Mike O’Brien – 2009 Speech to the National Association of Primary Care

Below is the text of a speech made by the then Health Minister, Mike O’Brien, on the 17th November 2009.

I am very pleased to be here.

Over 60 years ago, the people of this country made a bold and historic choice. Amidst the ruins of war, they chose to unite under a common cause and rebuild their shattered land. They chose to create a society where the needs of the many were put ahead of the needs of the wealthy elite. A welfare state where the success of a government would be judged against how effectively it battled Beveridge’s five giants of want, idleness, ignorance, squalor and disease. Where someone’s future would depend not on their family’s lineage and wealth but on their own talent and industry.

This is still very much a work in progress. But one of the greatest achievements in this battle to tackle Beveridge’s giants was the National Health Service – what Donald Berwick, of Harvard Medical School, has called the “bridge between the rhetoric of social justice, and the fact of it.”

Giving people access to the healthcare they need, free at the point of need, has transformed the quality of countless lives. And it has saved millions more. But this is not a political choice made once and then forgotten. It needs to be constantly renewed. The NHS was forged in the heat of political controversy with massive opposition to it. Again and again political controversy has swirled around it and its values. Like it or not the NHS is a political creation and will continue to be a matter of political debate.

A service to the public, free at the point of need, funded through taxation is about values. The consequences of a lack of commitment to its values were made clear in the 80s and 90s when a chronic lack of investment brought the NHS into crisis. Crumbling buildings, old equipment, over-worked and under-paid staff and patients waiting in pain and distress for a year, sometimes two, for operations. So the public was faced with a choice. This time between abandonment of NHS values and a move to private health care or renewal. They chose renewal. The result of which has seen massive and sustained investment in the NHS since the turn of the century. Again, amidst controversy. The increase in funding through national insurance rises was bitterly resisted by the Opposition.

In the last decade, investment that has given the Health Service in England, 40,000 more doctors, 80,000 more nurses, rebuilt or refurbished buildings, and given patients access to the latest NICE approved drugs and treatments guaranteed through the NHS Constitution, pushed through Parliament into law last week.

Most importantly, it saves tens of thousands more lives every year.

33,000 fewer deaths from cardiovascular disease, 40% fewer deaths caused by stroke, and almost 9,000 fewer deaths every year from cancer.

Of course, I suppose you would expect a Government Minister in charge of the NHS to wax lyrical about its achievements. But this is not spin or a case of looking at the world through some kind of rose tinted spectacles. We all know, for example how this morning’s report on Alzheimer’s’ care shows there are still big issues that need to be addressed.

For proof that the NHS is a truly impressive, world class provider of health care you need look no further than the esteemed Washington based think-tank, the Commonwealth Fund. Each year it compares the healthcare systems of various developed countries. They ask the people who deliver healthcare, the clinicians on the front line, what they think about their own system. It published two weeks ago and this year the focus was on Primary Care. Once again, the NHS has come out rather well. Of the eleven countries – including Australia, Canada, France, Germany, The Netherlands, New Zealand and the United States – the United Kingdom was;

Top for low waiting times for specialist care,

Top for the use of multi-disciplinary teams,

Top for the use of financial incentives to reward patient experience,

Top for quality of clinical care,

Top for management of chronic diseases,

Top for the use of data on patient experience,

Top for reviewing doctors’ clinical performance, and

Top for the benchmarking of clinical performance.

This is the NHS that you are responsible for and as a Health Minister I want to thank you for your hard work in transforming the Health Service and making sure it comes out top in all these categories. This report is a real vindication of the work you have been doing.

When it comes to primary care, it is hard to find anyone who does it better than the NHS anywhere in the world. It’s also hard to find anyone with more drive and ambition for doing more and getting it better, and for improving quality and improving the patient experience.

Of course, it’s great to know that we do things better than others. It’s gratifying to watch as Britain moves up the league of nations, vindicating our efforts. But it is not an end in itself. Our mission is to give every single patient the highest possible quality of care and the best experience of the National Health Service that they can possibly get. Why stop at just being better than everyone else?

It is testament to every person in this room and to the people you all represent and work with back in your communities that we have come so far and achieved so much in the last decade. That when the public chose renewal, they made the right choice.

But the next 10 years will be different.

If the last 10 years or so has been about quantity – more money, more doctors, more nurses, more hospitals and more clinics – we know we need to ensure that the next decade has to be about quality. Ara Darzi’s bottom-up review of the NHS, High Quality Care for All, has given us a vision around which we can all unite. A vision of a clinically-led Health Service where quality is always and everywhere the organising principle.

