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From the archives: NHS Alliance conference report 2008

From the archives: NHS Alliance conference report 2008

Editor's note

Some years back, NHS Alliance was a significant and insurgent influencer in the world of NHS primary care and commissioning. Its heft was in inverse proportion to its wealth and staff: that is one hell of a trick to pull off, but they did it. I got on well with their then-leadership, and was asked to write reports on their annual conferences for many years.

In the mid-to-late 2000s, the NHS was shifting very fast as commissioning started to be promised - if not given - teeth.

The 2008 NHS Alliance event seemed quite consequential, coming as the global financial crisis began to hit - and I think it was consequential. You'll hear from Chris Ham, Bruce Keogh, Mark Britnell, David Nicholson, Michael Dixon, Mary Warnock, Ben Page ... I also wrote it with my friend the late Professor Bob Sang, whose contributions to the analysis in the final 'coda' section have aged very well indeed.

So I'm putting the report online here, for students of NHS political and policy history. It's an unashamedly long read, but I think you'll find it's worth reading about how the NHS world seemed 14 years ago, when the Era Of Money was obviously soon going to end.

Andy Cowper

Editor, Health Policy Insight

August 2022

Vision Into Action – Primary Care Leading Change

Bournemouth International Centre

Introduction and context – living in recessionary times

2008 was the first time a deteriorating national and international economic climate marked the context for the 2008 NHS Alliance annual conference in Bournemouth.

The NHS has seen unprecedented financial growth over recent years; its budget tripling since 1997. Despite this, much of the service has also recently undergone a period of financial recovery to get out of deficit.

The bursting of the UK property asset price bubble, and the seizing-up of global credit markets in response to the fall-out from the US ‘sub-prime’ mortgage market (spread like a virus throughout international finance by collateralised debt obligations and credit default swaps), have culminated in the sudden economic slowdown in the UK.

The consequences of this are clear – reduced tax revenues, and increased demands on the public purse through rising unemployment.

Nobody attending the conference could be unaware that within just two short years, this will require the NHS to start doing the same or even more work with lower growth – possibly much lower than the service has been used to.

At such a time, innovators in primary care are more necessary than ever. Primary care remains the key demand management tool for the NHS.

Policy directs that more care should be delivered in community settings and outside of expensive hospitals. World-class commissioning relies on innovative providers of more patient-centred services; and also on commissioners to show an iterative vision of information-based community provision to move care upstream.

The stakes for primary care, in other words, could not be higher. The NHS Alliance’s 11th annual conference offers a unique forum for debate and discussion of how the challenges can be addressed.

This report of the 2008 NHS Alliance conference mixes reported summaries of some presentations, with others transcribed as closely as possible to the presentations and speeches given.

It also concludes with reflections on the possible wider policy consequences.

Professor Bruce Keogh, Medical Director, DH

DH Medical Director Professor Bruce Keogh spoke to the Alliance PEC chairs’ event, held on the eve of the conference. Keogh described his move to working in the DH as “like moving to another planet without leaving the Earth”, noting that he does not enjoy access to making appointments in his own diary.

In the context of the Darzi Review’s emphasis on quality and outcomes, Keogh cited the 1845 Lunacy Act which obliged hospitals to report whether their inmates were “alive, dead, better or not better”. He also noted that hospital league tables were first compiled by Florence Nightingale in the 19th century (who became the first female member of the Royal Statistical Society). Nightingale’s league tables were criticised on the grounds of dodgy data, perverse incentives and hospitals gaming for good position, leading Keogh to wryly note that “very little changes”.

He described 1998’s ‘A First-Class Service’ as the key recent document to try to legislate and quantify the process of assessing quality of care, whose heredity he perceives in the Darzi review’s ‘seven steps of quality’.

Keogh emphasised that a modern healthcare quality matrix involved:

1. Clarity on a definition of quality – which NICE’s expanded role producing NHS Evidence will affect just as much as the national standard frameworks

2. The measurement of quality. Keogh observed that he regards primary care’s quality measures as being in relatively good shape via the QOF, but described what exists in secondary care as “a shambles” – data going via patient administration systems to Hospital Episode Statistics, and coding problems en route leading him to suspect that much of it is fit neither for purpose nor for administrative use. He stressed the need for new quality metrics to be “clinician-friendly”

3. The publication of quality reports from 2010 – in reality, this will start with hospitals as other kinds of organisations’ data will be too crude to be useful

4. The influence of the new National Quality Board, to be chaired by NHS chief executive, and of the PCTs’ new Commissioning for Quality and Innovation (C-QUIN) initiative – which along with patient-reported outcome measures, will be able to affect incentive payments for quality to providers via tariff uplift

5. Raising clinical standards by increasing clinical involvement in commissioning, which Keogh described as “disappointing” in his former role as a director of surgery. he emphasised that clinical involvement in strategic health authorities needs to be “beefed up”.

6. Quality safeguards via the new care Quality Commission’s inspections – how light-touch or heavy-handed should this be, given that it will for the first time also have to regulate primary care? He noted wryly that the vogue for ‘light-touch’ regulation in the financial sector was now revealed as having been counter-productive

7. Moving to a normative basis for the national tariff for payment by results – Keogh noted the hard evidence that higher-quality care costs trusts less in the totality, adding that in his own specialty of cardiothoracic surgery, a study has shown that in totality, ‘very well done’ care is 30% cheaper than simply ‘well done’ care

Primary care leading the way

Dr Michael Dixon, chair, NHS Alliance

Welcome to our 11th annual conference. As always, you – our members and delegates – are the real VIPs: the people at the sharp end of NHS delivery every day.

Delivery, action and outcomes are the main themes of this speech. The last year has been dominated by the Darzi strategy – which is a good plan for primary care, including many points from our In Sickness And In Health document. Yet a plan, a plan of action and actual action are three separate things, and only action speaks in these troubled economic times, when primary care is so crucial. As T S Eliot warned, “between the vision and the reality / Falls the shadow”.

We must recognise and address the shadows of disparity.

Clinical engagement with the front-line working face of NHS remains much-discussed – it is the front-line who must deliver, so it seems obvious they should ‘own’ NHS reform – but most feel that they don’t. Maybe we should remember the old Chinese proverb, ‘tell me and I’ll forget; show me and I’ll remember; involve me and I’ll understand’.

Three years ago, our clinical engagement documents met a ‘see nothing hear nothing do nothing’ stone wall. Now everyone’s talking clinical engagement, but it’s mostly piffle. Clinical engagement must be a two-way street, so it’s time to stop talking about clinical engagement and start talking about leadership and ownership. The NHS should, connect, understand and even like its doctors.

Clinicians don’t feel liked by the centre, or senior managers. Sometimes, it feels like managerial clinical apartheid – we even read different media.

