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Secretary of State for Health's speech to the NCAS conference

  • Last modified date:
    7 December 2010


I’m quite taken with the title of your conference: Building the Present, Shaping the Future.

When it comes to the future, there are three kinds of people. Those who let it happen. Those who make it happen. And those who wonder what the hell happened.

We have to be very much in the second group – not the victims of events, but the architects of solutions to help us triumph over circumstances.


To do so, we need a clear strategy based on strong values and clear principles.

For the NHS, through the White Paper, we set out those principles:

First, a patient-centred NHS. Patients not just as beneficiaries of care, but as active partners in its design and delivery.

Shared decision-making. Patients feeling that invariably, when they encounter the health service, it’s a case of ‘no decision about me, without me’.

This is a principle not just for the health service, but a principle for the public service.

Second, an outcomes focus for the health service. Striving to achieve results for patients, not straining to meet arbitrary targets set by politicians.

Again, a principle for the public service – to focus on results.

And a third principle for the NHS and for public services: the devolution of decision-making, close to those who are responsible for the service delivered and wherever possible into the hands of those who are the service beneficiaries.

For us, in the NHS, giving much greater freedom and discretion for clinicians to drive change within their own organisations.  

And I think across social care those principles are equally clear:

A focus on prevention. Keeping people as independent as possible, for as long as they feel able, by providing earlier support.

On protection. Protection from harm and abuse. Reassuring people that support will be there and lifting the fear that everything they’ve worked for may be lost, simply because of the care needs they develop, on what sometimes seems to be an arbitrary basis.

A principle of partnership. Ensuring that individuals, carers, families and communities work together with local services, balancing family and community action with state support.

And the principle of personalisation. Giving people control of their own care, so they can choose the services that best meet their needs.

All of those principles come from core values that are at the heart of this coalition government.  The beliefs that support and sustain all of us involved in public services.

Values of fairness – caring for each other, and the social solidarity that both the NHS and our care services represent.

Of freedom – giving all of us greater freedom through those services to take more control of our lives; to feel ownership of the services, and their results.  

And responsibility – for our own health; responsibility of families and communities for the health and wellbeing of our community; and importantly, businesses demonstrating their corporate social responsibility

Those values become all the more important as we look to the future.

We now need to bring these values and principles into a vision of how our care services will meet the pressures and demands facing us.

Because care is at a crossroads. Demography is literally remoulding society and it is transforming demands on public services.

More older and more vulnerable people - for example falls are costing the NHS a billion pounds this year.

More cases of dementia – around 750,000 today, predicted to double over the next thirty years.

And more people living with serious long term conditions.

Only last week, new data told us that people over 75 spent in total an extra 1.5 million days in hospital last year – nearly 50% more bed days than ten years ago.


It’s clear that investment is only part of the solution.

We can’t continue putting more and more money in to meet ever-increasing demand.

We need a more sustainable way forward.

A new outlook.

A Big Society approach to caring for our ageing population.

An approach that shifts power from the state to people and communities.

That means giving real freedom and flexibility for the social care profession to find new ways of supporting people.

Ways that draw upon the innate relationships and sources of support that lie underused within our communities.

It will require a double devolution of power. From Whitehall to Town Hall. And then from Town Hall to the citizen.

Stimulating a shared sense of responsibility between the State and the individual for meeting care needs.

There’s no shortage of experience or knowledge about how we can make this happen.

Technologies like telecare and telemedicine are already increasingly used to help people stay safe in their own homes.

When I was in North Allerton, talking to North Yorkshire County Council, they told me about their programme of telecare services. This was established over three years ago.

They put it very simply: “For every hour someone is on the floor, it’s an extra 24 hours in hospital.”

They’ve shown the investment paid off. North Yorkshire has saved over a million pounds – more than a third reduction in costs, achieved by postponing entry into residential care or reducing the homecare support required.

The best councils are also testing new commissioning practices to support people differently.

Building new connections with the voluntary sector to bring greater flexibility and variety to care.

For example the community network organisation Shared Lives, which is helping micro-enterprises to secure local government contracts.

One of their most colourful stories was about an older lady who wanted to keep her flock of geese when moving into new supported accommodation.

