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Chief Executive of the NHS in England's speech to the NHS Confederation

  • Last modified date:
    6 September 2011
Sir David Nicholson, Chief Executive of the NHS in England

ACC Liverpool, Friday 25 June 2010

Sir David Nicholson, Chief Executive of the NHS in England

Thank you.  Right then, well it's great to be here.  I have to say I spent yesterday watching the Secretary of State and I was completely distracted by the words up there, so I'll try to be very careful not to say any words that might be construed as inappropriate.  The other thing I would say is that - just a slight apology for me.  I've got - you've heard of people who've got a cold, and you've heard of man flu, and I've got Chief Executive flu.  So, if you hear intonation in my voice it's because I am depressed or miserable about what's happening.  I genuinely am not.

And one of the things I thought about the Secretary of State yesterday when he said that after a week I'd smiled - I know when you heard someone shout at the back "it was wind", but I'll leave you to make your own judgments about all of that.

It's really fantastic to be here.  I think I need just to say something about Keith Pearson who did a fantastic job in the East of England, led a great turn around of that particular part of a system, who did huge amounts of work in relation to the Constitution, the real kind of beating heart of the NHS, and it's great to see him as chair of the Confederation.  I really do look forward to working with Keith over the next period.

The last six weeks, in particular, have been extraordinary for us at the centre in particular.  The development of the Coalition Government, the work around that is completely different to anything that certainly I had seen before.  I have seen four different Secretary of States, three Prime Ministers now.  And nothing quite equipped me for what was going to happen when the Coalition came into being. We can see that in all sorts of things that are happening, not just in terms of the substance of what they're saying but also in terms of the way that they work. 

We have this extraordinary thing now where we have a programme for five years.  We've got a Government that's saying it's going to be there for five years and we have a very detailed programme for those five years. So it seems to me that's a fantastic thing for us in the NHS because one of the things we'  have constantly had to deal with, this real big issue, first about clarity, but also about consistency of purpose. And I think I can certainly see in the way the Coalition is working that you possibly we can get both of those things.

It is not the same, I have to say, as having a one party in charge.  Our ministerial team has a Liberal Democrat as part of that membership.  They discuss openly the issues of concern between them in the Department and they are genuinely trying to work together in a way that genuinely surprised me. And I think we'll see this as we go through the next few years, the implication of all of that.

Now, one of the things, though I think you saw yesterday and I guess those of you who have been following the work that Andrew Lansley has been doing over the last period, is that this is a really very, very significant and important set of changes that are being proposed at the moment for the NHS which will have a big implication over the next few years.  And just to kind of give you a flavour of that I think - I mean first of all Andrew has been in Opposition and been the Opposition spokesman for six and a half years. So he's been walking round talking to many of the people in this room over the last six and a half years.  I can't think of any Secretary of State who's ever come into a place where they've been in that position.

But he's also a man in a hurry.  I think we have to understand that in terms of the way the Coalition is approaching all of this.  One of the criticism - or critiques if you like, of the change of government between Tory and Labour last time, was it took Labour about four or five years before it developed its fully formed ideas about the NHS and about the need for reform. And in a sense, the critique is that they lost four or five years during that period.  So, there is an absolute determination; we're going to make change, we're going to make it soon.  That's a great in lots of ways, an aspiration, and we can understand why people are in that place, but I think we need to understand that as we go forward.

The other thing I think that I would say, certainly my experience over the last period, is that you do have to start changing the way you think in order to understand the direction that people want us to go, the Government want us to go in.  There is no doubt if you look at some of the big issues, and I'll talk about it in a little more detail later, the GP consortia for example, a natural response in these circumstances because we're the kind of people that we are, is to think OK so how is the governance going to work, how is the accounting officer arrangements going to work, how is all of that mechanics going to work?  And I think that's important stuff, but in a sense it misses the point.  It's what we need to be doing as leaders of the system is think: what are the opportunities available?  The sort of things that we've tried to do in the past and haven't been able to work, the way we want to change services for patients which for a variety of reasons we haven't been - what are the opportunities for that in the future?

I have been going through that process myself over the last five or six weeks.  I've heard the ideas and I've been going back and working out, so how can I mitigate them?  How can I stop the worst excesses of them?  That won't get us the direction, it won't be able to provide us leadership in the system if we do that.  So, big change, big change. 

