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Editorial Tuesday 1 April 2014: "Think like a patient, act like a taxpayer" - Simon Stevens' first speech as NHS England CE

It’s good to be back - back in the NHS, and back here on Tyneside.

I know times are tough, and the Health Service is under pressure. But when people ask me why take on this new job? My answer is:  Because I believe in the NHS, and I believe in its future. That it will be there when we need it, at the most profound moments in our lives. At the birth of our children. At the deaths of our loved ones. And at every stage in between – as we grapple with hope, fear, generosity, loneliness, compassion – all the most profound elements of the human spirit.

I was reminded of this again this morning in Consett, County Durham, where 26 years ago I started work in the NHS. Obviously the hospital has changed a lot - the old Nissan hut wards are long gone, and services have moved. But the nurses and patients and GPs I chatted with on the cancer unit and rehab service had that same passion and commitment for health, and made a convincing case that the quality of care is better than ever.

Yes, there’ve been huge changes in hospitals across the country, and no doubt there are more to come. But ask yourself: would a child with leukaemia, or a woman with breast cancer, or a man having a stroke be better off now or back then? The answer is obvious – care is far better now. A timely reminder that the NHS has been continually adapting, and successfully evolving, since the very day it was created.

But there’s more to do – including better supporting patients with their own care. So at lunchtime I was in South Shields hearing how patients, the NHS and the council are now coming together to help people to take control of their own health. They’re one of the 14 ‘integration pioneers’ now getting going around the country. It’s early days, but if like me you believe it’s time to get serious about patient power, prevention and community partnerships, you’ll be encouraged by what they’re doing.

And now this afternoon, it’s great to be at the Newcastle International Centre for Life. Spend time with John Burn here, and you’ll see how breakthrough medical research and new ways of caring for patients are opening up amazing new frontiers that were impossible just a few years ago. We’re moving from mostly one-size-fits-all treatment to genuinely personalised care. And we can increasingly nip health problems in the bud before they get worse. We stand poised at one of medicine’s great inflection points.

What’s more, this Centre embodies a virtuous circle - of cutting-edge British innovation, new NHS treatments and regional economic growth. If, like me, you believe in a tax-funded NHS, you’ll want the Health Service to play its part in growing our nation’s economy, precisely so we can sustain public health services, for generations to come.

So today three different places; three different ‘sign posts’ to the future. And there are many more like this around the country.

Current realities
Now I know that for the NHS the stakes have never been higher. I’m personally grateful for the warm welcome I’ve been given since it was announced I’d be taking on this job. But given everything we’re facing, this is also a moment to speak frankly.

Service pressures are intensifying, and longstanding problems are not going to disappear overnight. As my predecessor David Nicholson has pointed out, this year is going to be a challenge and 2015/16 even more so. No one person can fix everything that needs fixing – certainly not me. Successfully navigating the next few years is going to take a team effort – involving the biggest team in the biggest effort the NHS has ever seen.

Fortunately, down the years, the NHS has shown a proven ability to rise to the occasion. People have come together, and amazing things have been achieved.

Cancer and heart disease deaths, slashed. Multi-year waits for surgery and tests, practically eliminated. Hospitals infections, cut. Many more doctors, nurses and other health professionals. And more openness and choice for patients.

Of course there’ve also been missed opportunities: on health inequalities, on quality and regulation, hospital IT, some PFIs, some pay reforms. But very few people I talk to would want to wind the clock back.

Today we face new challenges, and will need new solutions - while holding on to the vital gains of the past. The global recession has meant the NHS facing its most sustained budget crunch in its 66 year history. But let’s also state clearly and publicly: the fact is that care for our patients has in the vast majority of cases continued to be of an extremely high standard. And that is a remarkable tribute to the personal dedication - and shared sacrifice - of health service staff. The nation owes you a debt of gratitude. We should say thank you. As someone who has spent the last decade working in health care around the world, I know of no other country’s health system which has managed this economically turbulent period better.

Agreeing what needs to change
But my sense is there’s now also a widespread feeling around the NHS that some of the tactical solutions that have stopped the wheels coming off to date, can’t be repeated indefinitely, and aren’t going to suffice going forward.

So it’s time to chart a new course. One that combines hard-headed realism about the here-and-now with a sense of shared purpose and – dare I say it – even optimism about the future.

Yes, there are going to be bumps in the road. But delaying the journey just increases the risks. Of a downward spiral of care, of falling staff morale, and of eroding public support.

So what is this journey we’re talking about?

Today is not the moment to try and spell it out in detail, not least because first I want to spend the next several months out and about around the country. Talking to some of the NHS’ biggest supporters - and meeting some of its most outspoken critics. But above all, listening to what patients, carers and frontline NHS staff have to say. About how the NHS is doing - and about what needs to change.

This afternoon let me make three initial observations.

First, my assessment is that there is in fact now a widespread – if partly camouflaged - consensus on many of the big things that need to change.

We know that the quality of NHS care is usually very high - but occasionally it isn’t, and we all want that to change. We know we’re going to need patients and carers to help redesign care. And that an NHS with a ‘like it or lump it’ attitude will simply not survive. We know that of course not every whistleblower will always get it right, but the fact is: patients’ lives are saved when courageous people speak up - openly and honestly - and when each of us takes personal accountability for putting things right.

We also know that - increasingly - quality isn’t just about the individual test result or prescription or hospital stay, it’s about how all the pieces come together. An aging population with more chronic health conditions, but with new opportunities to live as independently as possible, means we’re going to have to radically transform how care is delivered outside hospital. Our traditional partitioning of health services – GPs, hospital outpatients, A&E departments, community nurses, emergency mental health care, out of hours units, ambulance services and so on – no longer makes much sense. There’s growing consensus on that too.

