Department of Health Skip to content

Please note that this website has a UK government access keys system.

You are here:

Secretary of State for Health's speech to the NHS Confederation - 'Shifting power to the frontline'

  • Last modified date:
    7 December 2010
Andrew Lansley, Secretary of State for Health

Thank you very much. It's a real pleasure to be back here with you.  

I wish I could see where you are – I can't see you! I've got lights in my eyes. I can't see all the faces out there, I was hoping they would be familiar faces. Many of you I've met many times over these years and it is a pleasure to be back with you.  

It's a year since I was addressing you as shadow Secretary of State for health, and a year is an exceptionally long time in politics.  Much has changed. 

But, do you know, one thing hasn't changed. One thing that has remained the same. I’ve been Shadow Secretary of State for six and a half years, Secretary of State for more like six and a half weeks, but one thing that's remained the same is I've really enjoyed visiting people whose job it is to provide services to the people of this country, healthcare services of so many different kinds in so many different places.  

Of course, when you do that as Shadow Secretary of State or as Secretary of State, there seems to be a tendency a desire to subject me to various tests.  I've seen inside my retina, I have seen inside my heart I have seen inside my abdominal aorta I have had my blood pressure checked, my cholesterol checked, my everything checked.  I even went to Preston Royal Infirmary and met the folk there who were following up on bowel cancer screening and they eyed me up a bit for the colonoscopy.  

Earlier this week I went to Berkshire, God it seems longer ago – it was actually yesterday morning – I went to Berkshire and I was meeting the people there who were providing talking therapies, the role of out IAPT and Paul [Burstow] and I were able to announce a further extension of talking therapies and I really enjoyed meeting them there.  

They felt the moment couldn't pass without taking the opportunity to ask us to do some computerised CBT.  Well, those of you who know about this stuff will recall in computerised CBT there is a little part of that which is about what's known as faulty thinking. I thought you'd be interested to know that as your Secretary of State I did 3 questions on the faulty thinking test and I got zero out of 3. 

But I do hope after 6 and a half years as shadow Secretary of State, if I make mistakes and no doubt I will make mistakes, that at least I hope you won't feel they are made out of sheer ignorance.  

But, I do know that I've learned one thing over that period of which I'm absolutely certain – that there are so many people in our National Health Service who have tremendous commitment, expertise and ability. My purpose is to let all of those people get on with the job they want to do.  My role, as I see it, as speaking for the service, for the public, for the taxpayer.  But, to be a leader and not a dictator.  

In truth, many things have changed and are changing.  The public voted for change.  But, let me tell you this: over the last year, and since this conference last year, my priorities have not changed.  

First, that patients must be at the heart of everything we do, not just as beneficiaries of care but as participants in its design.  We must see the NHS through our patients’ eyes and make delivering what they need and want a shared experience and responsibility.  

Second, if we are to achieve continuously improving outcomes, then it's outcomes on which we have to focus, not process targets, not measuring inputs, but a consistent, rigorous focus on those outcomes with the ambition of securing results and healthcare services in this country that are amongst the best in the world.  

Third, we must empower professionals to deliver. We must set you and them free to use their clinical judgment to do their jobs to the best of their ability and on the basis of the evidence. That way we can secure the quality, the innovation, productivity and indeed the safe care which is vital to achieving the best outcomes.  

Fourth, we must do much better on the health and well-being of our families and our communities.  Only by prioritising public health and by preventing ill health more effectively can we achieve the overall health outcomes for this country that we seek and need, and in doing so actually make the demands on the National Health Service for the longer term much more sustainable.  

Fifth, we must reform social care.  Seeing the relationship between quality and outcomes in care as well as in healthcare and their interconnectedness, delivering further integration in how the services are commissioned and provided.  

Those are our five priorities for the Department and for the National Health Service – they are the priorities of the Coalition Government and we set them out very clearly in the coalition agreement. Together we're already reshaping how we do things in order to meet those priorities.  

That's why I have instituted a full public inquiry into the events at and around Mid Staffs Foundation Trust and how the wider system failed to prevent the tragedies that happened there – so we can learn the lessons and move as a system towards a culture of safety and indeed a culture of challenge where things may go wrong.  

