Editor's blog Friday 19 November: Health Minister Earl Howe's speech to the NHS Alliance conference
Andrew Lansley sends his apologies that he can't be here, and his best wishes for your conference.
This government has two priorities above all others: to restore order to our public finances; and to ensure the health of our nation. Last month, Chancellor George Osborne's budget set out the plan to have debt falling by the end of this Parliament. We need to reduce public spending by £81 billion.
Just as important is protecting and improving our nation’s health. While we're reducing every other department's budget, the NHS budget is protected and has small real-terms increases every year.
You can all be deeply proud of the work you do in the NHS, which provides everyone with free, good-quality healthcare as and when they need it. That is not available everywhere.
However, while international organisations like the Commonwealth Fund praise NHS equity, we have further to go on universal excellence.
Here we need more than money. People in the UK are twice as likely to die from heart attack as people are in France. Our results for cervical, colorectal and breast cancer are among the worst in the OECD. Our rates of premature mortality from respiratory disease are poor.
It's about more than money, we need to think differently and act differently. This is a change of direction; and I want to outline how it will give all here a better chance of delivering the right result for patients
One of my colleagues has told me about 'Bertha' - this is, apparently, a cartoon about Bertha, a hardworking factory machine who is forever in need of tuning up to deliver the latest order. It reminds me of how the NHS was treated over the last decade; the Labour government tried to pull a lever to get out better healthcare.
The glaring problem with that approach is that the NHS is not a machine; it’s not responsive to an army of mechanics and foremen barking instructions from Whitehall.
The NHS depends on human relationships. Good healthcare is about an exchange between managers and clinicians; between clinician and clinician; and between clinician and patient. It’s not a numbers game: not definable by circulars for Whitehall.
Our White Paper is about creating a conduit for those close human relationships; not barriers to them.
We do this by putting patients at the centre - No Decision About Me Without Me.
This helps to focus on what matters: away from process-led targets, towards outcomes. No more hitting the targets and simultaneously missing the point: we want a new culture of evidence and evaluation and sense of entrepreneurship.
So our third principle is of an empowered front line, cutting the Whitehall apron strings, giving you back discretion and autonomy to do the right thing for patients. GP commissioning is a unique opportunity for all primary care clinicians
I was surprised to read yesterday and this morning that the government is planning to introduce national GP booking call centres and sack receptionists: take it from me, the government is planning no such things. Let’s encourage the NHS plan for local areas, but not jeopardise local decision-making or better outcomes for patients.
Andrew Lansley and I are grateful for NHS Alliance’s role in developing commissioning. Your Commissioning Academy and GP Commissioning Connect are really important for keeping consortia well informed, prepared and ready to take opportunities.
I sense that the more people learn about GP commissioning, the more they warm to it. NHS Alliance’s new survey shows the support is growing. Of course there are still questions and anxieties, as are natural in any reform and we are listening carefully. The Alliance’s membership listening exercise was very helpful.
NHS managers are sometimes misrepresented as the bogeymen of piece – this is the opposite of truth. The problem was not mangers, but a system of top-down direction and box-ticking. Excellent managers and are will continue to be essential. A more entrepreneurial innovative NHS will need NHS managers to provide support – all of our reforms will be impossible without great management.
SHAs and PCTs are to be phased out and management costs must fall, GPs will need management, as got to AWP and all FT status, excellent management will be essential.
I am often asked ‘why are you giving all the responsibility to GPs?’ I think there are 300 million reasons – with 300 million GP consultations a year, nobody knows the patients better. You also have the population responsibility; we know form PBC and Total Purchasing pilots that shifting decision-making to local consortia yields better results, Northampton’s NENE PBC group introduced peer review and dramatically cut acute referrals: they stopped 900 outpatient referrals in six months. Croydon GPs worked with senior acute clinicians to create a one-stop service for women with menstrual problems, and time to see a senior consultant dropped from 10 weeks to two.
The rhetoric about our reforms is overheated. I agree with Julian Le Grand's analysis: this is evolution, not revolution. Patient choice; FTs; quality standards: all Blairite ideas. Our aims are to substantially build on those half-finished reforms.
I also want to talk about how reform will change the GP role. We do not expect GPs to become administrators instead of doctors. Some GPs will want to lead consortia; others to show their leadership as advocates of their patients in their practices. Both roles are vital. Neither will general practitioners be expected to carry out all commissioning: consortia will be able to employ or buy in staff from external organisations.
You will lead, but you will not be alone. The independent commissioning board will be there with support and advice. And it will not be a new form of central government - not the DH under a new name.
Yes, we will hold you to account for the money spent and the outcomes achieved; but we won’t interfere with how you achieve your aims or run your consortium. We are not there to tell you what to do.
