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Secretary of State for Health's speech to the Royal College of General Practitioners

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

(As delivered)

Just three months ago, I published the White Paper, “Equity and Excellence: Liberating the NHS”.  It is an ambitious plan for reform.  It is focused around three key purposes:

  • to put patients first – to make real that, in the NHS, patients feel that ‘no decision is made about them, without them;
  • Secondly, to focus on outcomes, not inputs and processes, and to build a culture of evidence and evaluation.  To ensure that healthcare uses innovation and evidence to provide quality care, and is accountable for improving outcomes;
  • And, thirdly, that in order to deliver the best care, we must empower the NHS staff whose responsibility it is to give that care.  And, in particular, to take decision-making close to patients, and, therefore general practice, better to combine clinical decision-making with use of resources.

In short, to trust you.

If the White Paper is about anything, it is about these purposes and that trust.  It is about making “the system” reflect and support the essential human relationships that exist within it.  Not to act as a barrier, but as a conduit.

Our ambition is clear: for the health outcomes in this country to be amongst the best in the world.

Today, the NHS has some of the best people and the best facilities in the world.  But the fact of the matter is, when it comes to what is really important – to outcomes – we lag behind.  Survival rates for cervical, colo-rectal and breast cancer are among the worst in the OECD.  We are on the wrong side of the average for premature mortality from lung cancer, and heart and respiratory disease.  And you’re more than twice as likely to die from a heart attack here in the UK than you are in France.
Patients deserve better.  The NHS can be better.  And with the reforms we have set out in the White Paper, it will be better.  I know there is a wide range of opinion regarding the White Paper.  There always is when you try to do something substantial and challenging.  But I have been encouraged by the widespread acceptance of the principles of our reforms.  If we keep those purposes clearly in view, I am convinced we can work positively together to deliver them.

I have been responsible for health, in opposition and now in government, for nearly 7 years now.  For a politician, that’s a very long time.  And in that time I’ve visited most hospitals in the country and as many GP practices.  I’ve spoken to numerous doctors, nurses and other health professionals about just about every facet of the Health Service.  I’ve learnt a lot.  But I’m not a doctor.  And when all is said and done, despite all that I have learned on the way, I know that you, working together with your colleagues across the NHS, can organise the NHS from the bottom-up far better than I ever could from the top-down. 

One question that I am often asked is “why GPs?”  Why should the government – the taxpayer – trust the vast majority of NHS commissioning decisions and the NHS budget to General Practitioners?  Well, with around 300 million consultations every year, no-one knows patients better. And you are the only group of NHS professionals with a population responsibility, so vital in improving the health of a nation. 

Professor Barbara Starfield, from the John Hopkins Bloomberg School of Public Health in Boston put it better than I could when she said, “There is lots of evidence that a good relationship with a freely chosen primary-care doctor, preferably over several years, is associated with better care, more appropriate care, better health, and much lower health costs.”

Primary care deals with most health problems for most people most of the time.  Its priorities are to be accessible; to focus on individuals; to offer comprehensive care for all common problems; and to coordinate services when care from elsewhere is needed.

We also know that when specialists care for problems outside their main area of expertise, the results are not as good as with primary care. Since most people with health problems have more than one ailment, it makes sense to have a primary-care practitioner who can help decide when specialist care is appropriate.

But it is not enough to have excellent general practice.  To a large extent, we already have that.  No, we must go further and empower general practice to organise, to coordinate and to innovate beyond the confines of the practice. 

As its name suggests, our White Paper is about “liberating the NHS”.  Setting you free, not pulling you ever more under the control of the state, as the previous government did.  I value your status as contractors, independent from the state.  It is that independence which enables you to be the collective decision-makers on behalf of your patients and population; if you were all salaried GPs, then inevitably, the bureaucracy would control you and you could not be leaders.

So, we will free you from top-down targets – and have already started the job with the Operating Framework.  And we will liberate you from the dead hand of Whitehall and local micro-management. 

