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NHS Long-term Plan

Volume 794: debated on Monday 7 January 2019


My Lords, with the leave of the House, I shall now repeat a Statement given in the other place by the Secretary of State, Matt Hancock MP. Before I do so, I put on the record my appreciation and thanks to my noble friend Lord O’Shaughnessy. I am sure the House will agree that he has been an outstanding Minister and cares passionately about the NHS and the people who work in it. I wish him every success in his future endeavours. The Statement is as follows:

“Mr Speaker, with permission, I would like to make a Statement about the NHS long-term plan. The plan sets out how we will guarantee the NHS for the future. It describes how we will use the largest and longest funding settlement in the history of the NHS to strengthen it over the next decade, rising to the challenges of today and seizing the opportunities of the future.

It is worth taking a moment to reflect on when the NHS was first proposed from this Dispatch Box by Churchill’s Government in 1944—when, even after the perils of war, infant mortality was nearly 10 times what it is now; when two-thirds of men smoked and life expectancy was just 66; 10 years before we knew the structure of DNA; four decades before the first MRI.

The NHS has, throughout its history, led the world. But one constant has been that core principle set out by the national government—that the NHS should be available to all, free at the point of use according to need, not the ability to pay. As last year’s 70th anniversary celebrations proved, the NHS is one of our proudest achievements as a nation. We all have an emotional connection to it—it is part of our family history—and we all owe an enormous debt of gratitude to the people who make the NHS what it is and work so hard, especially during the winter months when the pressures are greatest.

Because we value the NHS so much, the new £20.5 billion funding settlement announced by the Prime Minister in June provides the NHS with funding growth of 3.4% a year in real terms over the next five years. This means the NHS’s budget will increase in cash terms by £33.9 billion, rising from £115 billion this year to £121 billion next year, £127 billion in 2020-21, £133 billion in 2021-22, £140 billion in 2022-23 and £148 billion in 2023-24. This rise, over £1 billion more in cash terms than proposed in June, delivers on our commitment to the NHS and will safeguard the NHS for the long term. This will help address today’s challenges. The NHS is facing unprecedented levels of demand. Every day, the NHS treats over 1 million people. Compared with 2010, NHS staff carried out 2 million more operations and saw 11.5 million more out-patients last year. Despite record demand, performance was better this December than last. So we will address today’s challenges, not least with the extra £6 billion coming on stream in under three months.

As well as addressing today’s challenges, the NHS long-term plan sets up the NHS to seize the opportunities of the future. At the heart of the plan is the principle that prevention is better than cure. In future, the NHS will do much more to support people to stay healthy, rather than just treat them when ill. So the biggest increase to any part of the NHS, at least £4.5 billion, will go to primary and community care, because GPs are the bedrock of the NHS. That means patients having improved access to their GPs and greater flexibility about how they contact them; better use of community pharmacists; better access to physiotherapists; and improved availability of fast and appropriate care to help communities keep people out of hospital altogether.

Organisations across the NHS, local councils, innovators and the voluntary sector will all work more closely together so that they can focus on what patients need. There will be a renewed clampdown on waste, so we can ensure that every penny of the extra money goes towards improving services and giving taxpayers the best possible return.

Ultimately, staff are at the heart of the NHS. The long-term plan commits to major reforms to improve working conditions for NHS staff, because morale matters. Staff will receive better training and more help with career progression. They will have greater flexibility in their work, be supported by the latest technology that works for them and be helped with their own mental health and well-being. This already happens in the best parts of the NHS, and I want to see it happen everywhere. We will bring in training, mentoring and support to develop better leadership in the NHS at all levels. We will build on work already going on to recruit, train and retain more staff so that we can address critical staff shortages.

The plan is the next step in our mission to make the NHS a world-class employer and deliver the workforce it needs. To deliver on these commitments, I have asked Baroness Dido Harding to chair a rapid programme of work, which will engage with staff, employers, professional organisations, trade unions, think tanks and others to build a workforce implementation plan that puts NHS people at the heart of NHS policy and delivery. Baroness Harding will provide interim recommendations to me by the end of March on how the challenges of supply, culture and leadership can be met, and final recommendations later in the year as part of the broader implementation plan that will be developed at all levels to make the NHS long-term plan a reality.