The Darzi strategy did include clinicians at SHA level - a welcome breeze of change. But this must reach beyond SHAs and get a wind of change from front-line clinicians – right the way through the system, and get primary care right to the top of the agenda. If clinicians need to change, then so must the centre, which means an end to the managerial hierarchy from the top to the bottom of the NHS excluding clinicians. We need new era of connected, empowered clinicians leading together.

There is a disconnect between practices and practice-based commissioners (PBCers,) and between PBCers and world-class commissioning. I hear people ask, ‘is PBC the master or servant of world-class commissioning?’ I think that question symbolises the division. In primary care, we have a flat management structure - working together, we have leaders but don’t need or want masters.

PCTs must do that, share responsibility and power with PBCers. Too many are not. The DH quarterly PBC survey shows little change. Over 1/3 have neither an indicative budget or an agreed comissioning plan, and PBC-PCT relationships don’t seem to be improving. Who is allowing this state of affairs to continue and why?

To lose one year of world-class commissioning may be seen as a misfortune, to lose another would look like carelessness - perhaps fatal carelessness. One start would be to use the innovation funds from Darzi to pump-prime service redesign, led by front-line clinicians and managers.

PBC will work if only we let it. World-class commissioning has legs too. But commissioning is about robust long-term relationships; about eyeballing suppliers and negotiating improvements; and only if that fails, going elsewhere. Our work last year on acute discharge information led to the new contract in April 2008, clarifying that all discharge summaries should have been issued within 72 hours of discharge last year; within 48 hours this year; and within 24 hours next. A real achievement. But have we yet changed the rather weak pH value of commissioning in the NHS? Sadly not.

Our new survey finds 70% practices say discharge summaries still come late; 40% say this directly affects patient care; 25% say it affects patient safety.

Secondary care commissioning is still not effective enough, too many patients still feel the pain. And in primary care commissioning, why is everybody so obsessed with tendering? Tendering is exhausting, stressful, direst attention and should be option of last resort - or patients will end up being cared for by financially strong organisations which have effective marketing teams who know how to submit a good tender. Do we want primary care run as a giant auction house, with little NHS values? That would surely repeat mistakes made in agriculture, giving us giant monoculture fields, with hedges raked up and soil raped of any goodness.

Whatever the commissioning process, we suggest that all public or private bodies involved in NHS commissioning must publicly commit to sharing NHS values, as our PBC Academy partners Humana do.

The primary care-secondary care divide still looms. I still sense deep arrogance in some acute mentalities, confining primary care to the NHS junior common room, when we know that good primary care leads to less deaths, fewer inequalities and better health,

Look at the signatories of Darzi – primary care names were outnumbered 4-1. GPs used to outnumber consultants by 3 to 1. Today, the NHS has more consultants than GPs. Did anyone make that part of a commissioning decision? Of all the services decommissioned last year, the vast majority in were in primary care and in the community - not in the acute sector.

The NHS says primary care is taken seriously, and now must look as if it does so itself. The solution has to be integration of services and integrated care – we suggested the integrated care organisation pilots that emerged from Darzi. Would that the NHS normally moved quite so fast on good ideas!

Fourth and finally, we must resolve the gap between the NHS and patients. Ever-changing patient and public involvement (PPI) systems - from Community Health Councils Patients Forums to LINKs within a decade - have been a complete and utter national disaster! But what an opportunity we now have to create our own practice groups, PPI, groups, citizens; juries, joining these to LINKs to ensure that our services fit community needs.

Primary care, where the individual patient meets the individual clinician, can help our patients to become part of NHS in fullest sense. Effective PPI is the NHS’s best sustainability plan – a means of encouraging self-help, personal and community help and joint commitment to make best use of locals resources. It would make the local NHS the responsibility of all of us.

If patients are treated and so act as consumers, a tax-based system will be unaffordable. The NHS has a mutual ethos, and we need primary care providers and business models that reflect this. We shouldn’t sell primary care off to have the taxpayer to buy it back. I make no bones – where possible, future primary care provision should be led by primary care clinicians and managers, where possible using PBC consortia, and ideally, social enterprise. The show should of course be run to tight business model, but keeping faith with its local population, and moving towards integration without compromising provider and commissioner roles. The out-of-hours provider rated best in the Healthcare Commission survey was a social enterprise led by local clinicians.

Over recent years, the NHS undoubtedly improved beyond recognition. Primary care has become uniquely accountable through the quality and outcomes framework, which the recent Commonwealth fund survey has shown to be effective and to be reducing inequalities. That was largely created through national priorities.

Now we need a new rhetoric about local empowerment. But local must mean local. Under current terminology, I fear that SHA localism is devolved centralism.

We need real redesign, and real devolution of power. Even Stalin recognised there’s a time for devolving power: when Moscow was nearly captured by the German troops, he handed over control to comrades in field.

That's you – it’s time for you collectively and locally to take power and responsibility – to make trouble and emancipate yourselves through the smoke and mirrors of localism.

For primary care, it’s been a good year for strategy but you can’t sell change if no-one’s listening or following. NHS Alliance has worked to bring down barriers between the sectors with passion, impatience and dogged determination. I know know we can be an irritation to the centre, but if we are going to have to change, then so must the centre.

If primary care is to take centre stage and have extended role in commissioning and provision, we need policy and strategy to reflect the selflessness of the NHS concept, which means releasing the unstoppable forces of localism.

Our NHS must make all its managers, all its clinicians and all its patients feel like VIPs, not recipients of others’ cant and self-congratulation. Our NHS must make us proud of working for and in it, so we will continue to put our patient before ourselves and go the extra mile every time.

This is an unblemished appeal to compassion not greed. We can only do these things if our NHS is not ruled by diktat or owned by shareholders, but belongs to managers, patients and people.

Never before have we had such an opportunity to make things so much better or such a threat of utter darkness if we fail. Primary care is the lamp, which has delivered relentlessly and ruthlessly, and can deliver the shadows between rhetoric and reality. We will show that British primary care is indeed world-class, and nothing will stop us from making it better and better and better.

Don’t take no for an answer – moral courage

Camila Batmanghelidjh, founder, Kid’s Company

I’m here to represent very vulnerable children and young people who use NHS services. What are their concepts, how can the NHS reach them and provide excellence?

Kid’s Company currently support 12,000 children with 2 street-level self-referral centres. We work with a comprehensive psycho-social programme, involving a range of strategies, in 37 schools across London with dedicated rooms.

What we learned from children at our street-level centre:

·      84% arrive because they’re homeless

·      60% are not registered with GPs

·      83% have suffered multiple traumas

·      87% have psychological problems including psychosis

·      81 % use drugs

·      82% get involved in crime for drugs

Some say to us, ‘we want to be legit, and do it like the rest of society’.

Why do children live like this? We have a social work service in London with 550,000 child referrals a year, but an average capacity of 30,700. What of the other 500,000+ who don’t get onto the child protection register? Why do most local authorities have 90-100 on child protection registers but 1,700 on youth offending registers?

