look at some of the other areas—the old professions, such as GPs—clearly you could rewrite how they are trained, so that they could go back to doing some of the things that, frankly, they did 10 years ago, rather than necessarily just relying on introducing these new specialist generalists.

Professor Powis: Our GPs have always been our generalists. They are the part of the medical profession that has the most general skills because they are the people at the frontline who see people coming in with non-specific conditions.

Q84            Anne Marie Morris: I am talking about specialist generalists. One of the challenges is that you often go to hospital for a skin problem and you chop a piece off for a sample and send it off for a cancer test. The GP could do that and in the old days they did do that.

Simon Stevens: Many GPs still do. My GP does that.

Q85            Chair: It is  just a question of getting him to stop.

Simon Stevens: It is just a question of getting in the stocks.

Q86            Chair: We don’t want any more information than that, but thank you for sharing. Professor Powis.

Professor Powis: Our GPs are very good generalists. As Simon said, the plan going forward is to support their general skills with a wide range of multidisciplinary staff, so that they can focus on what they do best, which is the complex conditions that they increasingly see with an ageing population.

Q87            Anne Marie Morris: Can I just challenge you on that? Given that we are always going to have fewer resources, given the demand, which is going to keep growing, having lots of people fiddling with the same group of people, rather than getting one person skilled up to deal with five or six different challenges, problems and health issues—

Professor Powis: There is a balance there. I could certainly take you to practices that very effectively work with a skill mix of general practitioners, pharmacists, paramedics and social prescribers to produce a holistic service for a patient, which absolutely delivers the care that an individual patient requires by the right professional.

The future is about that multidisciplinary, multi-professional working. That has been the direction of travel in my lifetime as a doctor. In my specialty, I wasn’t allowed anywhere near a dialysis machine because the nurses did the dialysis, and increasingly nurses manage transplant patients when they come back from follow-up, so our skill mixes are supporting each other in our professional groups.

Now we have put in place in general practice, in the long-term plan and with the GP contract, a multidisciplinary workforce based in primary care networks that will absolutely drive the delivery of multi-professional, team-based working. As Simon said, that is exactly what the GPs and the colleges have been asking us to do and been driving towards, so we have a lot of support in that direction of travel, and it has generally been welcomed.

Q88            Anne Marie Morris: It is the right way to go but I am also thinking about the best use of resources. If an individual is trained to do more things then ultimately you are going to get more for the money that you invested in training. The GPs want to be able to do more. I am not saying that they don’t want the networks but, if they want to do more and it the BMA wants them to do more, we shouldn’t just put them in aspic and put specialists around them; we should think about how we could help them do more.

Simon Stevens: Completely. If we had a panel of GPs here you would have a spectrum of opinion. At one end of the opinion would be, “As GPs, we should be operating at the top of our licence, doing the things that only distinctively we can do.” At the other end of the spectrum would be an opinion that says, “Actually, part of the therapeutic encounter in general practice is with the whole person. It is understanding all of the context, not just the particular thing that somebody walks in the door and presents with.” That is part of what makes general practice one of the most stimulating careers in the NHS. You have got that spectrum of opinion and diversity of experience but, across networks of practices in a given geography, serving 30,000 to 50,000 population, that is how we are going to get that mix of skills and GPs working for that population.

Q89            Anne Marie Morris: While that is happening, Mr Dalton, are you going to start looking at the qualification and training of each of these professionals to try to ensure that they are better able to work in that multi-skilled environment, which includes skilling them up to do a broader variety of things?

Ian Dalton: Bear in mind that the NHS is publishing an interim people plan shortly and after the spending review again, towards the end of the year.

Q90            Chair: That’s more definite than most people have said. It keeps slipping back.

Ian Dalton: We will be publishing a final people plan, which will necessarily address the issues that you raise about skills.

Q91            Chair: But it will take a long time to implement.

Ian Dalton: By definition, staff training has a long lead period. While you will see that the interim people plan has some actions in it that can be taken immediately—areas around retention of nurses, for instance—by definition we are also building the future state. That includes training people in different ways to do different things. That is certainly part of it. You will have seen in the long-term plan some statements of intent in that regard.