To an extent, this change is less radical than often represented; it is in truth one of degree.  You already influence commissioning decisions by how you manage and refer your patients and by deciding which medicines to prescribe.   You decide what is best for your patients based on the options available and your own clinical judgement of what would be best for them.  Within limits, your referrals and patient choice drive service configuration.  But only up to a point, and too often it does not. So, I want you to go further and create the choices.

Some of you are already going further and starting to design local services directly.

In Northamptonshire, the Nene Practice Based Commissioning Group has developed a peer review scheme that has dramatically cut referrals to their local hospitals.  In 6 months, the scheme prevented some 900 outpatient referrals to orthopaedics.  This not only improved patient care, in its first year it saved over £600,000.

In Croydon, GPs have worked with senior clinicians to start a one-stop GP-led service for women with menstrual problems.  As a result, waiting times to see a senior consultant have reduced dramatically from 10 weeks to just 2, with fewer than 10% of patients needing secondary care.  And their work is being recognised.  They have been nominated for two of this year’s Practice Based Commissioning Awards.

I want to build on this.  Giving the responsibility to shape the majority of NHS services to you. 

Another question I ‘m asked is what exactly do I mean by GP commissioning?  Some have caricatured the White Paper as some sort of attempt to turn GPs into administrators.  Well, we don’t lack managers (up by 20,000 in the last decade) so we can harness them to the task.  No.  What I want is your leadership and judgement, derived from your clinical role, your community stature, and your knowledge of your patients.  I don’t want to turn you into administrators.

In essence, GP-led consortia, with GPs in close partnership with other healthcare professionals, will establish the range of services and contracts needed to give their local population the access they need to services, and the choices they want.  In hard, practical terms, it means getting together with your colleagues across the local NHS to thrash out how you’re going to run the NHS locally.  To decide what good diabetes care looks like; what a good asthma service will provide, how pre- and post-operative care can best be organised, what a more integrated urgent care service looks like. 

And for those patients with complex needs – patients with severe mental health problems, the socially excluded, patients with multi-morbidity – areas where GPs can sometimes feel unsupported, commissioning allows you to pull in the support you need to provide better care for your patients and to prevent unnecessary admissions. 
Commissioning is the hard-headed, difficult stuff of designing the best possible care pathways for your patients. 

Yes, there will be contracting.  Yes, there will be negotiations and accounting and administration.  But unless you want to do it, this is not your role.  Your role is to ensure that the services you provide are clinically led, put patients first and focus on improving clinical outcomes.

And I agree that it would be “unacceptable for the rationing of limited resources to take place at the level of the individual GP and their patient”.  This isn’t what we mean by commissioning.  It’s about ensuring that the services you need are available and the choices are there.  Where investment or disinvestment is needed, these will be collective decisions, in consultation with healthcare providers and local authorities, not for an individual GP.  Of course, when budgets are tight, priorities must be set.  That is true now.  No GP should be ignorant of the relative effectiveness of treatments nor the impact of referrals or decisions on the overall service locally.  And, anyway, rationing happens now.  Too often, by PCTs in ways not sufficiently sensitive to the clinical need of patients and too often just cutting out what comes last or latest.

GP Commissioning will not turn GPs into managers, but it will enhance your role as leaders.  Just as it takes a teacher to run a school, it really needs a GP to run a consortium.  Some will choose that route but others will show their leadership through innovation or advocacy for their patients in their practices.  Both are vital. 

And when it comes to the day-to-day managerial and administrative tasks, consortia will have a separate budget with which to buy-in the support they need, be that from a local authority, a charity or independent contractor or elsewhere.

And you will not be alone.  The NHS Commissioning Board will be there with support and advice and to share and spread the experiences of others.   There will be no need to reinvent the wheel hundreds of times if one consortia has already worked out how to do it.

But one thing the Commissioning Board will do as little as possible is to tell you what to do.  And nor will I.  I will not dictate what consortia should look like.  Decisions of your size, organisation and structure are not for the Secretary of State, the Department of Health or your PCT.  They are for you. 

