Appendix 2

London Assembly Health Committee – 16 March 2021

Transcript of Agenda Item 6 – Learning from the Pandemic: Health Inequalities and Healthcare in London – Panel 2

Dr Onkar Sahota AM (Chair): We will be now moving on to look at the health and care workforce in London and the impact of COVID-19 on that. Can I please welcome two new guests? Dr Coffey is staying on and two new guests have joined us: Lisa Elliott, London Regional Director of the Royal College of Nursing (RCN), and Martin Machray, Joint Chief Nurse in the National Health Service (NHS). Welcome to Lisa and Martin.

Joanne McCartney AM: Because we have looked at the London , can I make a declaration? Can I just declare that I am the Mayor’s representative on the London Living Wage Commission? I am very proud of the work we have done there to raise the living wage to now £10.85, which is £2.13 more than what the Government call their National Living Wage. Just to correct something as well, the living wage was brought into being by an amalgam of civil society, Citizens UK. It was introduced by the first Mayor, , not the previous Mayor. Thank you.

Dr Onkar Sahota AM (Chair): Thank you, Assembly Member McCartney. Thank you for putting your interest on the record.

Can I move on now to looking at health and the workforce? We are a little bit late but hopefully we will make up some time in this section. My first question is to Dr Coffey [OBE] and to Martin Machray. How should London-wide initiatives continue to support the workforce during the pandemic and in the aftermath? For example, could the Healthy London Partnership be more effective in recognising the mental health challenges posed by the COVID-19 for London’s workforce?

Martin Machray (Joint Regional Chief Nurse - London, National Health Service): Thank you, Chair, and thank you all for inviting me along today. I will start by trying to directly answer that question.

What more can we do systematically across London to support London’s workforce? I came in at the back of the evidence of Professor Marmot to you. Professor Marmot was talking about the living wage and about how employment opportunities are one way in which we improve the health of our population. The NHS would recognise that we are a significant employer across the city. We employ directly over 280,000 people working at all levels on healthcare provision. If you add in third-party organisations that support us and you add in the care sector, you have over 500,000 employees in London working in the health and care sector.

Giving people real jobs with real opportunity is one way the NHS, as an anchor institution within the city, can make a real difference to the lives of people because if it has not already been said in your evidence this morning, wealth and health can sometimes be synonymous. We should think of the two together.

As a nurse in the city, I know that I want to be able to provide for my family and to give opportunity to my family. That is what the 70,000 nurses and midwives in the city do every day. They work hard for their patients and work hard for their families. The two go hand in hand.

We recognise though that over the past 14 months since the global pandemic was announced, the healthcare and care system of London has taken a significant wave, two waves, of the pandemic, which has really impacted personally on our staff. I am sure Lisa [Elliott] will talk about this as well. You cannot underestimate

the impact this dreadful virus has had on the lives of nurses, porters, doctors, everyone working in the system. You only have to visit and talk to Intensive Therapy Unit (ITU) nurses to hear their experience of what it has been like.

I remember, Chair, you asked me a question at a previous meeting, “Can you describe what it is like to have gone through that first wave?” I thought about that question a lot. I do not think my words do it justice. I am the son of journalists so the words should come easy to me, but I do not think I have words to describe what this pandemic has done to my colleagues in the NHS and in the care system.

We have to do more to support them to recover from that. Some of that recovery is about letting people go back to the jobs they chose to do: the diabetic nurse to go back and be the diabetic nurse rather than a helper on an ITU, a general practitioner (GP) to be able to go back and provide population-led healthcare for their list, not just be a telephone answering service. They have done more than that, but you know what I mean. It is the point I am making. That is part of recovery.

Across London, we also set up five Health and Wellbeing Hubs because we know that some of our colleagues need more than just that permission to go back to normal duties. They need time off, they need to recuperate, they need to reflect and some of them need a lot of support. That mental health support that was in your question is part of that. We have a whole raft of services now wrapped around our staff in healthcare, in the NHS but also in social care, which means that everyone should have access to the services they need, given the 14 months this virus has put them through.

I will stop at that point, Chair, but happy to take the questions that will come.

Dr Onkar Sahota AM (Chair): Martin, let me also declare an interest that I am also a frontline doctor and GP.

Martin Machray (Joint Regional Chief Nurse - London, National Health Service): I appreciate that.

Dr Onkar Sahota AM (Chair): The NHS and the staff have worked tremendously. When we talk about the NHS, we talk about the people who work for the NHS, otherwise it is just buildings and equipment. It is on record, the tremendous work they have done and what they have gone through. At some times, it was a like a warlike zone. I put on record of the gratitude of all the people for all the hard work the NHS staff has done.

Martin Machray (Joint Regional Chief Nurse - London, National Health Service): Thank you.