That's why, in literally the first week at the Department, I announced a moratorium on reconfigurations. Not to stop change but to empower patients and clinicians to have their say and ensure the changes that are happening now are consistent with our vision for the future. Because if we're looking to GPs to lead commissioning, it's essential that what happens now is consistent with their commissioning intentions for the future. And if we want patients to exercise choice, then those choices should influence access to services – and we cannot pre-empt and frustrate those choices now.  

As I say, it’s not about stopping change.  On the contrary, this is about ensuring that change is visibly linked to better outcomes, that it has the support and buy in of general practitioners and primary care, and that it is supported by the local people who we serve and represent. 

And just this week by publishing a revised operating framework we took a further step – putting in place a zero tolerance approach to infections, setting out how we can move from process targets to evidence based quality, developing payments for performance geared to results and moving towards a service which empowers clinicians and makes them more accountable for achieving the best outcomes for their patients.  

5 years ago, I told you that the NHS did not need half-baked, inconsistent reform or even a direction of travel if people had no idea what they were traveling towards or where they were going. I believed then, as I believe now, that the NHS needs coherent consistent reform and a clear understanding of where we're going and what we need to achieve.  

Our Coalition Programme is a plan for a 5 year Parliament.  We'll set out our strategy for the NHS as early as possible so everyone in the National Health Service can share that clarity of purpose, so that we can all have a sustainable framework within which to work and not just for 5 years but for the long-term.  Everything we do then can be consistent with that strategy.  

So, today I want to tell you about the purposes and principles which are at the heart of that strategy, following my speech a fortnight ago to the Patients Association and National Voices. In that first speech I made clear the first purpose: to create a system of patient-centred care, to put patients right at the heart of the National Health Service.  

Now, with you let me highlight a further purpose: to empower the service, the professionals and the front line.  

The NHS is admired around the world, and rightly so, for the skill of its staff, for our system of general practice, for the continuity of care it provides, for its evidence based approach.  But the NHS is also rightly admired for its equity.  For that ideal that inspires all of us, that the NHS is there for everyone, free at the point of need from cradle to grave.  There is much to be proud of, but it is clear to me that there is still a lot more to do.  

The NHS should be admired not just for its equity of access, but also for the excellence that we aspire to and we achieve.  The NHS should exemplify the ideal of equity and excellence combined.  

After 13 years of top down control from Whitehall, we still have over 100 major targets controlling clinicians and a bureaucracy that demands some 250,000 data returns from every trust each year. Yet, in the NHS today, outcomes still lag behind those of our leading European neighbours.  

For example, survival rates for respiratory disease and for many cancers remain poor compared to other countries.  The NHS has too high rates of acute complications of diabetes or avoidable asthma admissions.  Incidence of MRSA infections remains high relative to those countries and veinous thrombosis causes 25,000 avoidable deaths each year.  

I'm determined we must make quality of outcomes the defining principle on which this service operates and indeed when we talk about quality, for all Lord Darzi's leadership and the huge efforts many of you and your clinical colleagues have made in the past 2 years or so, the system simply is not yet designed around quality as it should be.  

What will make the difference?  More targets, different targets?  

No actually if we're going to improve outcomes the answers don't lie in the top down targets.  They lie in the consulting rooms, and the wards and operating theatres and the clinicians around the country – where the clinicians are and the patients are. So I want to empower front line staff, and trust the professionals closest to patients to act on their behalf. A freer more open system will mean better results. 

But I know there is a tension in the National Health Service. There always has been and always will be – between national standards in a national system funded through national taxation and local priority setting and local decision-making.  

It is a National Health Service, but it must be a locally delivered service

And that is where the power should lie.  

That is what the evidence tells us.  That is how we'll improve outcomes.  That is how we'll achieve transparency and accountability. 

Clinicians must be free to exercise their clinical judgment because, quite simply, those doctors and nurses that can best respond to their patients needs will achieve the best outcomes. They need and expect to be acting in line with the evidence. But they don't expect to be told what to do in ways which conflict with their clinical judgment. 

