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Gavin: Hello and welcome to The Lancet Voice, The Lancet's bi weekly podcast looking at the world of health. You can subscribe to The Lancet Voice wherever you usually get your podcasts. It's coming up to the end of January 2021 and I'm your host Dr. Gavin Cleaver and I'm joined as ever by my co host Dr.
Jessamy Baganal. Member of Parliament Jeremy Hunt was the longest serving Health Secretary in the history of British politics. After moving on to become Foreign Secretary he's now the chair of the Health and Social Care Select Committee who have been hearing evidence over the last year from major actors in the COVID 19 pandemic.
He joins us today to talk about the pandemic and health in Britain. Jeremy, thank you so much for joining us. Pleasure. We wanted to kick off by just looking back a little bit at the last year. So in 2017 at The Lancet, we published this study that ranked the UK's NHS 30th out of 192 countries in terms of health systems.
But it's commonly thought of as a world leading health system, but we've had one of the highest, if not the highest death rate from COVID 19. How do you explain this kind of incongruence for this difference?
Jeremy: I think we are a very good health system, but the reason for the recognition we get internationally is we were the sixth country in the world to set up a universal health system.
New Zealand was actually the first, and, but we were the first big famous country, if I can put it that way, without being disrespectful to our community. Kiwi cousins to do it. And and the British people really took that to heart as something very close to British values, the idea that it doesn't matter who you are, you can access decent healthcare.
And we remained in survey after survey, the most accessible healthcare system in the world, the healthcare system with the smallest gap between the care typically accessed by rich people and poor people. And we're very proud of that. What we haven't been as successful as doing is making sure that our quality is always the best in the world.
And I really hope that can be our mission post pandemic, that we say it's not just about access. We want the NHS to, be famous for the safety and quality of our care and we do. pretty well, but, we still have lower cancer survival rates than Germany and France double the number of baby deaths that Sweden has.
And I think what the pandemic showed is some gaps in our public health architecture. Too early to understand why our death rate was so high, I'm sure the government has made some mistakes. On the other hand, it's got some things very right, like the vaccine rollout. But I think most people would say that the health inequalities that we have left parts of the population more exposed to a pandemic.
The 10 12 year gap in life expectancy between the richest 10 percent and the poorest 10%. That poorest 10 percent often has problems with obesity. They are overrepresented in people from minority ethnic backgrounds. And so I think one of the things we will come out of this pandemic wanting to do is to have a much more sustained national focus on reducing health inequalities.
Gavin: What are some of the things you think we could do generally to address this this quality gap, as you say?
Jeremy: Some of them are within the policy bounds of the Department of Health and Social Care, and some of them are a whole government. exercise and some of them are about personal responsibility.
So it's a big thing, but I was proud to make a lot of progress on a smoking policy when I was health secretary. We introduced plain paper packaging, banned the display sale of cigarettes. And what I learned from That about public health is that these things take a very long time, but you can get momentum I think the smoking work really started under Caroline Flint when she was public health minister, and she Was responsible for the legislation banning smoking and inside public places Which was very controversial at the time, but had a very big impact and so on something like obesity you need to change norms We need to deal with the fact that often the cheapest food can be the least healthy, frozen pizza, tubs of cheap ice cream and so on, but people on low incomes might need it to fill themselves up.
So you've got to think about income inequality as well and housing and all these other things, so it's definitely achievable. Other countries have got less of a gap in life expectancy between rich and poor, but it's gonna need sustained focus from the top over a generation to make the progress that we want to.
Jessamy: Thanks, Jeremy. And you said there that these things take a long time. Part of the reason that they take such a long time is sometimes they're politically quite polarizing and people don't necessarily like the thought of, a state that's intervening too much in people's lives. Do you think post COVID 19 that will, that relationship, or that slight, libertarian view that There shouldn't be an impact in individuals lives on what they eat and how they eat will change.
Jeremy: I think it might do, because, we tried an uber libertarian approach in the early stage of the pandemic, and we found that it simply doesn't work. In a pandemic you have to act faster than the virus. And you just can't do that without clear, early, decisive government action. But, I do think that there are Also ways in which the libertarian agenda will progress positively in the years ahead.
Changes in technology will mean very soon that we will be able to access our entire health record on an app on our phones. And that will mean that people become, people like me who aren't doctors or have any kind of medical or scientific background, develop much more knowledge about the medicines and treatments that they're receiving become much more expert patients.