Dr Onkar Sahota AM (Chair): Dr Coffey [OBE], did you want to add anything?

Dr Tom Coffey OBE (Mayoral Health Advisor): Just to complement some of the remarks Martin [Machray] has made. Sadiq [Khan] wants to do what he can as Mayor to assist and our Good Thinking website, which has launched, has a special page in helping care staff, to offer support, to help the care staff. Pride in London has a health and care webinar series to make sure that people, who are now more and more using digital tools to access their healthcare, can use those webinars.

Thirdly, Sadiq has launched Capital Nurse, which is a campaign to try to address the nursing shortages in London so that people choose to work in our capital city.

Fourthly, the Adult Education Budget has been devolved to the (GLA) and to the . That programme is trying to see how we could use the budget to develop skills from

Londoners that perhaps do not have large numbers of formal qualifications to go on to the pathway to become nurses. I know in Newham a literacy project is working on that to get people without General Certificate of Secondary Education (GCSE) to start some work to allow them to become qualified nurses. It is so important. As Martin has identified, the NHS is the biggest employer in London. London has the most enormous resource of young people. How can we match those two together? Sadiq Khan would like to be part of the catalyst, part of the solution that allows that to happen, as well as supporting the existing nursing workforce, medical workforce and all the health and social care staff.

Dr Onkar Sahota AM (Chair): Thank you. Can I go over now to Lisa from the RCN? Lisa, what further support do you think a professional requires as we move out of the pandemic into recovery? What is the morale like at the frontline? How do nurses feel in the ward? What is the morale like in the profession? I put it, in a way, with my next question after this, but what is the morale like in the profession at the moment?

Lisa Elliott (London Regional Director, Royal College of Nursing): Thank you, Chair. It is important to realise where we were before COVID-19 and before we had started dealing with the pandemic. There was already a crisis in nursing. We had a chronic shortage of nurses. We are currently 8,500 nurses short. Some of what has contributed to that has been the cost of living in London, which does push some nurses out of the capital. The fact is that we do not have a domestic supply that meets our demand. We do not train enough of our own nurses to meet the need we have. The removal of the bursary did impact on that when that was taken away a few years ago. That pay has not kept pace with the cost of living.

We now have been through two waves and we know that nurses were very stretched doing that. They had to deal with many more sick patients being admitted. Nurses now are exhausted. You have an exhausted workforce there. They are very tired. Their morale is very low. I sat in a meeting with ten Members of Parliament (MPs) and nurses last week and they are feeling very undervalued. They have been through some very traumatic experiences. Nurses have given their lives, have died during this, and nurses have had to look after their own colleagues. These are all very traumatic experiences that nurses have been through.

Going forward, there needs to be real input and ongoing psychological support. We need to see that plans to restore services include rest and recuperation and respite for nurses within that. We need to see robust workforce planning going forward so we can fill those 8,500 vacancies that there are currently in the capital.

Dr Onkar Sahota AM (Chair): I know we have vacancies of 8,500 that you say, and this is longstanding. The profession is tired and yet I know that they found it comforting to some level that everyone has been out on their doorsteps on Thursday evenings to show their appreciation for the work. How has the Government only given them 1% pay rise? What do you think this has done to the morale of the profession?

Lisa Elliott (London Regional Director, Royal College of Nursing): Nurses are telling me that they feel undervalued. Lots of them are feeling very angry or disappointed by the potential 1% pay award. I have certainly heard from lots of nurses now who are considering early retirement and talking about leaving the profession, and we cannot afford to lose nurses. For the first time ever, I have heard nurses considering what kind of action potentially they could take. As a nurse myself, I know that we never want to go out on strike and we never want to do anything like that, but nurses are feeling that they are being pushed more. They do not feel valued at the moment.

Dr Onkar Sahota AM (Chair): OK. Martin, you have to deliver a service to Londoners and you have to cope with the workforce you have. What steps can the NHS take, how is your work in delivering the service you need to with the workforce you have, and what can the NHS do to make it more effective? I know that

applications to nursing schools have gone up by one third, but let us see how many will materialise into jobs and things. What can we do? How can we make it better?

Martin Machray (Joint Regional Chief Nurse - London, National Health Service): Obviously, there are a number of things we can do. I will pick on three.

One is the undergraduates. I want future generations to, like me and like Lisa [Elliott], turn to their parents and go, “I want to be a nurse”. It is a long time ago now since I said that. Having just reflected on my parents’ profession, you can imagine how horrified they were when I said I wanted to be a nurse, but they were enormously supportive when I did, and it is a fabulous profession. I have taken, as Lisa will have done, so much out of that. We need to get people in. We have about 600 extra students starting this year in comparison to last year, so just under 4,000. We are just under 5,000 next year and that is a great thing.

