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How to be health secretary - Rt Hon Jeremy Hunt MP and Nick Timmins Episode 1 of the Health Foundation podcast

Episode |22 October 2020 |

About 1 mins to read

What is the role of the health secretary? What should it be, and how does it and should it relate to the management of the NHS?

To mark the publication of the Health Foundation’s new edition of Glaziers & window breakers, Rt Hon Jeremy Hunt MP talks to our chief executive Dr Jennifer Dixon about his tenure as the longest-serving health secretary. They are joined by award-winning author Nicholas Timmins, writer of the new book, which includes interviews with 11 former health secretaries together with original analysis.

Our conversation looks back at the major themes of Hunt’s time in office – such as patient safety and how far he sought to ‘ignore’ the reforms of his predecessor. But it also looks forward. With the challenges of the COVID-19 pandemic holding the world’s attention, what would Hunt have done differently? And what are the key lessons for government as we enter a new phase of the pandemic?

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Dr Jennifer Dixon: If ever there was a time to talk about health policy, it's right now. The pandemic has meant public interest in health and how health care is being planned and delivered is stronger than it's ever been. In these podcasts, we'll be interviewing key players in health and health care, politics and beyond, and we'll be finding out what's happening, what isn't working, and most importantly, what needs to happen now.

First up, we thought we take a look at the number one job in the sector and find out how to be a health secretary. For this episode, we're really delighted to be joined by the former Secretary of State for Health and Social Care and current Chair of the Health and Social Care Select Committee, the Right Honorable Jeremy Hunt MP.

Rt Hon Jeremy Hunt MP: He basically accepted my judgment. I think that's what really happens, that prime ministers accept your judgment for as long as things seem to be working out. Then when they stop working out, they move you or they sack you.

Jennifer: We're also very pleased to be joined by Nick Timmins, seasoned former public policy editor at The Financial Times and author of many books, including the weighty tome, The Five Giants, a history of the UK's welfare state.

Nick Timmins: One of the first uses of the health secretary is to keep the private minister away from the NHS because they know nothing about it, and if things go wrong, they rush off to the other room and stamp their little foot and start announcing things.

Jennifer: Jeremy, I thought we'd first start by looking at the role of the secretary of the state itself. When you walked into your office in Richmond House in September 2012, was there a job description?

Jeremy: Not at all. I have to tell you that the health secretary is not the only cabinet job where there's no job description. There wasn't when I was culture secretary, and there wasn't when I was foreign secretary either. Ministerial jobs aren't really like that. It's much more sink and swim. You figure out what you need to do, or if not, you get chopped pretty quickly. I was coming, as it happened, at a time of great transition for the role of health secretary because the Lansley 2012 Health and Social Care Act had just become law. That had some very important changes.

Jennifer: I think you said in one of your interviews that the orders from DC, David Cameron, was to ‘calm it down’ after the Health and Social Care Act passed. Is that right? Is that the only steer that you got?

Jeremy: Pretty much. He was very, very concerned about the huge debates, you'll remember them well, that we had over that Health and Social Care Act. He made it the centerpiece of winning the 2010 election. You remember that famous poster saying, ‘I'll cut the deficit of the NHS.’ So, suddenly to be characterised as an evil privatising, slashing Tory was a big shock to him. It wasn't his plan. I think he probably wanted someone who could communicate better conservative commitments to the NHS.

Jennifer: Yes. What's interesting is the freedom that Andrew Lansley was given by the prime minister. Do you think some parameters or job description, if you like, or at least a set of priorities would be a good idea for a secretary of state to have when they walk into the job?

Jeremy: Well, I think it's not normally how politics works. It's so 24/7 and so rushed. I think in health, I'm a big believer that the only really effective way to be a government minister is to find one big thing that you want to change and focus hard on that. I have to say, because I wasn't expecting to be asked to be health secretary, I had no idea what that one big thing was. It found me pretty quickly when I had to deal with Mid Staffs within months of taking office, and that's why I landed on patient safety, but I really didn't know when I took on the job.