One thing I will do is put in place a payment mechanism that acts as a powerful lever for consortia, that encourages innovation and rewards those who improve health outcomes.  I will introduce a more comprehensive, transparent and sustainable system that really does mean the money follows the patient and that quality really is rewarded.

By 2013, we will have made a lot of progress: in getting quality into the tariff; into payment for outcomes, not just activity; into establishing efficient pricing; into developing negotiated risk-sharing or marginal pricing; and into extending tariffs into community and other services so that services can be commissioned on a care pathway or a ‘year of care’ basis.

The success of your commissioning decisions will be determined by the relationships you develop with others.  Your local specialist community nurses will be there to help you design the best community services, just as hospital consultants will be essential for designing specialist pathways before, during and after a period in hospital.  Local authorities will be crucial for helping you integrate health with other local public services to maximise outcomes.

And you will be free to organise yourselves within and beyond the consortia level as you see fit.  Not everything will need to be at either a single practice or a whole consortia level.  Where it makes sense, groups of practices within a consortium might work together as a sub group.  Two or more consortia might work together to draw on each others experience and expertise or to co-commission services over a wider area.  The flexibility will be built in to the system from the start because it’s up to you.

This approach is similar to the RCGP’s own idea of Primary Care Federations.  Of practices working together to deliver a whole raft of improvements for patients, including better access, health promotion and services such as x-rays and scans delivered in the community closer to home.  The Federation model recognises that groups of GP practices working together can achieve more than individual practices working in isolation.  And so does the White Paper.

But that collaboration need not stop at the NHS’s doorstep.  We are blessed in this country with an incredible wealth of experience, expertise and energy in the shape of our many specialist charitable organisations.  Organisations that help people with long-term conditions like diabetes, neurological diseases or dementia.  These will be a rich source of advice, information and experience as well as an valuable additional resource for you to draw upon.  This includes developing commissioning support services, as the Motor Neurone Disease Association, Parkinsons Disease Society and MS Society are currently planning.

For there is army of volunteers out there to draw upon, people who are willing to work with general practice to improve the lives of those around them.  People like the Lindsay Leg Clubs who, working with local district nurses, have helped thousands of people suffering with leg ulcers.  As you would expect, the Clubs make sure that patients have their wounds treated and dressed and show people how to prevent them recurring in the future.  But they are about more than that.  So often, it is the isolation and embarrassment that can accompany a conditions like leg ulcers that is the hardest thing to deal with.  The Clubs help people to get back out into the world, to achieve the simple, every-day dignity of meeting new people, sharing a cup of tea and a chat.  To feel human again.

I said earlier that you have ‘population responsibility’.  So do I.  And sometimes the NHS can focus too much on the directly clinical.  On treating the condition and curing the ill.  But the NHS cannot simply be the human equivalent to the RAC, fixing people when they break down.  We have to do far more to prevent people from needing treatment in the first place, to keep people healthy.  We need a new emphasis on public health.

We are often great at treating ill-health in this country but we’re not so good at preventing it.  We have the highest rates of obesity in Europe, rising levels of drug and alcohol use and, despite recent falls, stubbornly high rates of smoking.  As a result, nearly a quarter of all deaths in England, at least in part, stem from an unhealthy lifestyle. 

In December, we will publish a second White Paper, this one on Public Health.  Its aim will be to transform our approach to public health: protecting the public from health emergencies like swine flu and improving the nation’s overall health and wellbeing. 

Public health reform will follow three principles:

It will be local, with strong local democratic accountability – through Local Authorities and HealthWatch, a new local consumer champion – giving the public a real voice to reshape local public health services. 

It will be unified, with the new Public Health Service bringing together organisations like the Health Protection and Food Standards Agencies under one roof to develop and deliver policy at a national level.

And it will be integrated, because you can’t put public health in a box.  Cycle lanes, good quality housing, effective planning, and healthy schools all play a vital role in improving public health.  Big improvements can come when lots of linked, small changes are made. 