That is the approach we will be taking to support the NHS over the next decade, but what does it mean for patients and the wider public? It means patients receiving high-quality care closer to home; supporting our growing elderly population to stay healthy and independent for longer; more personalised care; more social prescribing; and empowering people to take greater control and responsibility over their own health through prevention and personal health budgets. It means access to new digital services to bring the NHS into the 21st century. It means more support for mothers by improving maternity services, and more support for parents and carers in the early years of a child’s life, so we can be the best place in the world in which to be born, in every sense. We will improve how the NHS cares for children and young people with learning disabilities and autism by ending inappropriate hospitalisation, reducing over-medicalisation and providing high-quality care in the community.

The NHS will tackle unacceptable health inequalities by targeting support towards the most vulnerable in areas of high deprivation. To help make a reality of the goal of parity between mental and physical health, we will increase mental health service budgets, not by £2 billion but by £2.3 billion a year. For the first time ever, we will introduce waiting time targets for community mental health, so that people get the treatment they need when they need it. We will also expand services for young people to include those up to the age of 25.

The long-term plan focuses on the most common causes of mortality, including cancer, heart disease, stroke and lung disease. The health service will take a more active role in helping people to cut their risk factors: stopping smoking, losing weight and reducing alcohol intake. The NHS will improve the quality and speed of diagnosis, and improve treatment and recovery, so we can help people live well and manage their conditions. We will upgrade urgent care, so people can get the right care more quickly.

The NHS long-term plan has been drawn up by the NHS, by over 2,500 doctors, clinicians, staff and patients. The plan will continue to be shaped and refined by staff and patients as it is implemented, with events and activities across the country to help people understand what it means for them and their local NHS services. The experts who wrote the plan say that it will lead to the prevention of 150,000 heart attack, stroke and dementia cases and to 55,000 more people surviving cancer each year. In all, half a million lives will be saved over the next 10 years, funded by the taxpayer, designed by doctors and delivered by this Government.

Today is an important moment in the history of the NHS. Our long-term plan will ensure the NHS continues to be there, free at the point of use, based on clinical need and not the ability to pay. But it will be better resourced, with more staff, newer technology and new priorities: a health service that is fit for the future, so it is always there for us in our hour of need. I am proud to commend this Statement to the House”.

My Lords, I join the Minister in wishing the noble Lord, Lord O’Shaughnessy, well in his new position. I suspect this probably does not mean that he will be any less active on these issues.

I thank the noble Baroness for repeating the Statement. It would be churlish not to welcome additional funding for the NHS, but to suggest in some way, as the third sentence of the Statement does, that the noble Baroness’s party and Government were responsible for the establishment of the NHS is breathtakingly cheeky, to put it mildly. That is particularly so given that her party proceeded to oppose and vote against the establishment of the NHS by the post-war Labour Government.

What must we welcome in today’s Statement? We can welcome the use of genomics in developing care pathways and the commitment to early cancer diagnosis—after all, that was one of Labour’s policies in the most recent general election and in the ones before it. We should of course welcome the commitment to new CT and MRI scanners—again, a Labour policy. We welcome the greater focus on child and maternal health, including an expansion of perinatal mental health services—we welcome it because it has been our policy for some time. We welcome the rollout of alcohol teams in hospitals because, again, we have been urging the Government to do that for some time.

More generally, it is a shame that the noble Baroness started her Statement in the manner of making claims which are not borne out by actions. In many ways this symbolises the disingenuousness which lies at the heart of the Statement. The Government’s words about their conduct and behaviour towards the health and social care services in the UK are one thing, but their actions simply do not match their words.

There is much that one can agree with in the 123-page document launched today, especially given the involvement of doctors in creating it. However, many of the ideas, such as “prevention is better than cure”, seem to have come as a great revelation to our relatively new Secretary of State, if his recent performance in the media is anything to go by. That has, however, been the thinking on these Benches and across your Lordships’ House in many debates over many years, as it has been for decades in all the think tanks and health charities and, indeed, among almost everyone involved in the NHS.

Here is the rub, however—and let us look at prevention. How can prevention happen when, according to the Health Foundation, public health budgets have suffered a real-term funding reduction of £700 million to £1 billion in the past few years? Some 85% of councils plan to reduce their public health budgets in the next year, totalling almost £100 million of cuts. Smoking cessation, obesity and sexual health programmes—to name but three that the Minister mentioned—will all be cut, with a profound effect on a range of long-term illnesses and expensive conditions to the NHS. Will the Minister give a commitment today, as part of the long-term plan, to reverse these totally counterproductive public health cuts?

