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Editor's blog Wednesday 14 September 2011: Andrew Lansley speech to NHS Alliance / NAPC commissioning conference

Below is a transcript of SOS Andrew Lansley's speech this afternoon to the NHS Alliance / NAPC commissioning conference.


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The survey results are not a surprise, and these are issues that we’re working on with you to ensure where you have concerns and feel constraints, they don’t get in the way of your getting on with the job you want to do.

Three quick points from me: firstly, I want people to focus less on structures, and more on incentives.

Secondly, the best results can only be achieved through clinical leadership of integrated services, working along pathways; services working with those who take registered population health responsibility and accountability for GP lists.

And thirdly, we need to focus on outcomes: I hope you have seen that alongside structures, go the accountabilities. There is no argument about those principles: they remain intact in the Health And Social Care Bill.

And if you’re working to those three principles, you’re not likely to go too far wrong.

Whether it was Hippocrates, or Linacre founding the Royal College of Physicians, or Nye Bevan, history gives the plaudits to innovators; modernisers, who see the status quo as something to be improved upon. Take John Snow (not he of Channel 4 News), work with the Broad Street pump, proved that it was infection borne in water, and not ‘miasma’, that caused cholera. There's a replica pump still there, and next to it is the UK's ultimate tribute: a pub named after him. Imagine going for a pint at 'The Michael Dixon'! [Dixon (interjecting) – “it'd be cheap!”].

They showed leadership, not arrogance or ideological posing. If you can embrace change and improve lives, people will follow you. You are at the heart of the means by which NHS will modernise or improve.

My task is to support you – we want to arrive at a point where notwithstanding legal and parliamentary accountability, you who work in the NHS should not on a day-to-day basis have to wonder what the Secretary Of State For Health thinks you should be doing. Too often in the past, you and colleagues have had to do that. We have to pass through the valley to get to this place, but I never lost sight of that objective for you to exercise your collective clinical judgments on your objectives for your patients.

We are 100% committed to free healthcare based on need and not on ability to pay. We're always fighting those who say, 'the NHS won't work; we'll have to pay and go to an insurance system'. This is about a quality service based on improvement, and we will carry on with year-on-year funding increases - this year PCT allocations will 3% more than last year. There is a 3.5% increase from outturn last year. We have to work hard to ensure, these rises deliver continuously improving results.

I want us to work together to influence the whole of healthcare policy. We need to achieve shared decisions not just with patients, so I’m pleased your two organisations are coming together in this coalition. The NHS is a part of our national identity, something we unite behind. As such, it’s a big symbol, and one that we have to improve and modernise.

The performance of the NHS is much debated, but it’s clear that even if we look to international comparisons, we do very well in this country given the level of resources. However, our variation in performance is huge: PCTs vary 5-fold in asthma admissions and 6-fold for children.

We have much to gain if we eliminate unwarranted variation. We need to understand and benchmark internationally. Our performance on cancer survival is less good; data from the winter before last has been used by Professor Mike Richards to show that nowhere in England was the rate of cancer survival from the four most common cancers as good as the average survival rate in Sweden.

Demography and pressures mean that we must constantly look at clinical service redesign and cost pressures. Clinical commissioning groups are actively engaged now in thinking about QIPP, about taking ownership of decisions sbout innovation and prevention in the context of the available resources.

It’s all about empowered clinicians; how you will use NHS resources to deliver better quality, better innovation and better patient experience. The UK has almost a million GP visits a day. GP practice staff know about public’s health. You can own the resource decisions, challenge wasteful bureaucracy, and find new ways of working.

Technically, PCTs act as agents of the Secretary Of State, so in the past ministers could and did interfere and tell PCTs what to do. In CCGs, if you meet your statutory duties, you will have more freedom to take the decisions that best suit your patients.

Already, GPs and hospital doctors are saving £100M and reducing demand and stress in going to hospital and freeing up time in A&E. In Northamtonshire, Nene Commissioning are reviewing GP referrals to ensure appropriate treatment – less duplication and passing from department to department – these are just some aspects of a modern NHS.

Some of these truths of any well-run health service are about getting the person treated at the right time, in the right place and by the right clinician. Good-quality patient care often goes hand-in-hand with improved resource use: see the Health Foundation report in improving quality and reducing costs. Clinicians everywhere should think how to do that in their local community.