Staying true to this vision will be increasingly important in the years to come as budgets start to level out. We need to find ever more creative ways for releasing funds to the front line. Now of course working more efficiently and cutting waste is important in the future direction of the NHS. But also working more effectively, continuing to improve the quality of care for patients.

Clinical leadership 

We will do this not by Whitehall diktat but through local clinical leadership. In many cases that means your leadership. You are the ones closest to patients, you are the ones who know where the waste and duplication lie. This government has done what it could do best, to push through the reforms needed to lift the NHS from poor to good. But the government cannot achieve quality through central mandate. It is now your turn to do what you can do best. To move the NHS from good to great.

Practice Based Commissioning

One of the principal ways of making this happen is Practice Based Commissioning. Practice Based Commissioning is about putting clinicians at the heart of PCT commissioning, giving them greater power both to transform the quality and the efficiency of local services. Where it has been embraced, the results have been impressive. In Bexley, major schemes include a cardiology service where virtually all aspects of the specialty, other than interventions, are carried out in the community.  Practices now receive hard, delegated budgets for prescribing. If practices make savings then they can use them, but they are also responsible for any losses. Through PBC, Bexley has so far saved £4m, money they can now spend in other ways for their patients, on more integrated, community-base care.

Many other PCTs such as Nottinghamshire County and Hampshire are actively drawing up autonomy and delegation schemes in collaboration with their PBC groups. Enabling practices to take on greater responsibility as their capability grows. But we have to acknowledge that Practice based Commissioning has not taken off everywhere. Even where it has, it is a way off reaching its full potential.

So you may well ask, if it hasn’t yet then why will this happen now, in the future?   Why will it be different this time?   My answer is it will be different because it needs to be. Because this is the only way to deliver High Quality Care for All. And, most dramatically, because the financial context has changed. This level of clinical leadership, of local leadership, will be the single most powerful way of driving up quality whilst releasing funds for further services. There is nothing to stop PCTs and Practice Based Commissioners from working together and devolving hard budgets to GPs. Nothing to stop every PCT in the country being bolder and more imaginative in how they work with GP Practices. Nothing to stop Practice Based Commissioning from transforming community-based care.

This isn’t just about holding hard budgets, it’s about giving practices real responsibility for the design of local services and then holding them accountable, so the hard budgets can be there. It is about more than that however. It is about requiring organisations to work together. There is nothing to stop us, but ourselves.

I would like to thank James Kingsland [President of the NAPC] for his work, independent of the NAPC, in leading the National PBC Clinical Network, doing what can be done to encourage the expansion of PBC. PBC is right for many surgeries. But it should be a matter of choice. Some GPs want it and their practices can cope with the administration it brings. Some GPs don’t want it. Particularly some small practices may want to focus on patient care not budgets. They may benefit from coming together with other practices. But some small practices could be broken if budgets are forced upon them. Lets leave the choice with GPs – rather than forcing GP budgets on all of them as some would do.

The NAPC manifesto for the election, which was published just an hour or so ago I believe, has a core proposal for Community Health Collaborations, which is a really interesting idea. Aimed at raising the quality of primary care. Bringing GPs together with some going on to become Foundation Practices with greater independence for leading high quality practices. I welcome these ideas. I promise to look at them.

Primary and Secondary

And our changes are not just in primary care. Increasingly, acute trusts are devolving budgets directly to specialist clinical leaders. Enabling them to spend money in a similar way to Practice Based Commissioners. The next step is to join these two up. And to allow us to devolve acute budgets to primary care. I am not saying you must do this, it is not a new target. But I am saying that surely it is the logical next step. For clinicians in primary and secondary care to work ever more closely together to create a truly integrated patient care pathway. Imagine the impact of this sort of partnership.

We talked for several years about moving care into the community, but the funding practices have not always encouraged this. We need to find better ways of doing this, with for example COPD to prevent repeated admissions when people take a turn for the worse but instead allow them to be cared for at home.

This is done in large parts of the country but not in others. We need to find ways of spreading good practices more quickly across the NHS. We must ensure collaboration between the acute and primary sectors, then we can get better outcomes for patients, which are more effective and cost less. The work to reduce C Diff and MRSA has saved  £240m in the NHS. Quality saves money.  But it needs true clinical leadership providing a better service for patients and better value for the taxpayer.

