Category: Speeches

Below is the text of the speech made by Jeremy Hunt, the Secretary of State for Health, at the Royal Surrey County Hospital on 4 August 2014.

Introduction

I am really pleased to be here at the Royal Surrey this morning – and many thanks to you Nick for hosting us.

I was delighted and honoured to open the Margaret Eaton wing of your ICU in June – and even more delighted to spend time with your brilliant A & E staff before Christmas where for the first time ever I took someone’s blood pressure as part of a frontline shift.

I try to go out somewhere on the NHS frontline most weeks and I can honestly say I have learned more from those visits than I ever do from sitting behind a ministerial desk in Whitehall.

What I know from my visits here is that you deliver superb care and under Nick Moberley’s leadership have the ambition to be the very best in the country. I want to wish you every success in that, and put on record my thanks – both as MP for South West Surrey and Health Secretary – for the dedication and hard work of the brilliant staff who work here.

Progress over the last decade

Every month, more than a million patients start specialist treatment. Keeping up with this demand is crucial: patients tell us all that timely access to treatment is one of the most important things they want from our NHS.

Keeping waiting times low is therefore a key objective for any government. And it is right to acknowledge that the last government made welcome progress in bringing down the number of people waiting a long time for their treatment, progress this government has sustained.

It is also right to pay tribute to the hundreds of thousands of NHS staff who have worked so hard to make that possible over the last 10 years.

Thanks to their efforts, access to NHS healthcare is now amongst the best in the world.

When the target was announced in June 2004, patients could expect to wait more than a year for treatment.

Since then we have seen spectacular improvements for patients: no longer do we read about the scandal of people routinely dying on waiting lists because access to the life-saving treatment they need comes a year too late. No longer are families suffering the pain of watching elderly relatives slowly lose their mobility, becoming trapped and isolated at home because the NHS can’t provide a simple hip operation for 2 or 3 years.

Delivering timely access to treatment has become part of the DNA of the NHS – and that is something we should all welcome.

A tougher context

It is also worth pointing out something everyone in this hospital will be acutely aware of: delivering that objective has been much tougher in the last 4 years than previously.

Until 2010 NHS funding generally rose faster than the demand for its services. We have had to deal with the deficit we inherited, and we have made some very tough choices to protect the health budget. Despite that, since 2010 funding has risen by around 1% a year even though demand for NHS services has risen by 3.6% a year.

Which makes the achievements of the last four years even more astonishing: every year, compared to 2010, 6,000 more people receive knee operations, 9,000 more people receive hip operations, and 10,000 more people have cataract procedures. Overall we are delivering an extraordinary 850,000 more operations year-in year-out.

And this increase in volume has not been at the expense of quality. A couple of months ago the independent Commonwealth Fund said that in the last four years the NHS has risen to become the top-ranked healthcare system across the 11 richest countries in the world – top for quality, top for efficiency, top for access, and top overall.

Targets can be dangerous

But – and there is a ‘but” to this – targets, as we also saw under the last government, can create the wrong behaviour too. What happened at Mid Staffs and many other hospitals was that targets distorted behaviours, changed clinical priorities and led to appalling care, sometimes with tragic outcomes for individual patients.

When the NHS started measuring performance against the 18 week target in 2007, something perverse happened. If faced with a choice between treating a patient who had missed the 18 week target or someone who had not yet reached it, the incentive was to treat the person who had not yet missed the target rather than someone who had – because that would help the performance statistics, whereas dealing with the long waiter would not. So a target intended to do the right thing ended up incentivising precisely the wrong thing.

And that in a nutshell is the problem with targets: unintended consequences.

Under huge political pressure, managers inevitably gamed the system to make their organisation look good – and patients suffered the consequences. Suddenly, real people with real illnesses and real needs find themselves treated like a number or a statistic, there not to be looked after but to be manipulated to show organisational performance in the best light.

So this government has made a determined effort to change that culture. Not by abolishing targets altogether – all organisations need priorities – but by making sure they are implemented more humanely and sensibly.

When we came to office in 2010 there were a shocking 18,500 people who had been waiting not 6 months, not 9 months but over a year for treatment.

I am pleased to say that even though none of those people count towards the standard 18 week target, we have none the less reduced that number to just 500.

But today I want to say that even 500 is too many.

A year is a very long time to wait if you are immobile, in discomfort or in pain. If a single one of those patients is waiting not out of choice, or for proper clinical reasons, but simply because the NHS has not been able to provide the treatment they need for a whole year then that is unacceptable.

So today I want to announce a new ambition for the NHS: I want this number of people waiting more than a year for their operation to be not in the thousands, not in the hundreds, but as close to zero as possible.

There will, of course, be exceptions to this which is why I do not want to fall into the trap of making this “another target”: there will be patients with multiple conditions where one condition needs to be treated first; there may be highly complex treatments which are particularly difficult to source; and sometimes the patient may choose to wait for personal reasons.

Unless there are those good reasons, no-one should have to wait more than a year for treatment.

So from today NHS England will review all 500 cases, and working with CCGs and local hospitals, ensure that any patients who can be treated will be treated as rapidly as possible.

Nor should this just be about people waiting for more than a year.

I want the NHS to put particular focus on anyone who has been waiting more than 18 weeks since being referred for treatment, so have asked NHS England to commission 100,000 additional treatments over the summer including 40,000 additional inpatient admissions.

This focus on long waiters may mean we undershoot the 18 week target for a temporary period, although we will return to meeting it before the end of the year. Indeed as the many NHS target experts will know we could ensure we met the 18 week target every month by focusing those 100,000 additional treatments on shorter rather than longer waiters. But that would be an indefensible betrayal of those who have been waiting the longest and not one I would be prepared to sanction as Health Secretary.

The truth is we need to ensure both that 90% of people get their treatment within 18 weeks – the official target – and that people who are not treated within that period are not neglected. So I have set a timeframe of this calendar year to deliver on both of those objectives.

An NHS about more than targets

Let me conclude with a broader point. Targets matter, but they should never be the only thing that matters. Patient safety, compassionate care, clinical effectiveness and efficiency are also vital.