Jennifer: Nick, you've interviewed a lot of health secretaries in your time, including in Glaziers and window breakers, the Health Foundation book, and I think it was Virginia Bottomley who coined that phrase, sometimes you need a glazier, someone who mends and keeps things tranquil, as Jeremy says, and sometimes you need a window breaker, someone who's just going to forge ahead. How does Jeremy's idea of the role, do you think, compare with those that you interviewed?

Nick: Well, I think he described it very well. I think prime ministers, most of the time, don't want to hear anything about the NHS. They want it to be quiet, trundling along, and doing its job. Ken Clarke has a great line on this. He says one of the first uses of the health secretary is to keep the prime minister away from the NHS because they know nothing about it. If things go wrong, they rush off to the other room and stamp their little foot and start announcing things. Part of the job is to make sure things are going well enough for them not to trouble the prime minister.

Jennifer: How would you say that a prime minister could assure themselves that the secretary of state for health, which is one of the most important jobs for the nation, isn't it, doesn't go rogue? Do you think there should be some kind of oversight? Is there some kind of oversight?

Jeremy: Well, the prime minister has to do that for all his cabinet ministers. In practice, prime ministers are very, very busy people. I suspect that- I mean, 2% of David Cameron's brain space was on NHS issues as he was dealing with whether to bomb Syria or what should be done with Universal Credit or how to deal with a deficit or how to get the economy growing. So, much of the time, he let me get on with it. He basically accepted my judgment, and I think that's what really happens. The prime ministers accept your judgment for as long as things seem to be working out, and then when they stop working out, they move you or they sack you.

Jennifer: How do they know when it stopped working out?

Jeremy: Well, I'm sorry to perhaps make you a little bit cynical, but I think it is mainly through the media. They want to make sure that you avoid any cock-ups in the media. In fact, in the case of health, it was considered a very good thing not to be in the media a lot because I think they felt during the Health and Social Care Act that the NHS was rather more in the media than they wanted. Keeping the NHS quiet was probably a pretty big part of what David Cameron wanted from me.

Jennifer: But if you've got a prime minister that wants a transformational agenda and we have had a few of those, haven't we, you want a window breaker, don't you? You could say Ken Clarke was one of those? Nick.

Nick: You do indeed. Ken Clarke was one of those, Alan Milburn was one of those. Andrew Lansley in a very odd way turned out to be one of those. There's quite a lot of wisdom in Virginia's remark about Glaziers and window breakers because there are times when you've got a fairly major reform program underway. In a sense, the best thing that a new health secretary can do is very little, except make sure that this is seen through, pursued, and not go shooting off in new directions because we all know there's opportunity costs to big reform. There are times you generally want someone just to get on with it and other times when you want someone to really shake things up.

Jennifer: Jeremy, I want you to imagine that you've still been secretary of state throughout this pandemic. This is a big question coming up, what do you think are the biggest lessons that the government and perhaps the Department of Health and Social Care need to learn from this pandemic?

Jeremy: Well, obviously, my new job as chair of the Health and Social Care Select Committee has meant that I've made a lot of comments about government handling and I've been perfectly willing to criticise it when I think that we've got things wrong, but I think it is important to say that in a pandemic with a new virus, no one's going to get everything right the first time. As a member of the public, what you really want more than anything is rather different from politicians in normal times. Normally we crucify people who conduct U-turns. In a pandemic, I think it's a thoroughly healthy thing to change direction quickly if the data changes.