And what are the lessons from the past?  Well, I've been in the NHS a long time and I know many of you have and I read with interest Nigel's document on big change and I think the thing - well, two things I would say about it.  The first thing is that - and all the evidence shows this of course - is that 70 per cent of big change programmes don't work.  They fail.  A real possibility in these circumstances.  70 per cent don't work.  Of the 30 per cent that do work, what are the de fining characteristics?  Well, the defining characteristic is not the brilliance of the vision.  You can have the most fantastic and coherent vision available, but unless the management of change, unless the transition is properly led, you simply won't deliver it.  You can have poorly thought out visions, which actually deliver real change.  So, while the vision is critical and important, the transition is what will make the difference.  The transition is the thing that will make the difference between success and failure.  And who is going to lead that transition?  You are.  And that is the big test I think for us as we go forward.

Big lessons from the past but the most important lesson from the past for me if I think about change I've been involved in is when we lose sight of the purpose, that's where it all goes wrong.  If we think about the problems we got ourselves into in 2004/2005, we got so obsessed and excited about the mechanisms and the mechanics of change, we lost sight of why we were there.  How do I know this?  Our staff told us, when we asked them, that's what was happening.  They thought the NHS was much more interested in a whole set of reforms than it was about delivering improvements of service for our patients. 

So, when we go through this change, how can we make that bridge between the past and the future?  Because that is the thing.  That is the transition.  That is the thing that is going to make the difference for us as we go forward.  And that bridge is very clearly absolutely fundamental to the work that we've done over the years and is reflected in High Quality Care for All.  If you look at that document, it is absolutely the bridge between the past and the future. 

What it sets out is that quality should be the organising principle of the NHS going forward and you get that through empowered clinicians and patients with clout.  That is the way you do it and that is absolutely central to the direction going forward that we need to keep hold of it.  It will make sense to us and it will make sense to our people if we concentrate our attention on that issue around purpose.

Now, if you look at quality and outcomes, critical for us as we go forward, and we put a lot of effort over the last two years of improving quality of service for our patients, and we have a systematic approach to it. We've talked about the setting of quality standards, we've got quality accounts, we've talked about transparency in information, we've produced huge amounts of comparative clinical data about what people are doing, people have got into quality improvement in all sorts of significant ways.  We made great, great progress.  But, we need to move further and faster.  We need to mobilise the whole of our system to improve quality.  One of the things that we learned from that is that quality was systemic.  It wasn't just about the activities of one individual clinician with all of us supporting it.  It was about a whole system.  It was about getting your screening right; getting your early intervention right; getting the primary care right, getting multi-disciplinary teams in the right place; properly managing end of life care.  All of those things are absolutely critical and that is what we need to focus our attention on as we go forward into the new world, but we need to do it further and faster.

It's no accident that next week we're going to be launching the very first quality standard, national quality standard on stroke services.  A real gold standard there for us to mobilise the system and our organisations and our people around to make real top quality services for people who suffer from a stroke in our society.  But, we need to move with it.

On patients, if I'm sort of self critical about the work we did around High Quality Care for All, we said we wanted to give patients more clout. But when you look at the way in which we dealt with all of that, the effort we put into it as compared with items on quality, I don't think we really did consistently in an organised way - we got a set of very interesting policies, but when you put them altogether, I don't think they make a step change for patients. So, how can we go forward using choice, using transparency, using all of those activities?  How can we do that to really give patients clout?  A really important thing I think as we go forward.

And, finally, the issue of clinical empowerment, empowering clinical staff.  Again, good work across the patch.  There are some practice based commissioning organisations which work really well, but it's not gone far enough and it's not consistent enough.  It's not an accident that we think that clinical service in primary care needs to take a greater role in the direction and moving of the NHS in the future.  GPs are amongst the most trusted people in our society.  Dare I say even more trusted than NHS managers and politicians.  And we need to understand that and work with it.  They also have a major effect on the way in which resources across the system are used.  Some of you may have heard the work that James Kingsland and his team have done which show that relatively small bits of change in primary care activity can have a massive cost impact on the service.  If each GP asks for one less blood test a week, referred one less patient to hospital a week, that would make half a billion pounds worth of difference to the cost in the system.  Now, I'm not suggesting that alone should be the reason why we should give them a greater role in the future of commissioning for the NHS, but it gives you a sense of the power that we could unleash if me could get that aligned with the improvement in quality of service for patients that we need.

But, that just doesn't apply to primary care, of course.  It would be a real problem for us if we managed to engage and encourage and support and develop GP consortia, but in secondary care the response was bureaucratic; that actually you couldn't get primary and secondary care clinicians talking together to improve service; that in secondary care people had to go through bureaucratic arrangements to make things change.