Robert Francis hit the nail on the head in his report on Mid Staffs when he said “targets were often given priority without considering the impact on the quality of care”.

Even before Mid Staffs, the Healthcare Commission attributed one of the causes of over 30 C diff deaths at Buckinghamshire Healthcare NHS Trust as an over-focusing by the Trust on meeting government targets. Many of you here will have had experience of similar pressures and conflicts in your own daily work.

Which is why last year we introduced a new inspection regime for hospitals that looks at performance more broadly than just targets. We must never go back to the bad old days where targets seemed to matter more than people – so where we do have targets they should implemented sensibly and in line with the clinical needs of patients.

And where there is poor care, it should never be swept under the carpet.

As well as identifying good hospitals such as this one, the new Chief Inspector of Hospitals has recommended a number of hospitals go into special measures – indeed 10% of all NHS hospitals have been put into special measures in the last year alone. But far from leading to despair, the resulting transformation in both quality and financial discipline at those hospitals has been striking.

But it isn’t just at failing or struggling hospitals we have seen improvements. Across the NHS we now have more than 6,300 additional nurses in our wards than in 2010 as we finally put behind us the scandal of short-staffed wards. At the same time we have become the first healthcare system in the world to publish key safety data on a single website for every major hospital in the country.

We have also become one of the first healthcare systems in the world to make a determined national effort to embrace the safety culture of airlines, where there is a much stronger culture of reporting safety concerns and near misses than there is in medicine. That means supporting people on the front line who have concerns about safety or care – and stamping out the bullying and intimidation that is still too common in many hospitals.

These are big changes – changes designed to increase clinical accountability and make sure we always put patients first.

Conclusion

Let me conclude by returning to the new ambition I am announcing for the NHS today.

Let’s continue to make sure we treat the vast majority of patients within 18 weeks of being referred. But let’s also make sure we don’t forget the minority who don’t. So let’s commit that no one – except in exceptional circumstances – should have to wait more than a year.

Targets that help patients get treatment when they need it – not targets followed blindly with no regard for the impact on individuals.

An NHS confident that – in the end – it will continue to meet the huge challenges ahead if it leaves room, amongst many loud, competing pressures, for the quietest but most important voice of all: that of the patient.

Thank you.

Below is the text of the speech made by Jeremy Hunt, the Secretary of State for Health, at Birmingham Children’s Hospital on 16 October 2014.

Let me start by saying what an enormous pleasure it is to be here today at Birmingham Children’s Hospital. This hospital is rightly proud of its record on quality and safety and has led the way in bringing the safety agenda to paediatric care, not least with its work on improving patient handover and on developing a safety thermometer for children and young people.

Indeed this hospital is powerful proof of the case I want to make today: that world class care is not just better for patients, it reduces costs for the NHS as well. And in doing so creates a virtuous circle where ever more resources can be invested in improving patient care rather than wasted on picking up the pieces when things go wrong.

A turning point

With huge financial constraints and the pressures of an ageing population, we are at a critical moment in the history of the NHS. So today I want to challenge head on those who say that the future will be about cost and not quality; who suggest that it is time to ‘move on’ from Francis and the lessons of Mid Staffs and want to focus on the ‘next thing’ – which they usually say is about money and nothing else.

“The path to safer care is the same one as the path to lower cost”. Those words were spoken to me earlier this year by Dr Gary Kaplan of Virginia Mason Hospital in Seattle, recognised as one of the safest hospitals in the world.

As a result of his hospital’s journey to safer care, which started with the tragic death of a patient in 2004, his costs for acute diagnoses are between 20 and 60% lower than his major competitors. Shorter hospital stays, more motivated and productive staff and lower litigation claims have led him to believe that hospitals could double their output on the same resources simply by eliminating the waste of resources associated with harming patients.

Not just in the US, but here in the UK too where Salford Royal is recognised as a leader in patient safety and quality improvement. Chief Executive Sir David Dalton says the focus they have had on quality improvements has yielded productivity improvements of around £5m each year, which they continue to reinvest in frontline care.

Across the hospital sector, the enormous progress made in recent years to prevent hospital acquired infections is showing how quality improvements save money. We have reduced C. diff infections by 45% and MRSA infections by 56% in the last four years, saving patients untold trauma but also an estimated £22.5 million in costs for the NHS.

The extraordinary ‘Sign up to Safety’ campaign that David Dalton leads has so far signed up over 100 trusts, including this one, to help spread good practice – making it one of the biggest hospital safety initiatives in the world. Indeed the enthusiasm for ‘Sign up to Safety’ is a remarkable testament to the commitment of the NHS to learn the lessons of Mid Staffs.

But my message today is that learning those lessons is not a one-off: it’s a permanent process of constant questioning and continual improvement in which the elimination of waste and the elimination of harm walk side by side as part of the same process.

Variation and lost value

Today the CQC are publishing their annual ‘State of Care’ report. Inevitably there will be media focus on examples where care is sub-standard. Indeed, shining a light on poor care is essential if we are to have the highest standards.

But the biggest lesson from today’s report is not actually the existence of poor care – it is the unacceptable variation in care outcomes across the system. And it is my job as Health Secretary to ask why it is that similar levels of resourcing, similar values and similar numbers of committed staff can produce such differences in quality.

My conclusion is that too many people still think that providing the best care is something you do only when you can afford it – and fail to appreciate that improving care is one of the best ways to control costs in financially challenged circumstances.

Which is why the report published today by Frontier Economics is so revealing in its analysis of the cost of poor care.

They estimate that it could be costing the NHS up to £2.5 billion every year.

And they highlight some of the shocking costs of poor care – from the £1.3 billion spent every year on litigation costs, to the cost of not ‘getting it right first time’ in orthopaedic care – which Professor Tim Briggs’s excellent work shows could save between £200-300 million every year.

These are large sums of money which the NHS is potentially wasting. But we should be careful not to anonymise their impact by sticking to large numbers. So today we publish further work to look at the cost of individual episodes of avoidable harm.

A single fall in a hospital is a tragedy – potentially life threatening – for the patient affected. It also costs the NHS on average £1,200 because of the extra care needed and longer hospital stay.