The second thing is we need to look after those who we already have, and Lisa has alluded to that already. The things that we can do in London, as the employers of those nurses, are to make sure that they do get rest and recuperation, that they do have those services, that they can get back to their normal duties and allow that. It is up to us, as the NHS and its leaders, to get the NHS back into that frame and look after those staff.

The third thing we need to do is to look after the great contribution of nurses - I am focusing on nursing because we have Lisa - and staff from around the world, who have joined the NHS over the past months and years, and make a massive contribution. With international recruitment, how do we do that well? How do we embrace people from different parts of the world? Also, how do we give back to those countries as people leave, having spent some time with us?

We need to spend time on recruitment, on retention and on looking after those who have given so much.

Dr Onkar Sahota AM (Chair): Thank you. Lisa, tell me. COVID-19 has exposed the need to address NHS capacity and resilience. What does this look like and how should the Mayor be advocating to make things better for the workforce in London?

Lisa Elliott (London Regional Director, Royal College of Nursing): What we have seen is that under-resourcing in nursing and not having enough nurses, coming into the crisis and coming into COVID, led to lots of pressure on the nursing workforce throughout this pandemic.

There are a couple of things that the Mayor could do that would help support. First of all, within their champion and challenge role, they can really advocate for the nursing workforce and hold to account both governments and providers on ensuring that they have adequate workforce to be able to provide the services that they deliver.

The other thing that we really need to focus on is cost of living in London. The average cost of a flat in London is over £400,000, which is simply out of the reach of your average nurse. There are things that the Mayor can do around the cost of travel and the cost of housing within London which will be helping to retain those nurses within London. We would advocate for free travel for nurses, as well as getting affordable housing for nurses.

Dr Onkar Sahota AM (Chair): Thank you. Dr Coffey [OBE], there you are, that is what the profession wants. Can the Mayor deliver?

Dr Tom Coffey OBE (Mayoral Health Advisor): Yes, on a number of those points, I, on behalf of Sadiq [Khan, Mayor of London], have met Lisa already quite recently. Regarding the advocacy role of champion and challenge, Sadiq has been very clear in all his work, any reorganisation, any changes to ensure there is an adequate workforce and we will challenge the NHS wherever possible.

Also, I think challenging the Government is very important at this point. As a minimum the nurses were expecting a 2.1% pay rise because that was in the NHS Plan, and so I think he [Sadiq Khan] was shocked, as many nurses were, at a 1% pay rise. He will be advocating very strongly to the Treasury to ensure that nurses get the pay rise they deserve, and will also be pointing out that it does seem very short-sighted. If you are not going to fund nurses properly, if you show them a lack of respect by offering a 1% pay rise after clapping them in the streets on a Thursday, you should not be surprised that the retention of nurses will go down. If retention of nurses goes down, you get more vacancies and you get agency costs going up. The cost of an agency nurse is much greater than the cost of a nurse employed by the NHS Trust, so you are creating extra costs for yourself by short-sighted short-changing of the nursing workforce. That, to me, is bizarre economics.

Regarding living costs and housing, I mentioned earlier that Sadiq [Khan] is very committed to building 85,000 houses during his term of office and 50% of these to be affordable so that the nursing workforce can afford to live in London.

Regarding travel costs, Sadiq has been very clear that the fares freeze and the Hopper fare, which have reduced travel costs compared to what was expected with that year on year rise, have been because of nursing staff. There were temporary suspensions of the congestion charge and Ultra Low Emission Zone (ULEZ) reimbursements for nurses during the pandemic. Sadiq would want to work with the NHS to find whether there are ways that the NHS can work together with Transport for London (TfL) to provide reductions in fares for nursing. This would have to be a discussion between the TfL and the NHS because, as I know people are aware, the transport numbers on TfL have gone down enormously. TfL is under enormous cost pressures but would want to work with the NHS to see if there could be ways to assist nurses with their travel costs. The fares freeze already has benefited somewhat to reducing the nursing costs of London. Sadiq will work hand in hand with the nursing unions and the nursing staff of London to try to persuade the Government to really think again. A 1% pay rise is not a pat on the back; it is a slap in the face.

Dr Onkar Sahota AM (Chair): Thank you, Dr Coffey, for giving the Mayor’s view on the areas in which he can help and also how he will be campaigning for a fair pay settlement for nurses.

Martin, to what extent are the current workforce challenges influencing the shift to greater integrated working across the integrated care system (ICS) that we are seeing developing right across the country, particularly in London also, the ICSs?

Martin Machray (Joint Regional Chief Nurse - London, National Health Service): There are benefits from integrated working in London to the workforce. I would not say it was the primary driver for integration. We need to integrate our services to serve our patients better and that has to be our main driver for integrating the services that we are doing, but there are knock-on benefits to that.

