17 min read

Editor's blog Thursday 24 June 2010: Health Secretary Andrew Lansley NHS Confederation conference speech reviewed

Hello from Confed. You will have seen the latest dose of Maynard Doctrine.

As ever, much to say and little time. Word is that July 5 will not see the publication of the White Paper: Treasury have sent it back refusing to sanction the proposed financial governance arrangements for GPs.

I’m up the top in the nosebleed seats. Lansley looks like a ghost on the screen.

The Health Secretary’s speech is online and unmitigated here.

Below is a version with a few reactions and thoughts.

Health Secretary speech to the NHS Confederation Conference 2010

‘Shifting power to the frontline’

Good afternoon, it’s great to be back in Liverpool, on this stage and with all of you.

Having shadowed this role for six and a half years I may make mistakes but not, I hope, out of sheer ignorance. And if I’ve learnt one thing over that period, it’s that there are a lot of people out there in the service who have tremendous commitment, expertise and ability. I want to let them get on with the job. My role is to speak for the service, for the public, for the taxpayer – to be a leader, not a dictator.

Mmm. I wonder: could this be a coded criticism of NHS chief executive (and counting) Sir David Nicholson? Does a kick upstairs await Lord Nicholson Of LookOutToYour Community?

Many things have changed. But let me tell you this, over the last year and the years before that, my priorities haven’t changed. They remain:

First, that patients must be at the heart of everything we do, not just as beneficiaries of care, but as participants in its design. We must see the NHS through their eyes – their experience, their outcomes – and make delivering what they want a shared experience and responsibility.

Second, if we are to achieve continuously improving outcomes, then that is what we must focus on. Not process targets, not measuring inputs, but a consistent, rigorous focus on outcomes, with the ambition of securing outcomes and services in this country that are among the best in the world.

Third, we must empower professionals to deliver – we must set them free to use their clinical judgement, to do their jobs to the best of their ability and on the basis of evidence. That way we can secure the quality, innovation, productivity and safe care which we need to achieve better outcomes.

Fourth, we must do much better on the health and well-being of our families and our communities. Only by prioritising public health and by preventing ill-health more effectively, can we achieve the overall health outcomes we seek, and make the demands on the NHS more sustainable.

Fifth, we must reform social care, seeing the relationship between quality and outcomes in care as well as in health – and their inter-connections, delivering further integration in how services are commissioned and provided.

That will be bracing, just as local government budgets are cut by 25%

These are now my priorities for the NHS – and the priorities of my team and the Coalition Government. And together, we’re already reshaping how we do things in order to meet them.

That’s why I called a full, public inquiry into the appalling events at Mid-Staffs – and how the wider system failed to prevent them – so we can learn the lessons and move towards a safety culture and a culture of challenge.

Its potential to embarrass NHS chief executive (and counting) Sir David Nicholson, on whose former SHA patch Mid-Staffs was, has no bearing on this.

That’s why, in my first week in the job, I announced a moratorium on reconfigurations – to empower patients and clinicians to have their say, and ensure that the changes that are happening now are consistent with our vision of the future.

One slight problem being that NHS London’s QIPP plan was ‘Healthcare For London’, which you binned.

If we’re looking to GPs to lead commissioning, it is essential that what happens now is consistent with their commissioning intentions for the future.

So you need to know what their future commissioning intentions are. Have you asked them?

If we want patients to have choice and that those choices should influence access to services, then we can’t pre-empt and frustrate their views.

This is not about stopping change. On the contrary, this is about ensuring that change is visibly linked to better outcomes, and has the support and buy-in of GPs and local people.

And so just this week, by publishing a revised Operating Framework, we took a further step – putting in place a zero tolerance approach to infections; setting out how we can move from process targets to evidence-based quality; developing payments for performance, geared to results; and moving towards a service which empowers clinicians and makes them more accountable for achieving the best outcomes for their patients.

Five years ago, I told the NHS Confederation that the NHS did not need half-baked, inconsistent reform or a direction of travel with no idea of the destination.   I believed then, as I believe now, that the NHS needs coherent, consistent reform, and a clear understanding of where we are going and what we need to achieve.