I obviously believe that we should have been focusing on testing, and test and trace much earlier than we did, but I'm much happier now that we've got to a place where it's a much bigger part of our response to the virus even though there have been plenty of teething problems. Generally speaking, I think what I found as health secretary was we're not as good as we should be in modern health care systems at learning when things go wrong, and this was a big part of my passion for the patient safety agenda and it's something that you've done a lot of work on as well, Jennifer. In a pandemic, you have to be incredibly nimble at looking at what's happening in countries all over the world. In January, it was very clear to me that the most successful places in the world were Korea, Taiwan, Hong Kong, Singapore, as it happened, the places with experience of MERS and SARS. I think that's the big lesson that we've all learned. That's really why not just the UK, but Europe, much of Western Europe and North America, had to have these huge national lockdowns, which they largely avoided in Asia with all the economic consequences that come with it.

Jennifer: One aspect of learning could be, what happens when you reorganise national organisations? One of the recent decisions, of course, has been to split up Public Health England having only conjoined that organisation five or six years previously, would you have done that?

Jeremy: I do think that the government focused on some of the structural reasons which may have led to a slow development of testing capacity. My own view is that wasn't really PHE, Public Health England's fault. I think they are acquainted to go- that basically has always done what the secretary of state asked them to do. They don't have the de facto independence that NHS England has. I think the real reason that we didn't focus on testing was because it wasn't a ministerial priority, and in fairness to ministers, they weren't advised it should be a priority by the scientists on SAGE who didn't even model test and trace until April, which was a long time after the pandemic had taken hold.

I think it'd be a mistake to blame Public Health England for some of those early mistakes. However, I think it is a positive thing to say we need an organisation in England, in the UK, like the Robert Koch Institute in Germany that has a very specific remit to monitor pandemics around the world and make sure that we're properly prepared. If we end up with that, that's a good thing, but I wouldn't want to lose the very good things that Public Health England do such as the campaigns against obesity, the campaigns against smoking. I thought they did a lot of those things extremely effectively.

Jennifer: You've also said that the job of the secretary of state, this is when you were interviewed by Nick, you said the job of the secretary of state is to hold the NHS account to its performance. You, of course, famously introduced ratings into looking at the performance of the NHS and social care providers. I think you're even thinking of doing the same thing to introduce ratings to assess government policies through your work in the Health and Social Care Select Committee. If you were to rate the government's handling the pandemic so far, how would you rate it and why?

Jeremy: I've been asked that question before, and I'm afraid it's not one I want to answer because I think it's unfair to give that assessment in the middle of the pandemic. Today we've actually launched a joint inquiry, parliamentary inquiry with the Science and Technology Committee, which is going to look at the government's handling of the pandemic. I think that's the place where we will give that verdict if you don't mind, Jennifer.

Jennifer: Nick, some of the lessons, as Jeremy said, will come out in an inevitable public inquiry, won't they? Is that going to be too late when everything has moved on? If we really have a commitment to learn, as Jeremy is saying, is the public inquiry really the route to learning those lessons, or do we need something in real-time?

Nick: We need something much quicker, don't we? It'll have to be it. We've been promised the public inquiry, it'll have to be a public inquiry, but you need to learn the lessons much quicker. I think what Jeremy has just disclosed that the twin Health Select Committees are going to look at this is a good thing. I think separately, they are doing a good job, both of them, at looking at what has happened and what is going on. If you wanted anything else, it would be a very, very fast inquiry by three or four people just to draw outside government, but to understand government, just to draw the lessons together so that we do better in the near future. The public inquiry may help protect us against future events like this, but that's going to be ages off, too late for now.

Jennifer: Thinking about the former Secretaries of State for Health you've interviewed for our book, does any previous crisis, do you think, come close to this pandemic? If it did, what attributes of previous secretaries of state for health do you think would be useful to help manage this crisis?

Nick: Well, clearly nothing comes close to it in anything like recent history. We've not seen anything like this since 1918, 1920 in Spanish flu. In living memory, it's unprecedented. The quality is to do this, to do this job well. Well, I think you need someone who clearly is decisive but is able to explain clearly and simply to the public what they are doing or why and what the uncertainties are.

There have been huge uncertainties here from day one and many remain. There's still a lot we need to discern about the coronavirus. Then when the evidence changes, they change course, and again, are able clearly to explain why they're doing that. One of my criticisms of the government is I don't think they've done that terribly well.

