Alan Milburn – 2002 Speech on Empowering Front Line Staff

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, to the British Association of Medical Managers on 12 June 2002.

It is a pleasure to be here today with you at your Conference. BAMM has been at, the forefront of improvement and innovation within the NHS for many years. The people at this conference today are leading change in all aspects of care and I want to place on record my thanks to you and particularly to BAMM and Jenny Simpson for the leadership you are giving.

I want today to set out the challenges facing the health service. And how I believe that with your drive and support the NHS can rise to meet them.

We are a long way from realising the ambition all of us share for a service which genuinely offers patients the choice of quick high quality care which always puts their needs first. But we are making good progress towards it. Since the NHS Plan was published two years ago the NHS has chalked up achievements in which all parts of the service can share.

In primary care, where waiting times are coming down. Where 10 million people can get out-of-hours care through a single phone call to NHS Direct. Where the prescribing of cholesterol-lowering drugs is up by one third.

In mental health services, where in hundreds of communities new crisis and assertive outreach teams are in place providing services to thousands of vulnerable patients. In older people’s services, where delayed discharges from hospitals are down, where more home-based care is in place and where free nursing care is now the norm.

In ambulance services, where today all but a handful are achieving the emergency response call time, when just two years ago only a handful were achieving that.

In hospital services, where a year ago people were having to wait up to 18 months for their hospital operation. Today the maximum wait at 15 months is moving towards the NHS Plan guarantee of a maximum 3 month wait. The number of people experiencing long waits for an outpatient appointment is the lowest on record. And for those with the most serious clinical conditions – cancer and heart disease – waiting times are lower still.

Yes, of course, there is a long way to go. But the NHS is now beyond first base in delivering the NHS Plan. Each of these achievements has been hard won. There are many more challenges to come. Anyone who says there are no problems has clearly got it wrong. But those who say there has been no progress have got it totally wrong.

While they accuse the NHS of being a black hole which simply absorbs public money without return, these critics should instead be pointing at dozens more hospitals, hundreds more beds, thousands more doctors, tens of thousands more nurses – and an NHS that is now on the up. They should go and see what I see in every hospital, health centre and surgery I visit. Not just the investment coming through but the reforms too – in how staff work and how services are organised.

And nowhere is reform more necessary than in the way we employ our staff in the NHS.

More than 50 years ago in order to establish the National Health Service my predecessor Nye Bevan concluded a contractual agreement with the BMA for the employment of hospital consultants. Today our 26,000 NHS consultants are working within a contract which has largely gone unchanged since 1948.

Most consultants work very hard for the NHS and with tremendous commitment to the principles of the NHS. I acknowledge many of them are working above and beyond their strict contractual obligations to the health service. That is a measure of their commitment which has not always been rewarded in their contracts.

The way consultants have been managed under their existing contract has been far from satisfactory. Too few consultants have proper job plans setting out their key objectives, task and responsibilities and when they are expected to carry out their duties. Even fewer have their performance regularly reviewed. And the issue of consultants’ private practice has remained a legacy of Bevan’s 1948 settlement.

In the NHS Plan, I committed the Government to a new consultant contract to recognise and reward those who do most for the NHS.

I am pleased to be able to tell the Conference that we have today reached agreement with the BMA on a new framework for the NHS consultant contract.

We are jointly proposing with the BMA that the new contract be accompanied by a 10% three year pay deal that we will also be offering to other staff in the NHS alongside reforms to their pay systems.

The new contract is good news for NHS patients and for NHS consultants. It is a something for a something deal. It offers more pay for NHS consultants so that more NHS patients benefit from more of their precious time and skills. Crucially, it recognises and rewards those NHS consultants who do most for the NHS.

It offers consultants a higher starting salary and increases in earnings over the lifetime of their work for the NHS. There will be extra pay for those with the heaviest on-call duties.

Unlike the existing contract, however, where there are automatic increases in salary, in future consultants extra earnings will be dependent for the first time on performance against agreed job plans. The job plan will set out how consultants time should be best used for the benefit of NHS patients. It will secure more face to face sessions with patients with an increase in the time consultants spend on direct clinical care. The current system of fixed and flexible sessions will go to be replaced with a new system in which NHS work is timetabled and typically carried out on site with no non-NHS work permitted during this time. The old NHS working week of 9-5 will also go. Instead NHS employers will be able to schedule consultants work and pay for it at standard NHS rates between the hours of 8am to 10pm Monday to Friday and 9am to 1pm at weekends. This new system of flexible working will be good for both consultants and for patients. As we expand consultant numbers it will make for more efficient and productive use of NHS facilities – such as operating theatres – that could otherwise lie idle. And because NHS employers will be able to buy extra consultant time within these NHS hours at NHS pay rates it will avoid some of the more inflated rates we have sometimes seen over recent years.

