Jeremy Hunt on the 10-Year Health Plan

The Health Foundation (2020). Glaziers and window breakers. Former health secretaries in their own words.

Nuffield Trust (2025). Exploring earnings of NHS doctors in England.  

The Health Foundation (2025). Taking a chainsaw to NHS England is not the sign of a healthy state.

HSJ (2025). Cuts to ICBs and NHSE slammed by ex-health secretary. 

HSJ (2025). Patient Safety Watch: Dash Review opens a crucial door. 

BMJ (2025). Government’s 10 year plan for the NHS in England.

Jennifer Dixon:

The NHS 10-year plan is out. Over the next few weeks, I've got some very interesting guests to give us their take on the plan. First up is Jeremy Hunt, the Secretary of State for Health for a long time – 7 years – between 2012 and 2018, under the Cameron and May governments. So what does he think of the plan? 

If you read the foreword to the 10-year plan, and quite a lot of the narrative around it, you get a kind of NHS is broken, existential crisis, last-chance saloon vibe to it. Do you buy that, what has been called ‘disasterisation’ of the public realm, in particular, the National Health Service? Is it really in such an existential crisis?

Jeremy Hunt:

I don't think it's in an existential crisis. I mean there's a lot of politics obviously in all of this, and when you have a change of government after over a decade, then it's a fairly standard political practice. Conservatives did exactly the same in 2010 to paint as grim a picture as possible of your inheritance to try and set the ground for some of the difficult decisions that you have to take.

But I do think the NHS is in a bad way, and I think it really has not got back on its feet since the pandemic. And I think that what we see now is the culmination of a process where successive Conservative governments tried to solve problems in the NHS by increasing funding and increasing doctors and nurse numbers, without really radical reforms alongside them. We can see that that hasn't worked since 2015. Doctor numbers are up 37%, nurse numbers are up 34% and productivity has gone down.

And so while I don't buy the disasterisation narrative, I do think we need a change. And I think Conservative governments always find big reform of the NHS very difficult, and that's why I hope this time, a Labour government might be able to really do something profoundly different.

Jennifer Dixon:

Now I was looking back at your essay for us with Nick Timmins in the Glaziers & window breakers book where we ask you to reflect on your time. And two things you said, one was the one thing I would keep from the 2012 Act was the independence of NHS England because you felt that kept the NHS at operating distance from the Secretary of State, which you thought was healthy. And then the second thing you said was, ‘I never felt that the Secretary of State couldn't get the NHS to do what I wanted to with the current arrangements,’ ie with NHS England at arm's length. So that's on the one side and on the other side I saw one or two comments you made in response to the shock announcement in March, which was, yes, I wish I'd done that kind of thing. So can you clarify this for us? What do you really think about this? Is it just a sideshow or is it a radical chainsaw move that we needed?

Jeremy Hunt:

It could go either way actually. It is something I've slightly changed my views on. So at the time I had some questions about the Andrew Lansley reforms, which I had to inherit the moment I became Health Secretary because it was a 2012 act and I became Health Secretary in September of 2012. And so I didn't really have much choice but to implement them. And I did think that setting up NHS England as it became, it started off as the NHS commissioning board of course, was a positive thing because it did depoliticise a lot of day-to-day decisions in the running of the health service, which were really getting in the way of making progress, particularly to do with reconfigurations of services. Things like the setting up of hyperacute, stroke units, those kinds of things, which are clinically obviously the right thing to do.

I don't think it really helps when they become very politicised and you have huge campaigns to save a local stroke unit or people very angry that they're going to have to drive 10 minutes longer to get to an A&E.

And those kinds of decisions became a lot easier with the NHS England structure. And I didn't actually get sucked into big reconfiguration debates in the way that, for example, my predecessor Patricia Hewitt did. I also think that there is a risk in what Wes Streeting has done, which is the converse of what I found, which is that when you suddenly tell all the people at the top of the NHS that over the next 2 years, every single one of you is going to have to reapply for a job and you may not get one, that it's very destabilising and there's a risk that the government's core reforms get neglected.

That said, I don't find myself totally against this reform, and there's two reasons. One of them is that as a former Chancellor, I do think that we had got into a situation where the government had kind of lost control of NHS funding. And NHS England had worked out how to present the government with demands for really eye-watering sums of money every year, and were able to say, look, unless we have an extra £6bn to fill our budget gap this year, £6bn, I mean that's a huge amount of money, then we're going to have to cut absolutely vital services and the public will go crazy. And I think that it's become very, very difficult to manage the NHS financially.