Anne Marie Morris: I’ve got just two more questions. Mr Stevens, one of the things that you said was that within the elective piece, there is a particular cohort of diseases and problems that are higher risk in terms of poor patient outcomes. As you said, you effectively have: everybody else; the elective; and the urgent. Is there any merit in looking at creating three categories, rather than two, so that you can actually isolate those problems within the elective group? Because of the nature of that particular disease, issue or whatever, you have got to get in there faster than for some of the others. You might not then have some of the poorer outcomes.

Simon Stevens: In theory, there could be, but in practice it would be very hard to operationalise—I am sure Stephen will want to come in on that. On the judgment about clinical urgency, you might have two patients with putatively the same condition, but the circumstances of one might mean that they actually need to be looked after immediately or much more quickly. Anything that you try to memorialise as a set of national guidelines would ultimately be too blunt a tool for the judgments that individual clinicians need to make with their patients.

Within the elective category, we absolutely want urgent patients treated very quickly, but to actually specify, “This patient with a throat cancer should get priority over that patient with a heart condition,” in some kind of memorialised guideline would be folie de grandeur at a national level.

Professor Powis: As a doctor, what I have done all my working life is essentially ensure that patients with the most urgent clinical need are treated as quickly as possible. I am absolutely sure that we are all trained to do that. All clinicians are constantly ensuring that the patients who need to be treated urgently are treated urgently. A set of standards is not designed—or shouldn’t be—to substitute for that clinical judgment. A set of standards should aid and supplement it.

Q92            Anne Marie Morris: Surely one of your challenges is an 18-week current wait. It was a clinician who said, “Well, it’s elective but normally that’s a GP,” and unless there is some sort of check halfway through—

Simon Stevens: On cancer, for example, we have a set of cancer-specific times.

Q93            Anne Marie Morris: But what about the others?

Simon Stevens: That is why in the A&E part of Steve’s review he also looks specifically at whether there is a way of doing some of what you have described.

Professor Powis: If I have a patient who I think needs urgent surgery, I will discuss with my colleagues and my operational managers how that patient can have urgent surgery, because the clinical need of individual patients will always take precedent.

Q94            Anne Marie Morris: Then you have already seen that patient. What about the ones who have just been seen by a GP, are referred, and wait 18 weeks? They might die in those 18 weeks, and nobody with clinical expertise will have intervened to ask the question.

Professor Powis: The 18-week pathway does not necessarily mean that you wait 18 weeks to be seen. It is a process that starts when you are referred in and there is then a process of out-patient care, which, as I described earlier, is typically decision making around diagnosis and treatment options. If I have a patient referred to me who I think needs urgent treatment when I first see them, as a clinician I will ensure that they are treated urgently. If another patient comes in to see me as an out-patient but does not need that urgent treatment, I will manage that case differently. That is what clinicians do day in, day out in the NHS. As I said, a set of standards helps to drive the organisational structures that support them in doing that, but it does not replace that clinical judgment and nor should it.

Q95            Anne Marie Morris: I totally agree. I am just concerned about those who get caught in that 18-week wait. Although you are a good doctor—and there are many good doctors—there are an awful lot of patients and an awful lot of doctors, and there is no way of pulling all that together and taking any view, and there is no way for the hospital to be held to account for what it does in that 18-week period.

Chair: There may be under Professor Powis’s scheme.

Professor Powis: My experience on a day-to-day basis, both as a practising clinician and when I was a medical director of acute trusts is that we would make decisions to prioritise and ensure that patients who needed the most urgent treatment would get their most urgent treatment. As Simon says, the cancer pathways are a faster pathway than the elective pathway because we know cancer has an effect on survival.

Q96            Anne Marie Morris: Mr Stevens, have you thought of a pathway for other conditions, although clearly not as detailed as for cancer? Otherwise elective is just too big a bucket to handle.

Simon Stevens: We have some of those—things like rapid access chest pain clinics are investigating cardiovascular or thoracic symptoms. A whole range of other services have those. There are professional guidelines and so forth that are configured around that. But that is not the same as an aggregate, overarching national target, which can never really capture the sophistication of the clinical judgment needed in those individual cases—

Q97            Anne Marie Morris: I understand. My concern is that it is very hard to hold the NHS to account for elective—

Sir Chris Wormald: It is very similar to the conversation we had last time about screening. The 18-week target is a public service target; it is not a clinical target. You have to leave that in the professional box. If people were taking the 18 weeks as being the clinical determinant of how an individual should be treated, I think everyone would be worried, wouldn’t they? Now, that is a public service expectation rather than a clinically driven decision.