So it's just as much a challenge to secondary care and I know in secondary care, service line reporting, all of that really important, but I do think this issue about clinical engagement is not just an issue about primary care, it's also an issue about secondary care and we really do need to take that forward.

So, can we make this change? Well, I think we can.  We've got a fantastic record of managing change in the NHS.  If you think about the last 15, 20 years, the way in which we've moved services, the way in which we've shaped organisations, the way we've transformed the way we deliver care for our patients.  We can do that. 

The question for me I think is whether - and the question for us all in this room - is whether we have got the will and whether we've got the energy to make it happen.

From my point of view, what I would say to you is that I'm absolutely dedicated to the NHS.  I have worked in it for 32 years and I think what I will say to you is, first of all, I will always tell it to you absolutely straight.  I will not give you false assurances when they are not there, and I will do everything that I can to make sure that we have a set of systems and processes that underpin this big change, that treat people, our people, the people who have delivered so much for us over the last few years, with the amount of respect that they deserve.  It seems to me that's absolutely what I've got to do as Chief Executive of the NHS in this particular moment.

And we've all got to look at these changes and I certainly have got to look at those changes in four kinds of ways.  First of all, can I use them to improve the quality of service for our patients?  Critical thing for us.  Can I use them to make sure that our patients can have a greater say in their care, can be more central to what we do?  Can I use them to make sure that clinicians and our staff are more empowered to make the changes that they need to make?  And finally for me, absolutely critical for me, are they consistent with a universal service free at the point of use?  But not a consumerist system, not one which deals with people as they arrive, but actually seeks people out who are in the most disadvantaged communities to make sure they get services wrapped around them.  It seems to me they're the important issues as we go forward in relation to these tests.

In light of all of this, what should we all do as we go forward?  If we take first, all providers of care.  Clearly, the QIPP process is critical to this.  The QIPP challenge delivering quality and productivity over the next period is going to be absolutely critical and even the most optimistic people, and there are even some in this room, even the most optimistic people would not say that we'll get this new system up and running in the next couple of years or so.  It simply isn't going to be there.

Even the best practice based commissioners at the moment, on a scale of one to 10 are about three or four in relation to the ability to be a GP consortia.  They're going to be able to help us and support us, but they're not actually going to be able to make that change.  We're going to have to make that change.

People who work in providers now are going to have to make those, so QIPP is absolutely critical to keep our handle on all of that as we go forward.

Those of you who are not yet FTs - whether it is community, mental health, ambulance or acute hospitals - get yourselves to become foundation trusts, and by going through that process, you'll have to do QIPP plans you'll have to do all of that. 

So, no excuse for not becoming a foundation trust. Even David Lawton in Wolverhampton will have to become a foundation trust in future.  Wolverhampton hospital has had a whole series of problem in the past. David has done a fantastic job turning it around.  It is, in fact, a year yesterday since they had their last case of MRSA in the hospital so a fantastic job you've done there David {applause}. Worth congratulating and recognising on all of that, so if you not a FT become one. 

If you are running community services, the purchaser provider split, we've got to do it end of March, make it happen, but that's not the big issue.  The big issue is how can community services be transformed for our patients to support the shift from secondary to primary care, to really get into intervention, early intervention, all of those things that me know will make the big change for our patients.

And ambulance services.  Something for all of us, actually. One of the ways in which we will get success over the next few years is to reform and transform urgent care.  Ambulance service have a critical role to play in all of that.   And you need to focus your attention on working with the rest of the system to make it a reality.

So, commissioners.  What's the message for commissioners as we go forward?  Well, the same in relation to quality innovation and productivity.  Very important that you get your plans together.  Start to build the new capacity for GP commissioners.  Get amongst them.  I've seen the results of the world-class commissioning stuff recently.  It's going to be published by PCTs sometimes towards the end of July.  It shows a remarkable improvement in our ability to commission.  We've built up huge amounts of skills and capacity in our system; some hugely talented people in our system.  We don't want to lose that.  We want to make sure we continue to improve our commissioning skills.  Now, sometimes they're not always recognised by the rest of the system.  Absolutely true.  That does not mean that they don't exist.  They do.  And getting amongst GPs, getting to understand the kinds of things we've learned over the last period about commissioning will be absolutely critical as we go forward, so make sure you get amongst them.  Make sure that the skills that you have as commissioners constantly improves.  Make sure that we don't take a step back on some really hard won and I say fantastic skills that people have got around the system.