It does. It also needs a timescale for change. Nobody is pretending that this policy framework is easy to write: it isn’t. The changes are radical, if not fundamental. There are big old legal and governance issues everywhere you look, not to mention how to unwind things if the system fails catastrophically.

The Coalition Programme is a plan for a five year Parliament. We will set out our strategy for the NHS as early as possible, so that everyone in the NHS can share that clarity of purpose – so that we all have a sustainable framework within which to work, and not just for five years but for the long-term. Everything we do will be consistent with that strategy.

We will be holding you to that last comment. Might it not be wise to tell the NHS your timescale for starting change? You’re not going to get anything done in the next 12-18 months. Why not just keep much of the system as is, allowing some of the top-performers like BEN PCT Tower Hamlets etc to pilot bits and pieces?

Today, I want to tell you about the purposes and principles which are at the heart of the strategy, following my speech a fortnight ago to the Patients Association and National Voices. That speech made clear the first purpose – to create a system of patient-centred care, to put patients at the heart of the NHS.

Now let me highlight a further purpose: to empower the service, the professionals and the front-line.

Ulp. This sounds a bit Big Society, Invitation To Join The Government Of Great Britain.

The NHS is admired around the world, and rightly so, for the skill of its staff, for our system of General Practice, for the continuity of care it provides, for its evidence-based approach.

Oh, come on. It isn’t, really. The NHS used to be admired around the world by finance ministers because it kept healthcare costs so low (hence the huge backfill spending post-Wanless). NICE is admired and being copied around the world for the same reason. You would be laughed out of the room if you seriously said that to a European gathering of health managers / policyfolk.

Moreover the NHS is admired for its equity – for that ideal that inspires us all, that the NHS is there for everyone, free at the point of use, from moment we’re born until the day we die.  

There is much to be proud of – but it is clear to me that there is a lot still to do.

This service should be admired not just for its equity of access, but also for the excellence that we aspire to – and achieve. The NHS should exemplify the ideal of equity and excellence combined.

Fifty percent of doctors are below average …

After thirteen years of top-down control from Whitehall, we have over 100 major targets controlling clinicians’ every movement – and a bureaucracy that demands somewhere in the order of 250,000 separate data returns from every trust, every year. Yet in the NHS today outcomes lag behind those of our European neighbours.  

If consortia commissioning works, it is going to have to control clinicians’ every movement. This reform is also simply going to shift the locus of bureaucracy from the DH to the independent board / commissioning regulator – they will need the data to inform judgments

Survival rates for respiratory diseases and many cancers remain poor compared to other countries. The evidence shows us there is much further to go on managing care more effectively. For example, the NHS has high rates of acute complications of diabetes and avoidable asthma admissions, the incidence of MRSA infection remains worse than the European average, venous thrombo-embolysm causes 25,000 avoidable deaths each year.  

I’m determined that we must make quality of outcomes the defining principle on which the service operates.

That is going to require at least as much bureaucracy and data as are required now.

For all Lord Darzi’s leadership and the huge efforts many of you and your clinical colleagues have made in recent years, the system simply is not yet designed around quality as it should be.

So what will make the difference – the breakthrough that we all seek? More government targets; different targets?

No, if we are looking to improve outcomes, the answers don’t lie in top-down targets – they’re in consulting rooms and on the wards around the country, they’re where the clinicians are and where the patients are. So I want to empower frontline staff and trust the professionals closest to patients to act on their behalf.

A freer, more open system will mean better results.
Have a chat with Mark Goldman, outgoing CE of Heart Of Birmingham. He’s being very candid that his experiences in relinquishing more control to directorates within his trust led to a radical worsening of matters.

But there is a tension in the NHS – there always has been and there always will be – between national standards in a national system, funded by national tax receipts, and local priority setting and local decision making.

It is a National Health Service – but it must be a locally delivered service.

WTF? That is was it has always been. Not getting this point at all

And that is where the power should lie. That is what the evidence tells us, that is how we’ll improve outcomes, and that is how we’ll achieve real transparency and accountability.

All bad things in healthcare happen locally. The national picture is a part of the context, true, but it is local failure every time. What is worrying is the NHS’s ability to ignore them for long periods (allied to the service’s shameful record with whistleblowers). It requires more bureaucracy to spot local failures – sometimes provided by private sector folks in CHKS, Dr Foster et al .