We have just been talking about the nursing profession. If you think about the qualified nurse, Lisa, you will correct me, but without the London Weighting, an entry level is just under £22,000 a year, plus a few thousand if you work in inner city London. It is still below the national average for a working wage. Think about the care workers. I was listening to Professor Marmot [Professor of Epidemiology, University College London, and Director, UCL Institute of Health Equity]. Unqualified staff, our porters, our healthcare support workers and our maternity support workers are paid on a lower level again.

Bringing integration together and trying to say, “Let’s wrap our services around patients and get standard employment contracts for many people who are currently on zero hour contracts and things like that”, will make a difference to people’s lives. It will not answer all the issues that Lisa has raised, but there are some benefits from doing that integrated working because we can start to work with local authorities, with the third sector and with the NHS to say, “What does a care team look like?” for a particular place, neighbourhood or borough.

Dr Onkar Sahota AM (Chair): You make the point very well, Martin, that the low-paid are the most important, the ones we could not do without, and that COVID-19 shows that were on the frontline. We need to value them and recognise that even more.

Lisa, did you want to say anything about the new ICSs and the effect on the level of the profession about that or what the profession thinks about that?

Lisa Elliott (London Regional Director, Royal College of Nursing): Yes, there are two points for successful integration. One is focused around workforce and making sure that there is robust planning within those systems because if you have not got adequate workforce, none of the services and changes that you are planning are going to happen and be effective.

The other thing that is really key to be able to facilitate these changes is having good, senior nurse leadership embedded within these ICSs to be able to deliver and implement care. Nurses will really bring those skills, especially with things like moving away from treatment to prevention. That is what I would like to add.

Dr Onkar Sahota AM (Chair): Thank you. I want to bring in Assembly Member Andrew Boff.

Andrew Boff AM (Deputy Chair): Thank you. This is a question I wanted to ask earlier until we were interrupted by Professor Marmot’s [Professor of Epidemiology, University College London, and Director, UCL Institute of Health Equity] depressing, Malthusian rant that we just had. Specifically, to Dr Coffey [OBE], we know that suicide is, unfortunately, an indication of the mental health of our city. In the Mayor’s 2016 election manifesto, he said he would, “Coordinate efforts to reduce the number of people who have taken their own lives”. That figure of the number of suicides per annum is now greater than when he took office. How is he going to change policy to really get to grips with the appalling rate of suicide that is in London?

Dr Tom Coffey OBE (Mayoral Health Advisor): OK. First of all, to answer your question, I can share the data that I have in my information systems for suicide. For the gap between men and women, suicides have reduced in men over the last four years, but for women it has slightly increased. I am not quite sure about the figures that you are indicating. It has gone from 9.2 per 100,000 to 8.2 per 100,000 from the 2014-2016 period to the 2017-2019 period. There are so many data sources. This is a data source that I have, which is the suicide rates in London. One thing I would say is the suicide rate in London is lower than the rest of the country, but the figure I have is that it has gone down.

Let me share with you what Sadiq [Khan] has done. The work that he has done, bearing in mind I have mentioned the Good Thinking website, is by making accessible health services but also on suicide specifically. That issue really is regarding Thrive LDN and trying to get that zero suicide. We are trying to do what is called a zero suicide campaign and it is trying to get Londoners to be trained in both mental health first aid, but also in suicide awareness. He has done the training himself and what you will find is we have had 200,000 Londoners now having done this suicide awareness. What he has tried to do is say to people, “It’s OK to talk about your feelings”, especially men, and that is what Thrive LDN is crucially about, making sure people will start talking about their mental illness and mental wellbeing.

Andrew Boff AM (Deputy Chair): Dr Coffey [OBE], we have done many sessions on this and we are well aware that people need to go to places to talk about their problems and that men are less likely to admit to mental health issues than perhaps women. We know this stuff. I just want to know what the Mayor is going to do more. The figures I am going from are from the ONS and they indicate that in 2016 there were 580 suicides in London and over the past two years they have exceeded 600 per annum.

Dr Tom Coffey OBE (Mayoral Health Advisor): Yes, I have --

Andrew Boff AM (Deputy Chair): If you have other data, if you could forward that to us afterwards and perhaps we can take it up another time.

Dr Tom Coffey OBE (Mayoral Health Advisor): I will do, yes. What I have tried to say is that we have the zero suicide campaign and also the mental health first aid. What mental health first aid is about is: when a person is in distress, what do you do about it? How do you get people to talk? How do you get people to express their suicidal ideation, if that is the case, and how do you get them help? That is what mental health first aid does, both in a school setting, youth mental health aid and mental health first aid among the business community. Sadiq [Khan] in his area of prevention in non-NHS services has done what he can to ensure that services are around for Londoners digitally and there are campaigns about Londoners talking early about their suicidal thoughts.

