Editorial Thursday 7 July 2016: Health Secretary Jeremy Hunt's speech to the 2016 Reform Health conference
Consider a country that has run out of money, just come out of a damaging battle in Europe with huge differences between the haves and the have-nots. Britain in 1948 (laughter). Despite those extraordinary challenges in 1948, the visionary Labour statesman Nye Bevan came up with his extraordinary vision of the NHS.
It made us the first country in the world to say ‘no matter what your background, you should have access to good healthcare’. Nye Bevan made it a reality. Successive governments have tweaked this or that about the NHS; but none have touched Bevan's founding vision. It’s the most important public service for British people, in pools, repeatedly ranked as a source of national pride ahead of armed forces, or the BBC.
The question on many minds today, as we face so many other challenges, including now the unexpected Brexit, is this. Is now the time in the NHS to reach for the stars, or the time to scale back ambitions?
Categorically, I say that we should renew our ambition with added determination to make the NHS the safety, highest-quality as well as the fairest health system in the world
The only thing that we should remember about Bevan – his vision was one of equity, but also of excellence. It doesn't work to say 'the NHS will provide mediocre healthcare for all' if the rich can fly to the Mayo Clinic for their cancer care, going business class. Bevan's vision says 'the NHS is there for you, no matter what your background or where you live', but in reforming the NHS, we need to remember excellence as much as equity.
The context has changed. Like 1948, we have very constrained public finances. The NHS was 68 years old this week. One change from 1948 to now is the fact that we have an ageing population: no surprise to anyone here. Remember that by the end of this Parliament (which I expect to be 2020), there will be 1 million more over 70s in England - and 1 million more by 2025.
The other absolutely critical change is change in technology. I believe we are only at the start of the internet revolution which is going to change healthcare. Health minister George Freeman has been a great champion of new technology.
Look how the internet has transformed retail, travel, banking, communication – those transformations, profound as they are, have largely been about convenience. In healthcare, we will see a mix of convenience with staggering advances in human potential to combat disease.
In the next 10-15 years, I suggest that we'll see one of the biggest changes in healthcare for two millennia. Since Hippocrates, the model of medicine has been that when you get ill, you go to the doctor for diagnosis of your symptom and help to get better by medicine / treatment.
And the sooner we diagnose/identify illness, the better our chances of correct treatment and recovery.
We know that one drop of human blood contains 300,000 biomarkers. In California, people are saying that in 10 years' time. they'll diagnose illness before any symptoms present at all. Why would we try to ask the human brain to calculate those 300,000 biomarkers in a drop of blood? Of course we'll still need more doctors than ever to meet the challenge of how to interpret that data and what we do to treat.
This will be as big a challenge for healthcare as driverless care are for the motor industry. A recent Sunday Times report showed that of the top 10 medical research universities in the world, five are in Britai. Healthcare is a vital industry, and we must be in lead.
For successful NHS reform, we have to factor in the world around us and solve tomorrow’s problems; not yesterday's. In that context, reforming how we do business in the NHS is not optional: it's a necessity if we are to stay true to Bevan's founding vision
Think about how reforms happened in other public services and other sectors: education, policing, prisons - the reform agenda has been about raising standards, focus on outputs, not inputs; and without sounding too market-oriented, thinking of consumer interests as well as producer ones.
In healthcare, reform is about putting patients first in all we do. Yes, we have to factor in technology, and also money. Money is a challenging issue for the NHS now - as it's always been. The onward march of healthcare technology - be it immunotherapy or cancer cures - we want them to be universally available in the NHS, but all technology comes with a big cost.
What is the roadmap for putting patients first and affording the big technology coming over the horizon?
Three steps are crucial. The first is about transparency: if we're serious about UK healthcare being the best available anywhere, then we must be honest when it isn’t. Look at the dramatic impact of transparency in education. Since OFSTED was created by ex-health secretary Ken Clarke, it’s had a huge impact. I’m a Home Counties boy: I went to Charterhouse in the 1980s, when the prevailing middle-class wisdom was that if you can afford to, you must go private.
That’s completely, dramatically and wonderfully changed, thanks in no small part to the power to put schools into special measures. And now for the middle classes, if your local school is OFSTED good or outstanding, the prevailing wisdom is that you should send your children there: that’s good for social equity and for the country.
The new CQC regime are doing that in healthcare. David Behan, and his team, and the new chief inspector of hospitals Sir Mike Richards, inspected all major acute hospitals.
One example how powerful. Wexham Park in Slough. We knew that for years, the safety of care was inadequate; staff were disempowered and disengaged. The CQC said there was a culture of 'learned helplessness'.
Following inspection and being put into speical measure, Wexham Park was taken over by Frimley Park under the outstanding leadership of Sir Andrew Morris. They achieved a successful culture shift, and the number of Wexham Park staff who'd recommend treatment there to their friends and family rose from below half to over two-thirds.
