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GPs go forth

Andy Burnham's speech in full

Health Secretary Andy Burnham's keynote speech on the future of the NHS, including details of plans to scrap practice boundaries, moves to drive forward PBC and why quality accounts will be important.

'Thank you, Niall, and thanks to all your team here who have helped put on this event.

Today, as you said, I want to talk about the NHS in the next decade.

It will, of course, be a very different decade than the last. In 1999, the big challenge was to get more people through the door; today, it is all about the quality of what they get once inside.

The financial context was tough back then, and it is again now. But there is a very big difference. In 1999, we had an NHS suffering from malnourishment. It will enter 2010 funded at close to the EU average of GDP, a platform of immense strength on which to build.

Even so, I know there is some uncertainty in the service about what the future holds, particularly on funding as Niall says. It is true that the era of large catch-up funding growth is over. But, as I hope to explain today, that doesn't mean going backwards.

With all the focus on spending, there is a danger that people in the service try to read the runes and conduct there own mini spending reviews. The risk is that necessary service changes or improvements may be postponed, wrong judgements made on incomplete information.

I don't want to see any of that ‘glass-half-empty' thinking set in.

First, let's remember that average growth in PCT budgets is 5.5 per cent this year and next; second, the NHS has always been Labour's priority and it will continue to be.

Working together, we can make sure that the next period in the NHS is not one of decline but continuing improvement in front-line services. But our optimism must be balanced with realism: the better services we want to see will have to be funded from taking on a bigger efficiency and productivity challenge.

So, today, I want to set out the policy direction and the steps we need to take to get the NHS ready for this new era.

I begin by setting a new level of ambition for the next ten years, based on a frank assessment of where we are today.

In the last decade, the NHS has gone from poor to good. Because of that, it has earned the opportunity to go from good to great in the next.

So that will be the mission of a fourth-term Labour Government: a great NHS, preventative and people-centred, placing quality at the heart of all that it does.

The NHS has made this a realistic goal because of the distance it has travelled and the mountains it has climbed. It has put itself in a position to worry more about quality than quantity.

Where once a majority of patients received sub-standard care, that situation has now reversed. The vast majority get good care from the NHS and are satisfied with it. In places, it is outstanding. But, as we have seen most recently at Maidstone and Tunbridge Wells and then at Mid-Staffordshire, there are still isolated examples of where standards fall well below acceptable standards.

So, let's celebrate our achievements without over-claiming for the NHS. On waiting times and infection rates, it has accomplished what many thought to be impossible. But it can be better. There are countless anecdotes of wonderful care, as the spontaneous ‘We Love the NHS' campaign showed, but it can still be a service that still discharges elderly patients late at night without enough regard for their home circumstances. While it can save thousands of lives, 365 days a year and cope with the effects of a global pandemic, it can still cause inconvenience and disruption to the home lives of those with chronic conditions or families with sick children by putting institutional convenience before the needs of the patient and their family.

There is, let's be honest, real room for improvement. And the big new challenge we all face is to make that happen not through large funding growth but service reform.

The inescapable conclusion I reach is that we will only achieve this if, learning from our experience of the last 10 years, we find a better, more engaging way of taking reform forward.

We also need real stability.

Labour's aim is to lock-in the progress we have made. That's why we've said that important public-facing targets – a maximum of 18 weeks from GP referral for elective surgery and 2-weeks for cancer – will become rights though the NHS Constitution.

When we started, waiting times dragged down the reputation and international standing of the NHS. It took a concerted national effort, directed from the centre, with clear and increasingly challenging national targets to turn that situation around. And over time the maximum wait fell. First to 12 months, then 9, then 6. Now, nobody waits more than 18 weeks and people often wait for less than 8.

This progress was hard-won. There should be no slipping back. Everyone, wherever they live, should know exactly what they can expect from the NHS, and what to do if they don't get it.

To remove these standards – as the Conservative Party propose – would, in my view, lead to more variable and less accountable services, handing power to the professions and not the public. And past evidence has shown that the biggest losers in postcode lotteries are often those living in least affluent areas.

When this proposal is considered alongside the plan to hand the NHS over to an independent board, the loss of public accountability is potentially very great. It would be the biggest structural change since the creation of the NHS. Mr Cameron's plans to create the world's largest quango out of our NHS urgently needs greater scrutiny.

But we want to do more than bank the progress of recent years. And that's where reform becomes more, not less important.

I can imagine some people being filled with dread when they hear those words. It will be taken as code for all sorts of unpalatable things. But I don't want it to be that way.

The time has come for us to set out a better way of pursuing reform in the NHS. Top-down reform was right for its time, but it can only go so far. It led to a feeing that reform was imposed; done to people, rather than with them. It gave unintended messages at ward level – ‘public bad, private good' – and process targets implied a lack of trust.

Going from good to great needs a new, more unifying approach. It means inspiring people with the goal – a great NHS improving and saving more lives than it does today – and building a much bigger sense of ownership of the reform journey needed to get us there.

