Website of the Department of Health
Please note that this website has a UK government access keys system.
Speech by the Rt Hon Alan Johnson MP, Secretary of State for Health, 29 January 2008: National Event for Trust Chairs
-
Last modified date:6 February 2008
I am pleased to have the opportunity to speak to you today at the start of this the 60th anniversary year of the NHS.
We are fortunate to be involved in the most cherished of our public institutions at a time when the post-war government’s vision of a universal, comprehensive health service – free at the point of need – is being provided with the level of resource that it has too often been denied in the past.
There are two misconceptions about the foundation of the NHS. The first is that it materialised from a political consensus and was launched on a wave of professional goodwill. The second was that it provided a monolithic, centrally-controlled institution that sucked authority into Whitehall. The reality is that the NHS was bitterly opposed politically and professionally. There were even disputes within the Cabinet as Herbert Morrison argued for local authorities to control hospitals whilst Nye Bevan fought for a genuinely National Health Service. When Bevan got his way, hospitals were in effect nationalised but remained under the effective control of various local bodies through Hospital Management Committees. Bevan’s famous remark that a bedpan falling on a hospital floor in Tredegar in his constituency should echo around the Palace of Westminster was not a description of how things were but how he felt they should be. The monolithic centralism is more a product of the 1970s than the 1940s.
The service has survived some traumatic times: In the 80s and 90s it was characterised by a crumbling infrastructure and horrendously long waiting lists.
Liam Donaldson tells the story of how, as a health administrator in the Midlands in the 1980s, he received a letter from an 82-year-old man who had been on a waiting list for a cataract operation for 15 years. He asked if he could use his will to leave his place in the queue to his 60-year-old nephew, who was just developing eye problems. Tragically, it’s a true story.
We expect to take the issue of waiting times off the political agenda completely by reducing the amount of time people have wait for specialist treatment from up to 18 months in 1997 to up to 18 weeks by the end of the year. On cataracts, the maximum waiting time is now 12 weeks.
Leadership and devolution
But for the public, waiting times are in a sense yesterday’s problem. They rightly expect continued improvement and the very nature of healthcare demands constant innovation.
Whilst we should all be proud of what has been achieved, there is a need for a different approach in addressing the challenges that face us now.
Obesity and other lifestyle diseases are as big a threat to our health service today as underfunding was 10 years ago. Stroke care needs the same level of attention as we’ve given to heart disease and cancer. And health inequalities remain deeply rooted. Health has improved for all social classes but the gaps between them have not.
We know that some of the most deprived areas in the country also have the poorest access to healthcare. Our investment in more GP practices and local health centres to address this recognises that access to primary care is a fundamental first step in providing a better service to the most disadvantaged communities.
But we cannot succeed in reducing health inequalities through healthcare alone. The problem is too complex. It is rooted in broader, social issues such as employment, education and housing. Success in tackling health inequalities therefore depends on a co-ordinated effort with health services working in partnership with other local agencies, particularly social care.
It also depends upon a more personalised service focused on predict and prevent, as much as diagnose and treat. Health inequalities is a public health issue and a prevention issue but, more than anything else, it needs a co-ordinated, concerted, local response. 75% of hospital inpatients are older people with continuing and sometimes complex care needs that have to be provided for in the community. Helping older people to live independently at home and reducing the risk of unnecessary hospitalisation is about looking after them effectively:
- maintaining regular contact with services to avoid people becoming isolated;
- providing basic personal care such as nutrition and hygiene; and,
- integrating appropriate health services into the social care package, be that pharmacy support or specialist nursing for diabetes or COPD [Chronic Obstructive Pulmonary Disease].
It is when we look at these issues in isolation – as the responsibility of one agency or another – that we fail our communities. And seeking to dictate solutions from Richmond House cannot succeed. The centralist approach is time-expired. Bevan’s ‘bedpan’ should ring around Whitehall no more.