Clinicians will be accountable in a different way.  Instead of being accountable to process targets, they will have to meet quality standards.  Those quality standards will not be about distorting their clinical judgment, rather it will be based entirely on clinical evidence and must be shown to achieve demonstrably better outcomes if followed and they will have to be clear, relevant and comprehensible for patients.  

And if we engage public commissioners more effectively in designing local services then they will make it clear that they want the right treatment in the right place at the right time – often in precisely that same place with local clinicians taking responsibility so that we can design those services best for each community.  

I intend that general practice should take control of commissioning, creating a direct relationship between the management of care and the management of resources that I think it is at the heart of any healthcare system. And when you look at why so many healthcare systems have lost control of what they do and resources they consume, it's simply because those who are responsible day to day for the management of care of patients are not themselves directly also responsible for the resource consequences of what they do. Making that happen must be integral to designing any healthcare system that is efficient, excellent and equitable.  

So, to support GP consortia in their commissioning decisions we will create an autonomous NHS commissioning board, free from day to day political interference. I am hoping I'll be the first Secretary of State for health whose principal purpose has been to give up power right through my time in office, to empower others rather than take power myself.  

But, at the heart of what the NHS board will then have to do will be to establish a set of quality standards and indicators that drive commissioning and quality – and they must mean the same thing right across the system, whether it's in commissioning and contracts, whether it's in payment systems that drive quality or whether it's in the care quality commission who are inspecting.  

If we create consistency we can also align incentives so that at every level, managerial and clinical, people can feel that they are working to a clear and consistent sense of what quality means.  

And this will mean improving the payment system.  If the peak of Everest is a payment system that supports precisely what commissioners are looking for and what patients need on every occasion, frankly we're barely beyond base camp.  

With the operating framework this week we've set out our goal for the system – benchmark pricing able to be contracted across care pathways crossing boundaries between primary and secondary care, focused on outcomes more than episodes or spells of care and payments, incentivised for quality.  I want to see a system that rewards performance and is tough on poor quality. A payment system which works for clinicians and patients rather than the other way around.  A tariff made for man, not man for the tariff.  

Actually the CQUIN framework has begun to do just that. In Birmingham it has incentivised innovation and now cancer units have agreed with their commissioners to introduce home delivery of chemotherapy making for better more convenient services for patients. In Yorkshire and the Humber, commissioners are requiring local organisations to work together to achieve improvements for patients with dementia. I know some of you here today have worked on those schemes and they are just the sort of innovation that I want to see commissioning unlock.  

There are many other examples of that sort of innovation but we need to see it happening systematically across the service. One of the virtues of the National Health Service is it attracts and inspires some of the brightest and best from around the country and around the world, but our system has failed to make the most of this potential.  We have to set the NHS free to innovate.  We should be constantly thinking about how we can do things better, encouraging the adoption of successful ideas throughout the Health Service. 

But we don't capitalise on innovation and ideas today enough because the system is too rigid, because we do one thing at a time, what the centre dictates and when it dictates it.  

To give you an example, recently I was in a catheter lab, happily not to have angioplasty myself, but I was talking to the cardiologist about the introduction of primary PCI. And it became clear from the way they were talking that they and I knew this from years back – they had known on the basis of the peer review journal evidence that primary PCIs as a first response to a heart attack was something that was going to be a better way forward. But they didn't believe they could do anything about it across the whole of the NHS until the Department of Health had in effect given them the permission to do so. The same was true − which I knew well − in relation to thrombolysis for stroke.

Why can other countries then move those clinical practices forward so much faster than we have done?  Why does our National Health Service appear to have acted as a brake on change rather than an accelerator for change?  

I think because too often we've been like a convoy.  We are big, we are national, we are all in this together, but actually that doesn't mean that we can only go at the pace of the slowest.  We have to make sure there are first mover advantages.  We have to make sure the incentives are there to do the right thing as quickly as you can, and to act on the basis of the evidence, not to wait around to be told to do it by the Department of Health. So the current way of doing things has to change.  

I want to provide freedom, responsibility and accountability so that clinicians don't have to wait, least of all for my permission, to move from the thing that is targeted to something better.  When the evidence says something works, they should be free to get on and do it and have the incentives and levers in managerial terms to support that.  