Were their past health secretaries who were good at doing that? Well, maybe Ken Clarke because he always had that ability to cut through to the public and could be transparently honest with them on occasions. This is not a health story, but I remember when the government crashed out of the exchange rate mechanism back in 1991, '92, and the interest rates were at 15% at the day as we tried to stay in, and we ended up having to leave, and Ken was actually Home Secretary at the time.

They put him on the nine o'clock news and the interviewer said, ‘What went wrong?’ With wonderful honesty, Ken said, ‘Well, we got to the bottom of a very, very deep hole, and we decided to start digging,’ and you could almost hear the nation go, ‘Oh, thank goodness for that.’ He's not trying to pretend it was all great. I think a lot of that is what's needed in the handling of this.

Jennifer: Jeremy, I just wanted to ask you another question about the pandemic, which is, of course, our response, the government's response at the moment rests on earlier decisions made including the state of social care services, public health infrastructure, and indeed pandemic planning. In hindsight, what things in your tenure as secretary of state you might wish you'd have done differently that might have left us better prepared?

Jeremy: I think we did an awful lot of pandemic planning. We did all the things that we were recommended to do, but unfortunately, we were part throughout the whole of my time of a group think that was shared across Europe and North America, which basically said pandemic equals flu pandemic. We did this massive exercise in 2016, called Operation Cygnus, which was a three-day exercise. It didn't get much media at the time because as far as the media was concerned, it was boring preparations for something that they weren't really interested in.

We got a big tick in the box from Johns Hopkins University who ranked us second in the world for pandemic preparedness after the number one prepared country, which was the United States, interestingly enough, but that whole exercise, you read the recommendations, the word 'testing' wasn't mentioned once. What we should have done, this was 2016, we should have thought about MERS, which happened in 2014, '15. We should've thought about SARS, which happened in 2002. We were just focused on pandemic flu for the perhaps predictable reason that we, of course, have had flu pandemics here. We weren't really touched by SARS and MERS. The countries that were turned out to be the Asian countries with the very, very best response to coronavirus.

Nick: Although it's interesting, some of their preparedness followed reviews by British public health doctors and others who were invited in to look at how they had handled it. In a funny way, we did have the expertise here. We just didn't use it.

Jeremy: Yes. I mean, the great irony is that the Korean government was severely criticised domestically after the MERS outbreak of 2014 for not ramping up testing quickly enough. They learned their lessons, and then they became the very best in the world when we had the big one.

Jennifer: With this commitment to learn, how best could we do this and learn in an ongoing way from international experience going outside of our bubble, our Western bubble?

Jeremy: The first thing is I think we need to be more open to what's happening outside Western Europe and North America because they've done some really smart things in Asia. The use of technology in Korea and Taiwan, which many people here would say is very intrusive in terms of personal liberty, but the fact is they have avoided national lockdowns, which are the most intrusive thing at all when it comes to personal liberties. I think the other thing is we've just got to be a lot more open-minded about the variety of pandemics that can affect us.

Jennifer: That leads us very nicely onto the next set of questions I wanted to ask you, which is about your time as health secretary. If the pandemic is defining Matt Hancock’s tenure, then a big thing shaping yours was surely the Health and Social Care Act, which was your predecessor's legacy. We'll talk about the act a bit more later, but one of its objectives was to reduce political interference into the NHS with the day-to-day management of the system, largely done by NHS England, not the secretary of state. How did this actually play out in practice, and in particular, your relationship with NHS England and its chief executive, Simon Stevens?

Jeremy: That's one of the bits of the act that probably worked better. We did have a de facto independence of NHS England. As a result of that act, I think the headline-grabbing traditional activities of health ministers where you'd go and unveil a cancer machine here or a new dementia program there largely stopped. I think that was a good thing. Simon Stevens and I actually had a pretty positive relationship. We met every Monday morning and the regularity of those meetings meant that we were both able to understand each other's priorities but also respect each other's boundaries. The de facto independence of NHS England is something that if we do further legislative reform I hope we don't lose because I think it is a good thing to keep the vast majority of operational decisions at arm's length from ministers.