Likewise a hospital-acquired bedsore is very dangerous for a patient. But it is also dangerous for the NHS, costing on average £2,500. And we had 19,000 of them across the NHS in 2013 to 2014.

Catheter-acquired urinary infections are unbelievably painful. They also cost the NHS £67 million in 2013 to 2014 – which could pay the salaries of 1,300 nurses.

So I want every director of every hospital trust to understand the impact this harm is having not just on their patients, but also on their finances.

And I want every nurse in the country to understand that if we work together to make the NHS the safest healthcare organisation in the world, we could potentially release resources for additional nurses, additional training, and additional time to care.

So today a poster and leaflet will go out to all NHS hospitals to display this vital message to their staff.

If you’re short of money, poor care is about the most wasteful and expensive thing you can do.

Good care costs less.

The right model of change

But it is one thing to identify lost value, quite another to develop practical strategies to release it. So how do we reduce variation and improve safety?

In the best of NHS traditions it would be very tempting to set up a new target. Or issue a new ministerial decree.

But that would be a mistake.

Because the culture change we need to achieve has to come from inside, not because hospitals are being forced from the outside. What Gary Kaplan called ‘institutional culture change’ is based on listening to and valuing doctors and nurses on the frontline – the people who know more than anyone else what is needed to improve care.

So let’s take a moment to look at some of the traits shared by organisations that have excelled in improving patient care and eliminating waste.

The aggregation of marginal gains

The first trait is attention to detail.

When I was Secretary of State responsible for the Olympics I had the privilege of meeting Sir Dave Brailsford when he was training the Team GB cyclists. One of those cyclists was actually called Jeremy Hunt so I was just a tiny bit disappointed that despite their extraordinary medal haul – the best in British cycling history – Jeremy Hunt didn’t pick up a gold.

Sir Dave famously argues that the success he brought to Team GB cyclists was not about a new big bang approach, but what he called the ‘aggregation of marginal gains’. Paying close attention to the detail, to things which, on their own, seemed insignificant – but when added up mean the difference between winning and losing. At the Manchester Velodrome Chris Hoy told me about his first ever gold medal at the Copenhagen World Championships. He won by 0.001 of a second. His aggregated marginal gain set him on the path to being our greatest ever Olympian.

This is really important because we should not think we can unlock £2.5 billion in one go with a new policy. But we will unlock it in hospitals with a new culture. And it’s a culture that really cares about the details, the little things, all of which add up to better care and less waste.

Some of these gains will be in the form of money – in management jargon, ‘cash releasing’. But some will be in the form of increased value for patients and staff – freeing up resources in ways that lead to better patient care, greater staff motivation and long-term productivity gains. In high-performing organisations, these two things will go hand-in-hand.

The right relationships

Another trait in hospitals with world-class safety standards is proper collaboration between management and frontline staff. We have recently seen powerful evidence to support this from the joint work by the Academy of Medical Royal Colleges and the NHS Confederation. They explore what they call ‘Decisions of Value’ and conclude that good relationships between clinicians and managers is critical in securing value for patients.

Their report shows that over half of clinicians do not believe they are involved in the financial decisions that affect their service or team. But how can you break the dangerous nexus between poor care and higher cost if the clinicians responsible for patient care have no input into the financial decisions that affect their work?

Likewise we need to build better partnerships between commissioners and providers, not least in developing integrated care pathways that we know both improve care and eliminate waste.

Openness and transparency

What else characterises leading organisations? Along with a focus on detail and relationships, they have an obsession with openness and transparency based on high-quality data.

Not far from here, patients at Queen Elizabeth Hospital can log onto ‘My Stay@QEHB’ which allows them to see how their specialty performs compared to hospital expectations.

Transparency can also be about reaching out to patients and the public: it is fantastic that one of the first things you see on the Birmingham Children’s Hospital website is a section called ‘What’s it like here?’ that makes the strange world of hospital care more familiar for children.

The best organisations crave data as a vital tool to drive improvement. We are blazing a trail with the new MyNHS website, which makes the NHS by far the most open and transparent healthcare system in the world. Now with detailed and easily accessible information on hospital, local authority and mental health performance, I am confident that this project will demonstrate that in the modern NHS the best way to improve performance is transparency not targets.

The best example of the power of transparency has been the way the NHS has responded to the tragedy at Mid Staffs. I could have said as part of the government response that I intended to hire another 10,000 nurses – and it would have been a disaster. Not only would we have ended up with the wrong nurses in the wrong places, but the measure of success would have been meeting an input target, not improving care for patients.

Instead we did something far more powerful.

Firstly we asked every hospital in the country to collect and publish information from their patients on whether they would recommend the care they received to a friend or member of their family. Based on the net promoter principle, this was the first time anywhere in the world patient views had been sought comprehensively across an entire health economy.

Then working with Chief Nursing Officer Jane Cummings we asked every hospital to publish the number of planned and actual nursing staff for every single ward. Finally, we made patient experience a central part of the new independent CQC inspection regime.

And the result? Yes the NHS did hire 5,000 more hospital nurses to fill in critical gaps after Mid Staffs, often in elderly care wards. But more importantly a change in attitudes to the importance of quality of care – as opposed to simply quality of treatment – saw an 8% jump in just one year of the people who believed they were treated with compassionate care by the NHS. No target, no extra money, just transparency about performance.

And in some cases improving on this has not required more staff at all. For example, there are some Trusts – including Portsmouth, Coventry and Royal Surrey – that are using an electronic physiological surveillance system to improve the monitoring of vital signs, with impressive early impact on patient mortality that has not required large increases in staffing.

And consider the example of Guys and St Thomas’s where they have been looking at how redesigning basic processes and using technology can give nurses more time with their patients. With only a small increase in staffing of one extra nurse working on discharge and another at night, they were able to increase contact time with patients from 48% to 75% while also reducing length of stay. Hugely beneficial to patients, and better for staff too.

Cost and quality: challenging assumptions

These therefore are some of the traits of high-performing organisations.