And of course with that responsibility comes a new kind of accountability.  In recent years it seems to me there has been something of a pretense about accountability.  Ministers have been very keen on saying that they are in charge and they have done things when things are being announced, when money is being spent, when new projects are being announced.  

But, in reality, often it wasn't they who could guarantee whether or not those promises were going to be delivered and when something went wrong, the response of ministers in Parliament − and for years I have been standing at the other dispatch box listening to it – was that it is all the fault of local management: ‘oh no, these decisions are all local decisions being made by local primary care trusts’.  

Well, for the future, in a strategic framework that I'm proposing, we will show what the relationships actually are and where accountability genuinely lies, with a separation of commissioning from provision which promotes individually regulated providers, commissioners themselves operating with greater autonomy, themselves having greater direct public scrutiny. 

I will set out what the Secretary of State is and is not responsible for and, where the Secretary of State is not responsible, I will set out who is.  

My view is clear: we have to strike a new balance of power in the service so that wherever possible responsibility should lie with clinicians and managers.  I intend to provide the leadership, the strategy, and the direction, not command and control.  

So, that means being clear what we are asking the service to achieve, not trying to tell you how to do it. It means more than ever we're making clinicians accountable to the people who really matter, the patients. Accountable in terms of the choices patients make but also for the results that the service achieves.  Supported by greater access to information for patients to empower them to make more and better choices about their care, and a democratic accountability too. As we set out in the coalition agreement, for the first time, the voice of the public will be heard across commissioning, the public health service and in relation to social care. Because in these very difficult financial circumstances, accountability for how we use taxpayers money – accountability to the public for the service we provide with the money that they provide is even more important.  

Funding for the NHS will rise in real terms in each year in this Parliament.  The real terms increase will not, however, be remotely of the order of recent years nor even what the NHS has been accustomed to over the whole of its life.  It affords a degree of protection, yes, but at the same time how that money is used is critical. So I want to deliver to you the same message that I delivered to you last year – which is that although the National Health Service will have protection relative to others parts of the public services in this period of serious financial constraint, I must apply, we must apply to ourselves exactly the same disciplines that are applied across the public services.

Protection for the National Health Service is not protection from the need for efficiency.  It is protection for patients.  

So the funding settlement will come with some pretty testing challenges for how that money is being spent and the results being achieved. So we have to provide discipline to what we are doing at every level, to management costs, to capital projects, in continuous improvement and in reducing the unit costs of what we do.  

The £20 billion of savings that David Nicholson has rightly identified and asked for is not a cut to our budget.  It's not about doing less, still less about doing worse.  

It's a 20 billion pound efficiency saving.  It's about doing more for less and that should be out central discipline across the service because in my view it is both a management and a moral imperative to reinvest those savings, to save money in what we deliver now so that we can meet the demand and quality changes which we face in the future.  

The NHS should be an example among the public services and an example to the private sector in terms of what it is possible to achieve and that is going to mean radical changes in the way things are done.  

For example, management costs are too high and they have escalated in recent years, so we will reverse the recent increase and we'll do that this year – and then that will be the baseline for the further reduction by a third which I announced last year. 

Remember the deal is this: every penny you release through greater efficiency and a discipline for financial disciplines, will be reinvested in improving services to help us meet the challenges we face.  Savings today will be our fund for growth tomorrow.  

I know the changes I'm proposing are far reaching.  They're intended to be.  

We are intending to see significant changes in the way the NHS does its work.

Bottom up, not top down. 

Purposeful, not process dominated. 

Patient led, not target driven.  

As decision-making shifts and we work together to deliver change, I know there will be some uncertainty, I can't avoid that. But I can and will create a bridge between the past and the future and help to map out the journey we need to take.  

I will be clear about what the strategy is and the shape of the new priorities and systems – and I will do this as soon as possible.  I will build on the good work being done, on QIPP, which is fundamental to success, on CQUIN, on Payment by Results, on practice-based commissioning, on foundation trust freedoms, the piloting of personal health budgets and joint working with local government.  