Innovation

I am certain that this sort of cooperation will lead to all sorts of new and innovative practices. Strategic Health Authorities now have a legal duty to innovate. Here in the West Midlands, GP practices are working with the Met Office to ensure over 6,000 people with respiratory diseases are given warning of bad weather and helped to take simple steps to take care of themselves and to avoid a hospital admission. In Halton and St Helens PCT, GP practices are working together to deliver an award winning rapid access home visit service.   I understand that with their Health and Social Care Award safely displayed in their trophy cabinet, they’re up for another award at this conference too. Recognition that is richly deserved. A detailed analysis of their Acute Visiting Scheme revealed a 30% drop in hospital admissions and a saving of about £1 million in its first 6 months.

Patients have better access to primary care,  the option to receive their care at home,  and are less exposed to the risk of infection in hospital.

Patients as a result report a 90% satisfaction rate and one GP said it was, “the best thing to happen in my 37 years of General Practice.” Best of all, it’s ripe for adoption and spreading across other PCTs.

We’ve been good at identifying best practice, but bad at spreading it further, and we must do better to spread innovation. In April, to encourage innovation across the whole of the Health Service and at every level, we announced the new £220 million Innovation Fund. The first round of awards have now been issued to SHAs. In Yorkshire and the Humber, they’re accelerating the uptake of telehealth technology to improve care for people with long term conditions. East of England SHA is encouraging practical solutions around long-term conditions, patient safety and keeping children active. And South Central SHA is funding a joint project between Milton Keynes PCT, Razorfish and Microsoft to support diabetic self-care. All providing a better service for patients and better value for the taxpayer.

Rights and entitlements

Last week, we announced the introduction of a new set of patient rights as part of the NHS Constitution. We propose that from April next year patients will have the legal right to start their treatment with a consultant within 18 weeks of GP referral, and to be seen by a cancer specialist within 2. If the NHS can’t deliver, then it will have to find an alternative provider that can. This means that patients will receive the same high standards of care wherever they live.  And, more controversially, working with the profession, we are looking at how we can give patients greater choice when it comes to registering with a GP practice. Perhaps one that is more convenient for them to get to, one with higher quality care or one with longer opening hours. It depends on what the patient wants.

As the NHS has been given more money, people are expecting more to be done and greater choice. The information is there for all to see on NHS Choices, and the choice will be theirs for the making. Improving the patient experience and driving up quality through competition is important.

In the next decade, the NHS must move towards being a preventative, people centred service.  So from April 2012 we want to give people over 40 the right to a 5-yearly NHS Health Check to assess their risk of heart disease, stroke, diabetes and kidney disease.  By identifying the risks early and provide a better service for patients and better value for the taxpayer. We’ll also soon consult on a legal right for a person to choose where they want to die and on personal health budgets, giving people power over their own care. These proposals, building on the NHS Constitution, are part of decisive shift guaranteeing standards for patients and putting power in their hands.

Targets in the NHS remain controversial. In 1997 the NHS budget was £35bn. It is now £103bn having almost tripled. Targets are a way of ensuring people get tangible returns for their money.  There is a choice here. The Opposition would end those targets. Some people would say ‘good’. But cancer patients would say otherwise. The right for suspected cancer patients to see a specialist within 2 weeks and get diagnostic tests in a week – gone. A maximum 18 weeks for an operation – gone. All A+E patients to be seen in 4 hours – gone. By contrast we would convert targets into patients’ rights. It’s a choice.  They would end extended hours access to GPs. Some GPs would say ‘good’. But patients wouldn’t. There are some difficult choices here. We would extend it. We support the GP-led health centres. They don’t.

We need to ask – where is the patient in all this? Where are they getting better care? Where are the real values of the NHS? The NHS faces tighter budgets than in the last decade. But more than ever we need to choose the kind of NHS we want.

Conclusion

Patient rights, patient choices, innovation and joined-up local clinical leadership need to become as deeply ingrained in the psyche of the NHS as being funded by the tax payer and being free at the point of delivery.

For this is about values. And if we are to maintain the values of the NHS, if we are to maintain the public’s confidence in the system for another 60 years, if the public are to continue to choose renewal, then we must always and everywhere be looking to make the Health Service better, more efficient and higher quality.

The investment is there. The mechanisms are there. The opportunities are there. It will never be a done deal. There will always be a need to improve. We have already gone from poor to good. Now, with your leadership, the NHS moves from being good to great.