Going forward, the role of the centre is to identify the problem – for instance, too much variation on length of stay, day case rates, prescribing and referral patterns. But local decision about how the trust moves up to the level of the best.

The centre can also help the NHS enter the new financial climate by giving the NHS more time to plan than we have managed to do in the past.

In the coming months, I want to issue a multi-year tariff for the four years covering the remainder of this spending review period and all of the next. It will begin the process of showing how we realise David Nicholson's challenge of finding £15-£20bn of savings over the next Spending Review period.

The multi-year tariff will set out the scale of the efficiency and productivity challenge year-on-year, building up over time with the most demanding savings coming later.

When set against the overall spending for the NHS, where my priority will be to protect and enhance front-line services, it will give the NHS certainty and a longer run at the challenge.

It also gives us time to make what can still feel a counter-intuitive argument to some in the service that quality and prevention are the best routes to financial sustainability. I am confident that we can win hearts and minds: for instance, winning the war on hospital infections through higher quality services has saved the NHS up to £260 million. So ‘quality cuts costs' is more than a sound-bite; in healthcare, it also happens to be true.

We won't dictate to people how to make these savings, these decisions are better made on the ground. But, by giving NHS organisations time to plan, we hope to avoid knee-jerk measures that can destabilise a local health economy.

However, we do expect local plans to be credible and deliverable and, we will require organisations to measure, demonstrate and account for delivery. Where organisations are off-track, we will ensure they take action to hit their efficiency targets.

But alongside this we need to take a fundamental look at how we measure quality and create the right incentives to encourage it. Ara Darzi's Next Stage Review identified the common purpose – quality – and it is now time to put real bite behind it.

In short, ‘payment by results' needs to do what it says on the tin – pay more for better patient experiences.

We have reached a point on the reform journey where it is right and necessary to develop our approach in this area.

Central direction has played its part in making us ‘good'. But no amount of command and control will ever make the NHS great.

To quote Professor Michael Barber: "You can mandate ‘awful' to ‘adequate' but you cannot mandate greatness. Greatness must be unleashed."

Labour's vision recognises that we need a smarter centre that creates the maximum freedom for local innovation, builds in powerful incentives but stands ready to intervene where services are letting patients down. For example, where we identify underperforming providers or commissioners we will act to drive up the standards of those organisations by liberating the best to actively support those who most need their help.

To open up this radical new phase of reform, and create space at a local level, we must mean what we say and dismantle some of the old apparatus of top-down change.

Many of the central systems were built for a different time and a different purpose – to place order on a failing system, to lift an NHS from its knees and onto its feet. But they are not necessarily the right levers to get the focus on quality that we now demand.

We must step back from measuring everything that moves to measuring less but with a relentless focus on what matters: clinical quality, patient safety and, particularly, patient satisfaction with services.

Going forward, I want to see patient satisfaction measured service-by-service in each hospital and published on a regular basis. By lifting the focus on this, it will encourage the system to concentrate more on how things look through the patient's eyes.

Currently, there is the potential for a disconnect between what the system is measuring and prioritising, and what matters most to the public. A hospital could appear to be doing well, ticking all the right boxes, but not good enough in the eyes of its local public on things that weren't measures but mattered more to them- dignity, cleanliness, how they were spoken to and yes, car parking.

At the moment there is no real incentive to do this. If a patient is being treated for two separate conditions in the same hospital, the service they get can be radically different in each. This is not acceptable.

Making this information readily available on NHS Choices will empower patients, helping them to make meaningful comparisons and informed choices about where they receive their care. It will also put commissioners on the spot, allowing people to ask awkward questions if they are tolerating inadequate services.

But, to create the bite on all-round quality that we need, it's got to be about more than shining a spotlight.

I want to see payment linked to levels of patient satisfaction through a powerful, new financial framework that rewards people-centred service and care.

At the moment, quality is only faintly recognised in the tariff. In the future, we'll progressively link a much bigger proportion of a Trust's income to quality and, importantly, levels of patient satisfaction.

This is a big culture change for the NHS, which has traditionally been paid by volume. But my judgement is that the service and its staff are ready to make this change.

We have already started to put in place the essential building blocks of an NHS built around the principle of quality. The National Quality Board will help guide the NHS and the Care Quality Commission will provide integrated oversight of the NHS as we come closer to achieving Ara Darzi's vision.

Another piece of the quality jigsaw will be Quality Accounts, published by all NHS organisations at the same time, and with the same weight as their financial accounts.

Today, I'm launching a consultation on what Quality Accounts will cover – and my thanks go to the many stakeholders, including Niall and his team, and many others here today, who have helped us develop our thinking.

I want Quality Accounts to bring transparency to every layer of the NHS and help make the NHS more accountable to patients.

We will start next year with the acute sector – and then move the spotlight into primary care and community services. So Quality Accounts won't just illuminate the quality of care intTrusts, they will do so in all other organisations.

Once patients and the public see what Quality Accounts can achieve, they will start to look into departmental and service level data too.