And underlying all of them is the shared assumption that cost and quality are not alternatives to be traded off, but different aspects of the same ambition to provide safe, effective care on a sustainable basis. This directly challenges the conventional wisdom that ‘you get what you pay for’ – as does the CQC’s ‘State of Care’ report which shows massive variation despite similar input costs.

It also challenges the received wisdom that there is little value left to get out of the system now that the so-called ‘low hanging fruit’ has been plucked.

And it challenges the other commonly held view that only large-scale change will release significant value. Of course we will need to continue to make important changes to care pathways – but as we do that we need to support trusts in making the small improvements that, when aggregated, will make a big difference.

Conclusion

I hope therefore that from today in hospital board meetings up and down the country one simple change happens: patient experience and patient safety are not discussed separately to finances – but as two sides of the same coin. Wouldn’t it be fantastic if a hospital board was as focused on its ‘safety improvement plan’ as its ‘cost improvement plan’, and saw them both as part of the same objective of doing a better job for patients.

I am proud of the additional investment this government has provided and will continue to provide to the NHS. Nobody would pretend that the financial sustainability of the NHS will be ensured by improving safety alone. But it has a critical contribution to make.

The path to lower cost is the same as the path to safer care.

Hospitals that embrace one embrace the other too.

Hospital safety and hospital finances both improving and patients as the winner.

Below is the text of the speech made by Jeremy Hunt, the Secretary of State for Health, at the National Children and Adult Services Conference on 30 October 2014.

Let me start with a thank you.

All of you have been talking about delivering integrated, joined-up care for a very long time and I know sometimes it has felt like banging your head against a brick wall. And now it is happening, for real. Instead of people just talking about it, you are actually delivering it. And without your vision, your determination, and your passion to do better for some of our most vulnerable citizens it wouldn’t be happening.

I am also pleased to be saying these words in Manchester which has been at the forefront of joining up health and social care and proved beyond doubt that integrated care, driven not from Whitehall but by local enterprise and initiative, can support the transfer of hospital services to out-of-hospital settings by truly focussing on the needs of patients and service-users.

And the fact that this kind of project is not peripheral but now central to the change we want to see in our NHS and social care system was demonstrated last week with NHS England’s visionary Five Year Forward View. It talked about inspiring new models of out-of-hospital care, exactly the change that people here have been arguing for. That plan and your ambition is completely consistent with the government’s own view about the future of health and social care.

We all agree that change needs to happen. But to work it has to be locally led, tailored to local needs and designed by those who know those needs best. So the role for government is clear: no grand blueprints, no structural shake-ups, no one-size-fits all. But our role will be to enable, champion – and yes fund – your endeavor.

So I want today, as my first response to the NHS England Five Year Forward View, to outline the four pillars of our plan to prepare the NHS and social care system for the challenges of an ageing population. And as social service directors your role will be absolutely central to every element of that plan.

Funding backed by a strong economy

The first pillar of our plan concerns funding. A strong NHS and social care system needs a strong economy to support it. The last four years have been the most challenging ever for both the NHS and social care system – and they started because of an economic crisis. It is in all of our interests to make sure the economy continues to grow, create jobs and generate the tax revenues that allow sustained ongoing financial support for health and social care. In Portugal, Spain and Greece we have seen services cut as the price of economic failure – and we don’t want that to happen here.

And when we did have to tackle the deficit, we prioritised the NHS by protecting its budget – which meant tougher settlements for other departments including local government. But the interconnected relationship between the services we both offer to vulnerable people means that we in the NHS have a responsibility – as we move to fully integrated services – to help you deal with a tough financial settlement. If we operate in financial silos the costs will be higher for both of us – hence there is no sustainable NHS without the tremendous strategic importance of the Better Care Fund which we are celebrating today.

Transformed out-of-hospital care

But it isn’t just about money: it’s also about the way we deliver care.

The NHS was set up in 1948 in a very different world. The model was essentially if you were a little bit ill you went to your GP; if you were very ill you went to hospital. You were then patched up and sent home.

With an ageing population our challenges are profoundly different. By the time of the election we will have nearly one million more over 65s than at the start of the last parliament. Within the next two years, we will have three million people with three or more long term conditions. A few years after that we’ll have one million people with dementia. And a few years after that – by 2030 – the number of over 80s will double to 5 million people, 10% of the entire population.

Older people with complex conditions need a different type of care, one that is usually best delivered out of hospital settings. They’ll be frequent users of the health and social care system so they need one person taking responsibility for their healthcare. And they need to know that wherever they go they will be dealing with someone who knows about them and their family, knows their medication history, and knows about their other interactions in the system.

So if getting a strong economy is the first pillar of our plans for the NHS and social care system, getting this new model of care right for an ageing population is the second.

Better Care Fund

And on that front I am pleased to report today some remarkable progress with the Better Care Fund, which for the first time anywhere in the world is integrating health and social care across an entire health economy.

Building on the excellent work by Norman Lamb on the Integration Pioneers that many of you were involved in, local authorities and local NHS commissioners have joined together and painstakingly planned commissioning for adult health and social care with pooled budgets. Budgets from the local authority side are for the first time helping to reduce emergency hospital admissions and budgets from the NHS side are for the first time helping to reduce permanent admissions to care homes.

I want to thank my colleague Eric Pickles for making this happen, and thank the Better Care Fund Team and Andrew Ridley.

Sceptics said this wouldn’t happen. Critics said there wasn’t the appetite among local councils or the NHS. The papers criticised it and opposition politicians called for it to be halted and when they were proved wrong said it didn’t do enough.

Well they were all wrong. Because today I am delighted to announce the total amount of pooled budget for next year is even higher than the government’s original £3.8 billion. It has risen to a staggering £5.3 bn.

I can announce that 97% of the 151 plans have been approved.

And that as a result of these plans NHS England estimate that the Better Care Fund will be supporting at least 18,000 individuals in new roles delivering care in the community. This will be a range of social workers, occupational therapists, care navigators, doctors and nurses, deployed based on local needs and delivering outside hospitals care to some of our most vulnerable citizens.