The argument is not about whether we should provide more autonomy; the debate is about how much autonomy we devolve to local level. It is about empowering clinical staff to be innovative in new ways of working, in developing the service and in re-designing patient pathways. And it is also about accepting accountability for these decisions at local level. The great American senator, Tip O’Neil said that all politics is local. Nowhere is that more true than in the NHS.
As the King’s Fund has recently pointed out, devolution from the centre has been underway for the last 10 years.
Key components of the system have been released from the vice-like grip of government. There is now:
- independent inspection and performance assessment by the Healthcare Commission;
- independent evaluation of the clinical and cost effectiveness of new technologies by NICE; and,
- independent hospitals through the establishment of NHS Foundation Trusts: owned by and accountable to the local community.
But, the system needs to do more to recognise that the shift in approach requires a change of behaviours at the centre.
Let me be clear, government should continue to set priorities in areas requiring national decision. And the Department will continue to drive efficiency and productivity in seeking value for public money.
To abdicate this responsibility and ultimate accountability would be wrong. As would putting the NHS in the hands of a giant unelected quango. This would pass power to the unaccountable, whilst responsibility would remain with those stripped of the power to exercise it. It would also be the biggest top down structural change imaginable, diverting time and resources. It is not the route that we will take.
But we will be less prescriptive about how services need to be delivered and more outcome-focussed in our approach to monitoring performance. The role of the Department of Health should increasingly be to set out what we want to achieve, and not always dictate how it must be secured.
Reconfigurations
As more decisions are taken locally, based on clinical evidence, we at the centre have a duty to support you in those decisions especially when those decisions are difficult. This is particularly important when it comes to reconfigurations.
As the people here from Greater Manchester know, in Greater Manchester, the health service tried for 40 years to change maternity services in order to save babies’ lives. They were always defeated by politicians defending bricks and mortar.
In London, a whole library of reports and reviews seeking to improve and modernise the service are gathering dust for the same reasons.
Where the evidence and advice from local clinicians and independent experts demonstrates that change can offer real improvements – they must be supported. The Darzi Review is looking at how we can ensure that this ambition can work in practice. The current situation where all decisions are referred automatically by me to the IRP and I accept their advice is a temporary solution: We need a permanent one.
The NHS has never stood still – if it had it would have failed long ago. It must and will continue to evolve and change, keeping up with the latest technologies and techniques.
A moratorium on reconfigurations would be a moratorium on change. It would represent a failure of political leadership and therefore, whatever hassle you’ve had to face locally, if there is a sound clinical case for change, we will support you.
Improving performance and tackling failure
Just as we should support you in making these important local decisions, we should have better measures in place to deal with difficulties and intervene to avoid failure.
That’s why we are taking through legislation in Parliament at the moment to establish a new Care Quality Commission with tougher powers to impose fines and close down wards in the event of poor standards.
Later this year I want to spell out in more detail what steps we should take to remove underperforming hospital management, enabling successful Trusts to take over failing hospitals to turn around their performance, and for PCTs to improve or replace weak GP and community healthcare services.
I also want to look at what more you can do to make sure your staff deliver the highest standards.
We've made remarkable progress on reducing infections and I acknowledge the very hard work of all NHS staff to do this. But we need to go further, particularly if we are going to make the same progress on Clostridium difficile as we have on MRSA.
As part of this work I have asked members of the Social Partnership Forum to consider how we can effectively use HR policies, procedures and practices to help. This will include consideration of best practice in effective recruitment, good induction, how training and the use of disciplinary procedures can help.
Effective staff engagement and partnership working with trades unions has a big role to play and needs to be a reality locally as it is nationally.
As we take an open, transparent and determined approach to failure so we will enable you to dramatically improve performance. We will increase your freedoms, enhance your autonomy, giving hospital clinicians and GPs stronger incentives to work together.
World class commissioning – and I know Mark Britnell will be speaking to you in more detail about this later - will require a different approach by Primary Care Trusts: one that is focused on outcomes and involves patients, the public, local authorities, clinicians and providers in making choices about priorities and how to deliver them.
This year’s Operating Framework reinforces this role for PCTs as World Class Commissioners and later this week we will publish the Vital Signs for the NHS, which is a framework for assessing health outcomes and healthcare performance at PCT level.
