This is an approximate transcript of the inaugural meeting in Parliament on 11 November 2025 of the Working Group on the NHS, chaired by Richard Burgon on the subject of Fit for the Future, the government’s 10-year Plan for Health. It was attended by MPs from across parties and members of the House of Lords, and by invited guests. Here is a link to the Working Paper they are holding.

Welcome from Richard Burgon

Good afternoon and thank you for coming to today’s event, which is the first meeting of a new Working Group on the NHS.

I wanted to set up this group because the NHS is such a central part of our post-war social contract, and it is also (after the cost-of-living crisis) very consistently the thing that voters care most about.

And it is not performing as it should. As Lord Darzi told the Health Secretary, “the NHS is in critical condition, but its vital signs are strong.” So, it is essential that we successfully deliver a turnaround in performance.

As you know, the Health Secretary published a report, Fit for the Future: 10 Year Health Plan for England, which he believes will ensure a successful turnaround of the NHS. And in just a few days, the Chancellor will unveil a Budget which, I have no doubt, will also claim to enable the renewal of the NHS.

Today’s session will explore whether they are right.

The NHS is a big and complex subject, so I felt we needed to give MPs and Peers a regular opportunity to explore important issues in a round-table setting with experts who have worked in and researched the field and who can help parliamentarians with the difficult challenge of distinguishing fact from rhetoric in discussions about the NHS.

So, while today’s session will focus on the 10-year plan and the implications of the Budget; future sessions will cover issues like:

• The Nature, Extent and Impact of Privatisation
• Staff Morale and Retention
• PFI and
• Mental Health.

Welcome to the Working Group on the NHS!

The panel and format

We have a very strong expert panel today.

Tim Dabbs is a former consultant ophthalmologist. For five years he served on the council of the Royal College of Ophthalmologists. For many years he was clinical director of Special Surgery and Ophthalmology. And he has seen the ups and downs in the service under every government since Harold Wilson’s.

Sally Gainsbury is Senior Policy Analyst at the Nuffield Trust, an independent think tank with no party affiliation. She has worked closely with the Mayor of London on health inequalities, and how to get the NHS to reduce them. And she is an expert on NHS funding and finance.

John Puntis is a former Consultant Paediatrician with 40 years of experience of the NHS through good and bad times. He was Director of neo-natal services for Yorkshire and is now Co-Chair of Keep Our NHS Public, a campaigning organisation that does what you might expect from the name.

Mark E Thomas is the Founder of the 99% Organisation. His book 99%: Mass Impoverishment and How We Can End It was one of the FT’s Best Books of 2019, and he is also the lead author of the group’s first working paper: Fit for the Future? Scoring the 10-year Plan for the NHS.

And there are quite a few other experts in the audience, including many pro-NHS campaigners and Margaret Greenwood, former MP for Wirral West and a long-time pro-NHS voice in Parliament.

The bulk of the session will consist of an opportunity for you to ask questions of the expert panel, but before that I will ask Mark to give you a quick summary of the working paper.

Scoring the 10-year plan

Thank you very much Richard, and thank you all for coming.

Our last report, The Rational Policy-Maker’s Guide to Rebuilding the NHS, set out our recommendations for how the government should go about restoring the NHS to health.

As you know, in July, the government published Fit for the Future, what it called its 10-year health plan for England. And in just a few days’ time, the Chancellor will unveil her latest Budget. Between them, the 10-year plan and the Budget will determine how the government will go about trying to restore the NHS.

So, we decided to compare what is in the plan and what may be in the Budget with what our analysis had shown would be necessary.

I’m very quickly going to cover three questions:

• How did the last Labour government turn around the NHS?
• Will this plan also succeed?
• What would it take to fix this plan?

How did the last Labour government turn around the NHS?

First of all, there is no question that the last Labour government succeeded in producing a turnaround in the performance of the NHS. If we start by looking at patient satisfaction, we can see that by 1997, satisfaction with the NHS had reached what were at the time all-time lows. Between 1997 and 2010, patient satisfaction rose to all-time highs. And since 2010, patient satisfaction has fallen to new lows.

And that subjective assessment by patients is supported by objective data. If we look at performance measures like waiting lists and the proportion of patients presenting to Accident and Emergency seen within 4 hours, we can see that, under the last Labour government, performance improved dramatically (and since 2010, performance has fallen off increasingly sharply).

Independent international benchmarks recognise that performance. Perhaps the most comprehensive benchmarks are those done by the US-based Commonwealth Fund which assesses healthcare systems in leading countries on a variety of dimensions which cover the three most important areas:

• Effectiveness: does the healthcare system provide high quality healthcare to patients?
• Efficiency: does the healthcare system deliver that healthcare for a reasonable cost per person?
• Equity: does the healthcare system provide health care based on need rather than ability to pay – is it accessible to everyone?

By the end of the turnaround, the NHS was rated not only as the best system overall but the best in each of those categories.

So, there is really no argument that the last Labour government succeeded in turning performance around – the question is how did they do it?