One independent commissioning board support will be the new commissioning packs – to help consortia reduce time they will spend on procurement and administration.
This isn’t going to be a big bang reform: there will be no Year Zero moment when the NHS commissioning consortia all start commissioning. This change will be incremental. We want practices testing the water with pathfinders, and the first groups of these will be up and running in the New Year. The DH commissioning evaluation unit will test the pathfinders’ work with them, and create new national learning networks with £1 million for learning programmes. But you will get no DH manual on how to do this – this is your opportunity to shape the future of your own services the way you want to.
I urge all of you to grasp it with both hands.
We understand address the concerns that consortia will inherit PCTs deficits. We are working with SHAs to straighten this out, and we'll say more in the new NHS Operating Framework later this year.
There’s a lot of work going on over tariff – in the new system, Monitor will set efficient maximum prices for NHS services to promote competition and drive productivity. We will publish final tariff and guidance in the spring.
In coming years, we want your support and enthusiasm to help us realise the potential of tariff. This is not just to transfer power to GPs, but also to patients and carers. We want the fundamental relationship to develop into partnership. That means giving patients real control over where when and by whom they’re treated; spending their own budget in thew way that suits their own needs – informed by proper information
The mantra should be transparency, including about practice accounts. People aren’t fools, and they’ll look at the evidence, which acute dept or consultant-led team offering best care – and choice.
There will be competition. Consortia will be free to choose form any willing provider all seeking the best outcomes in an open transparent way. Quality standards will be assessed by the Care Quality Commission, and Monitor will ensure fair and open competition.
We’ll give patients more information and more control over their own data. They will be able to access, add to and share that data. These real choices will increase innovation, stimulate productivity and incentivise providers to increase quality, and offer more personalised services.
We’ll also have strong local democratic accountability, patients voice via local authorities and new HealthWatch. There will be real powers of scrutiny and influence. All this opens potential to work closely with local authorities to jointly commission and pool budgets to tackle problems; closer working, involving social care, will mean that more can be done to enable people to live independently and reduce their reliance on NHS. It’s about putting power in hands of patients, clinicians and GPs.
The White Paper places new emphasis on the importance of public health, and soon we’ll issue a new public health White Paper. We hope NHS Alliance will welcome the emphasis on White Paper. As GPs, you are perfectly placed to make a real difference in your own community, to make prevention every bit as important as cure. Your input ensures that the clinically-led focus is on improving clinical outcomes. You can use your relationships with community providers and acute colleagues to design the best community and specialist services and specialist pathways. Local authorities too will be crucial to integrating health with other public services to maximise health outcomes.
This power promises to be an amazing thing. You’ve waited a long time for this level of freedom and control. Now is the time to be bold, challenge convention and be radical: use your talents and knowledge to fill to create an NHS that is truly the best it can be.
We will have sound financial systems for the use of public money and the capability is out there to start commissioning in the right way. We hope to present the health bill – we will, in a few weeks’ time, outlining the essential legal requirements to give you a picture of what consortia will have to demonstrate to the independent commissioning board. People rightly talk about localism and local buy-in, but there have to be quality controls from the outset.
QUESTIONS AND COMMENTS
Chris Ham (conference chair): Can you say anything about the money for the management allowance of consortia?
EH: The sums are still being done, and we’ll be much more specific fairly soon, but the numbers are shaping up. Take it from me: we want the management allowance to be sufficient for consortia to be able to do their job properly. We’re aware of anxiety money may not stretch far enough.
Delegate, GP: Successful commissioning involves relationships and exchange – Monitor’s role will be in promoting competition and you say that any willing provider is going to be essential. I have a concern that this may work for simple elective care, but my experience in Cumbria is that increasing competition and independent providers would make my job far more difficult than it is at moment. Please don’t throw out the baby of integration with the bathwater of competition.
EH: I sympathise entirely with your sentiment. The drive to competition and ‘any willing provider’ is a shorthand away of saying that Monitor is there to police unfairness in competition; not to drum up artificial competition where there is none.
Where services work well, delivering good outcomes, I don’t think services have much to fear. Where they’re falling short, getting too expensive or could be more cost-effective, there ought to be scope for other to do better.
I don’t see competition and integration as opposed – you can have both, integrating care pathways, and elements of competitive as appropriate along the pathway.
Our published response to the White Paper consultation will give a better sense in what we say about how this will be rolled and fleshed out. I think we’re on the same side.
CH: How far will consortia be free to commission from their constituent practices?
EH: They’ll be able to if they do so in a transparent and non-anti-competitive way. If there are cosy relationships between practice and community – they may be healthy, but if they get too cosy, we have to start asking questions. There is every reason in the world to go for a local community service as long as it is the best one going and as long as it is not anti-competitive.