There is a great deal of work there which I think can be a basis for what we do in the future – but put into a system that is far more coherent and works better for those who are trying to drive reform.  

And not least I will give leaders and managers real freedom and responsibility to deliver results and I want also to involve all of you in working out how to implement that strategy and to engage you consistently in the future.  

Functions will change so organisational form will change too.  But at the heart of making all of this happen will be leadership.  Stronger clinical leadership, stronger managerial leadership and I hope to give stronger political leadership.  

And in incredibly tough circumstances strong management is essential.  We're going to need high quality management, we're going to need leadership.  

For those who can offer both the reforms will offer real opportunities.  It is no surprise to me that some of the people who have most railed to me over years about a top down command and control system and the bureaucracy that it has created, are the managers who want to be able to run their hospitals and services and to show what they can deliver.  

For those managers in fact who themselves recognise the clinical imperatives of safety and quality and outcomes, and who are capable to motivate clinicians also to understand why and how we need the disciplines of performance management and financial control, they actually have exciting possibilities ahead.  

David Nicholson will be talking to you tomorrow, I've asked him to talk to you about the practical steps we need to take and how we want to engage you to make this happen.  I just want to say, David's understanding, far beyond mine, of what you do, how you work, how you have made things happen, the possibilities in many of the projects you have already started, I think has been really important for me to be able to rely upon. I have really appreciated it and I sort of knew we were getting somewhere when David Nicholson first smiled - it took a day or two!  

I know that what I've said today will throw up dozens of questions, I am tempted to say:  David will answer them tomorrow, but no.  

People will be thinking: what does this mean for my organisation?  How is GP commissioning going to work in practice?  How long will this take?  What does it mean for me?  

And I understand all of those questions and more, and I want to work with you to make sure that we answer those questions as soon as we can.  

All my efforts to publish our strategy and to do it early are in order to increase certainty, to let all of you know and others not just the direction we're traveling but where we're going, what that world looks like and how we can make it happen.  

Because I hear people asking other questions: How can I get involved?  How can we make this happen?  Do I need to rethink what we're doing now?  

We can start making progress now, we are not on the terraces as it were, but actually we all of us – and strictly speaking you more than me – you're on the pitch.  You are the people who are making this happen day by day and there is a lot we can do.  

We can accelerate in Primary Care Trusts the process of engaging commissioning consortia, practice based commissioning consortia, making it real now.  

NHS trusts that are not yet Foundation Trusts can now be pushing themselves to achieve FT status and think about how they can use the greater freedoms and responsibility we'll give.  

Everyone can ready themselves, in terms of the culture of our approach – a culture of safety, a culture of focusing on outcomes, of shared decision-making with patients, of opening up new avenues to public engagement and accountability.  

So let's remember why we're all doing this.  Because the NHS is special. Because of a shared commitment to the values of the NHS, because we know for all its brilliant achievements there is still more we need to do. We're doing these things so that we can improve the service the NHS provides, so we can improve outcomes for patients, improve patients’ experience, so we can ready the service to meet demographic and demand challenges, so we can continually improve the quality of what we do and achieve health outcomes that are literally as good as any health system in the world.  

We have a chance now to institute a clear plan for reform for the longer term and that's what I plan to do.  My mission is not a revolution but it is to give everyone clarity of how autonomy and accountability for the service in the future is to be exercised.  

The NHS today is strong, much has been achieved by people here in this hall.  I know the passion that people I meet right across the service have for what they do and the ability they have to do it.  

My goal now is to release that passion – to liberate that passion and ability in order to deliver.  

In a report the Confederation has published today, the Confederation points out that too often the NHS has been subject to unclear, poorly designed, short lived reforms.  

I understand that and I don't intend to fall into that trap.  

And I understand the warning expressed in the title of the report – it is called ‘The triumph of hope over experience’.  

Now, I don't actually think any of us would prefer to have a triumph of experience over hope; we know we can't stand still, we know there are problems to solve, we know there are things we can and will improve.  

What we need is both of those things together – to employ the wealth of experience within the service to realise our common hope for a better future for the National Health Service.  

With your help, and that of everyone in the NHS, that is what I intend to achieve.  

Thank you. 

Access keys