I think if we can accommodate a flock of geese we can accommodate most requests…

Or the advocacy and advice provided by SupportNet in Nottingham –helping people to use their Direct Payments to make new friendships, to improve disability access on local public transport and forming lunch clubs and exercise classes.

Direct payments and personal budgets are not just about people making decisions themselves, it’s about opening up new opportunities for people to be helped to make decisions – individually and collectively in local neighbourhoods.

As one local resident put it in Nottingham– it’s all about “getting people to care about each other.”

So we need a care system that reflects that principle; which uses those new kinds of design.

And I’ve been very encouraged to see a kaleidoscope of community and user-led organisations emerging around the country – all of them determined to do care differently.

But how do we make this systematic – not just good examples but good practice across the country?

How do we blend enlightened commissioning and the enterprise of the voluntary and independent sectors to collectively open more doors and create new possibilities for older people and for people with disabilities?


Well, it means new priorities, new ways of thinking and new ways of working.

Partnership on a new scale.

We know the benefits of that. But with some very worthy exceptions, they’re too often unrealised.

Dementia is a case in point.

A third of people with dementia who go into hospital from the family home never return home. They end up being discharged into a care home.

Also on dementia, as Sube Banerjee has told us, 1,800 people die each year because of the inappropriate use of anti-psychotic drugs.

Many of them are prescribed these drugs as the first response to behavioural difficulties, before other and often effective, solutions are considered.

If we can get all the key people – care homes, GPs, mental health professionals, social workers, all working in partnership, we can do much better.

Better for them, better for the taxpayers, better for our communities.

And thanks to the leadership of the Alzheimers Society the Dementia Declaration already has 45 organisations signed up from across the public and independent sector. This is a powerful model for the future.

Each of these organisations came forward, worked together, to pledge support to reduce anti-psychotic use and improve support for people with dementia.

That’s the kind of social movement that will drive change. It’s a Big Society response to this challenge.


Children’s health is another area where we know we need to do better, and where we can do better if we have health and children’s services working together more effectively. That is what Ian Kennedy’s report told us just a few weeks ago.

If we prevent just five children going into foster care, we can save £135,000 a year in care costs alone, and we give those children more stability and a better chance of doing well at school.

Or if we improve breastfeeding rates by just 10 per cent, you stop nearly 4,000 cases of gastroenteritis and 1,500 cases of asthma a year. That would save about £7 million a year.

Spot serious behavioural problems in just 10 children and you save society two and a quarter million pounds over their lifetime.

Prevent one case of conduct disorder, the most common form of child and adolescent mental illness; you save £150,000.

This is in the context where half of all mental health problems are capable of being identified before the age of 14 – so if we can boost child mental health we can transform over time the mental health of the nation.

So we are investing in 4,200 new health visitors to help us support families and provide services where they suit the family best – at home, through their GP surgeries, through Sure Start Children’s Centres and other non-traditional settings.

Last week, I announced that we will double the number of Family Nurse Partnerships, so that we can both achieve the universal service that health visitors should be and the very targeted service for the most at risk families that Family Nurse Partnerships presents.

And we’ve also launched a consultation document on the future of children’s health – and how we can bring services together to secure better outcomes.

I know that many colleagues here from across children’s services in local government will be actively involved in that.

And I very much agree with Marion Davies when she said yesterday that “Now is not the time to retreat into professional silos but to build on the benefits of local partnerships.”

We’ve known that for a long time.

Integrated working is an old message with a new urgency.

We need to implement change in the way that makes it a reality around the country.


Last month’s Spending Review confronted many painful necessities, including what I know will be painful reductions in grants to support local government services.

The potential impact on social care services was a very serious issue for us.

There were real concerns that depleting social care would mean drastic reductions to eligibility for care support and would overwhelm the NHS with emergency admissions.

We recognised those issues. We made crucial choices; and we secured a vital settlement for social care.

That was something that was achieved across Government. It wasn’t just the Department of Health, not even just DH and the Department for Communities and Local Government working together.

It extended to the Treasury, to Number 10, to the Deputy Prime Minister.

To take one example of a key individual involved, in Paul Burstow, care services and adult social care is a devoted advocate of care services and care support.