The long-term plan cannot be delivered if there are not the staff to deliver it, as was mentioned. The plan waxes lyrical about its intentions, but again the rub is in the action. Why is there a delay in setting out its ambitions for the NHS workforce today, when there are over 100,000 vacancies across the NHS, including 40,000 for nurses and 9,000 for doctors? According to recent estimates, by 2030 there will be 250,000 vacancies across the NHS. Experts and doctors’ leaders have warned that the Prime Minister’s vision, and that of Simon Stevens, risks being undermined and reduced to a set of “groundless aspirations” due to the NHS’s deepening staffing crisis, continued cuts to public health and limits to what the extra investment will achieve. Why does the long-term plan fail to address this mounting workforce crisis?

Turning to the suggestion of legislation, as a veteran of the Health and Social Care Act 2012, I read that the Government seek to:

“Remove the counterproductive effect that general competition rules and powers can have on the integration of NHS care”.

I have a mixture of reactions to that. We welcome the recognition that the Health and Social Care Act 2012 created a wasteful, fragmented mess, hindering the delivery of quality healthcare, but I cannot resist saying that that is what we predicted during the passage of the Bill. After billions of pounds wasted and the creation of a huge bureaucracy, are the Government now preparing to consign the whole of the Andrew Lansley Act to the dustbin of history? Will the Minister indicate when we will see draft legislation and the timetable for its consideration?

On social care and integration, if the care of the elderly, people with chronic conditions and co-morbidities and the disabled continues to be cut through successive local government settlements where billions of pounds have been lost, the aspirations on integration and joined-up services will be lost. The Government have set their face against tackling the social care elephant in the room and this plan, again, fails to address it. Where is the social care Green Paper? How can there be any empowerment if we do not have the staff or the expertise to deal with this?

What about the gaping holes in today’s announcement? We have waiting lists of 4.3 million with 540,000 waiting beyond 18 weeks for treatment. We have A&Es in crisis, trolley waits of over 600,000 and 2.5 million people waiting beyond four hours. Why is there no credible road map in this to restore the statutory standards of care that patients are entitled to, as outlined in the NHS constitution? Is that not a damning indictment of nearly nine years of desperate underfunding, cuts and failure to recruit the staff we need in the NHS? Will the Minister confirm that, once inflation is taken into account, the pay rise is factored in and the standard NHS working assumptions on activity are applied, there is actually a shortfall of £1 billion in the NHS England revenue budget for this coming financial year?

Briefly on Brexit, during the referendum campaign Vote Leave said that the money saved would bring £350 million a week to the NHS. When the Prime Minister announced the £20 billion extra in the summer, she said that it would partly be paid for by a Brexit dividend. Others have dismissed that suggestion. The Treasury has said that a combination of economic growth and perhaps even tax rises may be needed. Will the Minister comment on that and confirm which of those is correct and what will happen?

There are many welcome ambitions in this paper, but the reality is still that there is no plan to recruit the health staff we need, no plan for social care, no plan to restore waiting time standards, and no plan to reverse public health cuts. I am not convinced that the NHS is any safer in the Government’s hands now than it was before this Statement. We will certainly be monitoring this very carefully indeed.

My Lords, I associate these Benches with the very warm wishes sent in the direction of the noble Lord, Lord O’Shaughnessy, in his future endeavours.

We welcome the publication of the long-term plan today. It is a very important document. It will take time to absorb all its contents and we on these Benches would welcome an opportunity to debate it in more detail. Yes, there is a lot to welcome in the plan, particularly the focus on prevention. We welcome the focus on children and young people’s services and particularly the inclusion of issues relating to people with learning disabilities. But there are many concerns about how this plan will be put into effect. The workforce plan will have to work a lot better than any of the existing workforce plans, particularly if we are to be successful in retaining existing NHS staff as well as recruiting new staff and getting NHS staff to return, feeling that it is possible to work in more flexible ways. It will require a much more creative staff plan than we have at the moment.