The new contract also deals once and for all with the vexed issue of private practice. It removes a long running sore which dates all the way back to 1948. The relationship between private practice and NHS work for consultants has for too long been clouded by lack of clarity, lack of accountability and an inevitable – often unfair – perception that some consultants do not always give full commitment and priority to the NHS and to their NHS patients. The new contract will herald an entirely fresh approach, designed to prevent any perceived or actual conflict of interest, based on one overriding principle: that an NHS consultant’s first and foremost commitment is to the NHS and to their NHS patients.

For the first time it will be explicitly part of the consultants contract of employment that NHS patients come first and the NHS always has first call on consultants time. It does this first of all, by giving exclusive use to the NHS of up to 48 hours of a newly qualified consultants time each week – the maximum the NHS could demand under the Working Time Directive. Under the new contract this exclusive use of newly qualified consultants time will apply for the first seven years of their careers, as we proposed in the NHS Plan. Secondly, the new contract goes further than the NHS Plan because any consultant wanting to undertake work on privately paying patients after seven years of NHS service will need to give the NHS an extra session of four hours a week at normal NHS pay rates. Thirdly, new rules on private practice will set out how NHS commitments must always take precedence over private work with adherence to these new rules enforceable as part of the new contract. Access to higher salary levels will depend on consultants meeting these new standards and, of course, the objectives in the consultant’s job plan being met.

These are fundamental and far reaching changes to how NHS consultants are employed, rewarded and managed. NHS consultants will get more – but only if NHS patients get more. The old contract was a throwback to the world of 1948. The new contract will reform traditional working practices to deliver modern, flexible services to more NHS patients.

So the 10-year journey we mapped out in the NHS Plan is now firmly underway. And now we are moving up a gear.

The Budget on April 17th marked a watershed for the NHS. And I don’t just mean the scale of the resources or the length of time for which they have been committed. Yes, against any historic benchmark they are generous. Five years of real terms growth averaging 7.5% will take health spending in our country beyond the EU average – an average which the cynics said we couldn’t even meet. It is worth remembering that just six years ago spending on the NHS was falling in real terms. By 2008 it will have doubled in real terms.

What is more, social services – for too long the poor relation – are to enjoy big rises in investment as well. Six years ago spending on social services was falling. Today it is rising by over 3% in real terms. We know that more is needed. We have listened to what local government, private sector care homes and local health services have all had to say. So now, spending on social services will double to 6% a year over and above inflation for the next three years.

The Budget laid to rest a decade’s old fallacy – that we in Britain could have world class health care on the cheap. We can’t. The evidence is there for all to see. The run down buildings. The outdated equipment. The failure to invest in modern IT. The shortages of trained staff. The long waits that we inflict on patients.

We are bringing the decades of NHS neglect to an end. With the economy on a stable footing we can now put the NHS on a sustainable footing for the long term. As the reaction to the Budget has shown, there is overwhelming public support for the extra investment. But there is considerable public scepticism about the ability of the NHS to turn those resources into results for patients. A failure to deliver improvements will prompt only one response: not more money in the future for the NHS, but less. Not collective provision of health care, but more individual provision. Not the public sticking with the NHS but the public walking away.

You only have to read some of our newspapers to hear the voices of scepticism. Sometimes it is not just scepticism about the NHS. It is downright hostility. You can hear other voices too. Some in politics or in business who say the NHS, precisely because it is run on public service principles, can never actually deliver the goods for patients.

We have to prove those doubters wrong. And we have to do it together.

When we put taxes up to get more resources for the NHS – as people in the NHS urged us to do – we entered into a new contract with the people of our country. In exchange for extra resources we will deliver better results. Not just improvements in services for patients, but services which are increasingly shaped by the informed choices of patients. Not the old style take it or leave it NHS of the last century, but an NHS that is tune with the needs of this century – where services are responsive, where patients have choices, where quality always comes first. This is the challenge together we must now meet.

We can only meet it by a combination of sustained investment and far-reaching reform.

