Website of the Department of Health

Speech by the Rt Hon Alan Johnson MP, Secretary of State for Health, 5 November 2007: NHS Chief Executives Conference

I’m delighted to have this opportunity to address the NHS’s chief executives en masse so to speak, as you discuss issues around leadership and management.

For those of you who wonder what the difference is, someone once explained to me that leadership was when Noah heard the weather forecast and ordered the building of the ark. Management was when he said, “But make sure the elephants don’t see what the rabbits are up to.”

There could be no more noble calling for today’s world class managers and leaders than to exercise their skills in the National Health Service.

Nye Bevan said of the NHS when it was created “The service must always be changing, growing and improving.  It must always appear inadequate”.

I’m not sure I agree with the last part but all of you will understand what he meant. Such a comprehensive, universal system is bound to have an importance stretching beyond the medical, in strengthening our society, supporting our economy.

Its not an easy occupation for managers who are often portrayed as being unessential cost burdens except when things go wrong, when they become central to avoiding every mishap. 

A recent Healthcare Commission survey showed that 92% of inpatients considered that their care was either “excellent, very good or good” – satisfaction ratings which any company would give their eye teeth for but few ever achieve.

You should take pride in that survey and in the steady improvements we’ve seen in the NHS over the past decade.

The long waiting lists, crumbling infrastructure and regular winter crises are now largely distant memories.    

There are nearly 80,000 more nurses and 35,000 more doctors than there were in 1997.

Mortality rates from cancer are down by 17%; from cardio vascular diseases by 35%.

More than 1 million extra operations take place every year. In 1997, the number of patients who had been waiting for an operation for longer than six months was 284,000. Today, it is less than 500.

With this additional capacity in the service, and a settled structure, it is now possible to move to the next stage of the transformation of the NHS – by concentrating all our attention on improving quality.  

In the last few months, Lord Darzi and his team have spoken to thousands of people who work in and use the Service. A new vision is emerging of an NHS based around four over-arching themes.

The first is fairness. All forms of inequality are abhorrent, but there is no more chilling brand of inequality than when someone’s social status at birth determines the time and nature of their death. 

Lifestyle factors are responsible for around half of the inequality gap. We need a concerted assault upon smoking, alcohol abuse and obesity, but we must also address stubborn disparities which remain in primary care provision.

Many years ago, Doctor Julian Tudor Hart wrote about the inverse care law: the frustrating paradox that it is those most in need of care services who are least likely to receive them. Some of the poorest parts of the country with some of the worst health outcomes have almost half as many GPs and practice nurses per head as the most affluent. We must tackle these inequalities by bringing new and innovative primary care services into deprived areas to help drive up health outcomes.     

The second theme is personalisation.

If the post war challenge was to create a universal service, free to all at the point of need; then the challenge for the 21st Century must be to ensure a more personalised service which meets the pressures of today’s lifestyles. 

Many people struggle to make GP appointments within the constraints of current opening hours. Others simply do not know what provision exists, leading to unnecessary pressures on other parts of the Service, particularly A&E.

Primary care remains the main gateway into the NHS – and we must make sure that the high quality of our primary care is matched with greater accessibility.

The third theme is safety.

Every country in the world is grappling with the problem of Healthcare Acquired Infections. We are the only one with a universal national infection surveillance system. The report into Maidstone and Tunbridge Wells was truly scandalous, exposing terrible failings at every level.

Where safety standards are not met, trusts must be held accountable.

Incidentally  while I’m on this subject the public and staff in the NHS are rightly concerned about money being squandered on excessive payments to departing executives in questionable circumstances – it damages your reputation and it damages the reputation of the NHS. 

The Maidstone and Tunbridge Wells Trust, under the leadership of the new Chairman, has decided that it will not, at this time, be paying any of the severance package originally agreed with the former Chief Executive. I entirely support that decision. Indeed, as you’ll be aware, David Nicholson has written out to all NHS Trusts giving advice on the proper process and approvals that must be sought in relation to severance payments in those - hopefully rare - exceptions where contracts are terminated early.

The fourth theme is innovation.

The NHS has always been good at developing new medical discoveries but must match this with an increased readiness to adopt new working practices as well: so that we have a dynamic Health Service, at the cutting edge of innovative developments in products, processes and procedures. The new Health Innovation Council will promote the benefits of medical innovation to the NHS and social care system and provide leadership in supporting the discovery, development and adoption of cost-effective health technologies throughout the services, helping to coordinate and support existing work streams.

These increased ambitions for the NHS places an enhanced premium on strong leaders.

We know that transformation needs to come from the bottom up. They must be clinically led and locally driven.

This calls for a new relationship between the NHS and local communities.

Leadership will be required, not just of your organisation, but across partnerships, particularly with local authorities and the Local Strategic Partnership.  NHS leaders will require more varied and multifaceted skills. Passion and commitment will continue to be essential, accompanied by a greater sense of circumspection, dynamism and innovation.

This changing model in leadership is not a feature unique to the health service. Business leaders are increasingly quick to spot talent and ideas, rapidly responding to the most subtle shifts in technology, markets and economies. It is also true in politics, where the interconnections of the modern world mean few decisions can be made in isolation without reference to global, European or regional partners. Equally events and decisions taking place around the world have a significant impact on the UK.

World class commissioning will be the underpinning delivery vehicle for the achievement of world class clinical services and a world class NHS. It will be PCT commissioners, together with their partners, who will be the key enablers of the four themes outlined by Lord Darzi and the overall improvements that we want to see across the service.

