Read the full transcript of health secretary Andrew Lansley’s keynote address to the BMA’s Annual Representatives Meeting in Brighton.
‘A shared ambition to improve outcomes’
Everything I do as Secretary of State will be directed towards freeing up the service to deliver better results. At every stage I will be endeavour to be open, clear and consistent about my plans. And every step we take we must take together – I want to draw on your views and your expertise, starting today.
In opposition, and coming into Government, I have been clear about our priorities:
First, that patients must be at the heart of everything we do – as more than simply beneficiaries of care, but as participants in its design.
Second, the NHS must be focused on achieving continuously improving outcomes for patients – not inputs or processes, but results.
Third, we must empower clinicians – those responsible for patient care – to deliver those improvements.
Fourth, if we are to improve overall health outcomes and make the demands on the NHS more sustainable, we must prioritise prevention and create a public health service.
Fifth, we must reform social care alongside healthcare – and deliver closer integration in how services are commissioned and provided.
These are now my priorities for government.
And today I want to talk about perhaps the most important and fundamental issue of all – improving outcomes for patients.
This must be the primary purpose of the NHS: to improve the quality of care, and achieve outcomes that are amongst the best in the world.
Why should we not? The service has doctors, nurses, scientists, researchers, as good as any in the world. People, I know, committed to achieving the best possible care.
But I can’t count how many times doctors have told me, on a personal and professional level, how frustrated they are by the way the system works. How their judgements and activities are restricted by the rigidity of the system, and how their clinical priorities have been distorted by narrow process targets.
If we are going to achieve the outcomes we all want to see, we need to break down that system and build one that is focused on improving results for patients. To do this I think there are four steps that we need to take.
The first is to measure those things that really matter.
For too long the focus has been on measuring inputs and processes that are remote to patients.
The result has been the number of managers in the NHS increasing three times faster than the number of nurses, and a proliferation of targets – with over 100 major targets now governing your every movement.
So we are beginning to dismantle this system.
Just last week we published a revised Operating Framework to move towards scrapping the 18 week target for hospital waiting times, the 4 hour A&E target and the 48 hour target for GP access.
But in doing this and more in this direction, we have in parallel to develop proper measures of quality which prioritise what matters to patients – not boxes ticked and processes followed – but their actual health outcomes.
And so I am calling for your help in constructing a national outcomes framework for the NHS. A framework that will help drive up quality across all services and show how we are performing against other countries. A framework that I can use to hold the new NHS Commissioning Board to account, and that patients and the public can use to hold all of us to account.
I’ve suggested some possible measures:
• Mortality amenable to healthcare brought down to the level of comparable countries
• Improving one and five year survival rates for cancer, so that they are at least in line with EU averages and progressively improve relative to comparators
• Reducing premature mortality from stroke, heart disease and lung disease, so that they are at least in line with EU averages
• Year-on-year improvement in patient-reported outcomes for patients living with long-term conditions
• Year-on-year improvement in patients’ satisfaction with their access to and experiences of healthcare, and
• Year-on-year reduction in the number of adverse events
But – I repeat – I want to hear your views. Together we need to develop a small but balanced set of national outcomes measures that encompass the three things that we need to focus on to improve quality – the effectiveness, experience and safety of care. We’ll be announcing a full consultation soon.
In any healthcare system, a central factor in securing better outcomes is to bring the management of care together with the management of resources and services.
Most healthcare systems do not do this successfully – most suffer from this separation: to the greatest degree in America, where the third-party payment problem has inflated costs dramatically. Examples in America of physician-led, more integrated services, demonstrate how differently – and effectively – they can deliver care.
But even in this country there is a sense of management being separate from clinical care, whether in hospitals or where PCTs are remote from referral decisions about patients – creating the same lack of cohesion.
So the second step is to give control of commissioning to General Practitioners, working in local consortia, supported by an independent NHS Commissioning Board.
GPs coordinating healthcare so they are best placed to coordinate commissioning – but all clinicians must take on a much greater role. GPs will be expected to work closely with hospital consultants and their colleagues in all parts of the profession. As Iain Macleod told the BMA in the early 50s – seeing General Practice as much a multi-disciplinary team as hospital care.
I have discussed our plans with the GPC, and I will publish our proposals soon. There will be a full consultation on the implementation with the profession. I want to hear your views on exactly how this should work – we’ll work through the details with the BMA and we’ll negotiate those aspects that affect the GP contract.
But in doing so let’s keep our focus on what we’re trying to achieve.
The danger with contract negotiations is that we end up not only just seeing the trees, but actually examining, very carefully, the bark on the trees – and failing to see the wood.
So let’s be clear – our aim is a major transfer of responsibility to the GP community; in order to empower clinical decision-making and improve outcomes for patients.
Many GPs are keen to take this on.
And I want to appeal to all GPs – keen, or not so keen. I understand the philosophy that says your professional responsibility is to be concerned about the patient sitting opposite you.
But giving GPs greater commissioning responsibility isn’t about detracting from the support you give to individual patients.
Rather, it is about making sure that the really important decisions about the services available to your patients – and the quality you expect from the people providing those services – are driven by your clinical insight and by the holistic view you have of your patients’ needs.