What I was just going to say was - and Martin Machray made a very good point to Sadiq about a year ago - that it is not just about mental illness, it is about mental health. It is not just mental health services but keeping people resilient and having good mental health. What Sadiq has tried to do is work with Martin and his team, the NHS and the voluntary sector to ensure there are services around in the voluntary sector and the NHS which you can go to easily to access, in a preventative way, mental health support. It is no good just having an accident and emergency (A&E) department where you go in crisis. Then we have failed and it is too late. Sadiq has been setting up services in this field and I will share with you the data that I have, which will show that in fact suicide rates amongst men are falling in London.

Andrew Boff AM (Deputy Chair): Thank you.

Dr Onkar Sahota AM (Chair): Thank you, Dr Coffey. I am going to conclude this section now, but I just wanted to make my own comment, particularly in relation to the section with Professor Marmot [Professor of Epidemiology, University College London, and Director, UCL Institute of Health Equity]. Professor Marmot is a leading world authority, an expert in his area. We were very privileged to have him in front of the Health Committee today and we should be always respectful to all guests who come here and value their opinions, even --

Andrew Boff AM (Deputy Chair): We ask people to come to us for their evidence, not their interpretation.

Dr Onkar Sahota AM (Chair): -- if we find it uncomfortable, Andrew. I expect dignity and I expect respect for our guests, even if the Conservative members found it uncomfortable to listen to what Professor Marmot said.

Andrew Boff AM (Deputy Chair): It was not uncomfortable really, it was just a complete waste of time, but still.

Dr Onkar Sahota AM (Chair): It was not. He is a world authority. Your opinion may be yours, but on this Committee, I expect our guests to be treated well and with respect. Thank you. The next section, the final section, is on unequal access to healthcare. Assembly Member Desai, over to you.

Unmesh Desai AM: Thank you, Chair. My questions are put to Dr Coffey [OBE] and Mr Machray. It is clear that disabled people with physical disabilities or learning disabilities experience far worse outcomes from COVID-19. I know that Dr Coffey has already spoken about some mayoral actions already and you may be repeating yourself. In general, what action can the Mayor take that will stop health inequality going forward? We have about 20 minutes left and I have four or five more questions to ask you. You can bear that in mind as well, because I am sure you could take 20 minutes just answering such a broad problem.

Dr Tom Coffey OBE (Mayoral Health Advisor): I understand. I will start first, but I will probably hand over to Martin quite quickly. As you are aware, Sadiq’s [Khan] role is to convene services and to talk about health issues, to shine a spotlight of leadership and to champion, challenge and collaborate with the NHS, but he does not commission the NHS. Often, the reports that you have done over the last few years in this field have been very useful. What Sadiq will often do is use those reports in our weekly and regular meetings with Martin and [Dr] Vin [Diwakar, Regional Medical Director for London, NHS England] and Sir David Sloman [Regional Director for London, NHS] to raise these issues to challenge the NHS accordingly.

With access to services, the one which I will talk about very quickly at the moment is about vaccines. There were concerns. Was London getting enough of the vaccines? Were the people who are most affected by the COVID pandemic getting the best access to the COVID vaccine? The figures initially were showing that there was a much lower uptake. Of course, there is vaccine hesitancy, which we know is higher in younger people, people from the black, Asian and minority ethnic (BAME) communities, and the Pride communities. We have worked with the NHS and I have to say I think the NHS has done a sterling job at trying to ensure now that the provision of the access is in areas whereby it is accessible and unequal access is being addressed. I am going to hand over. Martin probably will have a greater span of control in this field.

Martin Machray (Joint Regional Chief Nurse - London, National Health Service): Yes, thank you. I wish I had control. There are three areas, Assembly Member, I would like to focus on, noticing your push for other questions.

One is making sure our services are in the right place for the people we serve. Historically, over time, lots of our services have focused on central London, over hundreds of years, and I am talking here not just the span of the NHS. We have to make sure that the services that exist across the city are there for all the population we serve. We need to make sure that, as we come out of CVOID, all parts of the city have plans in place to make sure that they are offering the breadth of services the NHS does wherever you live. You mentioned disabled people and particularly you mentioned people with learning disabilities, who you rightly point out have experienced a far worse 14 months than other parts of the population, not least in terms of the number of people who have contracted the virus and suffered because of it, with some people sadly dying.