And these changes will be done though commissioning. The current system's fragmented and often irrational, removing patients from commissioning decisions. The media has been highlighting PCTs irrationally reducing access to things like cancer diagnostics. Those kinds of decisions must be rational, and CCGs will ensure that they are based on clinical reasons. That is the benefit of moving decision closer to patients: having a better way of managing resources.

We still need to provide comprehensive health service, and can’t exclude patients. CCGs will have to devote attention to making sure GPs know that when they have patients and want to refer them, there are designed pathway to deliver efficient care for that patient by you and your colleagues. Imparting a sense of confidence about your local referral pathways will really matter.

We have 253 pathfinder CCGs covering 97%, which  shows your desire for this. We want CCGs to cover all of England and we want them to be fully authorised.

I know there is fear of the NHS Commissioning Board, about its potential for interference and to delay your becoming fully authorised. I was asked at last year’s NAPC conference, ‘who’s going to pour the treacle to slow everything down on these refroms?’ It’s not local authorities! It’s not Parliament (though at points I feared it might be). We’re now in a good place with Parliamentary authority and necessary autonomy.

I and we will resist constant efforts to try to prescribe how you achieve outcomes. That won’t be a job for the NHS Commissioning Board; their job is around authoriz.

I have no number to give you on the CCG management cost allowance today, but please remember that PCTs currently do many things that they won’t do in future (specialised commissioning, PMS contracting, dental and optometry and pharmacy contacting – th NHS Commissioning Board will do most of those, and local authorities will do public health). So you’ve got to strip that out for realistic cost comparison. You can even take out the £320M that the NHS spent on management consultancy in the year before the election.

The role of the NHS Commissioning Board is not to control CCGs or interfere in a random fashion. Once authorised, CCGs get real freedom. I’m confident you will thrive on freedom and commission in safety: none are better placed. Once CGs are fully authorized, we move from a vibrant network of pathfinders to statutory bodies. You’re on that path and I will support you. Sir David Nicholson says that his job is to support you to be as good as you can be.

In the Wirrall, they’ve achieved 60% delegation of financial responsibility for commissioning from the PCT cluster to the CCGs there already. Experience and track record will be key to authorisation. And the draft authorisation framework that’s now published; give us your comments – let us know what you think. CCGs, as start-up bodies, will be building up a track record of performance, and assumed responsibility from PCTs as well as LTC management

CCGs can start being authorised from next summer: it’s just months away. So you must put in place robust arrangements to commission. You’ll need to have non-clinical commissioning support – the ‘invisible stitching’ – and I want you to have as much flexibility as possible over how you do functions and where and from whom get support.

The DH ‘ready reckoner’ lets you figure out the different costs of different types of support. CCGs will get between £25-35 per head of population, so using that figure and the ready reckoner, you can start to look at staff structures and population to see how to get best value for money in commissioning support; whether by sharing with others, getting it from PCT clusters or elsewhere. Achieve better value, and you’ll have more to spend on clinical and quality aspects of commissioning.

One abiding difficulty of PCTs was that they all thought they all had to do all same things. You can work together to create joint activities. Commissioning support organisations can work across flexible geography, and you can seek back office or contracting support on a regional or national basis. Tell the NHSCB what you want them to do so that you get a market from which you want to purchase commissioning support. You tell them; it’s going to be that way round

Some commissioning support may come from the private sector; the vast majority will come from the NHS. And they will work for you, the client. That’s not me, it’s going to be you - and if they’re not value for money, you can decide to change it. That builds an environment where joint suppliers can thrive, doing what’s best for patients, and we’ll soon set out how we will support you in access to commissioning support you want and need.

Please continue close working with the NHS Future Forum, which connects us directly with frontline views. The Future Forum is now looking at education & training, integration services, how the NHS interacts with public health and improve, integrate health and social care services. The first Future Forum was an important process, and they’re helping us to continue listening. So we can be confident that as we implement the Bill and the White Paper reforms, we’ll take people with us and respond to your needs for implementation.

It’s taken a lot of work to get to where we are today. Thank you all, but there is more to do! We’ve created real momentum. As soon as I get away from Westminster, I’m now hearing in local area about new relationship, thoughts and approaches, always with a sense of momentum towards what we’ve set out to do.

Complacency has had its day. CCGs need not just motivation, but support with skills and capacity to be fully authorised. It won’t be quick and easy, but it’s important to do.

The modernisation of the NHS will mean that it’s still there for us when we need it, with greater choice and higher standards. My task is to ensure that success will not be the not product of political masters’ decisions, but that of millions of committed people working with patients to deliver the best care they can.