In some local authorities, service providers don’t pick children with problems up as they know those children will commit crimes, and thus go from the local authority budget to the national criminal justice budget. We spend £280 million a year locking up kids, of whom 80% reoffend. If we were a hospital doing that, we would be shut.

A child being abused behind closed doors can’t hold service providers accountable: their vote doesn’t count. When they’re being abused and not affecting voters’ quality of life, services don’t touch them. When they later grow up angry, anti-social, and affect voters’ quality of life, resources get mobilised, not because of the child but because of their victim. Politicians think that if they don’t honour the child’s victim’s dignity, voters will be upset.

But that child has a message for us: “when I was being abused; when people were violating me repeatedly; when I watched my stepfather break a bottle over mother’s head and had to run to the phone booth - where were you, civil society?”

The consequence is that such a child begins to conceptualise professionals and civil society as entities that do not protect and value childhood – “why was I not worth saving?” The only answer left to them is, “maybe I wasn’t good or precious or worthy enough to be saved”.

When a child begins to think of themself as unworthy of being treasured, they can reach a conceptualisation of themself as hateful. Then it’s easy to commit harm with disregard: if you’ve got no-one’s love to lose, your capacity to commit harm that much more robust.

I want you to understand how important compassionate interruption is. It’s the difference between a child feeling honoured and that their dignity is persevered. Otherwise, they think that even in your eyes, they’re not worth of respect

As you struggle with notions of vision and strategy, you also need to exercise your ethical and moral choices.

You can tick all the boxes, and be morally and ethically vanilla – but at the moment of moral and ethical choice, would you compromise for job security, or to avoid upsetting colleagues, by setting higher standards?

If we always protect professional dignities and boundaries, there’s a risk we sell the most vulnerable down the river. Human beings are about energy, clarity, being plugged into spiritual and emotional life sources. Each time you shut down your soul, you kill off a little bit of yourself, of own energy - you make yourself tired and humiliate yourself between the creative and visionary aspiration brought you into profession and what you end up delivering.

You owe it to yourselves to preserve your own spirit, The latest neuroscience research is proving that the medical paradigm now shifting – simple things like having been loved and cherished with sufficient maternal contact in childhood shapes brains and sculpts each individual.

Modern medicine will boil down to the capacity to care, love and have the privilege of exercising compassion in relation to someone else’s pain. The greatest disservice is to see the care profession as a process. The care philosophy is about creativity – compassion and tenderness are a privilege to exercise: it’s what makes us different from animals.

Why should we allow precious value-based notions to be taken out of the public narrative? Because we’ve been over-impressed with process and targets that are visible to the eye. Behind closed doors, we all know that precious moment in the clinical encounter when we are being kind. Maybe can’t cure an illness or we lack resources, but if we’re honest and kind, we notice the pain the problems cause people, which makes us sad for them.

With the moral courage to make our humanity available at every point, we can understand that the ultimate clinical task is the sharing of love and care, and we shouldn’t be ashamed to say so.

What hurts the kids we see is not just neglect and abuse, but the fact every agency often puts the policy before the child. They accept that their own parents and carers may fall short, and that an accident of birth delivers them to difficult and challenging conditions. But there is no excuse for civil society not to take responsibility for them – if we don’t compromise on our own personal moral courage, we could made a difference.

Capture every moment you have available to follow an inspirational ethical vision. You can deliver compassion: an incredible gift to someone who feels humiliated as they have not been chosen to be loved and cherished. You could be the difference between them believing in kindness or despairing at thought of human intervention. It works – we develop a service of all professionals under one roof, under one leadership style and philosophy – putting the child first. Loving compassion is the primary task.

Primary care – delivering innovation

David Nicholson, chief executive, NHS

It’s great to hear Michael Dixon quoting Stalin approvingly! And it’s great to be here among comrades.

The NHS is on a significant journey through a big set of changes. Lord Darzi’s next stage review changes the set strategy.

In my career, I’ve seen many plans and documents – 30 years of changes, some more significant and relevant than others. The process of the Darzi Review (which is described as an enabling document) involved tens of thousands of clinicians – that is giving clinicians real power, but it’s only the beginning. Lord Darzi and I have been going round the country explaining the Review and getting new ideas, which has involved hundreds of people in the development of clinical leadership. Bruce Keogh has been launching a significant discussion about how we measure quality. This is about building understanding, support and a bias for action.

The Next Stage Review defined quality, and said that it should be the NHS organising principle. People have been trying to do quality for years, but the Next Stage Review sets a clear definition. I have a definition of quality as a manager; clinicians’ definition is sometimes different - sometimes significantly. In defining quality, safety, effectiveness and experience are all essential. Quality is all three – do no harm; have great clinical and patient outcomes; and a good patient experience.

Quality is all three: not one or two.

Too often, we’ve taken just one in isolation and made that one the organising principle.

The really important thing in the Next Stage Review is the emphasis on evidence. It set out packages of information on evidence of best practice for people to self-assess locally and get beyond anecdote. Over the last few months, we’ve looked at the evidence to support management, and there’s a huge amount of powerful evidence internationally on what actually works to deliver large-scale change.

There has not been a huge number of DH documents on ‘Implementing The Next-Stage Review’ because we see the centre’s job to create the environment for the front-line to take power and make things happen - to help create the environment and build the capacity.

1. In relation to quality – international evidence says quality is systemic; not individual. Individuals can be as focused and committed as possible, but on their own, won’t transform things. Jaguar found that 40% of problems on their cars were related to components, so in cars made at the best Jaguar factory in the world, 40% of problems will persist. It’s not an easy switch to a healthcare system. But even if you had the best secondary care cancer service in the world, you can’t deliver world-class cancer services without preventative community and early referral. Quality has to be systemic, so we need to look across the system as a whole.

2. Leadership is absolutely crucial – there’s evidence that organisations with good leadership focus on customers and the community, rather than on national bureaucracy. Leaders should look out not up – there’s real evidence, if you want to change things for the better, that’s exactly what you need to do.

3. We tend to focus on poor or not very good services almost all the time - on the trailing edge. To get good services everywhere, we need to absolutely support and reward leading-edge risk-takers, who drive their organisations to the very edge of what’s possible in service. We need to do this in a significant way, and when we went through the primary and community care strategy, we focused attention on PBC escalator and on the new integrated care organisations – to be leading edge and to reward risks.

4. Change, not churn. Some clinicians would like a moratorium on change, but I say no (not because I’m some kind of change junkie). Change in healthcare is need-driven buy big global changes - not by government, demography et al. We need to ensure clinicians and front-line staff are driving change, which in the past we’ve tried to drive with structural change. Real change requires trust, understanding and relationships, which we can’t get if we constantly disrupt them by changing structures.