Taken together, these plans will mean savings [to the NHS] of £500m in the first year alone. More importantly in terms of patient care, they will mean 163,000 fewer hospital stays or 447 fewer hospital admissions every single day; and 100,000 fewer unnecessary days spent in hospital in total through organising better delayed discharges

This is a great start and everyone here should feel very proud. But based on the same principles that we’ve learnt in the last year I want to ask why should we not go further?

Accountable care organisations

For me GPs, whose services are commissioned by NHS England, sit at the heart of NHS community care. We need them to be part of this change too. So this year, for the first time, CCGs have been offered for the chance not just to commission social care jointly with local authority colleagues, but also co-commission primary care with NHS England. I hope the result will be in many areas a single integrated approach to commissioning all out of hospital care, whether through community care, GP practices or social care, often using personal budgets to integrate care even better around the person.

I think we can go even further than that.

Should we not adopt the same partnership approach we have so successfully pioneered with the Better Care Fund for public health responsibilities as well? You have made a great start with your new public health responsibilities – alcohol recovery rates up, smoking down, teenage pregnancy down and health checks at an all time high. It would surely make more sense for local authorities to plan their smoking, alcohol, drugs and obesity strategies alongside NHS colleagues who have a direct financial interest in making them successful. In doing this we can turn CCGs, working alongside local government colleagues in accountable care organisations, responsible for commissioning end-to-end integrated care for their entire populations – including both care closer to home and proactive prevention programmes.

And in the same vein, should we not also consider joint commissioning of children’s services, building on our review of Children and Adolescent Mental Health services? That review highlighted the importance of different organisations working together – so as we move to integrated care we should consider what the benefits could be for this very important patient group.

Innovation

A strong economy and integrated community care are the first two pillars of our plan. The third pillar involves being much better at embracing innovation and efficiency.

The technology revolution means that now half of us bank online, nearly two thirds of us have a smart phone and three quarters of us access the internet every day. Yet still in the NHS we employ people whose main job is to input the contents of faxes from hospitals onto electronic health records in GP surgeries.

IT investment has had a chequered history in the NHS but in the last two years we have made some good progress. By the end of this year a third of A & E departments will be able to access summary care records, as will one third of 111 call centres and one third of ambulance services. This will then be rolled out to everyone.

I know electronic record sharing is a key part of the Better Care programme you have been working on – so let me give you one example of where I think it could make a huge difference. Shouldn’t residential care homes be able, with a patient’s consent, to update someone’s condition onto their GP record on a daily basis? We’ve introduced named GPs for all over 75s this year, rolling out to everyone next year. But we could make this much more meaningful if the responsible GP was able to check on someone’s condition on a daily basis just by looking at their record on a computer.

Cost tracking

But innovation is not just about electronic medical records.

One of the most common criticisms of the NHS is that it is a slow adopter of technology, even when adopting such technology earlier would save overall costs. This tends to be because we look at costs in financial silos so people are reluctant to invest in costs upstream that benefit another part of the system downstream.

We therefore need CCGs and local authorities to collect full real time total NHS and social care cost information by patient and service-user. Only when we can see that will commissioners invest properly in the preventative innovations that both improve health and contain cost.

Culture change

Innovation and efficiency is the third pillar of our plan. And then final pillar is the most difficult of all, because it is not financial, it’s not operational it’s cultural.

We need to change the culture of a system that has too often failed to put patients at the heart of its priorities.

Almost two years ago, after less than two months as Health Secretary, I made one of my most difficult speeches I’ve ever made when – in the wake of Mid Staffs – I talked about the normalisation of cruelty in the NHS. And we have sadly also seen at Winterbourne View the criminal abuse of vulnerable adults.

Since that time, thanks to the huge efforts of people across the health and care system, we have made great strides in improving quality and safety in hospitals. We have 5,000 more nurses in our hospitals, every patient being asked whether they would recommend the care they receive to friends or a member of their family and with the new Chief Inspectors of Hospitals, General Practice and Adult Social Care we probably have the most robust independent inspection regime of anywhere in the world. And we are doing more as well to help adults and older people live independently, with the appropriate support, rather than in residential care.

And these things are all important – but unless the culture changes as well they will be for nothing.

And the heart of the problem is that for too long in the NHS, perhaps less true in the social care system, but in the NHS we have relied on top-down targets as the main way to raise standards. Whilst there will always be a role for some targets in any large organisation, the danger with too many targets people focus their energy away from the vulnerable person sitting right in front of them – as we saw at Mid Staffs with tragic consequences.

We need to recognise that transparency of outcomes and peer review is a far more powerful way to improve care than yet more targets.

Transparency of outcomes was pioneered by Bruce Keogh and our heart surgeons a decade ago: since they had the courage to assemble and publish, surgeon by surgeon, mortality rates we have moved from having some of the highest heart surgery mortality rates in Europe to some of the lowest.

The MyNHS website now displays comparative performance by hospitals and local authorities on a wide range of indicators, from food to efficiency to safety and public health. I want this to be the engine that turns our NHS and social care systems into truly learning organisations.

And as part of that cultural change we need to see, which is to make sure the primary accountability of doctors and nurses is not to system goals but to the patient standing in front of them.

From next year every NHS patient will have a GP who is personally responsible for their care, with the GP’s name at the top of their electronic health record. Named, accountable doctors so that both patient and NHS know where the buck stops. And GPs supported to discharge that responsibility with more capacity in primary care, whether through additional GPs, practice nurses, district nurses or administrative support.

Conclusion

So I wanted to spend some time explaining the four pillars of our plan to transform our health and social care systems over the next parliament: increased funding backed by a strong economy; integrated, joined up out of hospital care; innovation and efficiency; and a culture where patients and service users always come first.

If it sounds ambitious, I think it is.

But we have a few trump cards to play.

A social care system that has succeeded in weathering perhaps the toughest financial challenge in its history.

We have an NHS that was rated this year by the independent Commonwealth Fund as the top-performing healthcare system in the world – ahead of America, ahead of France, ahead of Germany, ahead of France, ahead of Spain.

The commitment and values of not just NHS staff, but also colleagues in the social care system who have given their lives to the most noble cause of all, giving dignity and respect for our most vulnerable and disadvantaged citizens.