And that's something that. Doctors were welcome and we will need to take more responsibility for our healthcare if we're going to move to a model of care where we put as much emphasis on prevention as on cure. But, I think the traditional hesitance of prime ministers to get involved in this because of the charge of, wanting a nanny state will dissipate.
And I think that we've seen that with Boris Johnson, even during this pandemic, where he has suddenly got religion on tackling obesity, which I think is extremely welcome because of his own experience.
Jessamy: Of course. And that sort of technological progress, which obviously we'd all like to believe is the truth, but with it obviously also comes.
It's huge problems with inequality in terms of the digital divide, education and, patients becoming, at least in my experience, patients becoming expert patients it's very much a socio economic based on education level. How do you see that?
Jeremy: We definitely need to deal with the education divide and that's not just because of health inequality.
That's just something that we, it's a kind of half achieved revolution. When I grew up in the 1980s, I went to a public school and that was a period where middle class parents said, if you possibly can send your children private because you can't trust state education. Now, I don't think middle class people would say that at all.
If you've got a good state school, they. They're every bit as good as the best private schools, but we don't do as good a job as we need to for people who leave school and don't go on to university. And that's a big challenge. And I think when it comes to health The challenge is going to be particularly when it comes to genomics because if you can imagine a world in which, which what I would like to see the NHS leading the world by, decoding the genome of every baby born on the NHS and that's sitting on your medical record What's going to happen quite soon is that rich people are going to get their genomes decoded there, there's a whole new class of doctor that is emerging in America who are genome understanders who specialize in helping people interpret their DNA and rich people are going to access those people to find out if they've got an enhanced risk of getting bowel cancer or breast cancer or whatever and I think the NHS may well end up being one of the first healthcare systems that spreads the benefits of that amongst the whole of society in a way that it's just not possible to do in America.
It's interesting in America now that doctors are beginning to worry ethically about that divide and about the fact that the benefits of all those extraordinary changes might not be spread equally.
Gavin: As a former foreign secretary, of course, as well as a former health secretary, what's your take over the last year on the kind of differing countries approaches to COVID?
And I guess the kind of lack of joined up international cooperation as well.
Jeremy: I make two observations. First of all, there is just a very clear geographical divide between East Asia and Europe and North America. And East Asia got it right. Mainly because they had direct experience of SARS and MERS.
Whereas in North America and Europe, there was groupthink that the way you tackle a pandemic is really from the flu playbook. In fairness to Chris Whitty there wasn't that groupthink in the UK when it came to vaccines. And we set up the UK Vaccines Network in 2016 and funded Oxford to work on a vaccine against MERS, which then became the foundation of the AstraZeneca Oxford coronavirus vaccine.
But we did have this group thing in terms of pandemic response, and we shouldn't have. And I was part of the establishment that had that group thing, so I have my share of responsibility as the health secretary at the time. But I think the bigger thing that worries me than that is that we, we're still not nearly as good as we should be in healthcare learning from other countries.
And it was very clear in January of last year that the best response to COVID was happening in Taiwan and Korea. Korea has not had more than nine deaths on any one day. And I think we should have been studying that a lot harder. And there was a kind of mentality China's communist so that's a different society.
And maybe not enough understanding of the fact that Taiwan and Korea are very lively democracies and yet they found ways to deal with the pandemic that they secured democratic consent for And we could have learned a lot more quickly.
Gavin: That's actually interesting. What is it?
What's your take on the kind of securing? Democratic consent as you say in these countries versus I guess what happened over here in the UK
Jeremy: The rather shameful thing for people like you and me who I'm, who support open societies and liberal democracies is that in the last year, people in China have had far more freedom to move around their country than people in the UK.
And I think that there are things that Korea has done, which would have been impossible to advocate a year ago, such as when they had a COVID case looking at people. Just without permission looking at people's mobile phone records and credit card statements to see where they'd been and then doing the contact tracing on the basis of that, which people might now consider acceptable in an emergency situation, given that they can see the number of lives you save by being able to use technology in that way is just so Huge.
Now you obviously have to have parliamentary locks on those kind of intrusions into civil liberties, but I think you might get consent for things now that you wouldn't have dreamt of before. For the simple reason that Korea has not had to have a national lockdown. Think of the intrusion of liberty that a national lockdown has meant for us in Britain, let alone the lives
Gavin: lost.