And yes, as patients we do have responsibilities as well as rights, doing our part to stay healthy and treating our nurses and doctors with respect. But equally, blaming the people who rely on our services – the worried parent or anxious carer - for failing to understand where ‘the system’ thinks they should go for care is back-to-front thinking.

Nor is the answer simply asking hard-pressed staff to do more of the same. Which is why one of my first steps is going to be considering with our partners how the newly agreed GP contract – which goes live today - can best support our most vulnerable older patients.

Fundamentally we also know we’re going to have to find ways of better blending health and social care for people with high needs. How best to do so is a debate we should have. Though as we do so, no-one should pretend that just combining two financially leaky buckets will magically create a watertight funding solution - it’s going to take more than that. So my aim is that NHS England and our local government partners get going, this year, on supporting and testing some practical new models that don’t need structural re-organisation. There are many current initiatives to build on, plus some international approaches that we should now try.

We should also be expanding the commissioning impact that high performing Clinical Commissioning Groups can have – and certainly not wasting time on yet another drawn out debate about whether there are too many or too few of them. Instead let’s focus on actually making commissioning work. Using the full tool kit that a National Health Service can in theory provide. And in doing so, let’s test new commissioning approaches – including in some geographies and for some services bringing together primary, community, and specialist care.

So my first point is that on many of these ‘big ticket’ goals there is in fact now a broad policy and political consensus for action, even if it’s sometimes partly hidden by day-to-day debates and argument.

Charting a new path
My second point is probably more controversial. Coming back to the NHS after working on health care improvement around the world, I’m also struck by the misplaced consensus that seems to exist inside the Health Service on various issues.

I’m not going to try and debunk them all this afternoon with a new ‘Dictionary of Received Ideas’. But things that are assumed to be inevitable care delivery constraints here, often turn out not to be in other countries.

Viable local hospitals that don’t all have to be huge – partly because of different choices about where and how doctors are trained. Mental and physical health, unified.

Employers actively engaged in the health of their employees. Faster uptake of digital technologies. The critical role of the Third Sector, and the innovation value of new providers. Clinicians in key leadership roles. More professional authority for nurses and midwives. Redesigned jobs, and pay systems that work. Comprehensive information sharing for care coordination. To mention just a few.

So over the next couple of months, as Clinical Commissioning Groups and provider trusts refine their new two and five year plans, one of the questions we at NHS England will want to ask - in partnership with Monitor and the TDA – is this: ‘If you’re going to get to a sustainable and future-proofed local health system, what are some of the longstanding assumptions and constraints we’d need to say goodbye to?’

Which brings me to my third point this afternoon, about how we’ll catalyse change.

Unleashing innovation and improvement
At a time when resources are tight, we’re going to have to find new ways of tapping into three incredible sources of ‘renewable energy’:

-          Boosting the critical role that patients play in their own health and care.

-          Supporting the amazing commitment of carers and volunteers and communities to sustaining their health and social care services.

-          And unleashing the passion and drive of the million-plus frontline NHS staff who are devoting their professional lives to caring.

I’m more and more convinced that these three energy sources are going to be central to our future.

I’m not naïve about how difficult some of this will be. But, as the old saying goes, ‘To will the end is to will the means’.

Fortunately many of the apparent barriers in our way are in our collective gift to fix. People from other countries are often surprised that we haven’t yet done so. To be clear:  I’m certainly not arguing we should be importing wholesale anyone else’s health system. What I am suggesting is that we’d be daft to ignore excellent ideas just because they’re ‘not invented here’.

The NHS needs to become the best at harnessing the best – whether spreading good ideas from within, learning from other industries, or cherry-picking from other countries. In doing so, we have the advantage over many other countries because these individual innovations will often work best when combined and embedded in local ‘organised systems of care’ – something the NHS should in principle be able to excel at.

Of course sometimes we won’t know at the outset what the exact solution should be. Which is why I agree with MIT’s Eric Brynholfsson and Andy McAfee that ‘the best way to accelerate progress is to increase our capacity to test out new combinations of ideas’. Inevitably some of them won’t work out, and there’ll be criticism and honest disagreement along the way. And I’m sure we’ll often find there’s more than one path to salvation.

But at all times our guiding principle will be: walk in the shoes of the people we serve. Think like a patient, act like a taxpayer.

As we do so, often it won’t be NHS England acting alone. As we work towards bold and transparent goals set out in a democratically-accountable Mandate, and with our strengthened focus on health commissioning and an operationally-independent Board, we appreciate the distinctive contribution of others.

But together we’re going to need to work in coherent and purposeful partnership, because the national leadership of the NHS has to be more than the sum of its parts.

The alternative, to quote Milton’s Paradise Lost: ‘Thus they in mutual accusation spent/The fruitless hours…And of their vain contest appeer'd no end.’ Given everything facing us, we don’t have fruitless hours to waste, and we can’t afford vain contests. Said less poetically, it’s time to roll up our sleeves, pull together, and get on with it.

The health care system that can solve-for the really big challenges – dementia, obesity, inequalities, mental health and wellbeing, personalisation, prevention and empowerment - that’s the health system that will prosper in the 21st century.

Amazingly, one-in-three of the children born across England this very day are likely to live to celebrate their 100th birthday. Our mission is to ensure that a caring, compassionate and modern NHS is there for them throughout their lives, every step of the way.        

Given the cards we’ve been dealt, that’s not going to be easy. In fact it’s going to be the hardest thing the NHS has ever had to do.

But if we can pull that off, then care will be far better, our country far healthier, and the Danny Boyles of the future will be celebrating our Health Service’s proud legacy for years to come.