Jennifer: You said in, I think, your interview with Nick, that one of your views of your role was to provide assurance that NHS England was doing its job, or at least the NHS was doing its job and you were holding it to account, but that's a kind of assurance role, isn't it? What about your role as a secretary of state in setting a strategy? Or is that something that you really felt ought to be left to NHS England to get more buy-in from the service?

Jeremy: I wouldn't describe it that way because I think ministers have to be responsible for strategy. We are the ones who are elected and given how important health is to ordinary voters, I don't think they would accept as any other way. For me, those nearly six years that I was health secretary, the overriding priority was to raise standards because I was dealing with Mid Staffs, Morecambe, Southern Health, a whole range of scandals, which showed how we have a huge variation in the quality of care. That, for me, was a very important part of the strategy, but NHS England were very, very closely involved in the delivery of that strategy, and of course, the delivery of many, many other objectives making sure that, for example, that we got through winters safely, which became increasingly difficult. I think it was the fact that I had very regular meetings with Simon Stevens that meant that we were very rarely had a kind of discussion which was sort of, ‘That's not your territory. That's up to me.’ It was a much more consensual relationship where he knew my focus on patient safety and quality. I knew what he was trying to do to reform structures to deliver better care within the framework of the 2012 act, which was not always easy. We tried to help each other as much as possible.

Jennifer: Nick, with that in mind, what do you make of Jeremy's interpretation of his relationship with Simon and also NHS England?

Nick: It's Jeremy's judgment, it depends if NHS England is one of the few good things that came out of the act. That's a judgment I would share. The most remarkable thing about the 2012 act is the extent to which large parts of it have effectively been ignored or worked around, sometimes with some quite clever legal footwork to join boards that technically can't be joined. They clearly seem to work very well together.

Virginia Bottomley had a great quote about one of the jobs of the secretary of state is to walk towards the guns. In other words, you take responsibility when things are going badly. When there were really bad pressures in the winter, it was Hunter on television and Jeremy on television defending all this stuff and taking responsibility for it. He didn't feel the need the rest of the time to rush around the country announcing 50 million for dementia here, or 20 billion for cancer there. The relationships of the secretary of state and NHS did change as a result of the act. It just didn't change in the way that Andrew Lansley envisioned it.

Jennifer: The NHS and the Health and Social Care Act, it was all about the NHS largely, wasn't it? The secretary of state's job is also for health. Looking back at that, would you like to have done more on health, Jeremy, particularly, as your time and tenure was at the time of maximum austerity, which was injuring the health fabric of the population?

Jeremy: There were some things where it became clear to me that the effect of austerity was becoming too damaging, and we needed to put rights such as some of the cuts to smoking cessation clinics, some of the sexual health services, drug rehabilitation. Certainly, that was an area where had I stayed, I would have wanted to negotiate better settlements with the treasury, but given that there was a limited amount I could do and I used up much of the capital I had in that respect by securing the 20 billion bumper rise for the NHS, and I say bumper rise, it may not be enough going forward, but it was still in its own terms a big rise in 2018, it would have been difficult to get a lot of extra money for public health initiatives, but I tried to make up for that, if I can put it that way, by making progress on things like obesity with the sugar tax, the commitment to halve childhood obesity by 2030 with some good progress on smoking cessation, plain paper packaging and so on. There are some things you can do on the legal side that don't cost money that can have a big impact in public health and that what I try to focus on.

Jennifer: Going forward, I mean, clearly everyone has seen the stalling of life expectancy particularly in the last recent years. What is the role do you think of the health secretary in thinking about the wider determinants of health which really is a cross-government issue, isn't it?

