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Secretary of State for Health's speech to the National Association of Primary Care's Annual Conference

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

One question that I am often asked is “why GPs?”  Now I’m sure that most of you could give me an answer.  But it is a fair question.  Why should the government – the taxpayer – entrust the vast majority of the NHS budget and commissioning decisions to General Practitioners? 

Well, for a start, we already entrust that money to unelected managers within Primary Care Trusts, and nobody seems too concerned about that.  The fact is, I think that GPs can do a much better job.  Primary care deals with most health problems for most people most of the time.  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.”

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 degree, we have that already.  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”.  We will free you from top-down targets and liberate you from the dead hand of Whitehall and local micro-management.  And we’ve already made a start, removing targets such as 48 hour access to a GP.

And up to a point, you already influence commissioning decisions by how you manage and refer your patients and by deciding which medicines to prescribe.   But it’s only up to a point.  I want you to go much further.

Many of you are already taking the lead and starting to design local services directly – improving patient outcomes and often reducing costs. 

In Northamptonshire, the Nene Practice Based Commissioning Group – whose Darin Seger won an award for clinical leadership yesterday – 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 also 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 by giving the responsibility to shape the majority of NHS services. 

Another question I’m asked is what exactly do I mean by GP Commissioning?  Does this mean, as some have caricatured, that I want GPs to turn into accountants?  To put down their stethoscopes and pick up a calculator?  Becoming more like administrators than doctors?  No.

We already have more than enough managers – an extra 20,000 over the last decade – so there are people we can harness to that task.  What I want from you is your leadership, your judgement derived from years of clinical practice, your status within your community, and the knowledge of your patients. 

GP Commissioning will not turn GPs into managers, but it will require you to be leaders.  Some may want to lead their commissioning consortia.  Others will show their leadership in developing clinical networks. Both are vital. 

You will lead but you will not be alone.  The NHS Commissioning Board will be there with support and advice.  The Commissioning Board is not some new form of central control.  It is not the Department of Health under a new name.  It will hold you to account for the outcomes you achieve for patients and for managing NHS resources effectively. 

But it will not interfere with how you achieve these objectives or how you run your consortium.  It is there to support you, not tell you what to do. 

One form of that support from the Commissioning Board will come in the guise of Commissioning Packs, the first of which we launch today.  I don’t want the job of designing clinical care pathways to get bogged down in a swamp of bureaucracy.  This is where the Commissioning Packs can help.

The packs aim to show Consortia how they can design services that will give patients the best outcomes and use money effectively.  To reduce the time GP consortia spend on things like procurement and administration.

The first Commissioning Pack, for cardiac rehabilitation, and developed with the British Heart Foundation, is now available.  Dr Paul Zollinger-Read, Chief Executive of NHS Cambridge and a practicing GP, describes the pack as, “central to the development of a high quality, comprehensive and patient-centred service.  No doubt [it will] prove an important tool for new GP-led Commissioning Consortia.”  Other similar Commissioning Packs will soon follow.

Of course, consortia can buy-in the support they need for the day-to-day management of commissioning, be that from a local authority, from other NHS services, a private company or elsewhere.  But Commissioning Packs may help to reduce the level of outside management help you need – there will certainly be no need to reinvent the wheel across hundreds of consortia. 

GPs have helped to design the packs and I expect them to evolve as GPs take on greater responsibility for commissioning.  This is exactly the sort of practical help and support you can expect from the NHS Commissioning Board.

So, in practical terms, GP Commissioning means getting together with your colleagues across the local NHS to thrash out how you’re going to run the things locally.  To decide what good integrated 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. 

It’s the hard-headed, difficult stuff of designing the best possible care pathways for your patients. 

Members of the National Association of Primary Care are among the most enthusiastic supporters of the White Paper and I thank you for it.  You understand the incredible potential of GP Commissioning, of local accountability and of patient choice.  In the coming years, your support, your enthusiasm and your leadership will help us realise this incredible potential.  Not only of primary care, but of the whole National Health Service.

But this isn’t just about giving power to GPs.  Just as much, it’s about handing power to patients and carers.  There is a vast amount of research that clearly demonstrated what every one of you will know instinctively.  That a patient’s treatment is always better and often cheaper when they are more than just a passive recipient of care, but an active participant in it. 

I want the fundamental relationship between doctor and patient to develop and become more of a partnership – jointly making decisions about the individual patient’s care.  “The meeting of two experts,” as Tuckett would say.  Some patients will want to lead the way and come to you pre-armed with firm views of what they want.  Others will be wholly dependent on your guidance.  All deserve the very best.