Of course it is good news that we will focus on prevention rather than cure, but will the Minister clarify the precise funding mechanisms that would allow that to happen, particularly the role of NHS England, Public Health England, and local authorities in this new world? Will she also confirm the role that pharmacies will play in the public health agenda and the funding mechanism for that? Also, when will the Green Paper on social care be published? It is critical to the agenda that is being set out. I particularly welcome the £2.3 billion set aside for mental health services as part of the long-term plan. What is vital now is that everyone in the NHS, local authorities, schools and employers work together to deliver these plans and ensure that that money gets to the front line. Will that money be ring-fenced?

I take a particular interest in children and young people’s mental health. We are told, and it is welcome, that there will be a new emphasis on crisis care and a new single point of access or crisis hotline delivered through NHS 111 and with that, we are told, all children and young people experiencing mental health crises will be able to access age-appropriate crisis care 24 hours a day, seven days a week. That is to be welcomed. But will the Minister say whether that new crisis care service, which I wholeheartedly support, will be part of or separate from the adult 24/7 community-based mental health crisis response service, which is also contained in the plan? Will it also include 24/7 availability of CAMHS assessment in all A&E departments in hospitals up and down the country?

My Lords, I thank both noble Baronesses for their contributions to this Statement. I am very grateful for some of the positive comments that were made from both Benches. I am very proud that this Government are putting £20.5 billion into the NHS. That is an amazing achievement. We must recognise that this is a great achievement for the NHS. The NHS is working closely within itself and with the Government to ensure that we can deliver the outcomes we all want, which are improved care for those who use the NHS and to prevent people from getting ill in the first place. I welcome this. As someone who worked in the NHS in my early days I recognise the importance of this money. We are not being disingenuous in what we are trying to achieve—far from it. It is because we passionately care about the NHS that we are doing this.

A number of points were raised by both noble Baronesses. I hope that they will appreciate that I have only just got this brief, but I will endeavour to do my best to answer all the questions. However, if there are any that I have not responded to, I will of course write to the noble Baronesses and place a copy in the Library. The noble Baroness, Lady Thornton, quite rightly raised the issue of staff. We need staff in the NHS if we are to carry out any plans. They are very important to us. She asked what we were doing. There are record numbers of dedicated NHS staff and they work tirelessly to make sure that patients get excellent care. We support them by training 25% more doctors, nurses and midwives, giving a significant pay rise to over 1 million staff and listening to the issues that matter to them. We know that this is a complex area and we are listening and talking to staff to see how we can bring about greater improvements in workforce planning.

To put this into context, there are currently record numbers of doctors, paramedics and ambulance staff, and all HCHS staff. The monthly workforce statistics for September 2018 show that since May 2010, there are over 45,900 more professionally qualified clinical staff working in NHS trusts and CCGs, including 16,500 or 17.4% more doctors, over 6,500 or 2.2% more nurses, midwives and health visitors, and 13,400 or 8.3% more nurses on our wards. We recognise that it is a complicated issue and that there are staff shortages in some areas, and we are actively engaging with staff and looking at solutions as we move forward.

Other issues raised by the noble Baroness, Lady Thornton, related to Brexit and to scrapping the 2012 Act as part of the long-term plan. That was about legislation and I shall deal with legislation first. I think the basis of the noble Baroness’s question was whether we are going to scrap the Lansley reforms. In June the Government asked the NHS to come forward with proposals for legislative reform to support the ambitions of the long-term plan, which have now been set out clearly. NHS England will continue to engage nationally and locally to refine the proposals over coming months. The Government will consider updating legalisation where there is clear evidence that doing so would improve services for patients.

The noble Baroness, Lady Thornton, mentioned performance and the noble Baroness, Lady Tyler, also touched upon it. The Government have been clear that through the long-term plan the NHS must get back on the path of recovering performance. The plan is clear on proposals for updating urgent and emergency care and on expectations to reduce waits for planned operations. We must ensure that we have a health system which focusses on clinically appropriate targets. The ongoing clinical review of standards, which will report in the spring, will be followed by a period of testing and evaluating any new or refined standards. The review is considering standards for physical and mental health.

