Editor's blog Thursday 18 November: NHS Alliance chair Dr Michael Dixon's speech to the NHS Alliance conference
Welcome friends and colleagues, old and new, to this year’s NHS Alliance Annual
Conference. Thank you for coming and thank you for coming in such numbers! What a conference this is going to be! The Government says the frontline of primary care is going to be the future. That means the future is here. You…, you are the future!
What different times these are! Only a few years ago NHS Alliance produced a document called “Engaging GPs in the NHS” and then further reports on engaging nurses and allied professionals. No Minister, no one from the Department of Health attended the launch of any of these. We were told they were “unhelpful”. We were told we were trying to solve a problem that did not exist.
At our conference last year, some of you may remember, I was a bit uncharitable about the National Leadership Council. Not one single working primary care clinician among the lot of them! I upset several people by asking exactly who it was leading, where, why and how!
Today, of course, the Health White Paper has changed absolutely everything. GPs and other primary care clinicians are invading the National Leadership Council and just about every other hallowed institution at the Department of Health. We are witnessing the last gasps of a centralist, secondary care dominated system that had become totally wrapped up in itself and completely disconnected from its clinicians at the frontline.
That phase of the NHS is over. Like Eliot’s returning Magi, we can and we will no longer live “at ease in the old dispensation with an alien people clutching their gods”. If things are different then we must see, feel and smell that they are different! That means more walls coming down, more doors kicked open, more sacred cows sacrificed. Because simply changing structures and systems is not enough. We must also change the culture and behaviour within them.
I now want to speak to two sections of this audience. To those of you working in Primary Care Trusts, what can I say? I know these are challenging days for you all. You must feel that you have been led by The Grand Old Duke of York. Marching up to the top of the hill and then marching down again.
You have worked for organisations you did not design. You met targets you did not make. You sorted access, out of hours and World Class Commissioning to name but three! Did anyone thank you? Shouldn’t we be thanking those of you who did manage to deliver all this? Especially those NHS Alliance Primary Care Trusts who did it with their clinicians.
I know that those of you who come to NHS Alliance conferences are committed, conscientious and skilled men and women. We will desperately need you in the future. Whether you become leaders within GP consortia or part of support organisations for GP commissioning, I hope we can continue to work together - liberated from that world of central targets and filling boxes.
Next, I want to speak directly to GPs, practice managers and all primary care clinicians among you. Also the unconverted outside this room. Please.., please.., please.., do not let this blessed opportunity slip through your hands! How long have you waited to be freed of that centralist grip? PCTs never had that chance. How long have you waited for a real chance to improve the health of your communities and the services they receive? Do not allow history to call general practice and primary care timid, workshy, selfish or small minded. That is not the General Practice that I know. The NHS and its future are in our hands. If we fail, the NHS will be done for.
GPs working in deprived areas such as David Widgery in London and Dr Sassal (“The Fortunate Man”) in the New Forest literally died for want of being able to make a real difference for their patients. Unbelievably, we are now being handed this on a plate. Dr Elizabeth Blackwell, the first woman doctor, said “We are not tinkers, who merely patch and mend what is broken… we must be watchmen, guardians of the life and health of our generation, so that strong and more able generations may come after”. We cannot act Pontius Pilate to whatever goes on outside our consulting rooms. We must not allow fear, apathy, greed or laziness to prevent this becoming the NHS’s finest hour. The question is simple. Do you care and do you dare?
If the answer is yes then we can claim the future. It is not a time for the critical or the cautious. We must become the progressive voice of that future.
Our NHS Alliance listening Exercise, “Listen Up”, during the summer, was designed precisely to give you that voice. Our electronic survey, the report from our four regional listening events, submissions from all our networks and a response from the National Executive all produced the same conclusion. The principles and direction of change were right. But we need to get the detail right if the NHS wants to avoid tripping over itself, once again.