So do you think, I guess in that sense that a coming pandemic would be dealt with quite differently from the beginning in the future in the uk.
Jeremy: I do. I think we have learned to act much faster. Of course, the government was criticized a couple of weeks ago for not going into the third lockdown more quickly.
But in truth the first day back after the Christmas holiday was the 4th of January and on the 3rd of January the Prime Minister got on television to say no, the schools are going to open. And on the 4th of January, one day later, he changed his mind. So he did act very quickly. And I think we have definitely learned the need to act fast.
Jessamy: A lot of what we've been talking about has revolved around tech and, different ways that you can manage these things. The NHS historically has a very bad sort of history with being able to implement big tech projects. And certainly, that seems to be one of the major problems again in this pandemic, test and trace and all of these other things.
Why do you think that is? And how can the NHS start to improve on that front?
Jeremy: The NHS has very quietly been having a pretty big tech revolution over the last ten years. And I say quietly because all anyone remembers about NHS tech is connecting for health and how things went wrong. But even back in that period of the 2000s under Tony Blair's government even though connecting for health didn't work out.
The GP's set up their own electronic health records which have turned out to be some of the best in the world and we've been using those records as the basis of a record that can be shared across the entire health and care system. So in my time we opened up. A& E departments to GP records. When I arrived, I think there was only one A& E department in the country that could access GP records.
Now they all can. We're gradually opening it to the whole of hospital care and it will be open to the whole of the social care system. And we're We've now launched an app which, you can book appointments with your GP, order repeat prescriptions talk about your data sharing preferences, and access your summary care record.
I think there's been quite a big revolution. I think the NHS could turn out, curiously, to be a leader in patient's use of tech. Where we are chronically behind is hospital technology systems, which are still absolutely creaking at the seams in too many places. Although we do have some. Some good ones but nothing like what you would get in an American hospital.
Jessamy: And for those hospital systems In terms of what the difficulties have been and how we might overcome them.
Jeremy: They've been squeezed of capital. Something that I hope will start to change now. Not least after the the 20 billion settlement that I secured as part of my last things as health secretary.
Because until that point we were so short of capital. cash that we were raiding the capital budgets and part of that is IT. I think when we do start to get these systems in place we need to learn from what happened in the U. S. where they charged headlong into automating into the digitization of hospital records under Obama.
And what they found was that a lot of doctors were spending more time looking at screens than at their patients. In fact there's a famous advertisement for An emergency care doctor in Arizona, where they put at the bottom of the ad No electronic health records here, and this is a selling point for the hospital because doctors are getting so cross in the U.
S. about having to spend so much time inputting data. So I think the key lesson from the U. S. is that when you move to electronic health records, you need to have electronic health systems that improve doctor productivity, not ones that slow them down in terms of their time with patients. That's what I think the GP, that's why the GP records that we have here have been so successful, because most GPs really do think they've helped GP productivity, and that's why they've embraced them.
Jessamy: So on investment, do you think that the years of austerity have hampered the NHS's growth?
Jeremy: I think that they were very tough for the NHS and I felt the NHS needed more capacity and more money when I was health secretary. I was part of the cabinet that introduced that austerity and I think it was the right thing to do because if we hadn't put the economy back on its feet, we wouldn't have been able to afford that 20 billion rise that Theresa May agreed in 2018, which is about 1 percent of GDP.
significant uplift. But I think we need more capacity. We need more doctors. We need more nurses. Has it had an impact for the pandemic? I think that's harder to stand up because so far, and it is only so far, every patient that needs it has had an ICU bed and had a ventilator. And I think that even countries which have more beds and more doctors per head than we have, like Italy, like New York, have had very big problems.
Where I feel the austerity years hit hardest was actually the social care system, and I very much wanted to secure a 10 year settlement for the social care system alongside the NHS. I was not successful. I was told that would come next, and then I moved to the foreign office. I really hope in this Post pandemic year that we settle that unfinished business and give the social care sector a 10 year plan just as we've done for the NHS.
Jessamy: Yeah, I mean you say there that we, that everybody has had a ventilator and a bed and I think that's true, but it's hard to feel that's not because of the incredible resilience and work of the actual NHS staff rather than the system itself and that it is. really under such huge pressure that it's the staff that are keeping things going and surely on the inequalities front It's hard to feel that austerity didn't add to that burden at some point.