The public health grant was touched upon by the noble Baronesses. We are already giving local government more than £16 billion for public health services over the current spending review period. The Government recognise the important role played by local authorities in supporting people to live longer, happier lives and managing demand for health services. We have a clear commitment to ensure that public health services continue to do that. Future budgets for PHE and the public health plan, which is part of the financial settlement for local authorities, will be finalised at the upcoming spending review.

I have a couple of minutes. On the adult social care Green Paper, it was recently announced that the Government will provide local authorities with £240 million this financial year, 2018-19, and £240 million next year for adult social care so that people can leave hospital when they are ready and go into a care setting that best meets their needs. This will help to free beds over the winter. There is a further £410 million for social care.

We recognise that the NHS and social care provision are two sides of the same coin and that we cannot have a plan for one side and not for the other. While the long-term funding profile of the social care system will not be settled until the spending review, we will publish the social care Green Paper soon, ahead of the spending review.

I am conscious that there were a couple of other issues, particularly in relation to the role of the NHS in relation to public health, which the noble Baroness, Lady Tyler, raised. I think I have highlighted it. On going forward and the implementation plan, as indicated in the Statement, the Secretary of State has asked my noble friend Lady Harding about how we move forward, particularly on workforce planning. An implementation plan will go to the Secretary of State by the spring and a more detailed implantation plan will be put in place once the spending review figures are available as part of the spending review framework. There will be a framework in terms of quality. I am conscious that my time is up, so I will write to the noble Baroness on the two other questions on adult social care and the differences in mental care for young people.

My Lords, I apologise to the noble Baroness for intervening. She paused, and I thought she had finished.

I refer noble Lords to the register and particularly to my advisory role with SweatCo.

I turn to public health issues. The plan makes a very bold statement about tackling some of our major public health problems. When it comes to specific government action, it is silent. I refer the Minister to the Chief Medical Officer’s annual report for 2018 which was published just before Christmas. It was very hard talking in some of the recommendations that the Government need to take. I shall cite just one of them. In relation to obesity the Chief Medical Officer recommended that the Government review the use of fiscal disincentives in relation to foods high in sugar and salt and of incentives to increase fruit and vegetable consumption. Why is the plan silent on these issues?

The plan is an overall strategy. The detail will be filled in over the coming months and years as we work closely with clinicians and people working in the NHS. That is why, looking at obesity, we introduced the sugar tax, which has been very successful. Noble Lords may say that we did not get as much money as we thought we would, but to my mind that is great; it means we have got preventive action because companies are now putting less sugar into drinks et cetera, which is a bonus. The noble Lord is right. That is why we are putting so much more money —£4.5 billion—into the preventive agenda so that we tackle the issues that he has just indicated.

My Lords, I declare my interest as professor of surgery at University College London and chairman of UCL Partners. I congratulate the noble Lord, Lord O’Shaughnessy, on the tremendous contribution he made to the work of your Lordships’ House as the Minister dealing with health and social care. He was greatly regarded and respected.

It is absolutely appropriate for Her Majesty’s Government to have focused on developing a strategy over 10 years to address the long-term sustainability of the National Health Service, which is something that your Lordships’ House elected to address through an ad hoc Select Committee two Sessions ago. There are many aspirations in this 10-year plan, but the important question is how Her Majesty’s Government propose to go about determining what is achieved, how it is to be implemented and how the outcomes are to be measured. There are important aspirations about, for instance, the adoption of personalised medicine, the adoption of genomics to drive diagnosis and the selection of care, the development of a workforce that is able to apply innovation and genomic medicine to the routine care of patients and the adoption of a digital strategy for patients and healthcare professionals to improve clinical outcomes. How are Her Majesty’s Government going to go about developing the metrics to determine how success should be measured? How will they go about providing a baseline picture of the current situation in different parts of the National Health Service so that the purpose and ambition of this plan can be properly measured? Which part of the NHS is going to be responsible for measurement and implementation: NHS England, NHS Improvement or, indeed, the Department of Health and Social Care?

That is almost all my brief. I echo the sentiments expressed by the noble Lord about my noble friend Lord O’Shaughnessy. The noble Lord is basically asking about next steps and who will be accountable for the plans. That is the question I asked: who is in charge? NHS Improvement and Health Education England are looking at workforce planning and clinical placements for nurses. They will relate to NHS England which is looking at the overall framework. The intention is that the work that my noble friend Lady Harding will be taking on will feed into workforce planning, and we will produce an overall framework in relation to clinical issues. A template will also be produced so that we know what best practice is, and this can then be filtered down to local areas through the integrated care system and clinical commissioning groups. NHS England will retain the overall strategy for all this. I hope that I have answered the noble Lord’s questions. As he knows, there are variations and a number of health inequalities around the country. It is imperative that we begin to address those and that is behind part of the framework.