With that, and the reforms of social care to be signalled later next year, much will change.  It will require careful, measured but purposeful implementation.

The changes set out in the White Paper are intended to come into effect by 1 April 2013, in two and a half years time.  It is too slow for some, too fast for others.  But there is no merit in long-drawn out organisational development.  Be clear about the strategy, the changes and then implement fast, is the clear conclusion of organisational development experts. Two and a half years allows for us to resolve issues over the coming months; to support pathfinder practices in 2011-12 using delegated powers, and to give all consortia, through a learning network, the ability to prepare their relationships and support plans.  Then, in 2012-13, a full dry run before the legal transfers.

So meanwhile, start thinking about what you will do in your area.  Consider what would be the most appropriate model to meet local needs. 

And there are lots of things you can do right now, under existing legislation.  Some practices are already leading the way.  Two consortia in Cambridgeshire launched ten days ago with control over a quarter of NHS Cambridgeshire’s £870 million budget. 

And NHS Cumbria has handed its Payment by Results community services and prescription budgets to six GP consortia.

If you want to move faster then by all means do so.  I am not saying that you must.  But I am saying that we will give you support if you do.  Explore the possibilities, build the relationships that will be so important in the new system, prepare the ground for what is coming.  And, if you are ready, talk to your PCT about taking further advantage of the current freedoms, through Practice Based Commissioning or setting up a shadow consortium like those in Cambridge or Cumbria.

It’s not only to general practice that we will hand power.  We will give power to patients and carers too.  As an overwhelming mountain of research demonstrates, and as every good doctor knows instinctively, treatment is always better and often cheaper when the patient is an active participant in their care, not simply a passive recipient.  In the coming years, we will give patients real control over when, where and by whom they are treated.  They will be central to all decisions about their after care, often spending their own budget in the way that suits their needs rather than the needs of the system.  And we will make much clearer the position over patient records. 

Previous plans for patient records made the fundamental error of putting the needs of the NHS before the needs of individual patients.  Your records would be put into the system and shared with all and sundry and you didn’t really have much say in the matter.  Yes, we all received a letter through our door saying we could opt out if we wanted to, but the letter was so long and poorly written that I’m sure I wasn’t the only one who struggled to understand what it was saying!

I can tell you today that we have reviewed The Summary Care Record and it will hold only the essential medical information needed in an emergency: medication, allergies and reactions.  If people don’t want this information shared, we will make it easy for them to opt out.  If they want more information stored, it will be their choice, based on explicit consent, with clear information. 

We will start with the summary care record, but we will not stop there.  We will arm patients with a wealth of clear, easy-to-understand information that they and their GPs can use to choose and shape their care.  Yes, everyone would like their nearest hospital to be the best.  But the fact is, it may not be.  People are not stupid.  When they can see which hospital, which department, even which Consultant-led team is offering the best care, they will vote with their feet. 

Personal choice will not be the only way that people will be able to shape their care.  They will also have a say in how you shape local services.  Strong local democratic accountability will be an essential part of GP Commissioning.  Patients will have a strong voice in local decision-making through Local Authorities and HealthWatch.  For the first time, local people will have real powers of scrutiny over local health services. 

GP Commissioning also opens up the potential for working closely with local authorities to jointly commission services, even for the pooling of budgets to jointly tackle local priorities.  For example, by working closely with the local authority and social care providers, far more can be done to help older people or those with a disability to live independently.  Reducing their reliance on the NHS by avoiding things like hospital admissions.

The Government’s proposals and the ethos of the RCGP share a common thread – we are both determined to improve the quality of the NHS and the outcomes for patients.  One example of how you are leading the way, constantly striving to improve the quality of general practice, is your Practice Accreditation Scheme.  Accreditation will show patients – patients with the power to choose – that a particular practice is safe and offers high quality care. 