Doctors must be free to exercise their clinical judgement – because, quite simply, those doctors who can best respond to their patients’ needs will achieve the best outcomes for them.

Doctors are still not revalidated after a decade of attempts, and unfortunately occasionally outlier doctors do bad things as a result of this, combined with paternalistic arrogance. The reality of the future is that doctors will be less free to exercise their judgment where it conflicts with the clinical governance rules of their commissioning consortia.

They need and expect to be acting in line with the evidence. They don’t expect to be told what to do, in ways which can conflict with their clinical judgement.

I refer you to my above comment

Clinicians will be accountable in a different way; instead of process targets they will have to meet certain quality standards. And these quality standards will not be about distorting their clinical judgement, rather they will be based entirely on clinical evidence, they must be shown to achieve demonstrably better outcomes, and they will have to be clear, relevant and comprehensible for patients.

And if you engage the public and commissioners more effectively in designing local services then, as you have set out today in the Confederation’s ‘dealing with the downturn’ report, we need to be prepared to provide the most appropriate care in the best place – not just switch it from one facility to another. Because patients don’t want to go to hospital …

You’re having a laugh, no?

… – they want the right treatment in the right place at the right time, and GPs are very often best placed to design those services in the community.

Therefore, we want to give GPs control of commissioning, creating a direct relationship between the management of care and the management of resources.

To support GP consortia in their commissioning decisions we will create an autonomous NHS Commissioning Board, free from day-to-day political interference.  I’m hoping I will be the first Secretary of State to give up powers throughout my tenure.

Will you be able to sack its senior responsible officer? Is so, it is not independent. I like the use of the phrase “day-to-day political interference” – reminds me of “we’ll abolish clinically unjustified targets”, son of “we’ll abolish targets”.

Again, at the heart of this will be a set of quality standards and indicators that drive commissioning. And as ‘quality’ must mean the same when the CQC are looking for it as when the commissioners are paying for it – the same set of quality standards and indicators will apply.

And this means improving the payments system too. If the peak of Everest is a payments system that supports precisely what the commissioners are looking for and that patients need on every occasion, then I’m afraid we’re still at base camp.

But with the Operating Framework we’ve set out our goal for the system – with benchmark pricing, able to be contracted along care pathways, crossing boundaries between primary and secondary care, focused on outcomes not episodes, and incentivised for quality. I want to see a system that rewards performance and is tough on poor quality – a payment system which works for clinicians and patients, rather than the other way round – a system which stimulates innovation.

Not paying for ‘never’ events is not the same as being tough on poor quality.

The CQUIN framework has begun to do just that. In Birmingham it has incentivised innovation and now cancer units have agreed with their commissioners to introduce home delivery of chemotherapy, making for a better, more convenient service for patients. In Yorkshire and the Humber commissioners are requiring local organisations to work together to achieve improvements for patients with dementia.

I know some of you here today have worked on these schemes and they are just the sort of innovation that I want to see in commissioning.

It’s not meant to be about the sort of innovation you want to see. If you are sincere about this, you are going to have to accept innovations you don’t want to see. Localities might opt out of offering choice … or choose to have targets …

There are many other examples of this sort of innovation, but we need to see it happening systematically across the service.

If it is happening systematically across the service, it is not innovation; it is competence. The two are wholly distinct.

One of the virtues of the NHS is that it attracts and inspires some of the brightest minds from around the country and around the world. But our system has failed to make the most of this potential.

We have to set the NHS free to innovate. We should be constantly thinking about how we can do things better – encouraging the adoption of successful ideas throughout the health service.

That is centralising quality standards in a national service. Like waiting time targets.

We don’t capitalise on innovation and ideas today because the system is too rigid – because we do ‘one thing at a time’ – what the centre dictates, when it dictates it.

Recently I was in a catheter lab, talking about the introduction of Primary PCI. It was clear that amongst cardiology consultants they had long known it was a better way forward. But they believed they couldn’t do anything about it until the Department of Health said they should. The same applies for thrombolysis for stroke.

Why can other countries move clinical practices forward so much faster?