Somebody who has understood it for years; somebody who believes in it; and somebody who is very well-placed not only in our Department but beyond to argue the case for social care.

He’s done it very effectively already, and I know when you listened to him on Wednesday you realised what a powerful advocate you have got inside Government.

Paul took you through the numbers on Wednesday, and I want to reinforce the points he made then.

The Spending Review is a strong platform upon which to base our planning for the future.

It’s a platform for change, a platform for improvement, and it is a bridge to the long-term care funding settlement which is being mapped out by Andrew Dilnot and his team. I don’t think there’s anybody better than Andrew Dilnot to be leading that work too.

I know there are questions being asked – such as “will the extra money get through?”

Let me take you through it.

Next year, there will be an additional £800m provided over and above the social care settlement, through the NHS, to support social care.

£150m of that, next year, will be spent on reablement – in addition to the £70m which we announced last month that will be available this financial year.

That will be backed by the new rules whereby NHS Trusts, from next april, will take responsibility for their patients for 30 days after discharge.  This is part of the focus on outcomes: the outcome of treatment is not that a patient is discharged from hospital, it is that they are discharged in a fit state, with support in order to then resume their activities of daily living at home. That’s what we’re aiming for – that responsibility.

After care will no longer to be an after thought for the NHS – it will be integral to the outcomes we want to see.

Hospital Trusts will need to work with you on reablement support to make sure these readmissions don’t happen; to make sure that outcome is being achieved.

But I know there has also been some discussion at this conference about the NHS money for social care beyond reablement.

For the remaining NHS money provided to support social care next financial year - nearly £650 million next year – there will be very clear instructions through the new Operating Framework to be published next month.

This will set out specific Primary Care Trust allocations that they will transfer to Local Authorities for spending on social care services to benefit health, and to improve overall health gain.

PCTs will work with you to agree where the money should be spent, with a shared analysis of need and common agreement on what outcomes need to be met.

I know that you need certainty in order to plan and work together effectively.

So in December we will set out allocations for next year, and we will set out indicative allocations for the year after.

That money provided to support social care will be
divided up using the social care allocation formula so it will properly direct funding to where it is most needed.

I think this is the clearest statement ever given by a Government that health and social care should be complementary, not conflicting. Integrated, not in silos. Cost-sharing, not cost-shunting. One system pulling together, not two pulling apart.

Let me just walk you through the whole of that settlement, to reinforce what Paul said on Wednesday.

I think we have been very clear: firstly that we have taken the ringfence off many of those grants that have been provided to you and continue to be provided to you.

• Adult social care grants representing over £1.3bn next financial year [rising to £1.4bn by the end of the Spending Review], without a ringfence [the grants will be rolled into formula grant]

• Learning Disability Transfer and Health Reform Grant together, of the order of £1.3bn next year, allocated on the basis of the Learning Disability requirements, but without a ringfence. So that is an unprecedented de-ringfencing of resources from the Department of Health to Local Government as part of that partnership.

• In addition to all of that is a total of £800m next year [through the NHS to support social care]. It’s very front-end loaded: it rises to £1bn in 2014-15 (and in the year prior to that it’s £1.1bn). It very rapidly rises because we recognise that you have needs that are going to have to be met next year, and a lot of financial pressure next year.

All of this represents a real opportunity to press on with reform.

To redesign care services for the future.


And that’s precisely what the proposals in the NHS White Paper and the forthcoming Public Health White Paper will help us to achieve.

The NHS White Paper had a clear aim to bring real, local democratic accountability to health care for the first time in 40 years.

John Ransford yesterday talked about how local government is good at shaping place and community leadership. I entirely agree.

That is why I want to make sure that joint Strategic Needs Assessments really give us the basis for local integrated strategies embracing health services, public health, and social care.

That Health and Wellbeing Boards be a magnet drawing the key people together around the table to build on common ground; to have a shared sense of place and a focus on delivering the best results.

I know many of you are keen to get going with these arrangements.

Some authorities are already working up their own plans for integrated working. So thank you for the all of that enthusiasm you’re already showing, and which was evident in the many responses we received to the White Paper consultations.

I want now to work with you to find the right way forward.

That’s why I can tell you that in coming weeks, we’ll be inviting local authorities to establish trailblazers, a collection of pioneering local authorities to show how these arrangements will work in the future.