The simple answer is that their plan was strategically sound: they looked at the big picture and understood that the success of the NHS is inextricably intertwined with the success of the UK as a whole.

Without a healthy population, you cannot have a strong economy; and without a strong economy, you cannot tackle the social determinants of ill-health or fund the healthcare system properly. If you get it wrong, you create a vicious circle; if you get it right, you create a virtuous circle. They got it right:

• They funded the NHS in line with need;
• They tackled the social determinants of ill-health; and
• they ensured effective prevention.

Let’s start with funding. The Conservative governments from 2010 onwards all claimed that they were protecting the NHS and funding it adequately, saying “we are putting record amounts of money into the NHS.” This sounds good until you realise that it was only true if you’re prepared to ignore the combined impact of inflation, a growing population, an ageing population and an increase in the rate of ill health within age cohorts. No rational policy maker would do that.

This chart shows what happens when you take those things into account.

First, inflation. Of course, £1 in 1997 was worth far more than £1 today, so inflation takes a big bite out of that supposed increase in funding.

Secondly, the population grows in size and, all other things being equal, the demand for healthcare grows with it.

Thirdly, our population is ageing. And older people in general require more healthcare than younger ones. The impact of this is far less than some politicians have claimed – and it certainly does not imply that the NHS will become unsustainable in the future. But it is a factor.

And finally, we have increasing rates of ill health within age cohorts – for example, increasing rates of obesity and diabetes, COVID and long-COVID (which, according to the Office for National Statistics now affects around 2 million people), and soaring rates of mental ill health.

So the top blue line reflects what the Conservative government was saying was happening; and the bottom red line reflects what was really happening in terms of funding in line with need.

What you can see is that the red line rose from 1997 until the Global Financial Crisis and then fell after that – by 10% from the peak. When the line is rising, funding is more than in line with need, and NHS performance can be expected to improve – and indeed did improve; and when the line is falling, NHS performance can be expected to decline – and indeed did so.

So, funding was the first thing the last government got right. The second thing was that they tackled the social determinants of ill health. Work by Sir Michael Marmot and others has consistently shown that social determinants have a huge impact on rates of ill health: if you are living in poverty, you’re more likely to have substandard housing, less likely to be able to heat it properly, less likely to be able to eat a healthy diet, less likely to be able to take regular exercise, and more likely to be living with a great deal of mental stress. So, you are much more likely to fall ill.

The next chart shows what happened to poverty under the last Labour government. Poverty had been rising sharply; it fell significantly under the last Labour government and has since been rising.

The third thing they got right was prevention. When the last Labour government left office, the incoming coalition government commissioned an inquiry into the state of public health and concluded that it was good.

So the 1997-2010 government succeeded because it had a sound strategy, but that doesn’t mean they got everything right. The Office for National Statistics provides data on healthcare productivity: the amount of healthcare provided for every £1 spent. This enables us to disentangle the additional healthcare output and see:

1. How much was driven by the extra funding; and
2. How much was driven by productivity increases.

As you can see, the growth in output was overwhelmingly down to the extra funding, and in fact the productivity growth was below the long run average – it was lower than it should have been. This suggests that, in aggregate, the tactical reforms introduced by the last Labour government reduced rather than increased productivity growth.

If you want to put it in terms of people rather than numbers, you could say that Gordon Brown did a good job by funding the NHS and enabling poverty-reduction initiatives, but that it would have been better if all the Health Secretaries had simply stayed home.

There are three areas in particular where there is evidence that the impact of their initiatives was significantly negative:

1. The private finance initiative, which did add capacity but at a ruinous cost which is contributing to the cost pressures we face today;
2. Blunt use of performance indicators: which can often produce perverse behaviours in order to ‘game’ this system. Last time, over-focus on financial indicators was a key contributor to the scandal in the mid-Staffordshire hospital which caused serious harm to patients. And we are now seeing that over-focus on waiting lists can seriously distort medical priorities, for example in areas like ophthalmology;
3. Using public money to build private sector capacity, which is not only often more expensive but draws resources away from the NHS, distorts medical priorities and delivers worse outcomes for patients.

I’m not going to give any more detail about these areas now, but I am sure that you will have many questions for the expert panel on these issues.

Just before we turn to how the 10-year plan stacks up, I want to highlight what happens when a government doesn’t get the big picture right.

The red line on this chart is the number of people of working age who have been forced out of the workforce due to ill-health: it’s now approaching 3 million people, or 8% of the workforce. The former Chief Economist of the Bank of England estimated that it is already costing us £150 billion a year in lost output  – no economy can survive that.

Will this plan also succeed?

The 10-year plan says that it is based on three strategic shifts:

1. From hospital to community;
2. From analogue to digital; and
3. From treatment to prevention.

If done well, all three of these could be positive.

Early intervention in the community to catch medical issues before they become serious could only be helpful. Automating paperwork and sharing data more effectively within the NHS must be a good thing. And encouraging people to avoid harmful substances like tobacco, ultra-processed foods, etc makes good sense.