Why does our National Health Service so often act as a brake rather then an accelerator for change?

Because too often it is like a convoy, with everyone going at the pace of the slowest. Because there is no ‘first mover’ advantage. Because the incentives are to do as you’re told to do by the centre.

Sorry, but that isn’t really the case. Ever since Payment By Results, acute trusts have had active incentives to do more of what they can do below tariff. You are not a stupid man. You have heard of service-level economics. There is a first-mover advantage in the NHS.

All of this has got to change.

I want to provide freedom, responsibility and accountability, so that clinicians don’t have to wait for permission to move from the thing that is targeted to something better.

When the evidence says something works they should be free to get on and do it – without waiting for Whitehall to issue a circular!

Whose evidence? Cochrane evidence? A pharma company’s evidence? A management consultancy’s evidence?

And of course, with responsibility comes a new kind of accountability.

In recent years there has been a degree of pretence when it comes to accountability at the centre.

Ministers have been very keen on political control when it came to announcing a new strategy, target or funding pledge. But in reality they couldn’t guarantee their promises would be delivered. And when they were challenged on them, or when something went wrong, the response was predictable – ‘it’s all the fault of local management!’

So I will set out a strategic framework, with statutory backing, which shows what the relationships actually are and where accountability genuinely lies.

Who can sack whom is crucial.

I will set out a separation of commissioning from provision, with providers independently regulated and commissioners operating with greater autonomy, under greater public scrutiny.

I will set out what the Secretary of State is and is not responsible for, and where the Secretary of State is not responsible, I will set out who is.

My view is clear – we have to strike a new balance of power in the service – so that wherever possible, responsibility should lie with clinicians. I intend to provide leadership, strategy and direction – not command and control.

This means being clear what we are asking the service to achieve. Not trying to tell you how to do it. And it means that, more than ever before, we are making clinicians accountable to the people who really matter – the patients.  

Accountability in terms of the choices that patients make, but also for the results and outcomes they achieve.

Accountability supported by greater access to information for patients, to empower them to make choices about their own care.

And, on top of this, democratic accountability.

As we set out in the coalition agreement, for the first time the voice of the public will be heard across commissioning, the public health service and social care. In these straitened financial times this accountability for how we use taxpayers’ money is even more important.

Though funding for the NHS will continue to rise in real terms, the broader financial context must be central to our approach. The real terms increase, we know, will not be of the order of recent years. It affords a degree of protection, yes, but at the same time how that money is used is critical.

So I want to deliver to you, as Secretary of State, precisely the message I gave to you last year as Shadow Secretary of State – which is that although the NHS will have protection during this broader financial restraint, we must apply the same disciplines that are applied across the public services.

‘Protection’ for the NHS is not protection from the need for efficiency – it is protection for patients.

The funding settlement comes with some pretty testing challenges for how that money is being spent and the results that are being achieved. So we have to apply discipline to what we are doing – to management costs and capital projects.

The £20 billion of savings that David Nicholson has identified is not a cut in our budget – it’s not about doing less or worse – it’s a £20 billion efficiency saving; it’s about doing more for less.

This should be a central discipline across the service.

Because it is a management and a moral imperative: to reinvest those savings, to save money in what we deliver now, so that we can meet the demand and quality challenges which we face in the future.

The NHS should be an example among the public services and, frankly, it should be an example to the private sector too in terms of what it is possible to achieve. And that is going to mean radical changes in the way things are done.

Management costs are too high and they have escalated in recent years. So we will reverse the recent increases this year and that will be the baseline for a further reduction by a third beyond this.

Remember, the deal is this: every penny you release through those disciplines and efficiencies will be reinvested in improving services to help us to meet the challenges we face. Savings today will be our fund for growth tomorrow.

I know that the changes I propose are far-reaching. They are intended to be. We are intending to see significant changes in the way the NHS does its work.

Bottom-up, not top-down.

Makes me think of proctologists.

Purposeful, not process-dominated.

It would be reasonable to admit that process targets, for all their unintended consequences, had a purpose.

Patient-led, not target-driven.

As decision-making shifts and as we work together to deliver change, I know there will be some uncertainty.    