In the first place, if the NHS is to deliver for patients it has to remain focussed on what counts for patients. And the extra resources must be properly focussed too. The NHS does many things. There will be many pressures from many quarters for many good causes. But none of us will be forgiven if having raised the resources we fail to use them to get the results that both staff and patients want to see. Shorter waiting times. Higher clinical standards. Better health outcomes.

The public’s priorities have to be the health service’s priorities. Getting waiting times down in every aspect of NHS care from ambulances to diagnostics, from primary care to secondary care. Providing quick, high-quality emergency services, not least in A&E. Making sure that the fundamentals are right – clean wards and safe care. Improving cancer, cardiac, mental health and elderly services.

These are the priorities. In time it is true we will develop further NSFs, but only at a pace the NHS can properly absorb. And to help local health services focus on these priorities, we will cut the number of plans that have to be submitted to the centre and, for the first time later this year, give local services three year allocations of cash so that there is financial certainty for the medium term rather than the short term.

Stability over resources will allow the NHS to implement a sustained programme of expansion. It is time to go for growth. To use the large scale increases in both revenue and capital funding to expand capacity. To get the staff, the buildings, the equipment the NHS needs. To shift the balance of services so that more patients can be seen in primary, community and social services, not just in hospitals.

The biggest constraint the NHS faces is shortages of capacity. So in addition to sustained growth in existing NHS provision, we will bring new providers from overseas into this country in order to further expand elective services for NHS patients. They will concentrate on elective surgery in hard-pressed specialties in those parts of the country where capacity constraints are greatest. I expect to see a growing number of these new providers in place beginning later this year. Like NHS use of existing private sector providers, this is not a temporary measure. These new providers will become a permanent feature of the new NHS landscape. They will provide NHS services to NHS patients according to NHS principles. And, in the process, they will open up more choices for patients and more diversity in provision.

These reforms are about redefining what we mean by the National Health Service. Changing it from a monolithic, centrally-run monopoly provider to a system where different health care providers – public, private, voluntary and not-for-profit – work to a common ethos, common standards and a common system of inspection. In such a system, wherever patients are treated they remain NHS patients because they get care according to NHS principles – treatment that is free and available according to need, not ability to pay. This is the modern definition of the NHS.

This new diversity in NHS provision, coupled with sustained expansion in capacity, provides the basis for patients to exercise more choices about their care. As capacity expands so choice can grow. From next April we will begin to move to a system of payment by results for NHS hospitals. Resources will follow the choices patients make so that hospitals who do more get more; those who do not, will not. Over the next four years, an increasing proportion of each hospital’s income will come to it as a result of the choices patients make. For the first time in the NHS, patients will be able to choose hospitals rather than hospitals choosing patients. That process will start this summer when patients waiting more than 6 months for a heart operation will be able to choose a faster waiting time in another hospital which has the capacity to treat them – whether it is public or private, on the doorstep or further afield, in this country or abroad. By 2005, all patients needing a hospital operation will be able to choose not just the location of their treatment but when to be treated and by whom.

Of course, different approaches will be needed to bring about improvements say, in emergency care or mental health services. But overall this is the most fundamental change the NHS will have ever faced. It will mark an irreversible shift from the 1940s take it or leave it, top down service. Patients will be in the driving seat – and not before time.

All of this is a fundamental change for the NHS. Not in how it is funded or the values on which it is founded, but in how it is organised. NHS healthcare no longer always needs to be delivered exclusively by line-managed NHS organisations. The task of managing the NHS becomes one of overseeing a system, not running an organisation. Responsibility for day-to-day management can be devolved to local services. None of this means the abandonment of national standards. Far from it. It is precisely because over these last five years we have put in place such a rigorous framework of standards nationally that the centre of gravity can now shift to how improvements can be delivered locally.

So while some advocate a false choice between national standards and local autonomy, the experience from elsewhere in Europe in the health sector, and from across the developed world in other economic sectors, is that securing improvements in performance requires both.

There is a simple deal on offer here. The better you do the more you get. It is a discipline that needs to work just as much in public services as in the private sector. I have lost count of the number of times I have been told by NHS managers and NHS clinicians alike that the NHS has got to stop bailing out the poorest performers, and instead reward the better performers in the NHS in order to provide the right incentives for innovation and improvement to take hold across the whole of the NHS. And that is precisely what we must do if we are to translate the extra resources into real results for patients.