The second thing that the NHS can do is advocate for those people who do not have a voice. We do not do that well enough, often, but we need to get better at that. That is our challenge; that we start advocating. GPs and our practice nurses and those really at the front of primary care do a brilliant job, but the rest of us need to start advocating more for that. One example of that is in learning disabilities and autism. You will have seen the change in the vaccine priority list on which people with learning disabilities and autism are now recognised as a clinically vulnerable group, which is partly based on the evidence we have got from the past few months of this pandemic. We need to do more about advocating for people.

Thirdly, we need to make sure that those services, when they are there, are accessible in terms of day-to-day access, not just where they are but the information we give people, the priority we give people and the way we interact with people. We are moving away from a patriarchal, “I know what’s best for you, patient. I’ll tell you what we need to do”, and over my career we have moved to one where we are now partners with our patients. We still have a long way to go, but we need to do more of that.

Unmesh Desai AM: There are two questions. One is about the vaccine if I could, maybe for either of you or Dr Coffey [OBE]. I was going to ask you this later, but you referred to the rollout of the vaccine. Here, I think we forget about party politics, albeit criticism of the Government’s awful handling of the pandemic. With the inevitable public inquiry, yes, questions will be put, but the way the vaccine programme has been rolled out the Government deserves credit, and we said that to Nadhim Zahawi [MP, Minister for COVID-19 Vaccine Deployment] when he came before the Assembly.

The question for me is: vaccine uptake is still remaining lowest amongst poorer communities and some BAME communities, for all the reasons we have discussed and that are well documented. Are you concerned that COVID will become just another endemic disease in areas of severe deprivation, poor housing, large BAME communities? How can we avoid this?

Dr Tom Coffey OBE (Mayoral Health Advisor): Yes, I will start and, again, I will be bringing in Martin probably quite soon afterwards. What is vital is to make sure that if someone turned the vaccine down, say at the beginning, one has to go back to them again and again and again. What I am finding is there are some Londoners who said, “Do you know? I’m not quite sure yet”, and you go back to them and they said, “Yeah, I’m ready now”. What you will see is although we have gone through our 80-year-olds already, the performance of London in our 80-year-olds is going up every week by 0.5% because people are coming back and being contacted.

Secondly, I would mention how we make sure that we use our advocacy and then our implementation to address some of these issues. I am going to talk about rough sleepers in hospitals and street homeless and hotels. Initially they were not considered a vulnerable group. The GLA - your colleague, Deputy Mayor [for Housing and Residential Development] Tom Copley - wrote to the Joint Committee on Vaccination and Immunisation (JCVI) asking that the rough sleepers should be prioritised, and they have been. That has been because of the GLA’s advocacy for that group to say, “This vulnerable group needs to be vaccinated now because over time they may become very dispersed out of those hospitals and hotels, and now is the time to vaccinate them”.

This is going to be about persistence. This is a marathon, not a sprint, because, like you say, what you cannot have is pockets of the population which are under-vaccinated but have a higher risk of COVID. When the third wave may come, that is the group which is going to be hit again. In the months to come, we have to work so hard to make it physically easy to access the vaccine but also to go back again and again. Martin?

Martin Machray (Joint Regional Chief Nurse - London, National Health Service): Yes, I would echo that. I and the NHS will do everything we can to avoid the scenario you paint, Assembly Member. It is a frightening prospect, is it not, that there would be parts of our city that would be at greater risk of a third wave or a subsequent public health challenge where some thrive and others do not? The health service is here for everyone, free at the point of need, and that is the ethos of the NHS. My job is to make sure that that happens right across this city.

It is not just about the vaccine, is it? It is about the way we engage with our populations, build trust with those populations and get them to take agency for themselves. We will work with those communities to make

sure everything in our gift we can do to address that, but this is not just about what the NHS does or about what the Assembly does. It is about what the nation does as a whole, what we do as a partnership: local authorities, the GLA, ourselves, communities and the voluntary sector. We all have to have this health equity question at the forefront of our minds.

Unmesh Desai AM: Thank you for that. That was going to be one of my questions, Mr Machray. It is more than just the vaccine.

Can I just make one point, Chair, on the vaccine? I took the Oxford [AstraZeneca] vaccine myself, my first jab, on Friday, and we may need to up our messaging on the Oxford vaccine because of the misinformation. Lots of the stuff you have seen in the public domain. I know of a friend of mine who went to Stratford Westfield, and when he found out it was the Oxford vaccine he said he did not want to take it and went back home, so I want to say publicly that I took the Oxford vaccine myself and another councillor friend on Newham Council took it yesterday. Everyone should take whatever vaccine is available out there. There are millions of people around the world who are dying for a vaccine.

Martin Machray (Joint Regional Chief Nurse - London, National Health Service): Literally.