Jeremy: The only person who can really lead the charge off of those kinds of changes is the person who is going to end up picking up the tab if you don't make those changes. The health sector has a very important role working, for example, very closely with the education department on mental health initiatives so that we pick up mental illness in teenagers early so that we can nip the problem in the bud. On all those kinds of cross-government initiatives, it has to be the health secretary who does it.

Jennifer: Just moving on to patient safety which was your big priority and your mission or battle cry as I think you described it, you did a lot obviously in your inspection regime, ratings, transparency and data, and then later on the role of culture in the NHS. What do you think makes the biggest difference to improve the quality of care of all the big levers that the secretary of state can pull? What do you think it is?

Jeremy: The first thing is that resources matter. They are necessary but not sufficient condition for high-quality care. The main thing that you need in terms of resourcing is not just hospitals that aren't falling down or decent cancer machines, but you need enough doctors and nurses. I did give a big boost to the doctor and nurse training places, but because of the long delay because it takes seven years to train a doctor, three years to train a nurse, none of those changes actually fed through when I was health secretary.

On top of that, transparency matters. You've got to have a culture where you're very open when your care doesn't meet the high standards that you want, where it’s easy for doctors and nurses to speak up because the truth is that doctors and nurses are much braver than most of us because they choose to go into a field where the price of the ordinary human mistakes that all of us make is sometimes that someone dies. If the result of someone dying is that their whole career gets put under a microscope, if your child is born disabled, the only way you can get compensation from the state is by proving in a court that a doctor or midwife was grossly negligent, that makes it really difficult to get the kind of constructive atmosphere where people openly honestly learn from what went wrong. You can see countries like Sweden which have about half the baby death rate that we have and haven't had a court case for the best part of 30 years, they've created a much more constructive learning culture, and that's where we have to go in the NHS.

Jennifer: I'm glad you mentioned that because you say that doctors and nurses are particularly brave, and of course, you had some very big battles on patient safety. One of them was with the junior doctors on contract negotiations. Can you just summarise for us what you thought you learned from that dispute and what you might be advising a future secretary of state, perhaps who is contemplating a battle with adopters?

Jeremy: We could talk for probably another hour, Jennifer, if you wanted to, but first of all, I really wish it hadn't happened. In politics sometimes, in fact, very often battles pick you rather than the other way round. What did I learn? I learned that you can get sucked into a battle very, very quickly without either side particularly understanding. This dispute lasted for nearly a year, almost as long as the miners' strike of 1984.

Looking back on it, I couldn't give way because it was a matter of principle for me but nor could the BMA leadership really give way because they'd balloted and they got 98% support for going on strike. Their hands were tied. I learned that I may have won the battle, but for the bigger patient safety agenda, because of the business of that strike, it became much harder for me to get my key messages across to junior doctors.

One very important part of leadership is to be able to communicate the things you want to change and to garner support for that. That became much harder and it took some time for the wounds to heal. That has now started, but there were some long-term costs to the patient safety agenda as well as the short-term benefits of changing the contracts.

Jennifer: Nick, Jeremy isn't the first secretary of state to take on the doctors or at least have the doctors take on them. I'm remembering Ken Clarke's clash with the BMA in 1991, for example. Are there any useful insights from other secretaries of state on how to manage all of this?

Nick: It might not be necessary, but it sometimes happens as a side effect, I think. I do think on the Juniors dispute, I have some sympathy for Jeremy's position because I think the BMA were at least as much themselves to blame. They didn't learn from their own history back in Barbara Castle's day when the consultants went on strike over pay, beds and paying conditions. If doctors go on strike, they lose. Initially, there's enormous public sympathy because it's doctors versus the government, but that just falls away really fast because, in the end, the public does not believe that clinical professionals should go on strike. The BMA's own tactics actually made it very, very difficult for anyone to get out of the dispute.

Jennifer: I remember that lovely poster of a big juggernaut saying, ‘What do you call a man who ignores medical advice? Ken Clarke.’ That was the BMA postage, remember, in '91.