And we have a growing economy. But the litmus test for us as society is what we do with the fruits of economic success.

Today shows that with hard work, imagination and commitment we can pass that litmus test and rise to the challenge of an ageing population by making Britain the best country in the world to grow old in.

There’s a long way to go, but today the journey has started.

Below is the text of the speech made by Jeremy Hunt, the Secretary of State for Health, to the King’s Fund in London on 13 November 2014.

Introduction

Here at the King’s Fund, in November 2012, I made the most important and difficult speech I’ve made as Health Secretary.

It was in the run up to the publication of the Francis report.When I described the problems at Mid Staffs and across the NHS I used words never used by a Health Secretary before – I spoke of the ‘normalisation of cruelty.’

But rising to the challenge of Francis has not been the only thing the NHS has had to cope with.

We’ve also had the deepest recession since the second world war with unprecedented austerity. At the same time an ageing population has given us nearly one million more over 65s than at the time of the last election.

This triple whammy has created perhaps the toughest financial climate for the health and social care system in its history.

Four pillars

Big challenges. Which call for big solutions.

Solutions that involve us all, owned not just by politicians and NHS leaders, but by doctors and nurses on the frontline.

Solutions that improve care and reduce cost at the same time – better care for patients and better value for the taxpayer.

And solutions that are sustainable because they go with and not against the grain of core NHS values.

So today I want to outline the four pillars of the government’s plan for the NHS – and how we intend to make a reality of the NHS England

Five Year Forward View

And I will be brave: by saying I am increasingly optimistic that working together we can build a historic new compact across the NHS which not only achieves the Forward View’s £22 billion of efficiency savings but also delivers higher quality and safer care to an ageing and increasingly demanding population.

So what are the four pillars of our plan?

Firstly to recognise that a strong NHS needs a strong economy.   This is not a political point but economic reality. Much of the current pressure was caused by an economic crisis. The way to relieve that pressure is both to end the crisis and to make sure it is never repeated. As the Forward View makes clear, the only way to grow the £113 billion NHS annual budget is to make sure we have an economy generating the tax revenue to finance it.

The second pillar is something you have championed for many years at the King’s Fund: the need for integrated care closer to home as the heart of our response to an ageing population.

Within the next 2 decades the number of over 80s will double to over 5 million. The care they need is different: proactive, out of hospital care focused on prevention and management of illness – rather than a narrow focus on emergency care when it is too late.   So in the last year we have been taking important steps: a proactive care programme which commits GPs to additional care for their most vulnerable patients; named GPs personally responsible for the care of individual patients, starting with over 75s this year and rolling out to everyone next year; and two weeks ago the £5 billion integration of health and social care through the Better Care Fund. 151 local plans to improve out of hospital care including sharing medical records, jointly commissioning social care and jointly working to reduce emergency hospital admissions.

The third pillar of our plan, is something I want to spend some time on today. How do harness innovation and value for money to improve care and make the Forward View’s £22 billion of savings?

Innovation

Innovation is not alien to the NHS.

It has had more “world firsts” since its creation in 1948 than any other publicly funded health system, including the first baby born by IVF in 1978 at Oldham General; the first ever heart, lung and liver transplant at Papworth in 1987; and the link between lung cancer and smoking, discovered at NHS hospitals by Sir Richard Doll in the 1950s.

But scientific innovation has not been matched by process innovation. We have not built a system that is good at adopting and rapidly diffusing new ways of doing things. Given that much innovation saves money as well as lives, we need to change the NHS from a lumberingly slow adopter of new technology to a world class showcase of what innovation can achieve.

Today I am taking an important step towards making that change.

Alongside colleagues across the health and care system on the National Information Board, I am setting out a plan to achieve personalised, 21st century healthcare for the whole NHS. We will not do this through bureaucratic top down initiatives but by encouraging and diffusing local clinical innovation. And harnessing the most powerful driving force for innovation we have: the power of individual citizens who care about their own health.

From next spring you will have online access to a summary of your own GP record, and access to the full coded medical records by 2018. By 2018, as well as access, you will be able to record your own comments. This means everyone will be able to create and manage their own personal care record.   From next April you will be able to book GP appointments online and order repeat prescriptions without having to go into your local surgery.

By 2018 a paperless NHS will ensure you only have to tell your story once: if you consent, your electronic care record will be available securely across most of the health system, and by 2020 across the whole of the health and care system, so that, when you need care, different health professionals have instant access to the information they need. This has already started with one third of A & E departments now able to access GP records and one third of ambulance services able to do so by the end of this year.

From next 2016 NHS England have said you will also have access to trusted NHS health ‘apps’ and social networks – so that you can monitor your own health, or join a virtual community of friends, family or other patients who can support you.

Personalisation and prevention

We know in other sectors technology has made personalised service economic to deliver – whether it is home banking, on-demand TV or personalised Christmas cards.

But in healthcare that is only the tip of the iceberg.

More personalised, responsive and joined-up care becomes possible with shared electronic health records.

But in healthcare, technology also unlocks personalised cures for illnesses. We know that diseases like cancer and dementia are not single diseases, but infinitely complex variations on a theme. We also know that it is often not economic – under current models – to develop cures for rarer diseases like pancreatic cancer or infantile epilepsy.   And that is why this government has committed to make the UK the first country to sequence and make research-ready 100,000 whole genomes. We want the NHS to spearhead a global revolution in personalised medicine based on individual genetic characteristics.

But in healthcare it is not just personalised care and personalised cures that technology unlocks. It is also a revolution in prevention.

If you are a vulnerable older person being cared for by Airedale Hospital in Yorkshire, you may well be given a big red button. This sits on your armchair and to use it, there is only one thing you need to do: and that is to make sure your TV is switched on. Then if you press the button – anytime, day or night, a nurse will appear on your TV screen to ask how you are.

Incredibly simple – but incredibly effective at reducing emergency admissions by making good care accessible from inside your own home. Airedale estimates a 14% reduction in such admissions for these patients – while NHS Gloucestershire, where I was yesterday, estimate they have reduced the cost of emergency admissions by 35% for patients with long-term conditions using a similar remote monitoring system.