The plan, however, raises concerns about each of these shifts.

Attempting to deliver hospital services in the community risks reducing the economies of scale which keep hospitals efficient as well as creating numerous logistical difficulties for patients and medics alike.

Substituting computer interfaces for human interaction could dramatically reduce access for vulnerable patients including the roughly 16% of the adult population who are functionally illiterate. And over-use of general AI risks worsening the quality of medical decision-making, which could be very bad for patients.

Finally, ‘prevention’ which ignores the root causes of the growth in mental ill health and completely ignores COVID – the word COVID does not appear once in relation to prevention – cannot be right. And tackling the social determinants of ill-health is regarded as being out of scope for this plan.

And there is an undeclared fourth shift, from public to private provision, which I have already hinted at, and which will be the focus of our next event.

Most fundamentally, however, even if the three shifts were executed perfectly, they do not substitute for sound strategy.

So, let’s look quickly at how this plan stacks up against what the last Labour government did strategically.

In terms of funding, the government is planning an increase in funding for the NHS compared with what the last Conservative governments delivered but does not even go half-way towards the levels of increase that the last Labour government provided. This government is not planning to fund in line with need, and that alone is enough, barring miracles, to stop the plan succeeding.

In summary, the plan stacks up very poorly against what the last Labour government did. It will not fund in line with need; it will probably do some good on prevention but has some important gaps; and wider government plans that we have seen so far suggest nothing that will produce the necessary impact on the social determinants of ill health.

Strategically, the plan is gravely flawed … and it hopes to make up for this with tactical reforms.

Unfortunately, it appears to be planning to repeat rather than to avoid the mistakes of the last Labour government. Although it talks about learning the lessons from PFI, it is clearly planning to tap into private capital – which is always more expensive than the government funding itself. There are clear indications that it will be using public money to build private sector capacity rather than NHS capacity. And although it talks about avoiding blunt use of key performance indicators and learning from the past, it has strong suggestions both of simplistic performance measurement and aggressive performance management – two key ingredients of perverse decision making. The tactical reforms will exacerbate the problems.

That this plan is set to fail is not simply down to poor planning within the Department of Health and Social Care: it reflects a wider failure of a government which has been constrained by three economic fallacies – that government debt is at unusual and dangerously high levels so borrowing must be brought down; that taxing the wealthiest would prevent the trickle-down effect and the poorest would suffer most; and that creating money inevitably leads to dangerous inflation. All of these are in contradiction with our own history.

A government which believes these three things becomes helpless, and ends up trying to run the country like a household, concluding that the government cannot drive national renewal and relying on the magic of market forces to deliver.

This in turn leads to perverse decisions such as those we have seen in this plan. We don’t have time to go fully into the economics of this in today’s session, but we did have a session specifically on these issues on 20 October, sponsored by Neil Duncan-Jordan which went into them in some depth – we have a few copies of the working paper that was discussed at that meeting.

So, what should the government do now?

What would it take to fix this plan?

The key lesson from last time was to get the strategy right, and this will require joined-up government. We need to find a way to fund in line with need, to tackle the social determinants of ill health and to make prevention effective.

We also need to avoid the tactical mistakes of the past, and the first step in doing that is to acknowledge them: we need a rapid but rigorous analysis of tactics like PFI, building private capacity with public money, and the type of performance management which drives success in a complex environment such as the NHS.

These things should be obvious, but right now they sound almost impossible because the government has created red lines for itself which it is now afraid to cross.

I have some sympathy: there is no question that this government had a difficult inheritance. But financially and materially it is nothing like as difficult as the inheritance Clement Attlee’s government had to tackle in 1946.

So can I ask you to join me in a little thought experiment: what would have happened if Attlee had followed this government’s approach? After the war, debt:GDP stood at over 250%; the cost of servicing that debt was over 5% of GDP; more than half of national income had been diverted to the war effort and over 5 million people mobilised into the Armed Forces; some 5% of national wealth had been destroyed, and 1% of the population lost.

If Attlee’s government had been constrained by anything like today’s fiscal rules, Attlee would have had to say, “although I am personally committed to the Beveridge plan and the idea of a National Health Service and a welfare state, somebody has to tell the country that it is simply unaffordable at the moment.” Had he done that, generations of Britons’ lives would have been blighted – and shorter.

Instead, Attlee’s government rose to the challenge. It listened to Keynes and Beveridge, and it created the NHS and the Welfare State, at a time when it was told that it would be economically irresponsible to try. And what was the economic cost? There was no cost: The UK enjoyed the most successful economic period in our history.

We should learn from these examples and from Keynes, Beveridge and Attlee. We should erase our red lines and create a new 10-year plan which will give the country the NHS it needs.

Thank you, I’m sure you’ve all got lots of questions.

There followed around 60 minutes of discussion, which unfortunately we were not able to record.

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This blog was originally posted by The 99% Organisation.

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