I suggest there are four principles to progress:

1. Co-production. I’ve learned over the last 18 months that change doesn’t come from a set of pointy-headed individuals at Richmond House. That is not how change works. If we work together with organisations like NHS Alliance, we get much better products.

World-class commissioning didn’t come fully formed out of Mark Britnell’s brain, but out of a set of discussions with hundreds of people across the system, and because of that, it has enormous power. This means we have to take more time over things, thinking them through in more detail and we have to talk to each other far more.

2. Subsidiarity. SHAs are just as alien as the DH to many people. Central power needs to provide a framework, but we need to put decisions on things like polyclinics as close to the front line as possible. Two years ago I asked you to ‘make trouble’. Look at social enterprise – we didn’t want the centre to decide how many and where they should be.

3. Clinical engagement and leadership. These are vitally important. In the past, when managers huddled together for warmth, we used to talk of clinical engagement, but it really meant getting doctors and nurses to do what we wanted (muttered aside, a Nye Bevan quote: “that is my truth”).

What’s powerful in the Next Stage Review is the chance to engage and work with 60,000 staff across NHS (and we surveyed over 1 million). They told us the obvious, we love our jobs (though you don’t always say it) ... the NHS scores hugely high for staff job satisfaction, much higher than the John Lewis Partnership. But - the issue is that while you love your jobs, you hate the system and you don’t see it as on your side.

That is about completely changing the nature of organisations and systems, so you have a genuine belief that they are there to help you improve services for patients. If we get close to that, it’s an enormous opportunity.

4. System alignment. There are hundreds of organisations defining and setting standards, all slightly different. There are 76 different guidelines for epilepsy. How on earth can we work like that? The new national quality board will align all this, so front line staff have real clarity about success. If we achieve real clarity, that will be enormously powerful.

I’m very proud of the NHS constitution, which contains an incredibly powerful set of principles and documents. One thing staff tell us is that they’re driven by values: the constitution sets out what patients, staff and public believe, and is very powerful, because it’s not written by management.

Two aspects are crucial – everyone counts and no-one gets left behind – so hard-to-reach groups need to be sought out. Most particularly, the issue of compassion is a very important driver for the way we work, and was powerfully expressed by Camilla. Finding time to listen and talk when it’s needed … small things like that mean so much

I’m absolutely committed to working with the NHS Alliance to make this a reality

Questions and debate with David Nicholson

DN – on avoiding gaming

“I come from a generation of NHS leaders who built reputations on delivering national government targets – in that environment, the potential for gaming and managing upwards is huge. We can do two things now to help: reduce national requirements to a minimum (the Health Secretary says no more national targets); and equip leaders in organisations to interact with and talk with other local organisations and identify what success looks like. We’re now saying that satisfaction and patient experience are best defined locally”.

DN - on access to primary care

“we are learning how to do this, and people in primary care are nervous and anxious, for mostly understandable reasons. If you look at the documentation on our general position, competition and contestability is a tool; not an end in itself, which is not where we were 18 months ago. PCTs have flexibility how to do this. If they decide not to tender, they’re accountable for that choice, and I think that’s important – tendering is a tool for use when required. If I am a PCT, and the quality of services leaves me and my patients unhappy, I think it’s perfectly legitimate to use competition and contestability to drive up unacceptably low standards.

“On access, we’ve tried three times in my career in the NHS to get increased capacity in primary care across the country to under-doctored areas. Each time, it failed: a cosy conspiracy of PCTs and general practice overcame it. This (the move to national procurement of new provision) was end of that process. The Government genuinely believed that to get change in the system, they had to go through that process. I still believe local GPs will win the majority of tenders.”

On hypocrisy around market values and compassion

Chair of social enterprise: “I think there is dishonesty and disjunction between talk of NHS values and compassion and the drive to introduce the marketplace. PCTs do feel obliged to introduce the marketplace, City and Hackney PCT wanted us to bid for a primary mental health team (which should be a core PCT service …) in a 2-week timeframe. We cannot do that. The for-profit motive and care and compassion don’t go together and bringing market values into our NHS is wrong.”

On local accountability

Martin Rathfelder, Socialist Health Association: “David, your ‘look out, not up’ mantra doesn’t seem like reality. In every one of the last 18 years, my local NHS has cared more what you think about them and less what I think about them”.

DN: “You’re absolutely right – this is one of our biggest problems. Over the past 10 years, the NHS has got incredibly efficient at delivering Government targets. What I’m saying is that was fine, but won’t deliver the personalised, locally accountable change we need for the future. We re not in any way there now, I need to create the environment in which that change will happen”.

Vision into action

Health Secretary Alan Johnson MP

It’s a pleasure to join you for the second year: I don’t normally stay in a Cabinet post long enough!

In the year of the NHS’s 60th anniversary celebrations, I want to reflect on primary care’s role in the genesis of the service. Access to primary care now defines the NHS. In 1948, people queued to be examined by GPs; not to be seen by the hospital. Primary care does 80+% transactions

The Next Stage Review may be written by a surgeon, but I hope you accept it’s not a manifesto for hospitals. As Barbara Starfield’s work shows, primary care is where we can affect health inequalities and the growing incidence and prevalence of lifestyle diseases.

Primary care extends far beyond the GP surgery or GP-led health centre, which we’re using to increase provision of primary care in the areas of greatest need. As Julian Tudor Hart’s 1971 ‘Inverse Care Law’ showed, in areas with the most sickness and death, GPs have larger lists and less hospital support.

This still applies, albeit to a lesser degree. There are still twice as many primary care professionals in Cambridgeshire as Manchester and on average, Cambridgeshire residents live longer. That’s why we’re putting 100 new health centres in the poorest areas, as well as the 152 polyclinics.

Improvements to the GP contract are about enabling and allowing a greater range of services. These contracts must drive improvement, keeping pace with heath needs. We will work with the profession to reduce spending on the MPIG income guarantees, because we know that practices who’ve not benefitted as much from MPIG are disproportionately likely to serve poorer areas.

Equally importantly, the QOF must better reflect the prevalence of disease - by 2010, it will take into account high numbers of patients suffering from long-term conditions such as heart diease, diabetes etc. that are more prevalent in poorer areas.

Plans to improve GP access have not beern without controversy – people have campaigned against us insisting on 8-8 accessibility 7 days, registered or not. They have suggested it will damage services, trying to depict the debate as a choice between depersonalised universal services on one hand and cosy consultations on the other. Which is bunkum.

New investment in under-doctored areas is long overdue, and will provide much-needed extra capacity. As for the allegation that this is privatisation of NHS, already over half the shortlisted bidders for contacts are GP practices and consortia.

Accessibility is the foundation of good-quality primary and community care - necessary, but insufficient. There are many ways in which providers are working more effectively to respond to need. Practices are developing better ways to monitor patients with long-term conditions.