That is the reason for star rating the performance of local health services so that those who are doing less well get more help, those that are doing best get more freedom and those that are persistently failing feel the consequences. Where there are persistent problems we will step in. Where there is progress we will step back. At one end of the spectrum new management teams – whether from the public, voluntary or private sectors – will be brought in through the franchising process to turn round NHS organisations that are in trouble. At the other, the best performers will become NHS Foundation Trusts, legally free from Whitehall direction and control. Three-star trusts will have less monitoring and greater freedom.

The more overall performance improves – as I am confident it will – the more autonomy will be earned across the NHS. That is what I want to see happen. We are at the start of a transition where more and more decisions about the NHS are taken locally rather than centrally.

It is time to unleash the spirit of public service enterprise that I know exists in so many parts of the NHS.

Some functions will still be carried out – as in any large organisation – at the centre. But rather than trying to drive improvements through top-down performance management, the transition will be towards improvements being driven through greater local autonomy in which PCT commissioning, new financial incentives and the choices that patients make become the driving force for change, with scrutiny through independent inspection. That transition will take time. It will require careful management and a new, more mature understanding about the relationship between government and the health service, where the government does less and the NHS does more.

In the end I don’t treat patients. You do. Whitehall doesn’t provide care. That is what hospitals, health centres and surgeries do. And that is where power needs to be located. On the frontline. Our core objective is to shift the centre of gravity in the NHS. It is right that standards are set nationally, but it is wrong to try to run the NHS nationally. This is something which the new strategic health authorities in their relationships with Primary Care Trusts will need to fully understand: the PCTs need to be helped and enabled, not commanded or controlled. In turn, they need to devolve resources to their constituent practices from the growing proportion of the NHS budget the PCTs will control. From next year, three-quarters of the NHS budget will be controlled by PCTs.

The simple truth is the NHS works best when it harnesses the commitment and know-how of staff to improve care for patients. That’s why we are putting ward sisters in charge of ward budgets and giving health visitors a greater say over community health budgets. It’s why matrons are being given the power to get the fundamentals of care – like clean wards and good food – right for patients. It’s why nurses are being given new powers to prescribe drugs and discharge patients.

And crucially doctors – with all their skills and knowledge – need to be empowered too. Too many doctors for too long have felt disempowered. Through PCTs there is now a major opportunity for doctors in primary care to shape local services to suit local circumstances. Devolution of budgets to practices will aid that process of clinical engagement. In secondary care there is more to do. Here a new effort to engage doctors in the process of change is needed. Just as PCTs need to devolve responsibility to their front-line staff, so do Trusts. Resources and responsibility need to be placed on the front line. That will become an absolute imperative as patients get greater choice and their choices are backed by funds. Clinical teams need to have the resources and authority to make their services more responsive to patients. And as patients choose particular clinical teams, to be rewarded too.

The people at this conference today are the key to delivering these changes. Chief Executives, Medical Directors and PEC chairs have a real responsibility to ensure that clinical teams are engaged and empowered. When they are – as in the collaborative programmes already begun in cancer, coronary and primary care – the results are staggering. More than 90% of practices involved in the primary care collaborative for example are already able to guarantee patients an appointment to see a GP within 48 hours. But staff involvement – particularly to harness the skills and expertise of doctors – should not have to be left to special programmes in some parts of the NHS. It should be the norm in every part of the health service.

That is why I warmly welcome the BAMM initiative – Fit to Lead – being launched at this conference. It is a critical piece of the jigsaw: for the first time, doctors in management and leadership roles will have the tools and the training to demonstrate their competence as medical leaders. It is why over these next two years, through the NHS Leadership Centre programmes, every medical director and over 500 other senior medical leaders in secondary care – mainly clinical directors – will have had the opportunity of attending a national leadership programme.

In a world where knowledge is king, other industries have long since learned that the successful organisation is one that consistently develops its staff and harnesses their potential. It is a lesson that the NHS has been too slow to learn. But through the NHS University – that BAMM has helped pioneer – through the NHS Modernisation Agency and the Leadership Centre we can now put that right.

In the end, the NHS is the people who work for it. I want to see an NHS that is true to its principles but reformed in its practices. Where patient choice and responsiveness to patients drive change. And where front-line staff are empowered to make those changes happen.

The Budget this year represents an enormous vote of confidence in all of you, in the whole of the health service.

Some have said that the Budget is a gamble. In some people’s minds it may be. But not in mine. I wouldn’t have fought so hard for the resources we’ve now got if I thought there was a better way of providing health care for our country. For me there is no better way than a tax funded, well funded NHS.

With your help the best days of the NHS lie in the future not in the past.