The early implementers of health and wellbeing boards will link with General Practice-led commissioning pathfinders to ensure we can get the right relationships in place.

And in particular I hope that will, in a number of places across the country, enable us to see how all of these new arrangements lock together in order to deliver benefits - and bring benefits sooner rather than later.

But, in truth, whether one is an early implementer of these arrangements or not, I can already see the benefits coming through.

Pretty much everywhere I go across the country people are not only talking to one another, but starting to put in place new relationships, new behaviour, and new ways of working: all designed to influence positively the current commissioning and service design arrangements, in order to secure better results, particularly in light of the financial circumstances that we face.


All of this paves the way for a Public Health White Paper, and a new approach to preventing illness and supporting health in our communities.

As you know, from 2013-14 onwards, public health improvement will be entrenched within local government, as part of your responsibilities.

There will be locally led plans, with local budgets and local powers.

Strengthened responsibility and partnership.

A health premium recognising deprivation and rewarding success.

Directors of Public Health providing new levels of expertise within local authorities – working with other local leaders to bring a new coherence to health, social care and public health together.

And, underpinning all of this, a new way of measuring success and gauging progress.

Not through targets or inputs that distort decisions, but through a framework of outcomes that make sure the decisions you make are relevant and successful in making progress.

Outcomes are the common currency that will bring services together. So I am clear that we need to connect across public services. We need the framework of outcomes for the NHS, the framework of outcomes for public health, and the framework of outcomes for social care to mesh together.  

We will shortly be publishing a consultation on how we develop the framework for outcomes for social care, to make sure this reflects exactly those objectives and your views about how those outcomes are best measured for your communities.


The essence of the Big Society is trust and optimism.

Through these changes, we are going to trust people in our public services, more; and trust local government to deliver for its communities.

And it’s optimism too. Being optimistic about the resourcefulness and resilience that resides in every community.

We need to believe in people again. To support and value the contributions they make. To show leadership and advocacy in embedding change within and beyond our organisations.

That kind of change for carers, for example – and we will be announcing plans in the next few weeks that will recognise and support the efforts of carers more fully.

And positive change for professionals too – to give them that greater sense of ownership of the professions that they are proud to be part of.


Social work has been a particular victim of a decade of micro-management.

Borne down by the paperwork.

Reduced to managing processes rather than achieving results.

So we need to rediscover social work’s original purpose, to re-professionalise social work, to give  them the skills they need, and the autonomy and discretion they are qualified to exercise.

So today, I’m also announcing plans for new Social Work Practice pilots to give greater freedom and control for the profession.

These pilots will explore how social workers can form independent groups, contracted to local authorities, working across health and social care to secure better outcomes for service users.

We have the benefit of example: the pilots already in place for looked after children are very impressive.

They’ve cut bureaucracy. They’ve improved flexibility. They’ve given social workers more time to concentrate on children and young people themselves.

We hope to achieve similar benefits for adult social services – cutting the paperwork, and improve the services.


So what does the future then hold for all of us in adult social care?

Some might agree with the Frenchman Paul Valery.

“The problem with the future,” he said, “is that it isn’t what it used to be.”

We would all like there to be a tide of money that can float us off any dangerous rocks and reefs.

I can fully appreciate the anxiety over what lies ahead.

But local government has a strong record on rising to new challenges.

It has an enviable history in health protection and improvement – stretching right back to the earliest days of public health, when the great advances in public health were actually civic actions led by local government.

So this is our chance, for you to take back that kind of freedom and power. To that extent, the future might actually be like what it used to be.

A chance to lead for your communities.

A chance to write a new chapter in the history of health improvement.

The future is in your hands. Don’t let it just happen to you. Let’s make it happen for you and your communities.

Let’s focus on outcomes; let’s work together across health and social care; let’s deliver the quality and level of support which fully provides for the young, the old, the disabled, and the most vulnerable.

We know that any government, any society, any local government, is measured by the way in which it responds and cares for those who are the most in need and the most vulnerable in society.

We can do better, we can achieve this, but only
if we work together. Health and local government, working within their communities, with local and professional leadership. Working together. Let’s make it happen.

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