Jeremy: Possibly I'm not trying to dispute that but You have to look at these things in the context that they were in, and we had a a financial meltdown, which was the biggest since the Second World War, and if we hadn't addressed that, if you look at, what happened in countries like Greece and Portugal they actually had to make real cuts in their health budgets, which we never had to do here, but not everyone would agree with this, but I do think that we had to take difficult decisions in order to put ourselves in a position where we were able to invest sustainably in our public services for the long term, but I wouldn't pretend at all it wasn't incredibly painful.
And indeed it was painful in the NHS, even though it didn't have any actual real terms cuts because demand was increasing faster than the budget. And so we had to find ever more challenging efficiency savings every year.
Jessamy: Exactly. I think, yeah, austerity is disputed, isn't it, in various But on
Jeremy: the staff point, I would say Jessamy, that, we need more doctors and nurses.
When I was health secretary, I put through a 25 percent increase in the number of training places for doctors, nurses and midwives. But We've got to have a better, long term way of doing this and it takes seven years to train a doctor, as three years to train a nurse, but by the time you've negotiated with a medical school to, Offer those places, it's going to take eight or nine years from a minister deciding to train more doctors and them actually arriving in the NHS.
I persuaded Theresa May in the summer of 2016 to increase doctor training places by 25%. There is still not one doctor in the NHS today. Additional doctor as a result of that decision. And I think that what we need to do is to ask someone like the ONS. To work with NHS England and publish an annual projection of the number of doctors, nurses, midwives, endoscopists, oncologists, every specialty in the social care sector as well that we're going to need.
So that we can then hold the government to account to really make sure we're training enough going forward. Because otherwise I just think we're continually not going to be training enough numbers.
Gavin: Do you think this uplift in staff is probably the key way that we could avoid, say, should a pandemic happen again, this kind of cancellation of core services that we've seen over the last year?
Jeremy: I wouldn't want to raise expectations because pandemics are so exceptional that, sometimes that kind of last resort thing is going to happen in any healthcare system. But we can't ask NHS staff to have to work as hard as they're having to work in a pandemic on a continual basis because of course after the pandemic is behind us there'll be a huge backlog of surgery then we often have a winter crisis, and it's not fair to ask people to carry on working this hard as a normal part of their job.
It's too stressful, it creates too much burnout and that's why the long term solution must be to increase the capacity of the workforce.
Gavin: Do you think there's a question here, about the kind of resilience built into these systems? Like how can we improve the resilience of the NHS?
Jeremy: I think it is through having a better long term plan for workforce, but I also think going back to my earlier point, my big passion when I was health secretary was patient safety, and I was very troubled by the high level of avoidable harm and death in all healthcare systems. It's not just an NHS issue, but in the NHS in England, we know that there's at least 150 preventable deaths every week, and we are probably middle of the pack internationally.
Some people say actually we're one of the better. a more safer healthcare systems, the Commonwealth Funds say that. But, to me I think the problem with the healthcare debate in this country is everything has become a debate about money. Now of course that's one thing that you can hold politicians to account for, and it's easy to measure, but it's ultimately an input measure.
And I think we ought to move the debate on. Not just to how much money we put in, but how can we turn the NHS, this precious crown jewel of our country, into the safest, highest quality health care system in the world? And I would like to settle the funding issue once and for all by saying, look, we currently fund our NHS at around the Western European average, but from now on we're going to fund it at 1 percent above The Western European average.
We'll renew that settlement every five years, but that's where it'll be. And we now want the NHS with that resource to deliver the highest quality healthcare in the world. And it's up to you guys to work out how to do that. But I think, Nye Bevan's vision was not just healthcare for all, it was high quality healthcare for all.
And that's really now what we need to be focusing on.
Gavin: Moving on to talk a little bit, about your role as the chair of the Health and Social Care Select Committee. You've been taking a lot of evidence from like crucial COVID 19 pandemic. What's next in hearing evidence from people?
And do you see a kind of role for an official inquiry in the future?
Jeremy: I think the Prime Minister said there is going to be an official inquiry and that I think is something that will be set up after the pandemic is behind us. But we want to present our findings before Easter. So sooner than that, because we want this year to be a big year of change for the NHS, where we learned some huge lessons and Really, if we think about the vision and imagination of the Attlee government in 1948, when the country was broke after the Second World War, but they still found the imagination to, and the courage, to set up the NHS, can we turn this most challenging year the NHS has ever had?
into another 1948 moment by fixing the problems in social care, by fixing our long term workforce problems, by sorting out our focus on quality and safety. And so we'll be doing inquiries during the course of the year, looking at just how you do this. We're about to launch one into young people's mental health.