Professor Powis: There is a balance in setting these highest-level standards, which is the set of standards in the constitution and the handbook that the public take most account of, that politicians do—for good reasons—and we do. If you have too many of them and we ask the service to measure too much, you start to lose the benefit of them and you start to try to micromanage everything. So sitting underneath that is professional judgment and clinical expertise. We have to allow that to be the bedrock of how patients are managed. Those standards need to be balanced in number, covering the key things, as I said at the start, in terms of outcomes and what we broadly want the system to do. But they cannot be so many and so detailed that we are trying to manage everything.

Q98            Chair: In your review, will you recommend, for example, a different approach to peer review or good practice sharing to ensure that you are constantly keeping an eye that those clinical decisions are being made in the right way for the right reasons so that best practice is shared—

Professor Powis: Not as part of the review, but that work goes on all the time. That is what NICE does, and it is what our specialist societies and our royal colleges do. As I said in terms of our cancer alliances, it is what they are doing all the time. Sometimes, we will produce national guidance which will assist in that in the NHS and in NHS Improvement, but we are not the only people who provide that expert guidance. In our cancer pathways, to talk about cancer again, there are pathways of care designed to ensure that patients with specific cancers and specific presentations move through their treatment as quickly as possible. That is complementary to a set of national reporting standards; it is not instead of it.

I should have said earlier that standards are only one part of a system that ensures that patients get the best care at the most appropriate time in the most appropriate setting. There are other things that we do as well that impact upon that.

Q99            Anne Marie Morris: Mr Stevens, I have one final question—you will be pleased to know—that goes back to funding and your assumption that there will be enough money in the social care pot so you will be okay in the health area with the money you are going to be given. Given that the Department is now across health and social care, what role will you take in ensuring that the Government give local authorities the money that is needed? If they do not, what are you going to do about it?

Chair: Mr Stevens, that is an open goal.

Simon Stevens: What we are going to do is, in a constructive way, help bring forward some of the analysis as to what the resourcing requirements in social care look like. Of course this is not just for frail, older people; this is also for people with learning disabilities and autism coming out of some of the children’s social care, working with our partners in academia, think-tanks and the university sector—and local government, I should say—so that those data and that evidence are available for consideration by policy makers whenever the spending review takes place.

Q100       Anne Marie Morris: But it is important for you that they get the money. So are you going to work very closely with local government to ensure that happens? That is a question for Sir Chris as well.

Sir Chris Wormald: As I said before, Simon is simply repeating the commitment the Government has made. As I think I have said to the Committee before, of course social care is a public service in its own right, not simply an adjunct to the NHS, and we will want to fund the whole of social care properly. We will need information both from local government and from the NHS to enable the Government to deliver the promise that they made at the time of the long-term plan on that element of the social care budget that directly butts up against the NHS in exactly the same way as we will want to take evidence from the NHS and local government—particularly local government—on the whole social care budget, which is more in the spending review process. We will need a lot of information both from the NHS and from local government—even better if it is done jointly—to allow us correctly to deliver the promise that the Government made at the time of the long-term plan.

Chair: We will come back in a moment partly on that, but first Mr Mills. Then we are nearly ready to wrap up.

Q101       Nigel Mills: As a final question, do we know whether patients waiting longer harms them? Is that something that we have tried to work out—whether failure to hit these targets has caused any harm?

Professor Powis: I have a number of responses to that question. First, going back to what I said earlier, individual clinicians will always manage individual patients within those overall standards. An individual clinician will be making a judgment as to how urgent a particular treatment might be, whether a knee replacement or a coronary artery bypass operation, and that will differ according to the patient. I am confident that clinicians are trained to do that—that is what they do, and they do it to minimise harm—so that works at the individual patient level, beneath those high-level standards.

Secondly, where clinicians, managers or anybody involved in care feel that harm has resulted from a delay in treatment, our expectation is that that would be reported as part of the incident reporting systems that all providers have in place. The purpose of those incident reporting systems is to ensure that the incidents are recorded, that lessons are learnt locally, and that action plans and improvement are put in place to ensure that improvements are made. The reasons for those delays can be quite complex; they are not necessarily straightforward. That information is collected centrally and the NAO Report shows that, but I do not think that it is possible easily to answer the question based on that cumulative set of incidents, or to extract from the data a direct answer to the question of whether changes in waiting times have an effect on harm—because of the way that those things are reported.