Unmesh Desai AM: Anyway, that is my rant. Just moving on, conscious of the time, there are three more questions. Looking at the bigger picture, how will the Mayor and the NHS work together to improve trust and engagement with healthcare services across London? You have already given some examples, I think, the role of local authorities and that we need to have a bottom-up approach. Again, some wider thoughts on that?

Dr Tom Coffey OBE (Mayoral Health Advisor): I might bring in a report which came out recently, the King’s Fund report, which the Mayor commissioned to look at the NHS services in London in light of the COVID pandemic but also in light of the new ICSs.

I have to say previously the King’s Fund report four or five years ago was quite concerned about some of the changes the NHS was making in London regarding bed reductions and some of the financial issues.

The latest report, which came out about two weeks ago, painted a very different picture of very impressive collaboration between local authorities, the GLA and the NHS, especially during the pandemic, addressing how we care for our most vulnerable, how we run a vaccination programme and how we safely discharge patients from hospital. Also, it looked forward - in answer to your question, Assembly Member Desai - at how they will work together in the new ICSs and, very importantly, in the place space, the borough-placed activity. It is saying the borough-placed work, integrated care partnerships, will be vital to where that partnership will really occur between the local authorities, the voluntary sector and between the NHS. The King’s Fund painted quite a strong picture - albeit with anxieties regarding workforce and estate, which I think we both share as concerns - of using the learning from the pandemic partnership in how we are going to work in the future.

Martin Machray (Joint Regional Chief Nurse - London, National Health Service): Yes, the last 14 months has been a crucible for us and it has brought us together out of necessity. I would be enormously disappointed if we lost the benefits of that joint working as we come out of this. For local authorities, let us recognise the impact that has been on them over the past few months. Financially and service-wise, it has been an enormously difficult time. We need to work collaboratively together.

I have mentioned them a couple of times, I think, but just to be explicit, the partnership is beyond just the NHS and the local authorities. It is beyond statutory services. We have some fabulous work that is improving the health of Londoners through the voluntary sector and we can commission some of that, we can contribute to

that and we can rely on it, too. We need to have that partnership continue to strengthen as we go forward and that is at the neighbourhood level, at the borough level and across the city.

Unmesh Desai AM: Just moving on, in terms of the ICS in London, what are the challenges there for improving equality of access for healthcare, the governance and so on?

Martin Machray (Joint Regional Chief Nurse - London, National Health Service): Yes, I wonder if I can pick that up and give you an example of one of the ways we are challenging that. As you might imagine, over the past few months as we have dealt with the wave of patients suffering from COVID, patients on a waiting list for surgery - what I would call elective surgery - has grown over the past few months. The two GPs on the call will know their own patients are waiting longer than they should have been or we would have liked them to be, because of the global health emergency we have been facing. We have got to start to now get on top of that backlog and get people, who have been waiting, in my opinion, too long for surgery to get surgery.

If we did not work as an ICS, those people with the loudest voice and served by the biggest hospitals would do better than those in the smaller hospitals and the quieter voices. What the ICSs do is bring those people together and say, “This is not one hospital’s problem or one community’s problem. This is a group, an integrated care challenge. We have to make sure”.

If you take where I live in southeast London, there is a southeast London ICS covering six boroughs, two massive university hospital trusts, two really excellent mental health trusts and just under probably about 900 GP practices. You can imagine that. We make sure that whether you live in Erith, here in Waterloo or anywhere in between, you get the same opportunity. If you need your hip replacement, you wait the same length of time. That is not about merging services and organisations. That is about merging patient lists, making sure we are all dealing with the challenges ahead and that is one way we can really get on top of the health inequality question.

I am sorry, I sound like a schoolteacher now, but if you have been waiting for a hip replacement for 18 months and you cannot pick up your granddaughter when those lockdown rules are released or you cannot get back to work, your quality of life is severely, severely damaged. It should not be where you live or who your doctor is that matters; it should be that you need a hip replacement. That is what the ICSs should be focusing on, improving the population’s health and reducing those inequalities.

Dr Tom Coffey OBE (Mayoral Health Advisor): To add to that, the King’s Fund did say the big difference in the ICS plans that were present in 2020/21, compared to four or five years ago, is in fact health inequality is central to all those five plans. That was in fact the biggest change it saw in the last four years.

Unmesh Desai AM: OK. Chair, I have asked the questions I was going to. Can I just end on this note, Chair? You may wish to sum up because this is the last meeting so I think it is your prerogative as Chair, but I will say this because I think this will encapsulate the whole picture. There have been some fantastic contributions from yourself, Dr Coffey, and Mr Machray and our other participants.

Professor Devi Sridhar [Professor of Global Public Health] - I am a big fan of her writing - from the University of Edinburgh had this to say today:

“I'm optimistic for the future. I see a cautious path out of this crisis for rich countries. Vaccinate 80-90% of the population [which the Government is doing], build test/trace/isolate to jump on outbreaks, enable surveillance with waste water testing & re-open our economies & normal life.