Many of you warned that we must avoid replacing one form of centralism with another. The National Commissioning Board, Monitor and the Cooperation and Competition Panel must not mushroom into all pervading monsters that might stifle and destroy localism. We have seen that happen before! We must not recreate another disconnect between the frontline and the centre. We have seen that too! We proposed, among other things, that the National Commissioning Board should have half its members coming from GP consortia and thus, perhaps for the first time, bring together those, who are doing it at the frontline with those who are trying to run things at the centre.
You also voiced concerns about how we could make the commissioning process fairer for new GP consortia. How could they possibly get on their feet if they were already saddled by huge deficits? How could they keep within budget if they could not control the costs? How could they commission when the data and our current commissioning mechanism are no longer fit for purpose? You proposed that tariffs should only be a maximum. That we should have a commissioning system, where the providers put in timely bills, which are paid when and only when the service has been rendered and it has been shown to have been rendered. Where budgets were severely challenged, we advised that GP consortia should be able to set cost limits on their providers. We must be radical if we really want to redress the historical imbalance between commissioner and provider, which has so blighted commissioning in the past.
You raised issues around purchasing and provision. NHS Alliance believes we must make it as easy as possible for GP commissioning consortia to commission from their constituent practices, when and where appropriate. Otherwise the movement of services from secondary to primary care will simply not happen. The question, of course, is how we can do this without creating a system that might put self interest before patient interest.
One answer proposed has been to have a menu of enhanced GP services approved by Monitor and the Commissioning Board. Some feel that social enterprise is the answer, while others suggest that “Any willing provider” will produce the necessary competitive environment. But a procedural fix is not enough.
Because there are enormous issues of trust, which can only be answered by openness and transparency. These might be achieved simply by insisting that all NHS providers – third sector, general practice or traditional private sector - should have open accounts in their dealings with NHS commissioners. Then we would know exactly what value we were getting. If we really want a fair system then transparency, transparency, transparency must become our mantra!
Others expressed unease about the future relationship between GP consortia and local authorities. Would GP consortia be allowed a proper role in improving health and would local authorities fully value general practice and primary care as future providers of health? All the evidence from Barbara Starfield in the USA and Brian Jarman here in the UK suggests that they must. That is why we are in discussion with the Local Government Association to make sure that this happens.
NHS Alliance will continue to work with Andrew Lansley and Earl Howe on these issues. They are good and courageous ministers with over 20 year’s health experience between them. But, the battle for the NHS will not be won or lost upon this field of detail. It will be won by the GP Consortia themselves. Their success will depend upon good plans, good leadership, good relationships and a strong social conscience.
Take plans first. We need to be absolutely clear about what we are trying to achieve. Why on earth are the number of hospital admissions and discharges in Britain almost three times those of comparable countries? The movement of services from secondary to primary care has simply not happened… yet!
Why do specialities such as care of the elderly, diabetes, dermatology, rheumatology and general medicine - to name just a few - remain in hospital at all? Why am I unable to do a same day scan on an acutely ill patient that might avoid him or her needing to go to hospital? Why are services for dementia or for children and adolescents with mental health problems generally so lamentable? Why, especially during this “Self Care Week”, which NHS Alliance so strongly supports, is all the talk about self care not yet being translated into action at the frontline? Good commissioners need to be sure what they are going to change, why and how!
That requires good leadership. Do we have 500 clinicians and 500 managers ready to make all this work? Do they have the commitment, the courage and the enthusiasm to blast through all the obstacles? I believe they have. Because many of those leaders are here in this room.
I should add, right away, that I have been utterly stunned by the enthusiasm and commitment of all our leaders within NHS Alliance. They are now at the centre of every activity and request. They – and you know exactly who you are – have been magnificent and inspirational. That is the sort of commitment that we now need to recreate in every locality. Optimistic and visionary. Realistic and pragmatic. We do not need glassy eyed evangelists on speed. We do need good, brave and grounded leaders. NHS Alliance leaders over the past week have been producing documents, burning midnight oil, in every area from: - how we make GP commissioning effective and improve out of hours services to future practice management, involving patients and working with specialists – all papers being produced today and available at the NHS Alliance stand..