Of course, being very affected by the pandemic, but again, some really exciting changes that we Can and should be making in our school system to help intervene earlier with mental health problems. We're looking at maternity safety because if we have the same safety rates as Sweden, we'd have a thousand fewer baby deaths every year and I think there are some really important things we can do.
There we're going to be looking at learning disability and autism because we still have 2, 000 people locked up in secure units that would be much happier and healthier if they were in the community.
Gavin: We've got a lot on our plate. Talking as well, because you know it's a major passion of yours is social care, and you mentioned it there previously when you were talking about, towards the end of your time as Health Secretary.
What do you see as the future of social care policy in the UK?
Jeremy: I think we've got to really do three things on social care. First of all, we have got to put it on a sustainable financial footing. There's no two ways about it. It's going to cost more. And we probably need to put in an extra seven billion pounds a year.
By the last year of the parliament, which is a significant uplift on the current budget to deal with demographic changes, increase in the national living wage, various things like that. So there is a financial element, but there are two other things that I think are equally important. One of them, we've got to deal with the unfairness that We cover all the costs that a cancer patient would have, but we don't do that for someone who has dementia.
And if you end up having to go into a care home, you have this terrible thing where it's not just the person who has dementia's life savings being cleaned out. You might take the view they're going to die anyway, so, that's it's Very unfortunate, but the money's got to come from somewhere.
But of course, their family are then given this incredible dilemma. Do we put someone into a home where they're well looked after but lose our life savings for the people who are going to live on? Or Do we try and somehow protect our own futures and we shouldn't be having this disparity and that's a terrible injustice and unfairness.
The third thing we need to do is to properly integrate the social care system into the NHS so that for patients it's a seamless transition. They don't get. push from pillar to post. There's a single budget, a single care plan on an electronic health and care record shared between both systems. Every professional dealing with an individual knows what that care plan is.
And that's a, that's another major thing we've got to sort out.
Jessamy: Jeremy, if you're, if you were Health Minister again now, and Health Secretary and you had your wish list, within the realms of reality, what would be on it to happen now?
Jeremy: I think it's about ambition. It's about saying, look, we've just come, coming out of the toughest period the NHS has had in its history.
It's more than risen to the challenge. Let's use this as a really big moment to make the changes that the British people want because they are massive supporters of the NHS. So let's sort out the social care system, which is as important for the NHS as it is for the social care system. Let's sort out our workforce problems.
Let's sort out our quality and safety issues. This is the moment for imagination And let's grasp it. I've learned in politics that you do have to be opportunistic. And in a way this is opportunism because this is a moment when I think you could see big public support matched with big government support for a real change.
Gavin: Do you see this broader renewal as a kind of general project for the Conservative Party?
Jeremy: I think from the Conservative Party, I'm, sick to death Of being, of having our motives questioned on the NHS when we've actually been running the NHS for longer than the Labour Party since it was founded and Indeed the NHS was It was first mooted by a conservative health minister in 1944 in the, in a white paper.
So it would have been set up by a conservative government if Churchill had won in 45. But, here's a chance to prove our NHS credentials, if you like. To make sure we have this transformative moment of vision and imagination.
Gavin: And do you think this transformative motion is something that will, should occupy all departments?
A kind of government wide look at how we can renew the country coming out of this crisis. And of course post Brexit as well.
Jeremy: I think there are lots of things that we need to renew coming outta the pandemic, but certainly when it comes to health inequalities, that isn't just something for the Department of Health.
But yes, I think it could be a moment of great change for our education system. And indeed we are also gonna have some big foreign policy challenges with the rise of China and the future of democracy across the world.
Gavin: Jeremy, we really appreciate you taking the time to talk with us today.
It's been fantastic to have such a kind of broad ranging chat and great to hear about your thoughts about, about, the problems of the last year, but also looking forward to a kind of brighter future. So thank you so much for talking with us. Not at all. Good luck with the series.
Jessamy: So thank you to Jeremy.
And thanks to you for listening to this episode of The Lancet Voice. You can subscribe to The Lancet Voice in your usual podcast places, and we'll be back in two weeks time for more discussion about the world of health. Thanks for listening.