And this is not just about the frail elderly. Google and Novartis are collaborating on a new contact lens to help people with diabetes monitor their blood sugar levels through analysing tears.

7 million people now wear devices or use apps to monitor their own health. My own FitBit One says that today I have done 8553 of my 10,000 daily steps. In the US Kaiser Permanente are looking to integrate pedometer data into electronic health records to give physicians a better understanding of people’s prevention regimes.

Too often, though, the NHS has lagged behind other countries in offering access to these kinds of products even though the NHS itself is the winner if costs are contained by preventing illness. This will not change until healthcare is commissioned holistically, so that the budget holder who pays for innovative prevention sees the financial benefits that accrue as a result.

So today I can announce that as part of a step towards becoming accountable care organisations, all CCGs will be asked by NHS England – with support from HSCIC – to collect and analyse expenditure on a per-patient basis.

CCGs will then, as co-commissioners of primary and specialist care with NHS England, and co-commissioners of social care and potentially public health with local authorities, be able to pinpoint more clearly where there is the greatest potential to improve patient outcomes by reducing avoidable costs through more innovative use of preventative measures.

Protection

But alongside personalisation and prevention, there is a third “p” that is vital if we are to embrace innovation – and that is the protection, protection of personal medical data. If we lose the confidence of the public that their data is safe none of this will be possible.

So we need to be as robust in protecting personal data as we are ambitious to reap the benefits of sharing it.

This year’s Care Act put in place a number of measures, controls and independent oversight of the use of personal data. New data security requirements will be published by October 2015 and mandatory for all providers of NHS care.

But today I am going further.

Just as we now have a Chief Inspector of Hospitals to speak without fear or favour about standards of care, I am today announcing the establishing of a new National Data Guardian to be the patient’s champion when it comes to the security of personal medical information.

I am delighted that Dame Fiona Caldicott, who has done so much outstanding work in this area, has agreed to be the first National Data Guardian for health and care. She has agreed that it will be her responsibility to raise concerns publicly about improper data use. And organisations that fail to act on her recommendations will face sanctions, either through the ICO or the CQC, including potentially both fines and the removal of the right to use shared personal data.

I have already asked Dame Fiona to provide independent advice to me on care.data. No data will be extracted from GP practice systems – including during the ‘pathfinder’ pilot phase of the programme – until she has advised me that she is satisfied with the programme’s proposals and safeguards.

I intend to put the National Data Guardian on a legal footing at the earliest opportunity, but even before that the CQC and the ICO have committed to pay special attention to her recommendations, including sanctioning organisations where they find breaches, that do not comply with Dame Fiona’s recommendations, even before any new legislation is passed, so patients will benefit immediately from a much tougher and more transparent regime.

Reaching the £22 billion

A more personalised service that helps people stay healthier is not just what people want: it also reduces cost.

The banks have persuaded more than half of us to bank online. And in doing so cut their own costs by an impressive 20%. By embracing the lower costs of virtual shopping, websites such as Amazon deliver products more conveniently but also more cheaply too. Skype is not just handy – it means international calls are free. Higher quality and reduced cost at the same time.

And likewise this has happened in healthcare, where the Veterans Association estimates that a fully integrated, digital system including accessible electronic health records, remote monitoring, and online consultations has saved $3 billion over 6 years.   It is, now difficult, of course, to predict exactly what the savings might be for the NHS – but to give you one example, if better care at home reduced the cost of emergency admissions by 30%, we could save £5 billion by 2020. A one year delay in the onset of dementia would save £1.5 billion. Money that can be reinvested in more frontline staff and more preventative care, creating a win-win for patients and staff alike.

The Forward View £22 billion savings challenge

But there is also a lose-lose which we are grappling with now.

Because every pound wracked up in deficits is a pound taken away from patient care, which is why maintaining financial balance is vital. But true financial sustainability means rethinking how we spend money not just day-to-day but more fundamentally. Just as in 2009 Sir David Nicholson set up the Nicholson Challenge to save £20 bn this parliament – something that has largely been delivered – so the Forward View sets up a £22 billion challenge for the next parliament.

The challenge may be similar but the way we deliver it will change. As the Forward View makes clear, long-term pay freezes are unlikely to be viable if the NHS is to retain the staff it needs. But as before we will need a combination of national and local initiatives, so today I want to outline 10 savings challenges we can help NHS organisations deliver, challenges which between them could save between £7 billion and £10 billion by 2020.

The first challenge is safer care. Last month, at Birmingham Children’s Hospital, I spoke about the huge cost that is placed onto the NHS by poor quality and unsafe care. A single avoidable fall costs the NHS £1200 because of the longer hospital stay it causes; but we also know avoidable bedsores cost the NHS £50m and orthopaedic surgery infections cost between £2-3m every year. A report by Frontier Economics, bringing together the available evidence, suggested that the total cost of preventable harm in the NHS may be between £1 and £2.5 billion.

One of the areas identified by the Frontier report forms the second challenge: ensuring the safe, effective and optimal use of medicines. Last week, the Academy of Royal Medical Colleges estimated that adverse drug reactions resulted in costs of £466 million through additional bed days. This may be the result of prescribing errors. Or clinicians may not know that a patient has an allergy. And some patients, particularly those taking multiple medicines, may find it difficult to take the right doses at the right times. The report argued a further £85 million of savings could be found by prescribing lower cost statins, without impacting on patient care.

So poor use of medicines is connected to the third challenge: the £300 million of waste each year in primary care from unused drugs, half of which could be avoided according to a study by the University of York and the School of Pharmacy. We have already started to help systems tackle these issues through the roll out of e-prescribing systems using the Safer Hospitals, Safer Wards fund, and through more one-to-one pharmacist consultations as part of the New Medicines Service. But there is much more to do to support patients and clinicians to get the best outcomes from medicines.