Jeremy: I heard many much less repeatable slogans used about my last name rhymes with during the doctor's strike. I think Ken got off lightly.

Nick: Indeed.

Jennifer: Yes, he seemed to relish it actually at the time. Do you remember?

Jeremy: He said, actually, in his autobiography that the BMA were the most difficult opponent that he faced in his entire political career, which I think in a way, quite a compliment to the BMA.

Jennifer: Jeremy, do you have any regrets? I think you've mentioned one of them, perhaps, which was about not reforming social care or convincing the treasury to properly fund it. That's got to be high up on the list.

Jeremy: That's probably my biggest one because what I realised when I was looking at the shortage of doctors and nurses, that very soon leads you to conclude that an organisation like the NHS needs at least a 10-year plan because you've got to look forward at least a decade and be thinking, ‘How many doctors are we going to need? How many nurses are we going to need as a bare minimum,’ to make sure that you train them up in time.

Exactly the same is true for the social care sector. What I actually wanted was a 10-year plan for both sectors to be produced at the same time and, obviously, two plans that fitted together because they work together so much hand in hand. I was told when I negotiated the NHS 10-year plan, that the social care would have its turn later on that year. Unfortunately, I was moved to Foreign Secretary and then we had all the Brexit stuff and the collapse of Theresa May's government, so that never happened. I am absolutely determined that it will happen and I'm using my position in parliament to campaign as hard as I can for that.

Jennifer: Looking forward, do you think that the NHS should stick with a long-term plan? Is that long-term direction the right one? I suppose, secondly, on the health side, not the NHS side, what do you think the big thing the government should be doing to try to achieve its own target, which is increased healthy life expectancy by five years by 2034?

Jeremy: I think that this decade that we're now coming up to, the 2020s, is the decade when we finally need to deliver integrated wraparound care for vulnerable people with multiple long-term conditions. The people are going to have an awful lot more with an aging population, bringing together the health and social care system. In terms of public health and life expectancy, I think the evidence is very clear that socio-economic disparity is the main driver behind low life expectancy. A lot of the lower life expectancy that we have is sadly very dependent on people's social class. That is a whole government agenda, but if we're going to really deal with that, it needs a prime minister to say, ‘This is a priority for me.’ That's a very bold ask of a prime minister because it won't be delivered, it's very unlikely to be delivered in any one prime minister's period of office. It really does need someone who's prepared to take a very long-term vision.

Jennifer: The very last question I think for both of you, really, what advice would each of you give to future secretaries of state on how to survive and thrive in the role? Nick?

Nick: It's quite interesting, the number of former health secretaries that had to sit down and have a good think when you get the job, work out what it is you want to do rather than rush around making announcements and things.

Jennifer: Jeremy?

Jeremy: I think my advice would be, choose the one big thing that you want to change and stick at it, week in, week out. Don't just assume because your civil servants have told you they've got a plan to make it happen, or NHS England has told you they've got a plan to make it happen, that it's going to happen. The NHS is the fifth largest organisation in the world. As Bill Clinton once said, ‘Politics is like working in a graveyard. There are lots of people underneath you, but they're not necessarily listening.’ Keep at it, but if you do, you will find, as I think most of the people in the next book would say, that being a health secretary is indeed one of the biggest privileges of your life.

Jennifer: That feels like a very good place to end. Thank you very much to both of you, Jeremy Hunt and Nick Timmins, for your reflections. If you'd like to read more about Jeremy's time in the role of health secretary, then check out this episode's show notes on whatever app you're using to listen to this. You'll find details there about how to order a free copy of our Glaziers and window breakers book, which features his full interview with Nick Timmins alongside some equally revealing interviews with his predecessors.

If you've enjoyed the episode today, then do also subscribe to us on your preferred podcast app, and of course, consider rating the podcast in true Jeremy Hunt style. Next month, we'll be turning to the subject, does Nanny have a role to improve the nation's health?

Thank you very much for listening and see you next time.

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