My Lords, I thank my noble friend and other noble Lords for their kind words. It has been an absolute pleasure to work with them on health and social care issues over the last two years, as well as with the amazing staff in our health and social care system, who inspire us, treat us and look after us all the time. Like my noble friend, I am incredibly proud that in the 70th year of the NHS it is a Conservative Government who are making this historic funding settlement. However, I believe that this is an important document for another reason, which is that it marks a significant milestone in moving towards truly personal care that delivers precision medicine designed for individuals and better uses technology and the kinds of genomic medicines and innovations that the noble Lord, Lord Kakkar, talked about. It became clear to me during my time as a Minister that this can happen only if we complete the digitalisation and joining up of patients’ data so that, wherever patients land in the health system, any clinician has access to all the relevant information about them and can tailor treatments to them. Not only does that bring tremendous benefits for direct care but it has a huge positive impact on our life sciences industry, which is one of the great strengths of this country and one of our great hopes for the future. Can my noble friend confirm that the long-term plan involves the ambition of fully digitising the NHS and bringing that data together for the benefits that I have described?

I thank my noble friend Lord O’Shaughnessy for his comments. Of course, data and information are very important. It is very difficult for clinicians when they do not have good information and data, because they have to start again, asking questions and looking at the investigations that have been undertaken on a particular patient. Therefore, the future lies in the greater use of technology and data-sharing but, at the same time, this must be balanced with ensuring that safeguards regarding who accesses the data are put in place, as well as ensuring that the data is accessed with the patient’s consent.

My Lords, I echo the words of other noble Lords who have raised the extremely good work that the noble Lord, Lord O’Shaughnessy, did during his time as a Minister. I always found him helpful and diligent when I raised health issues with him. Therefore, I am sure that I speak on behalf of the House when I thank him and wish him well.

The plan talks about genomics, artificial intelligence and data, which are all about a new way of working for the NHS. However, if the rules and ethics do not keep up, there will be severe unintended consequences for both individuals and society as a whole. What specific work, undertaken by which specific body, will be carried out to ensure that the rules, laws and ethics of this new world mean that the new way of working takes place within a framework that is safe for individuals and society and does not lead to significant unintended consequences?

The noble Lord makes a very valid point. As I indicated in my previous answer, data-sharing, although important, must be balanced with ensuring that safeguards are in place for the patient. We work, and will continue to work, very closely with the Information Commissioner and the data protection guardian. I know that we recently passed legislation for those posts to be put on to a statutory footing, although I do not think that that has happened yet for the data protection guardian. I am sure that they will ensure that a very keen eye is kept on these matters, but of course NHS England, the CQC and other regulatory bodies will also have a duty of care to ensure that the safeguards are implemented effectively, as will local organisations that provide those services.

My Lords, I declare my health interests and associate myself with the remarks about the work of the noble Lord, Lord O’Shaughnessy. I welcome the priority for mental health in the long-term plan, particularly for children and vulnerable people who find themselves in the criminal justice system. However, currently approximately 85% of spending is on physical health and a mere 15% on mental health. As the additional funds are invested in mental health and learning disability services, will the noble Baroness please tell the House what the new balance between physical and mental health will be in 2023 to achieve parity of esteem?

The noble Lord makes a very important point. This Government are keen to see parity of esteem between mental health and acute services. Mental health will receive a growing share of the NHS budget—in real terms worth at least a further £2.3 billion a year by 2023-24. To give noble Lords an idea, by 2023-24 an extra 345,000 children and young people up to the age of 25 will receive mental health support in the community and in schools and colleges, with access to round-the-clock mental health crisis care through NHS 111, and an extra 380,000 adults will be able to access talking therapies. However, I am afraid that I do not have the information to answer the noble Lord’s question about the exact difference in spending between the two.