I am especially pleased at how closely you’ve been working with the Care Quality Commission, ensuring a good fit with the new CQC Registration requirements, which are conversations I have enjoyed in Opposition and now in Government.  So today I can announce that if a practice achieves RCGP accreditation, the CQC will use this as evidence towards registration and take a ‘light touch’ approach to ongoing monitoring.  This will improve transparency whilst significantly reducing the burden on practices. 

Another area where the RCGP has been active is working with the Department and the General Medical Council on the revalidation system.  The public expects that their doctor is up-to-date and fit-to-practice.  As professionals, you expect nothing less of yourselves.  But there will be some who, for whatever reason, do not quite measure up to the professions’ own high standards.  Who may have let things slip a little.  Revalidation will help to lift everyone up to a basic level of competence and safety, and give the public the reassurance they need.

Now, some people have interpreted my decision to extend piloting for another 12 months as kicking it into the long grass.  Those people are wrong.

The extra time for piloting is not about getting rid of it.  It’s about getting it right.  It’s about making sure that we balance the needs of the system with the needs of patients.  That we are certain that the benefits clearly and significantly outweigh the costs.  That it does not become just another tick-box exercise. The extra time will allow us to test the procedures and to streamline any processes.  Practices should be thinking now about what revalidation will mean to them.  Annual appraisal of doctors, effective clinical governance, responsible officers with the right support.

Practice Accreditation, CQC Registration and GMA Revalidation will all help to give patients and the public full confidence in NHS doctors.  This is about, as all things should be in the NHS, putting patients first.

Before I finish, I would like to pay tribute to Steve Field who in a few weeks is stepping down after 3 years as Chair of Council. Throughout his time, Steve has believed in general practice as a positive force for change.  He has been a great representative and leader for your profession.  His work to promote the 'federated' model of patient care – with practices working together to provide more services in the community - has been an inspiration for the White Paper. He has always striven to improve the standards of care provided by GPs and primary care teams, leading the call for more patient and public engagement.  He has argued powerfully for a stronger public health priority. And he has constantly championed the causes of the most vulnerable in society, including the homeless, travellers and asylum seekers.  Steve, you leave the RCGP stronger than you found it and I am sure I speak for everyone here when I say thank you for everything you have done as Chair.

I would also like to welcome Clare Gerada to her role.  I have already enjoyed our discussions.  Clare will take forward the new Institute of Quality Improvement, Innovation and Commission Support to help GPs to deliver the White Paper.  Clare understands the central importance of education and training for GPs, and so do I.  Later in the Autumn we will consult on how we move to an increasingly responsive, evidence-based system of education and training, making sure local skills match local needs.  As I have made clear I am looking to leadership from within the profession to shape this. And so I very much look forward to working with you, Clare, and the college as you provide this.

I started today by saying how everything we do is based on the principle of trust.  Well, as well as trusting patients to choose, and GPs to lead, I hope that you can also trust us, the government, to do everything we can for the NHS.

In just 11 days, George Osborne will set out his plans to rid this country of its crippling deficit, so that no longer are we burning more money than we spend on health and social care combined.  The impact of this will be significant cuts almost across the board. 

It is a measure of the importance that we place upon the National Health Service, and the future health of the nation, that its budget will not be cut, but protected. 

We all know that this doesn’t mean there will be no pain.  With a growing and ageing population, new drugs, new technologies and the ever-increasing expectations of the British people, the NHS budget will be stretched like never before.  We will need to make great efficiency savings just to stand still – and we need to do far more than just stand still – and to some it may certainly feel like an unprecedented squeeze. 
But the key difference for the NHS will be that every penny saved, is a penny available to be reinvested in the Health Service.  It’s a penny spent on new cancer drugs we otherwise couldn’t afford.  On better public health where once this would have been the first budget to be cut.  On higher quality, integrated, patient centred, outcome focussed health services led by you.

Real leadership is about making hard choices in difficult times.  To govern is to choose.  The choice we have made is to put the NHS first.  To trust the NHS.  And you can trust us to stick to it.


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