With care plans for long-term conditions, and the expert patient programme, we’ve drawn extensively on the best in general practice and community services. Personalisation and empowering patients are key as we move to the implementation of the Next Stage Review.

Empowering GPs and practice nurses is central – as the chief referrers of patients, you have the detailed knowledge of patients and of which services are right and convenient for them.

We know there’s a long way to go in improving commissioning. We know that practice-based commissioning mustn’t just be something that a few do and the rest talk about. We recognise we haven’t done enough to support PBC.

PCTs will be held to account for this through the world-class commissioning assurance process. David Colin Thome is establishing national teams, and we will provide more training for practices who want involvement in commissionig (which I think is the majority).

Integrated services should no longer be a novel idea, and we must overcome practical barriers. We launch the integrated care project prospectus today, and hope you get involved in the pilots.

NHS Alliance are such a progressive force for good in the NHS and in primary are. Not only do you know the route, we know you;ve cleared much of the undergrowth for us. We want to empower clinicians to agitate for better deals for their patients, in a 21st century health service true to its fundamental principles established 60 years ago – making the best available to all, irrespective of health and social class.

Questions and debate with Alan Johnson

On the credit crunch’s effect on NHS budgets

AJ: “The PM announced that there will be no change to the budgets for health (going to £110 billion a year in this CSR) … as a former trades union negotiator, I don’t renegotiate deals”.

World-class commissioning one year on - what have we learned that will make practice-based commissioning really work?

Mark Britnell, director-general of commissioning and system reform, DH

A year ago, I promised you I would find a way to hold PCTs to account for practice-based commissioning (PBC). I think that I have, but you will be the judges.

I am also responsible for the integrated care organisation pilots – if any of you doubt that your moment has arrived, there has been no better time to be a practice-based commissioner.

I know there will be a debate of whether we’re going back to GP fundholding or forward from PBC. I encourage the best of PBCers to become one of our 20 national pilots, and I believe our pilot programme will meet your needs almost entirely.

I’m aware some of you think world-class commissioning (WCC) is a distraction. Certainly, if it allows PCTs to navel-gaze, it will have failed.

For 60 years, the NHS has been largely defined by provision. Since 1989-90, the purchaser–provider split has been dominated by providers and hospitals. In economic turbulence, it’s a no-brainer for PCTs to support PBCers. And PBCers have now got rights, not entitlements

I think it’s unfortunate that there are not more PCT people here today, but I’ve learned over the last year on PBC, working with them on the primary and community care strategy, you can’t rely on the benign benevolence of PCTs to make PBC work. That’s why the primary and community care strategy talks about PBCers’ rights to clinical and financial information; rights to management and financial support, with incentives for those who want to go further faster.

We’ve also got the world’s first commissioning compliance and assurance system, with PCTs facing 360-degree reviews – in which you PBCers will be asked to comment on their support for PBC, and your PCTs will be marked up or down accordingly. Soon, they will have no place to run or hide. They have to give you what the primary and community care strategy outlines.

You need to let me know whether you want more national regulation on clinical and financial information and on financial and management support. I’m not itching to provide more national guidance, but will do if it’s the best way to ensure progress.

The raison d’etre of world-class commissioning is to focus on patient outcomes. We can’t do 21st century healthcare by annual fiscal targets and cycles: they never allow you to plan with great confidence.

PBC has a fundamental role in commissioning – you can’t do it all, nor can the PCT. Ask them for their 10 most important priorities for the community, and then work out how to meet them.

By January 2009, PCTs should have 5-year investment plans – not in policy, in practice. One question with the economic slowdown is, how big is the next Comprehensive Spending Review cliff-edge going to be?

World-class commissioning Competency 7 –to stimulate the market – has been misunderstood. It doesn’t mean that you have to competitively tender every time. Commissioners do have to decide how you are going to deal with it when there is a lack of responsivesness or cost-effectiveness by providers. Without that, you’re just passive grant-givers of state money to beneficiaries who are not encouraged to do more or to innovate.

The bidders for polyclinics have split 50% GPs, 40% private companies and 10% foundation trusts.

We do have an evidence base for the 11 world-class commissioning competencies, and each one has three key indicators. Proportionate governance is important – requiring a business case costing £10,000 for a £50,000 service is clearly unwise. We’ve looked at providing freedoms and rights, and once PBC gets into its stride, you should not always have to produce business cases.

I can try to design a system nationally, but unless we work through its development together, it will not work locally.

We’ve put in a £1 million investment for regional support organisations. World-class commissioning the assurance compliance will ensure PCTs are held to account. PBCers who want to go further faster will get proportionate governance.

For the next 2-3 years, PCTs must understand that world-class commissioning is a constructive challenge to their role. Governance is about grip – the board’s ability to work and control its organisation effectively. That means producing demystified health benefits.

I would say what we’ve got today has been worth the wait – with rights and entitlements, PBCers also get freedoms. Integrated care organisations will be based around practice lists. In political terms, I hope you can see how the four rights to information I’ve announced enable you to take more control and manage your affairs.

Questions and debate with Mark Britnell

On the need for speed

MB: ”Success breeds success, and the new freedoms have to be delivered pretty quickly”.

On barriers to PBC

Delegate: “Barriers to PBC remain over clarity of roles and responsibilities; capability and capacity for PCTs and PBCers; poor governance; confused relationships; and low or variable motivation and engagement”.

On PBCers’ right to apply for innovation funds

MB: “I’d like to put on the record that with the £250 million innovation fund announced in the Darzi Review, PBCers are just as entitled to bid for funding as teaching hospitals. You should use it as seed funding to innovate more widely”.

On innovating and ICOs

MB: “For the Integrated Care Organisation pilots’ prospectus, we specified the characteristics of good integrated care. It’s not impossible for you to think about some ICO pilots using secondary care clinicians.

“I had to speak at a Circle conference recently – the doctors there were like Moonies, pumped-up GPs and consultants ready to take on the world. But I warmed to their spirit of entrepreneurship, their speed of innovation and their clarity on what they want to do. Don’t leave the field to Circle!

“You need to use ICOs – they come with very few rules attached. They’re based on registered lists, and your bid must be supported by your PCT - why would we back bidders who are scrapping with their commissioner? ICOs offer a chance to move beyond fundholding and PBC pilots – it’s a radically new form of care whose time has come.”

On the future for ICOs

MB: “I can see ICOs getting better and bigger. Private sector people whom I meet say they’re happy to be supportive of them”.

On ICOs and plurality

Delegate: “Do ICOs potentially snuff out competition and choice? The draft NHS Constitution guarantees these. Collaboration and cartels are completely different things – what if you have 2 new ICO centres very close to each other?”