Yesterday, we began a programme with Primary Care Contracting to support and enable GP Consortia and PCT leaders to get the best out of each other during this transitional phase. Recently we extended our popular “Practice Based Commissioning Academy” with Humana in to the NHS Alliance “Commissioning Academy”. We have a three year track record delivering training to over a thousand participants and can lay claim to be the best and most proven educational support for future GP commissioners. Today, we are also launching “GP Commissioning Connect”. This will help all GP consortia to keep up to date and informed. If you want to know what is going on and you want support to achieve your aims then GP Commissioning Connect will do for you – what no others can!
Along with good plans and leadership, I mentioned social conscience. Leadership at every level must put patients and communities before self. GP Commissioning Consortia need themselves to be strong community based organisations. An intrinsic part of the Big Society, not just a bolt on. Those were the principles behind our recent initiative “Who’s NHS is it anyway?”
Because GP commissioning, ever since we invented the term in 1993 has, itself, been about what we can do for others – not what we can do for ourselves. NHS Alliance is through and through a value based organisation .Our GP Commissioning Federation is committed to supporting all patients and all GP consortia at every level of development and achievement. These reforms must never be allowed to become a way of supporting only the elite and the strong or lining the pockets of GPs, managers or big business. That is not what we have been fighting for, all these years.
Leaders require followers. Both must work to create a corporate identity and ambition. That is why NHS Alliance believes that consortia should not, at this stage anyway, be directly responsible for holding primary care contracts - though much of the management of those contracts may be devolved to them. Just now, the priority of GP consortia must be to engage, support and enable. Not to dominate, punish or exclude. Otherwise, once again, we will repeat the mistakes of the past. That view is strongly supported by most GPs in our joint survey with GP newspaper published this week.
I began by saying you are the future and, oddly enough, I really did mean it. This White Paper can give us no more than the means of success. Success itself will only come by our own efforts.
I also began by mentioning our predecessor organisation, The National Association of Commissioning GPs. We began 18 years ago, when I was a young man! 30 GPs and managers met on a foggy morning in Telford. Those few are now a multitude. That multitude is now unstoppable.
Because the NHS now has a new centre of gravity. It brings together clinicians and managers: generalists and specialists: GP Practices and Primary Care Trusts: vision and reality. This new centre ground bridges compassion and cost effectiveness. It offers an alternative to bureaucracy or big business. It is our centre ground, it has been hard won and no one, but no one, is going to take it away from us.
Because this is your revolution and NHS Alliance intends to make sure it stays that way. We will encourage and inspire always. Enable and support wherever we can. Where you feel frightened, overstretched and out of your depth – we will be there for you. To those of you, who think that the health and wellbeing of their communities is not your business – we believe it is time to raise your game, reach for the skies and leave your comfort zones. To those, outside this room, who are apathetic, greedy or workshy – it is time to get real.
They say the darkest hours come before dawn. These are, indeed, dark hours – financially at least. But we are now given the responsibility to lead the NHS out of these shadows and to become a service that is the best in the world. An NHS, where every patient, every clinician and every manager has a leading role. It is your destiny to move the NHS from fright and despair to courage and optimism. That process starts right now, at this conference.
In May 1997 – yes almost 14 years ago (!) – I said “For the first time, this White Paper will allow all GPs to have a commissioning role. No longer cogs in the great NHS machine”. It did not happen. We have had some false starts. We have had a few knocks. There have been disappointments. Quoth the Raven – “Nevermore”. This time it is for real. From now on, we, and not the same old vested interests, are ready to take the NHS forward. Forward in strength. Forward together. As never before. As never will be seen ever again.
You carry a huge burden. Believe me, though, you are up to it. That is why General Practice and Primary Care have been chosen. So, let’s wrong foot those that don’t like GPs, don’t like clinicians, don’t like primary care, don’t like losing their centralist grip and don’t like sharing the daily suffering and frustrations of our patients. Surprise them! Deny them! Displace them! Show them that the NHS is, indeed, safe in our hands!
There are conferences. And there are NHS Alliance conferences. This is the best. Why? Because you are, quite simply, the best and together we will create an NHS that is also the very best.