Patricia Hewitt – 2006 Speech to NHS Confederation


Below is the text of the speech made by Patricia Hewitt, the then Secretary of State for Health, on 20 June 2006.

I want to thank the Confederation – Peter, Gill and all your team – for your leadership of the Confederation. The leadership you showed in your recent report challenging the idea that bed numbers are the measure of success. The leadership and support you have provided this week to this vital part of the NHS family.

I have learnt a great deal over the last year, and what I’ve learnt has deepened my admiration for NHS staff and my absolute determination to give you the support you need to give every patient and user the best possible care.

I am here, as always, to listen to you – which is why I’ve asked Ian to join me for a discussion with you. But I want to take the next 15 minutes or so to acknowledge the difficulties we are facing, talk about the change in culture we need and underline why the reforms are so important.

The last twelve months have been far more difficult than we anticipated. So I am here, first and foremost, to thank each of you for the leadership, the dedication and the sheer professionalism you contribute to the NHS.

And in thanking you, I am also here to celebrate with you the extraordinary achievements of the NHS.

Just one example. There is scarcely a family that hasn’t been affected by cancer. That’s why we made it a priority and asked you to get rid of the delays between the GP’s referral and the start of treatment.

And you’ve done it.

I also know that it is first-rate managers who make first-rate care possible. I spent a morning recently with the cancer team at the Whittington Hospital, sitting in on the multi-disciplinary team meeting, … I saw for myself, what you see every day, brilliant clinicians and front-line staff absolutely focussed on what each individual patient needed. And it was the clinical director (Mrs Celia Ingham-Clark, a consultant surgeon) who told me that the person who made the team’s work possible was Stephen Dunne, who helped patients navigate around the system, ensuring that everyone had the information they required.

It is people like Stephen, it is you and all your colleagues who have made it possible to bring down the waiting lists, get rid of the trolley waits in A&E, save the lives of thousands of cancer patients.

We put in more money. But you did the work.

I will go on championing your successes and telling people about the extraordinary achievements of the NHS in every part of our country. That’s part of my job as health secretary.

But I will also tell the truth about the difficulties we face.

As I look around at a world that is changing faster than most of us imagined even ten years ago, as I see the extraordinary potential of scientific breakthroughs to transform people’s health and well-being, as I find health services across the developed world learning from what we are doing here in the NHS, I am excited this about journey of change that we are on.

But I know that excitement is probably not the emotion most of you feel right now. Anxiety. Uncertainty. Weariness that change never seems to end – and that change seems to be done to you, not by you. That’s what I hear people telling me.

I know that the latest changes to the strategic health authorities and PCTs compound those feelings, even amongst those of you who believe we’re making the right changes. We are making the changes because we believe they will help make life better for patients and the public. But they are also making life very hard for many of you. Some of you here don’t know if you will have a place in the new structure or what that role might be. Together, we need to do more to support everyone who is facing that insecurity.

There is another reason why I want the opportunity for dialogue with you today. Some of the things you’ve taught me have shocked me. The senior member of a PCT, for instance, who told me that she knew last year’s financial plan was unachievable … but she’d been told submit the plan anyway, and if there were problems, that was her problem.

Of course it isn’t like this everywhere – but too many people have talked to me about a macho culture, bullying, not being able to give bad news.

Ian said yesterday that the centre wasn’t listening.

That has got to change.

So our discussions here are part of creating a new culture: leaders who listen – to bad news as well as good – a culture of openness, honesty and respect. I want that in every strategic health authority, in every PCT, every part of the NHS and throughout the department of health – and I will go on reinforcing that expectation with all my colleagues including the Boards of the new health authorities and Trusts.

From “top down” to “bottom up”

But if we’re going to keep on changing, it has to be the right kind of change. When we started making the investment, when we launched the NHS Plan, we needed national standards and targets to make sure the changes happened everywhere.

But you’ve taught me that there is now too much top-down micro management, too much emphasis on targets set by Ministers – and not enough support for managers and clinicians and other front-line staff to respond directly to patients and users and local communities.

The vision of the NHS plan, “care shaped around the needs and concerns of patients.” That’s the vision for today and tomorrow. And it can’t be achieved by diktat from Richmond house.

So we need to create a system with in-built incentives to improve and innovate. A system that supports you to look outwards to patient and users, rather than upwards to Whitehall and Ministers.

Of course there will still be national standards: without them, empowering front-line staff and local communities just creates inequality and a post-code lottery.