For leaders in general,  and all of us here, we have to get ourselves, our minds, inside the way the world will look in the future.  It's our responsibility to do that, to make sure that we can do that.  Now, while all this is going on we've still got - and the immediate effect of all of this is probably on about 100,000 people in the NHS when you look at all the people in PCTs, SHAs, departments, arms length bodies, general practice - about 100,000 people. Which still leaves 1.2 million, 1.3 million people out there delivering services for our patients.  Now, they need oxygen from us.  They need support and help from us.  They do not need us to look at our own navels and get worried about the future.  They need that oxygen that only we as leaders can provide them.

And that's why it is so important this whole issue about behaviours.  And there are three things I'd say about those behaviours as we go forward.  The first thing is we need to avoid turning into commentators. We need to avoid that - I can perfectly understand it.  I've been there.  Sat in the terraces telling people what they think of what's happening.  There will always be a bit of that and I understand that's part of being an organisation but we need to be there actually making things happen and the faster we do that the more likely we are to get the results that we need.

Secondly we can't afford to be inward looking, we - there lies real dangers for our patients and our system.  It is very - I can perfectly understand the attractiveness of being able to say well I'll look after my department or I will look after my organisation and the rest of them, well, that's up to them.  The idea of islands of success in a sea of failure for the NHS is not a place we can get ourselves into.

Good leadership has always been about looking across boundaries, it has always been about that sort of thing, it has never been about standing behind your walls and defending yourself. And in this time of change it is inevitable that people will worry about that but we simply can't allow ourselves to do it. 

And the final thing about behaviours is, well, I think we've seen it in the World Cup, we've seen it in that we do not want to be the French football team of the NHS.  We don't want people to look back to us and say we turned into the French, though I have noticed one or two Anelkas around as I have been looking but we don't want to be in that place. 

We have to get hold of this and I know I've said to you on occasions before, looking out not up, focusing our attention on our communities and our patients, is where we'll get things absolutely, absolutely right.

So, I think we can make these changes.  Have we got the will and the energy?  Well I think my will and my energy comes from the values I hold as a person who works in the NHS I am sure it does for you as well. And it seems to me this is the time for us who call ourselves leaders in these circumstances, this is the time that we've got to take up that particular challenge. Aned where it says on the tin, says leaders on the tin, that's what we have got to do now, we have got to lead.

Conclusion

I want to leave you with this with this thought. There are significant changes; there is no doubt about it. For many people in this room, and many colleagues that we've worked with for a considerable amount of time, over the next two or three years we are going to see that change unfold.  It is going to unfold in a different way to what it has done in the past.

One of the issues about the past, whenever I think about Commissioning a Patient-Led NHS or Shifting the Balance of Power, with all of those things there was a certain a kind of something happened, then something else happened, then something else.  This is going to be a slightly different way of change happening, much more of a kind of chemical reaction of changes than a sort of set of levers and structures happening.

So, in that environment that we're working in, I have obviously said that it is part of my responsibility to make sure that people are treated with respect and we support people through all of that.  But there are three things I would say about as we go forward in relation to that.

The first one is focus our attention on purpose.  Lose that and we lose everything.  Make sure as we go through this change we concentrate on improving quality of service for our patients, making patients at the centre all what we do, and empowering and supporting our staff to make it happen. 

Secondly I think we need to be realistic.  There is a big management cost saving to be made; a significant management cost saving to be made.  I am not going to kid you that it's all going to be okay.  Its not.  Some people are going to lose their jobs during this time.  So we have to be realistic.  Do not give people false hope.

But the third and final thing for me in relation to that is that we should have confidence because we have done great things before.  We have as a group made great change in the past.  And I am absolutely sure that we should use that confidence for the future.

I will finish off by saying something that I know many people have heard me say before. When the British people are asked about their greatest achievements, they say the founding of the NHS was one of, if not the greatest achievement, that the British people have ever made.

The NHS is not the plaything of individual in this room, it is not the plaything of managers, it is not the plaything of boards.  It's not even the plaything of politicians.  It is a very, very important thing for our people.

And just to read the beginning of the Constitution, for me focuses us on the purpose.  Focuses on why we are here.

It says:  'The NHS belongs to the people.  It is there to improve our health and well-being, supporting to us keep mentally and physically well, to get better when we are ill and, when we cannot fully recover, to stay as well as we can to the end of are lives.  It works at the limits of science - bringing the highest levels of human knowledge and skill to save lives and improve health.  It touches our lives at times of basic human need, when care and compassion are what matters most.'

It seems to me that is a fantastic aspiration and a fantastic purpose that we, as leaders of the NHS going forward ,need to keep very central over the next few years.  Thank you very much.

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