From penicillin to PET scans – the NHS now and then

Dr Phil Hammond, Baroness Mary Warnock, Ben Page and Dr David Hibbard

This session was entertainingly chaired and compered by Dr Phil Hammond. Baroness Warnock reminisced about the introduction of the NHS in 1948, stressing its importance even to educated children of professionals like herself (her father-in-law, a GP, thought the NHS would be a disaster) in alleviating the need to worry about the cost of healthcare.

Warnock recalled how “the founding fathers of NHS optimistically believed that its free services would so improve the health of the nation, that healthcare would become less and less expensive to provide. However, my GP father-in-law was proved right to believe demand would always grow”.

Citing the vast increase in medical capability and technology, Warnock wondered, “how far can it go on? I’m very gloomy about the future of the NHS. We long ago lost universal free prescriptions, spectacles, and dentistry; and we must face future losses. How far can the original NHS values be preserved? I don’t find the Darzi review helpful in this … for all talk of openness and accountability, we’re far less than honest that not everything can any longer be afforded. How transparent can we expect NHS managers to be?

“I don’t want hospital choice when I break my ankle, or a choice of whether it’s set with metal plates or plaster and splint. I believe choice is absolutely irrelevant to what we want from NHS, yet since Thatcher, it seems what the system wants. I think most of us are happier with doctors’ orders. Choice goes out the windown in certain really acute circumstances, like when a doctor decides future treatment of a sick child would be futile. Choice is not in that picture at all. Nor around death.

“The emphasis to look after your own health in Darzi is good, but anyone who can read knows they should eat 5 portions of fruit and veg a day, drink less alcohol, and exercise. As David Hume points out, it’s another thing to conform the will to it

“So emphasis on choice may not save a lot of money. I do find the talk of ending postcode lottery quite proper. With the equality principles of NHS must come justice. Nothing is more unfair to be denied a cancer drug living in one place, which you would have got living 10 miles away; or to get three attempts at IVF rather than one. It’s hard to reconcile these with the insistence different regions must manage their own budget locally, in accordance with democratic constitution. There are huge demographic differences between places. Even if we could ensure fairness across the country, that does not address the crucial issue of finance. What is to be done?

“The answer must be means testing. In the 1970s, direct grant schools (in effect, grammar schools) did this – while some better-off parents paid full fees, others paid less less and some none. No pupils knew who paid; and it was great – they all got the same excellent education – which was equality, but also justice, depends on means testing.

“Could the NHS not learn something from this extraordinarily successful system, which was abolished by a Labour government. Means testing of some kind is the way forward for true excellence according to need.”

Ben Page of Ipsos MORI presented a raft of opinion polling data on attitudes to the NHS. Among respondents to MORI polling:

·      60% agreed that the NHS was one of the best health services in the world, even in the Patricia Hewitt NHS deficit era

·      Satisfaction with the NHS is run is up in MORI’s tracking for the DH – 65% are happy, and only 1 in 6.5 unhappy.

·      Support for the NHS, at 80%, is similar to support for the monarchy - people surveyed reported feeling proud of the NHS, and regard its continuation as an absolutely sacred principle for society

Should there be limits to what treatments the NHS offers?

·      48% disagree; 31% strongly disagree

Should there be limits to what the NHS provides?

·      55% disagree; 29% strongly disagree

On cost-effective and clinically effective treatment:

·      28% accept NICE’s view that the NHS should use most effective drugs and treatments if they are cost-effective.

·      41% think the NHS should offer any drugs and treatments that work, no matter what the costs

·      31% think the NHS should offer any drugs and treatments even if ineffective, no matter what the costs

Page points out that these last data show massive public expectation, facing the NHS with an impossible task, given that medical care is becoming much more expensive.

He quoted oncologist Professor Karol Sikora’s comments argued that while the public know healthcare is getting more expensive, they are “still becoming more demanding, like teenagers”.

Page added, “There’s a stronger sense of what we’re being denied by NHS. There’s unfinished business between what should be decided and rationed locally and nationally – at a time when consumerist politics offers people everything.

“This is not just cognitive dissonance, but cognitive polyphasia. People have attitudes that it’s outrageous their son can’t afford a house locally, but it’s also outrageous to build new houses in their back yard. 77% of the British public tell pollsters that if the government needs to change the law to protect the environment, they should do so; but 77% also say that ‘green’ taxes just aim to raise revenue.

Dr David Hibbard, an American GP, offered delegates “greeting from the US colonies.” A GP in the US for 40 years, he addressed three main questions:

1 is the NHS a better system than what we have in the US?

2 is the NHS sustainable?

3 is the NHS getting too close to the US way of operating, or not close enough?

To question one, Hibbard answered, “the NHS is absolutely and positively a superior system … 2/3 of US public are in favour of a simliar design of system to the NHS, and physician surveys show that we want a centrailsed, unified system like the NHS. The US College Of Physicians voted 2008 to advocate for such a system.

Highlighting the deficiencies of US healthcare (exclusions, high cost, non-universality), Hibbard asked delegates, “do you know how fortunate you are to have your NHS? I think older patients know how fortunate and blessed they are … This US GP feels people should thank God they have the NHS and should work to protect it at all costs.

As to question two on sustainability, “only you can answer that – I can’t. It rests on your shoulders and your work ethic. If I were in your shoes, I’d work my butt off to ensure its sustainability.”

On question three (whether the NHS is too close to the US system or not close enough?), Hibbard discussed rhetoric from the centre of more competition and pressure from private business for opportunities to profit from greater involvement in the NHS. “I strongly advise you to be very careful and vigilant about letting for-profits into NHS provision of healthcare. Social enterprises and not-for-profit providers look acceptable and may be of great value. Remember that for-profits like United Health, Virgin and Asssura are just that – they exist for profit. Money goes to their shareholders and investors; not back in to patient care”. He cited United Health Group’s former CEO Bill McGuire’s 2005 salary and bonus totaling $125 million.

Hibbard also cited research showing kidney transplant patients had a 20% greater chance of dying in for-profit transplant units than not-for-profit ones, as well as a Canadian Medical Journal 2005 sytematic review and meta-anaylsis comparing mortality rates, which found that the risk of death was 2% higer in for-profit hospitals. “Why? because for-profit hospitals spent less on adequate numbers of doctors and nurses. It’s the bottom line.”

Ensuring the sustainability of the NHS and the planet for another 60 years

Sir Jonathon Porritt, chair, UK Sustainable Development Commission

Sir Jonathon Porritt gave an entertaining and balanced presentation between fear of the real risks of climate change to sustainability and the more positive ‘can-do’ approach he sees in businessmen (though he argues many of these are showing Panglossian levels of optimism about the dangers of climate change).

He described the way in which the “gigantic con trick” of a “global economy built on a mountain of debt, aided and abetted by governments in retreat” had been revealed.