My Lords, can the noble Baroness tell us exactly how the review carried out by the noble Baroness, Lady Harding, will be undertaken? There is already considerable evidence that further investment in health visitors, district nurses and continuing professional development for all professional non-medical staff is vital to achieve the outcomes set out in this plan, which I wholeheartedly support. I join the rest of the House in thanking the noble Lord, Lord O’Shaughnessy, in particular for the way in which he has worked so constructively with the non-medical workforce over the past few years.

Basically, the workforce proposals will depend not only on the outcome of the spending review; as the noble Baroness mentioned, my noble friend Lady Harding is also being tasked to carry out a review. Her programme of work will be to develop a workforce implementation programme that agrees, in advance of the spending review, the additional investment that is needed for the training, education and continuing development of the workforce through the HEE budget, which is yet to be set by the Government. The workforce implementation programme will be published later in 2019. Of course, how that review is undertaken is a matter for my noble friend, but it will be sharp, rigorous and clear, and her findings will be available to the Secretary of State by the spring.

My Lords, I have a slight advantage over other noble Lords in that I was a fan of my noble friend Lord O’Shaughnessy long before he became a Member of this House.

My noble friend is right to say that these are amazing sums of money and indeed it is a very serious document. However, it bears some relationship to earlier long-term plans, by this Government and previous Governments of different hues, in so far as it talks about cutting down on waste, improving best practice, co-operation with local authorities, improving training and a shift towards personal care—all of which would release precious resources. However, our success in achieving all those things has been fairly variable. Can my noble friend tell me why the plan will be different this time? How will its success be monitored, and will regular reports of the monitoring of how efficiencies are dealt with be made to this House?

I thank my noble friend; as he says, there is a challenge. For the record, since everyone around the House, quite rightly, has praised my noble friend Lord O’Shaughnessy, I am not his replacement; I am standing in for him.

It is an interesting question; we know that publishing this document alone will not translate all the plans and objectives into reality. As I have already said, that is why we have asked the NHS to develop a clear implementation framework by April, to set out the commitments that should be delivered by local systems to ensure that there is transparency for patients and the public. This is not something that has come out of the ether from nowhere; we are building on success. It is not a radically different plan; we are picking out the best of what we need to achieve. The plan builds on what has been achieved in recent years and the learning from previous reform programmes. It has already benefited from widespread engagement during its development, working with organisations that represent over 3.5 million people to ensure that its vision and aims are the right ones.

My Lords, I bow to no one in my admiration of the NHS, having worked in it for many years—and of course I have, with the merry band of admirers, strong admiration for the noble Lord, Lord O’Shaughnessy. The document is extremely strong on aspiration and it identifies many of the problems but, as always, the big problem is implementation: how it is carried out, and whether we will achieve it. As always, implementation is dependent on the workforce.

I was going to ask about what we are doing in public health but that has been asked already, so I will ask about general practice. The Government have made many valiant attempts to improve general practice, but the fact is that general practitioners are unhappy, dissatisfied and under a lot of stress. Many are retiring early; many are not able to get recruits into their practices to succeed those who are leaving. Can the Minister explain what is happening to a friend of mine, who is a general practitioner and tearing her hair out because she cannot get a successor to a partner who has left? She is increasing her workload and is on so many committees that she can hardly spare the time to go to her clinical practice. General practice is in a sorry state. If we cannot improve it, none of this can happen.

The noble Lord is absolutely right that implementation is key. We can have great aspirations, but we must have a proper plan in place to ensure that we can deliver. The implementation plan that I have spoken about previously will flesh this out in much greater detail so that we can look at what the IT systems will be, what the genomics will be, what clinical issues we want to tackle and what performance areas we want to highlight. On primary care, I have already indicated the amount of money that we are putting in place for preventative measures. GPs are the gatekeepers to secondary care, so it is important that we have a healthy and viable workforce in primary care.

Primary care is of course very important. We are committed to delivering 5,000 more GPs; we recognise that this might take longer than we had hoped, but there has been a bit of improvement in the numbers from last year to this year. NHSE and HEE have a number of schemes in place: to recruit more GPs, including increasing the number of doctors entering GP training; to boost retention through the GP retention scheme and the GP retention fund; and to support doctors through the GP Health Service and the releasing time for care programme. Last year, to put it in perspective, we recruited 3,473 GP trainees against a target of 3,250. That was a 10% increase on 2017, but I recognise that we need to do better.