Many of you will already treat your patients as partners.  Involving them in decisions, giving them as much choice as is possible within the bounds of appropriate treatment.  This should be the case for everyone.

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 own needs rather than the needs of the system. 

And because you cannot make an informed choice without proper information, we will arm patients with a wealth of clear, easy-to-understand information so that they and their GPs can choose and shape their care.  Of course, everyone would like the hospital around the corner to be the best in the country.  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. 

And we will not only give them more information, we will give them control over their own data.  The new Summary Care Record 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. 

Personal choice, long spoken of, will finally become a day-to-day fact.
Genuine choice, with money following the patient, will stimulate innovation, increase productivity and provide far stronger incentives for providers to improve the quality of their services and to make them more personalised. 

And people will be able to go further.  They will be able to help shape not only their own care, but local services too.  Strong local democratic accountability will be essential to GP Commissioning.  Patients will have a strong voice in local decision-making through Local Authorities and HealthWatch, a new patient champion.  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 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.

Power in the hands of GPs.  Power in the hands of patients.  All working with and accounting to local authorities and the local population.  The White Paper represents an end to the top-down management of the NHS.  It is a fundamental turn-around of the traditional culture. 

But this removal of power, this end to micro-management, does not stop at Parliament Square.  The responsibility for designing and shaping NHS services will not lie with the Department of Health.  But neither will it lie with SHAs or even PCTs.  That responsibility will be yours. 

I will not dictate what consortia should look like.  Decisions about your size, organisation and structure are for you and your consortium.  You are the ones who know your patients.  You are the ones with the clinical training.  You are the ones with the wealth of invaluable experience.

Unfortunately, I have heard rumours of some PCTs attempting to corral GPs into particular groupings, or even “rejecting” GPs proposals as to the size of consortia they wish to form.  Let me assure you, they do not have this power.  PCTs have an important role to play.  But it is to support you, it is no longer to control you. 

The White Paper places a new emphasis on the importance of public health. 
How can we be satisfied in making the sick well when we have the opportunity to prevent people from becoming sick in the first place?  The public health approach is better for individuals, better for communities, better for the country and far better for NHS budgets.  And I would like to thank the NAPC for your clear support in this area. 

The big killers of today are not the communicable diseases of the past.  They are heart disease, diabetes and stroke.  Diseases that are as much to do with lifestyle as anything else.  And diseases that we can avoid if we alter, often in just a small way, the way we live our lives. 

Again, GPs are perfectly placed to make a real difference in their communities.  Giving advice and information in the consultation room.  Working with community nurses, social care providers and the local authority to make prevention every bit as important as cure.  Your input will ensure that services are clinically led, put patients first and focus on improving clinical outcomes.

Relationships with your professional colleagues will be essential.  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.

Johnny [Marshall, Chair, NAPC] has described the White Paper as “a unique opportunity to raise the bar in the commissioning and delivery of care for patients.”  I must say, I agree with him.  But it will only happen with the commitment and support of everyone in general practice.  And for that to happen, I need your help.

In response to the White Paper consultation, there has been widespread support for the principles, including for general practice-led commissioning. At the same time, there have been apparently conflicting responses to the timetable. Some have said it is too rapid, and that we must iron out every variable first. Others have said it is too slow and they are keen, and even ready, to make progress.

The conclusion we draw is that we can and should support those who want to make early progress and, in doing so, give the wider commissioning community the basis on which they will have the confidence to join in.

So, today, I invite GP-led commissioning consortia to put themselves forward to their PCT and SHA as ‘pathfinder’ consortia. There will be no complex approvals process. Simply show that you have local GP backing, strong clinical leadership, engagement with your local authority and are fully signed up to the Quality and Productivity agenda locally.

Early pathfinders, nominated from the end of October, will be supported to form a National Learning network. We want to see pathfinder consortia established with the support of their PCT and SHA. Early pathfinders will be able to participate in a formal evaluation process run through my Department’s Policy Research Programme. I hope that, countrywide, there will be local learning networks in place before next April, so that 2011-12 can be a year of substantive development of consortia relationships, engagement, leadership and identification of preferred support arrangements.

I will look to all PCTs to offer opportunities for GP clusters or pathfinder consortia to be active participants in commissioning decisions and budgetary responsibility during 2011-12.

No one should feel they lack support to make progress now, if they are ready; and no one should feel they have to take on responsibility without learning and support available.

For seven years, I’ve heard “why don’t they listen? We know we can do it better”. Now is your chance.

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