Thirdly, there are circumstances in which we have asked provider organisations to undertake harm reviews for long waiters in cancer and in elective care. I was involved in one of those locally when I was a medical director, and we reviewed a large number of cases. Actually, the number of patients who suffered severe harm, of those thousands of patients, was I think two—from memory, both of them were cancer cases that came through an elective pathway rather than a cancer pathway—and that is because a lot of the patients on those long waiting lists are orthopaedic operations, ENT operations or plastic surgery, where a delay does not impact on survival. It might mean that some pain lasts a number of weeks longer, but there is not a major impact on survival, which is what we classify as severe harm.

I would also say of the 92% standard of 18 weeks is that—this is one way of thinking about it—it is being met at about 22 weeks. In the round, that is a four-week difference. If you think about it, though it is important to get these procedures done quickly, as we said earlier, for a patient to get a hip operation, a four-week difference in the round—

Simon Stevens: For the 92nd percentile patient—

Professor Powis: Is unlikely to make a huge difference in outcome. That is not to diminish the effect that a delay might have on an individual patient, but a direct answer to your question about harm.

Finally, when you look at the literature, as I have done, it is not consistent. When people have looked at the question of whether changes in waiting-list times are directly linked to harm, it is very difficult to get into. It is very contextual for the condition—the answer for one procedure might be different from another one.

It is a difficult question to answer. My conclusion is that I cannot overwhelmingly say that there is a positive correlation between the sorts of changes that we have seen in the waiting lists in the last few years and an overall effect on harm. The conclusion of the National Audit Office in the Report was that that data is difficult to extract.

Q102       Anne-Marie Trevelyan: Going back, Sir Chris, to the question about money and social care and making sure that it works better, how much is money—clearly some, particularly in the social care sector; you have managed to snaffle your part of the extra cash—and how much is actually going to be legislative change requirements? What sort of levels of change are going to be required to prove it? Clearly, as Simon knows, I speak as a Northumbrian who has had the pleasure of watching Jim Mackey make it happen in Northumberland through the level below legislative change. But at a national level, how much is that going to be necessary to make it work smoothly?

Sir Chris Wormald: That is a question that we could double the length of the hearing in answering. The short version is exactly as you say. Clearly money is a factor; we have never denied that. As you say, there are an enormous number of things that can be achieved under the existing legislative position, and that is what our primary focus is on. As I am sure you have observed in Northumbria, most of the most important joining-up is done between individuals, because they decide to, as opposed to because there is some law or piece of legislation.

Then there are some quite specific legislative barriers that make it more difficult for people to join up if they want to, which are some of the things we are looking at with colleagues in the NHS as part of the legislative proposals. My personal view is that those are the end of the story, rather than the beginning, and in the vast majority of the country, there is an awful lot more that can be achieved within the existing legislative framework, if everyone enters into the conversations with the right mindset and the aim of delivering for the individual. That should be our first set of focuses.

Q103       Chair: I have a couple of last quick questions. In all these changes, and Professor Powis has outlined clearly some of the great ideas and opportunities, how, in the settlement that is available, especially given that we do not have staffing plan yet, can you be sure that there will be enough people like therapists and others in the system to make sure that you can actually deliver on the new targets? I look at Sir Chris first and then maybe Simon Stevens.

Sir Chris Wormald: That is at the heart of the work on the human resources questions that we are—

Chair: But it is not just about the human resources; it is about the money to fund that. That was not part of the long-term plan.

Sir Chris Wormald: Just to be clear, of course, the vast majority of the money for people is within the mandate. By a long way, the biggest proportion of the NHS budget goes on human beings. The bit we have not settled and waits for the spending review is the HEE component, about £5 billion, which is completely dwarfed by what the NHS spends on people. There is an awful lot that can be done, and is being done, within mandate resources. The spending review will then settle the bit on the end, which is about training and then the component—

Q104       Chair: We could say that the waiting list is a bit of a sign of under-resourcing from the start, is it not?