I cannot avoid that – but I can and will create a bridge between the past and the future and help to map out the journey we need to take.

• I will be clear what the strategy is and the shape of the new priorities and systems, and I will do this as soon as possible;

• I will build on the good work being done – on QIPP, which is fundamental to success; on CQUIN, Payment by Results, the Practice Based Commissioning structures, Foundation Trust freedoms, the piloting of personal health budgets, and  joint working with local government;

• I will give competent managers real freedom and responsibility which will enable them, be they commissioners or providers, to show how they – how you – can deliver results;

• And I want to involve you in working out how to implement the strategy and engage you in the future.

Functions will change, so organisational form will change. But at the heart of making this happen will be leadership.
Could you define leadership?

Stronger clinical leadership.

Stronger managerial leadership.

Stronger political leadership.

Oh, OK, you’re just repeating it. That means it’s a mantra

In incredibly tough financial circumstances, strong management is essential.

To achieve the ambitions for patients that we all seek, we need not just high quality management, we also need leadership. For those who can offer both, the reforms will offer real opportunities. For those who can deliver results, the reforms offer the levers they need.

For those managers who can recognise the clinical imperatives of safety, quality and outcomes, whilst motivating clinicians also to understand why and how we can deliver performance management and financial control, the future is exciting.

I have asked David [Nicholson] tomorrow to talk to you about the practical steps we need to take, and how we want to engage you to make this happen.

His understanding – far beyond mine - of the service and how it works and how we can make changes happen, has been great for me to be able to rely upon. I’ve really appreciated it. I knew we were getting somewhere when David first smiled. It took a day … but he did it.

Note the past tense. Thank you and goodnight, Lord Nicholson?

And I know that what I’ve said today will have thrown up dozens of questions. People will be thinking:

‘What does that mean for my organisation, for PCTs, for SHAs?’

‘How is GP commissioning going to work in practice?’

‘How long will this take, what does it mean for me?’

I understand that anxiety and I want to work with all of you to meet these challenges.  

All my efforts to publish our strategy – and to do it early – are in order to increase certainty, to let people know not just the direction we’re travelling, but where our destination lies and what that world looks like.

But I also hear people asking: ‘how can I get involved?’ – ‘how do I need to re-think what I do?’

Because we can start making progress now.

PCTs can start accelerating their efforts with their practice-based commissioning consortia – to make them real.

NHS Trusts that aren’t yet Foundation Trusts, must now be pushing themselves to achieve FT status and to show how they will use greater freedoms and responsibility.

12 of the 22 trusts registered with conditions by the CQC were FTs.

Everyone can ready themselves for these changes – focusing more on outcomes, on safety, on shared decision-making with patients, on opening up new avenues to public engagement and accountability.

And let’s remember why we’re doing this. We’re not proposing these changes just because the NHS is special.

We are doing this because of a shared commitment to the values of the NHS; because we know for all its brilliant achievements it is still less than it could be.

And we are proposing these changes so that we can improve the essential services that the NHS provides, improve patient outcomes and experiences, ready the service for the demographic and demand challenge, and to achieve continually improving results for patients: to achieve health outcomes as good as any in the world.

We have a chance now to institute a clear plan of reform for the long-term. And that is what I plan to do. My mission is not revolution,

Other disagree

but to give everyone clarity of autonomy and accountability in the service.

The NHS today is strong and much has been achieved over recent years – a lot of it by people in this hall.

I know the passion there is for the service and the wealth of ability there is within it. My goal is to release and liberate that passion and that ability.

In another report that the Confederation has published today, you point out that too often the NHS has been subject to unclear, poorly designed and short-lived reforms.

I understand that anxiety but, as I’ve set out today, I do not plan to fall into that trap.

And I understand the warning expressed in the title of that report: ‘the triumph of hope over experience’.

But at the same time, I don’t think any of us would subscribe to ‘experience over hope’.

Don’t understand this. Experience is learning, no?

We know we can’t stand still. We know there are problems to solve. We know things can improve.

So what we need is both together – employing the wealth of experience within the service to realise our common hope for a better future.

With your help, and that of everyone in the NHS, that is what I intend to do.

Thank you.

Muted applause. "Elvis has left the building".