The fourth challenge is procurement. The NHS spends almost £15 billion each year on medical equipment, devices, office supplies and facilities. Prices for surgical gloves vary from £2.43 to £5.44 across the NHS, and the NAO found variation of up to 183% in the prices paid by Trusts for the 100 most commonly ordered products. So we have established the Procurement Efficiency Programme, led by Lord Carter, which aims to deliver savings of at least £1.5 billion from the NHS procurement budget from next year. Mid Cheshire Foundation Trust made savings of 9% on their orthopaedic wards and reduced clinical time spent on stock management by 74% by embracing modern procurement and stock control principles, and I am confident we can make similar changes across the NHS by collecting and sharing data, getting a grip on stocks and supplies, and helping providers with central frameworks and core lists to purchase common products.

My fifth challenge is agency staffing. Agency staff can be an essential way to fill difficult gaps quickly and to ensure that services continue to be delivered. But we know that a Band 5 agency nurse can cost three times more than a permanent member of staff. And data from University Hospitals Birmingham suggests that high use of temporary staffing can be a sign of poorer quality care, something that Professor Sir Mike Richards has also noted during his inspections. The amount being spent by trusts on agency fees has gone beyond a sensible response to new staffing levels required by Francis and become an unacceptable waste of money.

So we are supporting Trusts by publishing a new toolkit to help reduce spend on agency staff. And we will bring down these costs further by working with providers to improve their processes and challenge agencies that are ripping off the NHS and the taxpayer. We know it is possible – Taunton and Somerset Foundation Trust, for example, saved £2.5 million by introducing clear rules for hiring agency staff and using electronic rostering.

The sixth challenge is on surplus land and estates. In many areas of the country the NHS owns buildings and land that it no longer requires, as care is increasingly delivered in the community or in people’s homes. There is huge potential for that land to be used for better NHS primary care facilities or indeed housing and schools – whilst at the same time, reducing NHS overheads and generating cash for reinvestment in NHS services. The London Health Commission estimated that the total value of surplus estate in the capital alone was worth £1.5 billion.

The seventh challenge is to ensure that visitors and migrants pay a fair contribution to our NHS. Government and the NHS need to ensure that, where people need to pay for their care, every effort is made to recover the charges. Independent research from Prederi suggests that up to £500 million can be recovered from visitors and temporary migrants accessing NHS services. That would be enough to pay the salaries of almost 10,000 nurses. To do this we are providing financial incentives to trusts to promote the identification of people who should be paying for their healthcare. Identification will also be made simpler through details listed in healthcare records of visitors and migrants.

The eighth challenge is back office costs. The health system is on track to reduce its administration costs by one third over the course of this Parliament, which will save £1.5 billion – and we are committed to save a further £300 million in next year including through shared services and bearing down on estates costs in the department and its agencies. All of these savings go back to supporting frontline care. But it is vital that the NHS continues to look at how it can reduce back office costs in order to support better patient care and these could produce an around £0.5 billion of savings.

The ninth challenge is to come up with more solutions ourselves by reducing the £500 million plus we spend a year on management consultants. We have the ideas and people inside our NHS to deliver the change we need. It is our doctors, nurses, healthcare assistants and managers who will create a sustainable NHS but we won’t grip this if we try to subcontract the challenge of working out the solution. The final challenge is a personal priority of mine: making better use of IT to free up time for frontline staff. A study by the Health and Social Care Information Centre found that 66% of a junior clinician’s time is spent finding, accessing and updating patient notes – compared to just 24% on patient contact. Electronic records systems could make a real difference in freeing up time to care for patients. And that is why I want all clinicians in primary, urgent and emergency care to be operating without the use of paper records by 2018.

Taken together these changes could save a significant part of the Forward View’s £22 billion – and combined with local innovation we can surely find the rest. But some of them are not new – so why am I optimistic we can deliver them this time round?   Because I think the Department of Health has learned that simply coming up with an initiative and hoping to “roll it out” from the centre is rarely successful. These challenges will only be achieved if we construct and implement them with the full support of NHS organisations and their frontline staff.

So I want to do something different this time.

I want to build on the consensus around the Forward View to develop a compact around both the amount and the way we embrace innovation and efficiency to deliver the savings needed. A compact between the bodies leading the NHS and NHS organisations themselves. And a compact that goes on to be translated at a local level to agreements between Trusts and their own staff as to how we are going to improve both care and efficiency at the same time.

Fourth pillar

So that’s the third pillar is a compact to deliver real change in the way the NHS embraces innovation and efficiency.

But there is a fourth pillar, perhaps the most difficult and important of all. And that is to make sure we get the culture inside the NHS absolutely right. We can make the investments, find the efficiencies, we can even invent new cures – but if those changes are delivered without the right culture of safe, compassionate care they count for little.

I will return to this on another occasion, but let me leave you with a thought about the two biggest areas of culture we still need to improve. First of all safety: why in healthcare is it somehow acceptable that one in twenty deaths are avoidable? In the NHS in England that is 1000 avoidable deaths every single month. I want us to be the first country in the world that aims to eliminate avoidable deaths in healthcare with the same standards of safety they have in the airline, nuclear or oil industries.

And we will do that by nurturing a new culture in which the main driver of performance improvement is not endless new targets, but a culture of openness, transparency and continual improvement through peer-review.

And the second area we need to think about is accountability. Still too often in the NHS it is hard for patients to see where the buck stops. Whether it is frail elderly with complex conditions, adolescents with severe mental health trauma, inside hospital or outside we still have a system where corporate goals trump responsibility for individual patients. Patients will never be at the heart of our system until we have professionals truly accountable for making that happen patient by patient, person by person.

Conclusion

So ladies and gentleman it has been a longer speech than normal, even for a politician.

But I wanted, in the wake of the Forward View, to put some flesh on the bone with respect to the government’s response and the plan we want to work with you on for delivering for the NHS.

I’d like to finish then on a note of optimism: we are not alone as a country in facing these challenges. But if we implement the plan I have outlined this afternoon, we will be the first country in the world to do so across an entire health economy.

A properly funded healthcare system backed by a strong economy.

New models of care appropriate for an ageing population with the safe sharing of data.

Innovation and efficiency that both saves money and puts patients in the driving seat for their own healthcare.

And a culture of safe, compassionate care where patients always come first.

And an NHS that turns heads across the world as it blazes a trail for 21st century healthcare.

Thank you very much.