All PCTs will report performance across the Vital Signs indicators. This will enable benchmarking and inform local decisions on priorities and improvement targets. It will also facilitate performance monitoring against the national priorities.
But, I want to be clear that the Vital Signs do not represent a list of national requirements and I do not expect the Department of Health to be second guessing PCT decisions on priorities: the assurance of this process must be at a local level. We tried very hard – a difficult ministerial process - to pare down the national priorities to the things that are vitally important.
The role of the SHA
The role of Strategic Health Authorities (SHAs) is especially important in the changes that are underway. SHAs need to provide assurance on the performance of PCTs and NHS Trusts in their patches and are developing an increasingly important role as system managers.
Lessons learnt from events at Maidstone & Tunbridge Wells last year demonstrate the potential for failure of governance where the Chair and the Board are unclear as to their responsibilities or do not have the underpinning systems and information to hold management to account.
I know Maidstone and Tunbridge Wells caused some difficult ripples thoughout the system but anyone reading the report know it’s such a serious issue that it has to represent a watermark in how we deal with these issues.
I believe that public trust in senior managers in the NHS is eroded when we hear of large payouts for failure. It is all too easy to agree the kind of compromise package that allows a senior manager to depart quickly, with minimal fuss and with nobody losing face.
But, I think the public and indeed other staff have a right to expect that due process will be followed so that the case for any additional payments are scrutinised and subjected to the approval by the SHA, as well as being referred to Her Majesty’s Treasury. It also means effective performance management of individuals.
Local accountability and the Constitution
One area where we do need a moratorium is structural change. One of the first things I did as Secretary of State for Health was to announce the end of top down re-organisations of the structure for the foreseeable future. I hope this has eased the sense of waiting for the next upheaval and allowed you the space to concentrate on delivering better clinical outcomes and engendering real cultural change at local level.
The Prime Minister in his major health speech at Kings College earlier this month said that we want to see 3 million foundation trust members by 2012 - up from 1 million today - and give them an even greater say in the workings of their trust. That's 2 million more staff, patients and members of the public playing a direct part in running their local NHS and it gives them an even greater say in the working of their Trust.
But this sort of accountability and patient involvement should not be restricted to acute trusts. Through the work of Lord Darzi’s review, I want to explore ways of improving the legitimacy and accountability of primary care trusts and of the commissioning decisions they make on behalf of their local communities.
As part of this change we also need a new articulation of the rights and responsibilities of a modern 21st century National Health Service.
So this year the Prime Minister and I have commissioned the first ever 'NHS constitution'.
This will cover a number of areas. Patients should know the guarantees of service they can expect. For example the right to treatment within a maximum time after referral from a GP; or the right to be seen in A&E within 4 hours; or the right to screening and advice at certain atges in life.
But we will also set out the responsibilities for individuals that come with these rights.
The responsibility to make good use of NHS resources by turning up for booked appointments. Patients who do not turn up should not have the same entitlement to waiting time guarantees.
The responsibility to respect NHS staff. So those who are abusive and violent in A&E should have these rights removed. I assure you that, contrary to press speculations, there is no question of this constitution introducing an obligation not to smoke or become overweight as a condition of treatment. In any case, the constitution will be widely consulted upon, both in its formulationand eventual approval.
Conclusion
The potential pitfalls facing the NHS today are greater than ever before. But we are investing in our capacity to meet these demands. We employ many more talented people, who have consistently shown that they are capable of rising to whatever challenge the future holds. You in this audience are talented people with vast experience outside the NHS and, like me, you come to the NHS in the main with a fresh perspective. I am enourmously grateful for the work you do.
The relationship we have with you and that you have with the public is changing. Over this year it will evolve further so that together we create a more accountable, more personalised, higher quality service that responds to local needs in a more effective way.
An NHS 60 years on, moving from world-class in some areas to world-class in all areas. Your leadership in this process is absolutely crucial and your obvious commitment will be key to our success.
Additional links
Ministers' responsibilities and biographies
Access keys