Next year, as trusts begin to publish Quality Accounts, we'll start to see a big change in the information publicly available on providers. And this information, linked to a new payment system, will start to transform the way in which clinicians and managers drive up quality.

With quality at its core, I think the NHS can finally move beyond the polarising debates of the last decade over private or public sector provision.

Let me begin with where I stand in this debate, and that is that the NHS is our preferred provider.

But it is the important job of the commissioner to test whether these services provide best value and real quality.

Where a provider is not delivering quality – and the new accountability information will more readily demonstrate that – we will set out a clearer process that will provide an opportunity for existing providers to improve before opening up to new potential providers.

This is fair to all as it means everyone knows where they stand and services stand or fall on the quality they provide.

This rigorous approach must also extend to Foundation Trust policy.

Foundation Trust status is a reform that has worked, the new freedoms from the centre driving up standards across the system.

But it should never be a one-way ticket and freedoms should continue to be earned. We need to learn from when things go wrong, as they did at Mid-Staffs.

If a failing organisation continues to benefit from Foundation Trust status, it risks undermining what Foundation Trusts status signals to the public.

The proposal to give Monitor the power to de-authorise a Foundation Trust corrects this. I want to see FT applications coming through in the pipeline, but it must not mean any dilution of the high standards that they represent.

In a NHS focused on quality – and where reform is led locally – I also believe we need a better focus on staff satisfaction. For me, this is another learning point from recent service failures.

Alongside patient satisfaction, I propose to measure staff satisfaction more systematically.

I said earlier that I wanted a smarter approach to reform, less polarising and imposed. So I believe the service should publish comparative staff satisfaction data. It brings out into the open where things are not going as well as they might, acting as a helpful barometer and early warning system, securing earlier resolution of problems that might in time lead to deteriorating patient care.

More positively, it would engender more empowering and inclusive ways of working, bringing on the new era of NHS reform. Where staff are truly engaged in reforming services, the results can be breath-taking.

Whistle-blowing can't be the only route to flush out poor practice. The reform we want is based on a strong partnership between front-line staff and their leaders, and between staff and the public. It can never be in the patient's interest if staff morale is low.

Staff must be free to challenge the status quo, whilst also allowing them to be held to account by local people.

Empowered staff can drive the reform of a service. But so too can empowered expert patients. We need both.

Achieving the preventative and people-centred NHS I spoke about at the beginning rests upon deepening and widening what we mean by choice. Extending further patient choice in primary care, but also extending the very concept of patient choice and seeing it more as patient control.

Today's ‘good' NHS can sometimes focus on delivering services where it's best for the provider. A ‘great' NHS would deliver services where it's best for the patient – for example, by giving people receiving chemotherapy or renal dialysis control over where they receive their treatment: in a hospital, in their local community or in the comfort of their own home. Control also means new services to help patients to manage long term conditions, with an early expansion, once our Bill has been passed by Parliament, of the use of personal budgets.

The NHS needs to look more and more at whether services can be offered in the community or in the home if that's what the patient wants.

So, through reform, I will also look at how we stop the perverse incentives that mean that providers are better served admitting people into hospital rather than treating them in the community.

Where quality and patient satisfaction dictate moving services outside the hospital, then we need a payment system that actively encourages this.

So, next year, we will introduce the ‘best practice tariff,' for stroke, hip fractures, gall bladder and cataract surgery. This will link tariff payment to delivering the highest quality, not just the average cost.

But from the other end, we need to put a renewed emphasis on Practice-Based Commissioning, and greater speed in approving business plans that will mean spending differently to keep people out of hospital. And we need to sit down and listen to how Transforming Community Services can regain momentum.

In my own constituency, there is a real dynamism for the first time in GP services and primary care, as new GP groupings use new facilities to expand the range and quality of what they do.

But I want the best to be available to everyone, not according to where they live. This means extending choice within primary care.

Too often, people's choice of GP practice is unnecessarily limited by practice boundaries. So, with the profession, I want to open up real choice in primary care. Within the next twelve months, I want to abolish practice boundaries for patients to allow people to register with the surgery of their choice.

That may mean a practice near work, or in their local neighbourhood from which they are currently excluded by dint of their postcode. But it means that their practice is based on their own needs, not by lines on a map or what is easiest for PCTs We will work with stakeholders and the profession to make this vital change for patients, and ensure that crucial services for those most in need, such as home visits, are protected.

This is what I mean by a people-centred NHS.

So Niall, in conclusion, in the last 10 years, we have expanded the traditional model of delivering healthcare. In the next, that model will undergo real change as services come out of hospitals, are built around individuals. It means spending differently and the NHS working more closely with other partners such as local authorities. It means more change in the next 10 years that the last.

We are on the brink of the most exciting decade in the history of the NHS because of the distance it has come in the last, what is now within our reach and because we have a common purpose – to make our good NHS great.

Thank you very much for listening.'

Health Secretary Andy Burnham Health Secretary Andy Burnham

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