More concerned for poor countries ... left behind: with vaccines ... and even basic medical interventions like oxygen. We live in a global world and have to continue to act like one human race. As we've learned, viruses don't care about borders or citizenship.”

I do not think that is controversial at all, what she is saying. That is a roadmap for the future. Let us be positive. Thank you again.

Dr Tom Coffey OBE (Mayoral Health Advisor, Greater London Authority): Thank you.

Dr Onkar Sahota AM (Chair): Thank you, Assembly Member Desai, for giving us an international perspective on this because we are all in it together and until all the seven billion people in the world are protected, none of us are protected.

Unmesh Desai AM: Absolutely. Absolutely.

Dr Onkar Sahota AM (Chair): Finally, one thing I want to ask you, Martin. I am sure this has probably impacted on the AstraZeneca vaccine, some countries have suspended it and hopefully the World Health Organization (WHO) will today give us an undertaking. It brings into question this question about trust, how trust is important and how governments and people in authority have to be open and transparent with the public. That is something we have learnt. It is about trust.

I am already seeing in my general practice people saying, “We don’t want AstraZeneca. We want to have Pfizer, we want to have...” Are you picking this up across London also? Secondly, I see no reason why the WHO would not say that this is safe vaccine. How are we going to address this, on top of all the other work we are doing about hesitancy? This will be another thing which is affecting people’s confidence in the vaccine. I just wonder how you would respond to that.

Martin Machray (Joint Regional Chief Nurse - London, National Health Service): Yes, you are right, trust is based on transparency. Let us be really transparent. There are concerns raised by some countries about one of the vaccines that is available, the one that we are using a lot of in this city, the AstraZeneca-Oxford vaccine.

Let us also be transparent that in the 2.75 million doses of vaccine we have given in London, both AstraZeneca and Pfizer-BioNTech, we have seen no cases reported of blood clots associated with the vaccine, none. Britain has one of the most well-developed and mature safety reporting systems in the world. If there was an associated blood clot, we would know about it. That is not to say that we have not seen them reported elsewhere in the world, but the numbers are tiny in comparison to the number of doses given.

There are probably 100 blood clots reported every day in London anyway, despite the vaccine, because people suffer from blood clots. Just because something happens and something else happens, you cannot put the two together. There is a great article by Dr [David] Spiegelhalter [Chair, Winton Centre for Risk and Evidence Communication, Cambridge University] in yesterday, just describing how you should not make those cause and effect assumptions.

Let us be clear that after 2,750,000 doses, there is no report of a blood clot associated with that. We continue to believe, until the scientists who know better than I tell me, that this is a safe vaccine on proven technology.

That will change. You have already said, Chair, that this changes over time. When we started, lots of people were saying, “We want the British vaccine. We want the Oxford vaccine. We don’t want the Pfizer vaccine”.

That has changed and we are going to continue to monitor that because we cannot pick and choose at present which vaccine we have, neither as professionals giving it nor as patients receiving it. I am just eternally grateful we have a vaccine that we can offer at all, because that is our way out of this.

Assembly Member Desai, I might be quoting you in the future. Your description about your approach to last Friday was brilliant. I think I said to a [London Assembly] Plenary session that the only time I have cried in the last 14 months is when my wife said she was getting the vaccine, and that was out of sheer joy. We should be eternally grateful to our scientists, our laboratories and our drug companies for producing this vaccine so quickly. It is safe and it is effective.

Unmesh Desai AM: Absolutely. Hear, hear.

Dr Onkar Sahota AM (Chair): Thank you, Martin. We end up on a positive note. Can I thank our guests for their contributions?

As this is the final Health Committee meeting for this mayoralty, can I thank you all for your contributions on the Health Committee and for all the hard work you have done? We can all be proud of the outputs we have had from this Committee and the quality of witnesses we get here. Thank you, all Committee Members, for your hard work and for being Members of this Committee and I wish you all good luck.

Andrew Boff AM (Deputy Chair): Can I just say, Onkar? Can I also extend that thanks to the superb support that we have had from the scrutiny team and the Committee services’ excellent reports and excellent questions to ask? It is right that we record those thanks.

Dr Onkar Sahota AM (Chair): Yes. Absolutely right, Andrew. We can only do the work we do because the excellent support we have from our supporters. Let us put on record all the hard work of the secretariat and all the Committee services and thank you very much to all the officers who support us in our work. Thank you, [Dr] Tom Coffey, for coming here and spending the morning with us. Thank you, all the guests.

Dr Tom Coffey OBE (Mayoral Health Advisor): It is a pleasure.