The debate now, Porritt argues, is “shifting to different ways to create and use wealth and the dynamics of capitalist system. If we’re only extending use of credit to spend our way to notional happiness, we’re storing up fantastic problems. The Sustainable development Commission’s figures show “the UK health system in systemic dysfunctionality: mental ill-health costs the nation £76 billion (net cost to the economy). Obesity and diabetes cost £3.7 billion and £1.3 billon per annum respectively.”

He warned that the principles of sustainable development “are unapologetically about creating a strong, healthy and just society. If we learn to live within environmental limits but perpetuate halth and wealth inequity, there will remain huge distortions and we won’t have a sustainable society – it needs to be strong, healthy and just.”

Porritt highlighted the NHS’s “huge carbon footprint directly, of 3.7 million tonnes CO2 – indirectly, likely to be 3-4 times that”. He highlighted the SDC’s resources to help organisations develop:

·      business cases for change

·      financial saving (energy waste)

·      improved staff morale

·      faster patent recovery rates

·      healthier local population

·      effective local partnerships

·      long-term viability of the NHS – future-proofing

Porritt concluded that “sustainable capitalism is the only thing that stands bwteeen us and a miserable decsent into ecological collapse, resource wars, worsening inequity and social exclusion.”

Closing remarks

Professor Chris Drinkwater, President, NHS Alliance

Professor Drinkwater’s closing reflections echoed Jonathon Porritt’s themes on sustainability; Camilla Batmanghelidjh’s appeal for dignity and personal integrity and Phil Hammond’s humorous but accurate reflections “on ourselves collectively as healthcare professionals”.

Drinkwater concluded, “the take-home message is that we need to start to take responsibilty to ensure healthcare costs in the NHS don’t become unsustainable – if necessary, using commissioning to tear down the acute citadel and refashion it. As practice-based commissioners, we must always ask how we can save NHS costs. As ever, I’m upbeat, but big challenges lie ahead”.

Coda - policy reflections

Conference reporters Andy Cowper (editor, Health Policy Insight and Commissioning Health) and Professor Bob Sang (director, Sang Jacobsson) reflect on the policy implications and priorities.

Choice issues

The setting sun of the economic slowdown will cast long shadows – so much of NHS policy is all about following the money. However, discussions at the conference, from speakers including Baroness Warnock and in questions from delegates concerned about equity, also showed choice to be an unresolved dilemma.

This brought to mind a previous publication from 2004, “discomfort about the idea of choice in health stems from two sources: choosing service and treatment options can never be a process free of risk; and choices all have consequences, for which all participants share both responsibility and accountability.

“The very fact that The NHS Improvement Plan – Putting People at the Heart of Public Services (CM6268, June 2004) needs its subtitle describing the need for patient-centred health services tells us that we are (still) not there yet. Largely an update of The NHS Plan (CM3487, June 2000), The NHS Improvement Plan states: ‘The next stage in the NHS’s journey is to ensure that a drive for responsive convenient and personalised services takes root across the whole of the NHS and for all patients’. ”

(Cowper, Keep & Sang, British Journal of Healthcare Management 2004 10:11, 329).

The discomfort we alluded to then still resonates today, despite the further ambition of Lord Darzi’s Next Stage Review, High-Quality Healthcare For All (DH 2008) and the advent of World Class Commissioning. These reforms shaped both the context and content of the conference in Bournemouth, where optimism and discomfort were found in equal measure.

Indeed, NHS Alliance, with its unambiguous commitment to a sustainable, high-quality, publicly funded NHS underwritten by the founding values of equity of access and free availability, found itself wrestling with the consequences of choice.

Throughout the event, lurking in the background were two current national consultations: cancer czar Professor Mike Richards’ review of ‘top-up’ payments (since resolved in favour of allowing them, provided no extra NHS resource use is involved), and the draft NHS Constitution: both fed into colleagues’ optimism and discomfort. As such, the real issues under debate are those which will shape the future of the NHS.

Practice-based commissioning – forever delayed?

“PCTs often seemed disturbingly uninformed aboiut what they were buying from the acute sector. It is hard to see how authentic patient choice can be achieved, when this lack of clarity combines with a low commitment to patient involvement.” (ibid)

Despite Mark Britnell’s promise of new rights for practice-based commissioners, informal networking with delegates and comments in various seminars indicated that practice-based commissioning – which the NHS Alliance has championed vigorously – remains much more of an aspiration than a fact of NHS life.

Working and not working: the four As

We suggest four statements that could be ascribed to the current NHS policy deliberations:

·      We now know what works - anchors

·      We know what does not work - anomalies

·      We also know what we want to work - aspirations

·      We are beginning to know ‘what we do not want to work’ - antipathies

These four ‘As’ represent a set of litmus tests of NHS reform. They also raise questions about the congruence of the policies and perspectives presented during the conference, during lively seminar sessions and workshops and throughout the exhibition and social spaces.

The potential extension of ‘means testing’ suggested by Baroness Warnock (which works for some and not for others) into healthcare commissioning as a result of ‘personalised care’ policies (which many want to work) – opened up important debates and reflections.

Sir Bruce Keogh’s speech on the eve of the conference introduced four themes that the Department of Health certainly hopes will work. These ‘guiding principles’ for implementing the Next Stage Review offer a new jargon, which also raises new questions:

Co-production: “discussions and decisions made in partnership with the NHS, Local Authorities and key stakeholders” – who presumably include patients?

Subsidiarity: “Where necessary, the centre will play an enabling role but wherever possible, the details of implementation will be determined locally” But by whom; and under what conditions and constraints? One SHA, NHS South West, has already decided to shift the 18-week waiting target down to 8 weeks: an example of ‘local determination’?

Clinical ownership and leadership: “Staff continue as active participants and leaders as we implement the NSR and they make necessary changes.” So who determines what is necessary, and how?

System alignment’: “the NHS is a system, not an organisation. The wider system needs to be aligned around the same goals, enabling us to use our combined leverages to drive up quality across the system”. This may present interesting challenges to statute and Parliamentary oversight.

Building on this final point, Sir Bruce pointed to the need to grow the evidence-base of initiatives that demonstrate improved quality and reduced costs: the key to a sustainable NHS. Central to his contribution was a commitment to sustaining and developing the evidence base (an anchor); determination to sort out healthcare information and IT (aspiration and anomaly respectively); and a commitment to removing some of the barriers to clinical collaboration (antipathy and aspiration)

Michael Dixon – mind the rhetoric gap

Alliance chair Dr Michael Dixon challenged the growing gaps between the rhetoric of policy and the realities being experienced by NHS Alliance’s members and their colleagues. His ‘litmus tests’ related to four key themes:

Integrated care: services that truly address ‘mind, body, and soul’

Primary care access: making the most of new investment

Clinical engagement: a working partnership at every level

Localism: especially through the agency of practice-based commissioning

Despite high aspirations in the various policy drivers, many delegates expressed the view that progress remains slow for each of the above aspirations. Where is the engagement to facilitate local leadership, ownership, and action in relation to this crucial agenda?