But within a framework of national standards, fair funding and proper accountability, we need to shift the whole emphasis from top-down targets and performance management from Whitehall to change from the bottom up.

And that’s exactly what this next stage of the reforms will do.

The four parts of the reform programme work together.

First, more choice for patients with stronger commissioning by PCTs and practices. We know the public want more convenient, more personal, more local services when they’re ill. But they also want the NHS to support them in becoming and staying as healthy and independent as possible.

As we build on the success that so many PCTs have already achieved, and deepen our understanding of what excellent commissioning means, you will have the tools to focus on the needs of every community, to do more – not less – on public health and prevention, and to work with local practices to design services around the needs of individuals not institutions.

By giving GPs and practices more freedom and more responsibility, with practice based commissioning, we are creating the right incentives to do that everywhere.

Of course, choice has to be within available resources. But for elective care, as we give more choice to patients, we also give every hospital a powerful incentive to focus on how to give patients faster access and better, more personal, more convenient care.

But for choice to be real – and for commissioners to get the best services – we need providers who are constantly looking for better ways of achieving the outcomes that patients, local people and commissioners want.

So the second element in the reforms is a greater diversity of providers, with more freedom to innovate and improve – but also more responsibility for their own success.

Its been there for a long time in mental health and care for older people. We’ve now extended it to acute services.

In primary and community services too, we will increasingly see new providers adding to the great diversity that already exists. Services provided by local authorities, PCTs, GP practices … but also nurse practitioner led services, private firms, social enterprises and the third sector.

When East Derbyshire PCT wanted new and better primary care services for one of their communities, they didn’t specify who was going to provide it, they specified the services people wanted – and they chose the provider who they believed would offer the best. We’re all patients and users ourselves, isn’t that what we’d all want our local NHS to do?

I have no doubt that this diversity brings great strengths to the NHS. But it also brings greater complexity. Sometimes different organisations will be competing to offer the best possible care. Sometimes you’ll be collaborating with other organisations to provide the care that an individual patient or a whole community needs. All within the NHS family. All of it free at the point of need.

And then we need the third element of our reforms, payment by results. We have to get it right, we have to give you proper time to plan – and we’ll work with you over the next few months to do both.

But the reality is that the tariff supports patient choice, it will empower practice based commissioners and it is crucial in both driving improved efficiency and liberating clinical staff , inside and outside hospitals, to develop the services that patients want.

And the fourth element, of course, is the Regulatory Regime that we need – particularly to guarantee safety and quality – so that we can promise the public that the services will be there for you, wherever possible you will have a choice and on the NHS you can’t make a bad choice. It’s not easy to design a light-touch regulatory regime that fulfils our promises to patients without stifling your ability to innovate. But we’re determined to do it and we will be saying more on this next month.

Meeting future challenges

We all know there are huge challenges facing every health service. People want more. Medicine can do more. And we have to cope with these new demands and new costs within a budget that will be higher than ever before because we’ve asked people to pay more than before. But even in 2008, when we will have trebled the NHS budget and reached European levels of healthcare spending, the NHS will still have to live within its means.

So what do we do? Do we cut back on the services that we should be providing? No. We’re not going to do that.

Do we make patients pay top-up fees – as some on the Right are demanding. Never, because that would destroy the values of the NHS.

Or we can do what you’ve been asking for this week: make services far more productive – improving care for patients and improving value for patients and the public too. That is how we safeguard the values of the NHS for another generation.

We will never turn healthcare into a business. But we can and we must be more business-like. Not because we care more about money than about patients but because, as the Prime Minister said this week: every pound wasted is a pound not spent on the values of the NHS.


The final point I want to make before our discussion is about my responsibility to you.

I believe my job is to create the space for you to do your job.

I will play my part with Ian in creating the different kind of leadership that is needed for the next stage of our journey.

Less day-to-day interference: more collaboration and empowerment.

Less instructing, more listening: to the bad news as well as the good.

Not ‘its your fault’, but ‘its the responsibility of us all.’

And I will make sure that if you have the best plan for patients but need to take difficult decisions to deliver them on the ground, we will give you the political support you need to make those changes happen.

Those are the targets you are setting me: the targets I am setting for myself.

And when we meet here again in twelve months’ time, we will know that we are on the right track – not just because we will be back in financial balance. But because, together, we will be creating the culture and the partnership that is right for you, right for patients and true to the values in which we all believe.