Core care quality rose from inadequate to good/outstanding in all the main areas. It happened thanks to a bit of DH effort, much staff effort. Once we're honest about the problems, many problems solve themselves.
Of the 27 trusts put into special measures after inspection, 11 are now out or coming out – look at the case of Medway, which languished in poor performance for years, with care that frankly their staff wouldn’t want to defend. Huge improvements are under way, and it’s very exciting.
Transparency is very important. The second step in the process comes after what I like to call 'intelligent transparency', because the aim is not to 'name and shame' but to identify problems to enable us to fix them. Second point is about the proper learning to put problems right.
In my speech a year ago, I said I wanted the NHS to become the world's largest learning organisation. What does that culture mean?
Firstly, as in education, where we find deficiencies, we must put in support to coach and develop people. But it's deeper, it's about having a learning culture at the front line.
I believe we make it much too hard to speak out honestly if they or a colleague make an error, or something goes wrong in the organisation. Those staff (rightly) worry about being sued, GMCd, and/or disciplined.
We need to create a situation where for example if a tragedy in obstetrics happens and a baby is born with lifelong injuries, or a baby dies, currently, the system makes it most difficult for clinicians to speak honestly so that the correct learning can happen.
We need to get to a situation where, when something in a treatment goes wrong in the John Radcliffe, clinicians know in Sunderland and Bristol within days. Our first focus will be on maternity, as that's where we can make spectacular gains.
We’re going to bring forward legislation to create a safe space for doctors and nurses to speak out, and (as in the airline industry) we can create environments where people feel able to speak out openly about errors, near-misses and adverse incidents.
Having last month set up the new healthcare safety investigations branch, I'm delighted to announce its CE is Keith Conradi, who ran the air investigations unit for a decade.
In tackling deficiencies in learning culture, when things go wrong, the NEJM suggested that last year in the USA, medical error was the third-biggest killer after cancer and heart disease. Britain's probably no better or worse, but we have the ability to collect and share data across our whole system.
The third point: to get this right, we have to think about culture core reform territory: where really put patients first and recognise this in our health tech revolution.
In other words, people-powered possibilities enable individuals to take decisions about their care plan for themselves. That is the technology revolution we need to think about. It's not just about making doctors' and nurses' lives easier: it's about putting patients in control of their treatment plan: do that, and we get outcomes much better.
This year, the NHS took a small but significant step, giving all NHS patients full access to their GP records, which are probably the best in the world (whereas our acute records are very definitely not). GP records are particularly valuable, as they're the lifetime record of your whole care. People can now access their GP records, account of care going back decades.
This lets us do interesting things. People can insert preferences for their own data use. We announced this yesterday: people can opt in/out, and can change their preferences at any time. For sensitive things like end of life care preferences, people should be able to go online and change/explain their preferences at any time.
We also have to remain robust in determination to get value of every pound: the NHS has particular financial challenges this year.
If this all seems difficult or impossible, remember the famous Mohammed Ali quote "Impossible is an opinion ... impossible is nothing".
What would be impossible would be to have an NHS where we're not kept on our toes and under constant scrutiny by the media, science and technology and our own people. But it's possible to build an NHS where safety comes first: the highest-quality health system in the world
Hugh Pym, BBC News: is there a risk the current NHS financial challenge becomes so pressing the longer-term reforms you've described are put at risk?
JH: That's why it's essential we restore financial discipline in NHS, to make long-term progress. It's important that in the NHS, people understand that it's not a choice between healthy finances and quality care; both go together. Virginia Mason namecheck. If fall in acute avoidable with better nursing care, three days longer stay and cost £1200 more infection 12 days £2,500. We need financial discipline and elimination of waste. It's striking that the acute trusts with the best CQC ratings also have lower deficits.
Andy Cowper, Health Policy Insight: You mentioned the importance of culture. The NHS is going to scale currently with mergers/shared management teams, hospital chains and GP practice federations. What are the risks of the NHS going to scale on the basis of its less positive and less transparent aspects of culture?
JH: The issue of culture and chains / groups needs a lot more thought. Look in the commercial world, mergers often destroy shareholder value above the benefit to the new merged organisation, and they can be a huge distraction. Thing go wrong, and big is not always beautiful.
If you look in education, which is closer to health, we now really understood how to get chain academies working.
The Department for Education (DfE) approach is brilliant: if a philanthropist wants to support a chain of academies, they'll typically say 'I want one of them to be my old school': the DfE put 20 schools together, some good, some struggling and group that one into package which they make most likely to work as a viable chain. 10-15 years ago in education, there were problems with this: we saw a number of outstanding schools which took over struggling and then lost their OFSTED outstanding rating as the eye went off the ball fixing the weaker school.
This is a real risk, and acute trusts are bigger and more complex than schools. We need to do this, we're going in the right direction on this and we have to get it right.