Delegates described policymakers having relied too heavily on the ‘chosen few’. Sustainable policy implementation means breaking the hierarchical paralysis, and encouraging extensive engagement at a local – as in practice - level. Such local leadership depends on dialogue, trust, and a ‘peer process’ among all clinicians: primary, secondary, tertiary, and their local service partners in the voluntary, community and social services sectors.

While world-class commissioning fully endorses such an engaging approach, local practitioners reported that they have yet to see the evidence of a fresh, inclusive approach by SHAs and PCTs.

Dixon confirmed that there was, and is, continuing evidence of policy failure in practice:

·      70% of discharge summaries arrive late into primary care for secondary care, with significant attendant risks to patient safety in 25% of such cases.

·      Despite the policy drive toward a ‘primary care-led’ service, primary care services are the ones being decommissioned.

·      Improved primary care access, through means of commissioning new centres and services has become a ‘corporate auction house’, not the genuinely engaging value-based development that was envisaged and needed.

Indeed, the frequent failure of SHAs and PCTs to engage, both with primary care and with local communities, not only ran against the Darzi proposals, it prevented localised sustainable development of services that could, in the longer run, foster mutuality and self-care. Failure to harness patient and public involvement in improving primary care access and in co-designing integrated care puts both policies at risk – turning a major opportunity into a potential disaster.

Dixon’s own values were very clear: “mutuality before market share”; “local must mean local, and not devolved centralisation”. If practice-based commissioning is to work, then by catalysing local empowerment and engagement, it could result in bespoke, accessible service design and development – treating local people as citizens and partners, not recipients.

Perhaps it will come down to the Alliance, its members and networks, to demonstrate that more effective local collaboration, enriched by active clinical leadership and community engagement, can produce the improvements in quality called for by policy-makers.

This is, of course, a very tall order for the Alliance.

Limits of the market, constraints of consistency

Conference chair Professor Chris Ham reflected that the enduring strength of primary care, and growing recognition of the limits to market-based solutions, coupled with growing recognition of the potential value of more active democratic participation in decision-making offered a way forward for the NHS, locally and nationally.

He also pointed to the strategy challenges to come:

·      the unprecedented force of the objective global drivers of healthcare policy;

·      the continued necessity of achieving more effective service integration;

·      and the persistent problems of variable service quality and inequalities of access that impact intransigent health inequalities, and which restrict access to healthcare benefits.

These strategy challenges present formidable obstacles to transforming the NHS ‘from good to great’ (to borrow Jim Collins’ slogan).

Camila Batmanghelidjh

Camila Batmanghelidjh’s compelling speech described the lives and experiences of the children with whom she works: the highly marginalised children who refer themselves to her organisation KidsCompany.

Her speech was a plea to reassert the NHS as a moral belief system, no longer preoccupied with targets – as a force which is capable of reviving the dignity and sense of self-worth of our most vulnerable children. For her, it is time to reinforce civil society’s duty to value and protect childhood: “to be the difference, in practice, between belief and despair by ensuring that vulnerable and traumatised children are made welcome and have the chance to heal and thrive in every community.”

David Nicholson

The Chief Executive of the NHS seemed in optimistic and colleague-ly mode. He assured delegates that quality will be at the centre of the continuing conversation about implementing the Darzi Review’s reforms, and moving towards a bias for action”.

To discuss quality and its attainment in healthcare, we must engage with two other crucial ideas: integration and leadership. As Russell Ackoff put it, “quality is a term so general and ambiguous as to be almost completely meaningless. Use it as often as you can!”

Moreover, quality in healthcare is measured through means of complementary criteria: safety, effectiveness, outcomes and experience. All of these depend on building the capacity for innovation and improvement throughout the healthcare system.

Nicholson referred to evidence showing that sustainable quality improvement grows from four fundamentals:-

Quality is systemic: a shared responsibility at every level

Quality improvement requires leadership that is patient and community focussed: “looking out, not in and up”

Support the leading edge: the innovators and risk-takers (for example, the Integrated Care pilots)

“Change; not churn”: build trust and mutual understanding of the purposes for change at a local level. Thus, the role of the centre was “to create the environment, build the principles; and to hold the account – together”

The concept of ‘co-production” that emerged from the Darzi Review suggests that the centre will enable the dialogues, focussed on quality, between providers and commissioners.

Questions from the floor following his speech exemplified the tension between the worthy aspirations for ‘togetherness’ and the potent anomalies that exist within a highly transactional, centralist, culture.

Workshops and fringe meetings

One unfortunate frustration in writing this report is the finite number of the workshops that we can attend. Rather than discriminate in favour of the sessions we could attend, we have identified three overarching causes for optimism and causes for concern, leaving our glass half-full and half-empty


The innovation test: There are impressive examples of GP-led service developments that will improve access, reduce inequalities, and support local co-management of long-term conditions, improving local outcomes

Realising the potential of PBC: Despite delays nationally, and inertia in some regions, the pioneer PBCers are demonstrating and building the relationships, vision, systems and local governance structures to ensure an impact. The challenges will be to move from this ‘pioneering’ phase to embedded system change.

Democratising the NHS. The NHS does not have a ‘democratic deficit’. It does have a ‘democratic difference’. Throughout the conference, supported by some of the workshops, there was a growing awareness of the value of working in partnership with local people: in service design, locality-based commissioning, and in the new local governance structures and collaborative processes.


Policy contradictions were evident everywhere. How will the NHS at the centre learn to enable and lose the habits of control? The relationship between PCTs and PBCs seems caught in an unhelpful stasis, with the PCTs still “looking up, not out”.

Whose choice is it anyway? Innovative support for self-care and integrated personalised care (both of which take time and trust) are at odds with the policies that position patients as individual choosers, buoyed up by a plethora of information sources focussed on a ‘plurality of providers’, and not on improved wellbeing.

Health inequalities and sustainability – despite the evidence and the growing sense of priority, it appears that the NHS is still at the beginning of the beginning in developing a concerted and effective approach: locally and regionally.

Closing the gap between vision and action

Despite an economic context that could have created deep pessimism, delegates to the 11th NHS Alliance conference responded with energy and evident commitment to the challenges set by Alliance leaders and their partners.

The 2002 Wanless Reports for HM Treasury into making the NHS sustainable bears re-reading in this context – as does the Kings Fund’s 2007 Our Future Health Secured? report on progress towards the ‘fully engaged’ scenario.

The clear way forward is for the DH and Government to trust, endorse, and back the innovation and collaboration that is emerging from primary care across the NHS. This is a stated aim of World-Class Commissioning and of practice-based commissioning – the learning from the assurance process, due out early in 2009, will be instructive.

Such sharing of power will require genuine courage from those currently in authority, as well as recognition of the legitimacy of scrutiny from those who want to lead locally.

What matters now is what happens next.