The other thing is that if there was one big regret I had from my time as health secretary, I think the NHS is far too micromanaged, and I think that NHS England became the apex of the most micromanaged health care system in the world. There are just way too many targets that hospitals and GPs and every bit of the NHS has. They've got a little bit better, it has to be said in recent years, but I think NHS England had become a kind of target factory. If this reform is handled well, it could be a positive thing.

Jennifer Dixon:

I'm kind of hearing that it's finally balanced in your mind, and as you said, I think on another occasion it's all about the chemistry between the Secretary of State and the Chief Executive of the NHS largely. Is that still your view?

Jeremy Hunt:

Yes. If I look at my period as health secretary, we actually made steady progress in terms of improving the safety and quality of care. But we ran up against capacity constraints, which meant that in the second half of my period we were missing waiting times targets. I will never turn that around. And that was why I did the workforce plan and the increase in doctor nurse training places. Fundamentally, there was a stability there because I had a good working relationship with Simon Stevens and he helped me achieve my objectives, which was to try and really move the dial on quality and safety and it was a good partnership. So I think it can work, but I do think we also did find that when we had COVID-19 and then the NHS needed some shock surgery to get it back on its feet, maybe ministers felt they didn't have enough control to do things quickly.

Jennifer Dixon:

Let's go on to the big question, which is about the NHS plan. You talked about needing to do something radical, the NHS plan, is it the radical fix that you feel is the medicine needed here?

Jeremy Hunt:

The truth is, when you sort of cut through all the noise around it and the spin, it's actually pretty similar to the 2019 plan. I don't think that in terms of the things that Wes Streeting is saying he wants to do prevention rather than cure, moving treatment upstream, digitisation. They're very different to the plan that Simon Stevens, me and Matt Hancock put together in 2018, 2019.

So I don't think there's a very big difference in strategy, but that's not a bad thing because those are the things that health economists and people like you have long said need to happen. The real question is delivery. The NHS has had more grand strategies than any other health care system in the world, but it still struggles to deliver the same quality of care and the same outcomes as other European systems that spend broadly similar percentages of GDP. And in fact, there are systems like Australia and Denmark and the Netherlands that actually spend a lower proportion of GDP and in many ways get better outcomes.

I think one of the issues is whether Wes Streeting has got the political courage to stop the resources that he's getting, which are actually slightly lower than the annual increased promised in the 2019 plan, whether he can stop that all being diverted into pay. And I wholly salute the tough stand he's taking against the Junior Doctors Union at the moment because I think that if he allows all that money to be taken into pay, and remember what the BMA are characterising as just a small deal for the junior doctors would have an immediate knock on effect with the pay awards he would then have to give to agenda for change staff. And very soon there will be nothing left for any kind of reforms or increases in capacity or bringing down waiting lists or whatever the other priorities are.

So I think that is one really big challenge that he has. And I think the other challenge is the thing that actually Patricia Hewitt herself warned about in the Health Service Journal, which is that the abolition of NHS England doesn't end up becoming a replacement of NHS England targets with Department of Health and Social Care targets and even more micromanagement from the centre.

Jennifer Dixon:

Looking at the direction of travel of the 168-page NHS 10-year plan, a lot of it is familiar just as you say, but what's quite interesting is there's a kind of mélange of levers in there to make improvements. So some of it is a bit of total placed, something that looks very integrated and place-based and everyone's collaborating to integrate care. And then there's another bit of the spectrum, which is also a dollop of what we remember from Lansley and earlier, which is competition, foundation, trust, status, pay for performance. Do you feel that there's inherent contradiction in that, or is it okay to have a bit of incentives looking like one paradigm here and a bit of incentives looking like another over there?

Jeremy Hunt:

I think there's confusion there, and I think that the plan ducks the central big reform that the NHS really needs. There is no dispute or argument about the need to move care upstream and prevention's better than cure and keep people out of hospital, etc, etc. But the single thing that the NHS always swings from one extreme to the other is this default about centralisation or decentralisation.

And I think that it's very clear that if you look at other health care systems which deliver better quality of care, better outcomes, shorter waits than the NHS, they have less central control, not more central control. So I think competition and choice are all very good, but in the end, if you have these big heavy hand of top-down targets, what it actually does, is it disempowers managers and it stops innovation and creativity on the ground.

And if you look at bits of our public sector, which are getting results, for example, state education, the transformation in standards and state schools over the last 25 years has happened because progressively we have empowered heads, we've removed national targets and what they get is complete freedom. They get their budget, there's Ofsted, their exam results are published, but basically the boards of schools have freedom to innovate. If you have the kind of level of central control that we have in the NHS, it makes that innovation at the local level very difficult.