I want to be clear that world class commissioning is not an end in itself. In order to prove themselves successful, commissioners will need to demonstrate better outcomes, adding “life to years and years to life,” as the saying goes.  PCTs will need to have a clear local vision of what they want to achieve, and use commissioning as the means of achievement.

In order to support the vision for world class commissioning, it is important to understand the characteristics and organisational competencies that PCTs will need.

For example, leaders in PCTs must reach out, react and respond to the local community which they serve, with proper accountability for the quality of service that is provided. PCTs, with their local authority colleagues, should, be visible community leaders. Together they will undertake Joint Strategic Needs Assessments which will provide a strong understanding of the needs and wishes of the local population. This will enable them to jointly invest funds effectively on the community’s behalf.

We need PCTs who are forging innovative partnerships with outside organisations; developing solutions which match the needs of their community: fully utilising the potential of pharmacies, sports centres and high street walk-in centres to meet patient needs.  By working in partnership with a range of organisations, in particular local authorities, PCTs can develop a shared ambition and look outside of the traditional methods for delivering services.

In addition to competencies around leadership and partnership working, PCTs will need to support meaningful clinical leadership and engagement, be expert knowledge managers, be clear about the outcomes and improvements in quality that they want to see, and back this up with robust procurement, contracting and performance management processes.

Local Area Agreements provide an opportunity for PCTs, Council and partners in the voluntary and independent sector to agree local priorities for improvement. LAAs can be used to lever improvements in services for older people, people with dementia and people with learning disabilities.

As David said, this is a big ask, but we know that many PCTs have already demonstrated that they are well down the road towards world class commissioning including my own PCT in Hull.

Slough Primary Care Trust has developed a technique called “Health Needs Mapping”, using complex data to ensure that they fully meet the needs of their local population: pinpointing precise postcodes which require special intervention, enabling them to reach the local South Asian population in particular.

Heywood, Middleton and Rochdale PCTs have joined forces with Sport England and the Big Lottery Fund to regenerate sports facilities in the community.

Liverpool PCT regards itself as a ‘strategic commissioning organisation.’ Their stakeholder engagement initiative provides members of the public with an integral role in determining and designing services and selecting the providers. 

More PCTs should follow the standard of the best: and in the coming months we should look at what support mechanisms and frameworks need to be in place to help you all to achieve these standards.

We are working closely with the NHS Confederation, NHS Institute, and a wide range of PCT and SHA colleagues to determine what the support and development framework for world class commissioning should involve.

We know that commissioners will wish to draw upon such resources differentially according to their local strengths and weaknesses, so we need a framework that can evolve to meet these needs. 

The framework will offer resources for sharing; for example sharing best practice, or sharing services such as the West Midlands Commissioning Business Support Agency; for building internal capability, such as the NHS Alliance/Humana commissioning academy; and for buying in external expertise, for example the Framework for Procuring External Support for Commissioners.

World class commissioning is the important key to unlocking so many of our policy aspirations: tackling health inequalities; and shaping a Health Service in which the emphasis moves much further towards investing in health and well-being, which joins up public health, mental health and adult social care much more tightly.

A shift towards a prevention based society can’t be achieved by the NHS alone.

It requires individuals to take more steps around improving their own health, with healthy eating and regular exercise.

As the recent Foresight Report on Obesity pointed out, employers should also do more: for instance, providing loans for bikes, not just season tickets; subsidising gym membership, not just canteens; and small things such as putting fruit out at meetings, rather than biscuits.  

Local authorities have an important role to play in ensuring that health is built into towns and cities, making it easier for people to build activity into their everyday lives.  Local action could include: increasing the number of cycle lanes, designing safe walking routes to schools and town centres, and modernising playground and leisure centres.

Government must be much bolder in the field of public health to be far less trepidatious about “nanny state” accusations. I believe the public are less worried about a nanny state than a neglectful state.
 
In recent months, we have made a number of major advances, including:  going smokefree in public places, making psychological therapies available nationwide and vaccinating young women against cervical cancer. The Prime Minister and I will come forward with further measures, in the coming months. 

An increased focus on prevention will also be crucial in tackling health inequalities.

In some poorer communities, tooth decay is twice as high as in the most affluent areas.  Taking two areas with similar population characteristics – Sandwell and Bolton Children’s tooth decay has halved in Sandwell in the last ten years. It’s stayed at the same high levels in Bolton. The difference is that since 1986 children in Sandwell have benefitted from fluoridated water.

I hope that more PCTs and SHAs will grasp the nettle and consult on fluoridation in areas with high levels of dental disease. Although it can prove a controversial local issue, it is an essential means of tackling health inequalities. We know it works, and it delivers the greatest health benefit to the poorest people. 

The NHS has to bring this often neglected public health issue back to life if it is to tackle inequalities in oral health.

So Nye Bevan was right, the NHS continues to change. This is different from the late 90s when we had to take a Service which was on its knees and administer life saving resuscitation. It is about moving the NHS from good to great: so it is world class in all areas and not just some. Leadership has never been as important in the Health Service as it is now.

As Jim Collins said in his famous book “From Good to Great”, you can mandate ‘good’; ‘great’ has to be unleashed. You’re the principle unleashers in the NHS and I want to do everything I can to support your valuable work.  

I give you my very best wishes for a useful and productive conference.