Sir Chris Wormald: I do not want to repeat what we have said previously, but despite the resourcing pressures, it has remained stable. Clearly, there are, in a lot of things we have discussed, a lot of capacity questions, which come down to people. Meeting those challenges is a combination of several things. It is partly about recruitment, but that is of course over the longer term. An awful lot of it is about retention and then an awful lot of it, as my colleagues have described, is about how staff are used and the skills question—

Q105       Chair: I feel like, if I close my eyes, I could be back a year, or two years, or even several years before that on this Committee, because we have heard those things many times.

Sir Chris Wormald: And they are the types of questions for which the answer is never finished. When you are dealing with a system where creating a new doctor, even the most junior doctor, takes seven years, and creating a senior doctor takes decades, you will always be in a state of trying to consider the future of the health service and work out what you need to be training right now, with a new undergraduate or a new nurse or—

Q106       Chair: Except you did say earlier that the demographic part of the picture is quite predictable, so we could have predicted some of this.

Sir Chris Wormald: As we have described to the Committee before, there is a whole series of workforce and human resources things in train, including the expansion of medical places and medical schools, which we have described previously. It is not that there is nothing happening. New resources allow the NHS—given that the vast majority goes on people—to begin to address all those questions. We have a whole series of things in train and then we have a set of things that are to come.

Q107       Chair: We heard from Mr Dalton, who said, “We know what areas need and what their demand is.” Mr Dalton couldn’t quite say, “We will then give them what they need,” because he does not quite have the purse strings, as he might like, so it is down to you, Sir Chris, to ensure that they have the resources to deliver that.

Sir Chris Wormald: As I say, the vast majority of the resources are fixed, whereas the part outside the mandate is not fixed, and will be fixed in the spending review. What I am saying is that the vast majority of the capacity questions we are talking about are not going to be solved by starting to train a new person right now.

Q108       Chair: I am afraid I have some bad news for you, because half an hour ago the Chancellor said that if Brexit is not resolved, there will not be a spending review. Mr Dalton talked about it being at the end of the year. We have had later and later dates from all your colleagues across Whitehall. If there is no spending review this year, which is entirely plausible at this point, what will you do? What is the plan B? You must have a plan B in the civil service.

Sir Chris Wormald: I cannot comment on what the Chancellor has said, but I have not heard. Clearly, budgets for whatever the next year is need to be set somehow.

Q109       Chair: So is there a plan B in Whitehall effectively to roll over the last year?

Sir Chris Wormald: I can’t discuss plans from the Treasury that I have not heard the Chancellor say.

Q110       Chair: Whether you can tell us or not, please just reassure us that there has been some discussion at the colleagues meeting at least, or somewhere at the Treasury, as to what the plan B is if there is no spending review.

Sir Chris Wormald: Of course, we discuss these things all the time, but I am sure the Treasury will set out its proposals.

Q111       Chair: It is unfair perhaps to land the Treasury officer in case he has not heard the Chancellor, but it was at the Treasury Committee about half an hour ago.

Marius Gallagher: In that event, I am sure that the Treasury would have a conversation with Departments, including DHSC.

Q112       Chair: We will have to have a conversation with Departments. Can you tell us how quickly those Departments would know the outcome of that?

Marius Gallagher: I wouldn’t know that at this stage.

Q113       Chair: It sounds like a bleak moment potentially. But Simon Stevens is grinning, because you still have the money settlement for the long-term plan. So at least you have some of the money.

Simon Stevens: It just shows the wisdom of having that five-year long-term plan.

Chair: There we go: long-term plan—bingo! I think we can end on that.

Simon Stevens: So that the NHS can proceed despite the national uncertainty.

Q114       Chair: I am not sure whether this is the last hearing at which you will have the Comptroller and Auditor General here before us. I am trying to think whether we have another health one coming up. I am sure Sir Amyas is going to miss the health sessions particularly. Is there anything you would like to say, Sir Amyas, as a last statement, before we move on?

Sir Amyas Morse: Is there anything I have to say? Is this a question or a statement?

Chair: It is entirely up to you.

Sir Amyas Morse: I have very much enjoyed the creative testimony I have heard from the Health team.

Chair: Thank you very much. You see, honesty comes out in the final weeks.

Simon Stevens: We feel it is entirely consistent with the degree of objectivity in the judgments from the NAO.

Chair: I think that is a very low blow, if I may say so, Mr Stevens. The NAO has our full support under the current Comptroller and Auditor General, and his successor.

Thank you for your time. The transcript, as ever, will be up on the website in the next couple of days uncorrected. You may now go and read what the Chancellor said.