I recognise that what Alan did in the 2000s left the NHS in a much better state than when he found it, and it really did bring down waiting times. But I think in the end, there's a short-term gain in terms of performance that you get from those top-down targets. There's a long-term cost in terms of the utilisation of NHS managers and the learned helplessness that you get through a system where everyone is in the end just looking over their shoulders to see how well they've done with their monthly targets.

Jennifer Dixon:

When I look back over, again, the Nick Timmins essays, yours and Alan Milburn's in particular, you both said similar things. And he [Alan Milburn] kind of said, ‘If you leave it all to the service, you get F all," he basically said, and that the politicians have to be there to provide some grit and shock in the system, more or less. And you feel that zeitgeist, that narrative going through this plan. There is a kind of air of do it or else, bit of menace, particularly around the deficits that we will not have them anymore. So how do you square the need to use all the talents from the shop floor, who all wants to do the right thing, mostly do. And on the other hand, the need for radicalism.

Jeremy Hunt:

I don't think you'd find anyone in our state schools saying there has been a lack of rigour, a lack of accountability, a lack of consequences for people who don't deliver rising standards. In fact, the opposite. And what's happened is that we created a structure which incentivised people at the most local level to do the thing that ministers most want, which is to raise standards in schools. But we haven't done it by the education secretary saying, I want 16,000 A level physics passes at grade C or above next summer.

And then regional department for education managers getting you on the phone to every single comprehensive in the country. So I totally agree that you need shock and you need awe and you need pressure to raise standards, but it's when you do it by central targets that in the end, you disempower the very people who you actually need to innovate and solve problems on the ground.

Jennifer Dixon:

And if you consolidate all these ICBs then into say, 27, which is the plan, and you've really not got much between them and the Secretary of State in this consolidated central unit now with Department of Health Managers England, is that optimal? Does there need to be some kind of layer which is more strategic at a regional level?

Jeremy Hunt:

I don't think it matters if you have a layer on top to help resolve issues, which genuinely need to be resolved at a regional level like the number of trauma centres. But the fundamental operating unit in the NHS, it seems to me is at the level of the trust and the area that you live in.

And those are the units where you need to be asking yourselves, have I got the right incentives in Gloucestershire? Have I got the right incentives on the acute hospitals in Gloucestershire so that they are improving care for patients? And I think the best way of doing that is by transparency over outcomes, transparency over waiting times, transparency over quality of care and consequences when things are not going in the right direction.

Jennifer Dixon:

And presumably a financial physiology in the system that nudges people to do the right thing as well.

Jeremy Hunt:

Yes, although it's a very uncomfortable thing to say, the system needs to understand that it has to live within its means financially. And I think there has been a culture in the NHS which essentially has meant that we'll do our best when it comes to money, but we don't accept the requirement to live within our budgets and the way that will be the case in every other public service.

Jennifer Dixon:

One of the things you said was that you're most proud of was the CQC inspection regime, and you'll have seen Penny Dash's review of regulation in the system. And I wondered what you thought about the principles of that report, and is it along the right lines?

Jeremy Hunt:

I think it is. We do have a lot more focus on quality and safety than we had before, and I think that Wes Streeting is really aware that whilst he wants to grip the system and bring down waiting times in the way that happened under Alan Milburn. He doesn't want to fall into the trap of a targets culture that ended up with problems like mid-staffs.

You need to have a quality and safety architecture that makes sure that there is a flaw when it comes to quality and safety below which the NHS is never allowed to fall, but the safety architecture had become too complex. Where I think it's really important that we get back to is the overall ratings for hospitals and GP surgeries, which the CQC very recently has started to move away from.

The CQC lost its way in the last few years. But when I set it up with Mike Richards and David Behan, what we had was a system where actually there was an overall judgement made about the quality of care in a hospital. And most people accepted that it was reasonably accurate and fair, and the big advantage of that was that we then knew where the well-run hospitals were, but we also knew where the problems were so we could spend time helping to turn them round. And by the end of that period, by 2018, 2019, 4 million more patients were being seen every year in good or outstanding hospitals. And the dial was beginning to move. Unfortunately, then we had the pandemic, which threw everything up in the air. But I think it's really important as you bring down waiting times, you also continue to move in the right direction on quality and safety.

Jennifer Dixon:

So we must leave it there. Very interesting thoughts from Jeremy Hunt on the plan. Next time Alan Milburn will be giving his take, and of course Alan also had a hand in writing and crafting the plan. Meantime, thank you very much to my colleagues, Sean and Leo at the Health Foundation, to Paddy and his team at Malt Productions, and it's goodbye from me, Jennifer Dixon.