It is based on the understanding that to achieve the best for each patient, you need the power to design services that are right for all your patients. And that to get the priority right for each patient, you need to set priorities for all your patients.
As the Royal College of Physicians argues – the responsibility for the use of resources is now a core responsibility for the whole profession.
And so, to support commissioning we need to have clear definitions of what constitutes excellence.
So the third step is to introduce proper measures of quality across the service.
Clinicians will be accountable in a different way – not to tick-box process targets, but to quality standards.
Standards which do not distort clinical judgement, but which are based on clinical evidence. Standards which achieve better outcomes and are comprehensible to patients so that they can hold clinicians to account.
And I’m pleased to say that this work is already well under way.
Last week we showed that we were serious about putting quality at the heart of the NHS when we scrapped unjustified process targets.
And today the National Institute for Clinical Evidence are presenting me with the first three Quality Standards – covering stroke care, dementia care and the prevention of VTE. Setting out an authoritative, evidence-based view of what high quality care looks like.
These standards will improve quality across the system from today. And they will be a central part of commissioning to meet key outcomes measures tomorrow.
And not just commissioning and continuity; also they need to be central to the future design of HRGs and payments; and to the quality inspection process, so that we have consistent measures of quality, and incentives for quality, and we do away with conflicts or distorting targets and measures.
The fourth and final step is to improve access to information – because better information means better care.
Sweden has 69 National Quality Registers on a range of areas from cancer care to diabetes to depression – all developed by doctors themselves. And they’ve shown real results.
Their Hip Arthroplasty Registry has been active for more than 30 years. Now covering 20,000 patients a year, it monitors their quality of life alongside revision rates. Sweden now has the lowest reported frequency of revision operations in the world.
In England and Wales, our own National Joint Registry opened in 2003 and it is now delivering feedback to clinicians to help improve the quality and outcomes of hip and knee replacement operations. It should become a basis for quality and outcomes measurements and for information to patients to support choice.
And we saw the benefits that this can offer when we published data on heart surgery – focusing right down to the performance of the individual surgeons.
Sir Bruce Keogh led this work, and not only did they get the data, which was an achievement in itself, but they validated it, published it, compared results in the UK and went over to Hong Kong to draw international comparisons.
The 2008 National Adult Cardiac Database Report set out that, ‘despite the fact that the risk profile of patients has increased, mortality has fallen dramatically’.
It’s a model which we should look to repeat elsewhere.
I’m committed to publishing more data about clinical performance.
For example, clinical audit. When I talk to clinicians about this, I find they’re content as long as it is evidence-based and does not distort what they do.
I agree. Information should be used to support good practice and reinforce it – and clinicians must have oversight. You must have the opportunity to challenge and test the data – effectively to sign it off.
So I am bringing forward plans to expand national clinical audit to cover a wider range of conditions and interventions.
These audits will be collecting data on at least two outcome measures, such as survival or morbidity – and they will name the provider.
Putting information in the public domain is a catalyst – it forces providers and individual clinicians to look at and compare their performance. And it is essential to accountability. Patients should have a right to expect good quality, accessible information, particularly on the things that really matter to them.
Advancing Quality in the North West
And we shouldn’t wait to begin taking these steps. I’ve already describe some examples of good practice today. And just two weeks ago, I saw a programme which embodies everything I’ve been talking about today – clinicians taking the initiative to improve their services, to improve quality of care, access to information and patient outcomes.
For the last two years, beginning with five high cost and high frequency interventions, including heart failure, pneumonia, and hip replacements, clinicians in the North West have been collecting outcomes data to drive improvements in their work – and their Advancing Quality programme is now going public.
They’ve been measuring their performance – not against national targets – but against their own standards, and working to improve the quality of the service they provide.
It’s the first time in the UK that such data has been reported on behalf of a regional health system, assured by the Audit Commission and made available online so that the public can see exactly what’s going on.
And this programme is also playing a key role in the region’s efforts to meet the efficiency challenge that we all face.
Last week’s Budget set out the scale and severity of the measures required to cut the deficit. It will be painful.
We have been clear about the priority we attach to safeguarding the services that the NHS provides and on which we all rely.
So funding for the NHS is protected, and we will increase it in real terms. But we should remember what a privileged position we’re in.
We’re not protecting the NHS in order for things to carry on as they are, or for people working in the NHS to feel that they’re being personally insulated from the disciplines that are being applied across the public services. Still less for the NHS to go on recruiting non-essential, non-clinical jobs whilst across the rest of the public services vacancies are not filled and tough decisions are made to stop spending programmes. We must be at least as tough on ourselves.
This protection for the NHS is protection for patients – to ensure that the sick do not pay for the debt crisis.
But let me be very clear, every penny saved in the NHS in efficiencies will be available to reinvest in the service – to meet the increasing challenges and increasing demands that we face, to improve the service we offer and the quality we deliver. Every penny.
This is a huge challenge and opportunity for everyone in the NHS. We have a duty now to find exceptional levels of efficiencies so that we can reinvest in the service where the money is needed more.
Last week the Prime Minister and the Deputy Prime Minister asked public sector workers for their ideas on finding efficiencies. All those who work on the frontline should be thinking carefully, and imaginatively, about how we can do things differently. The QIPP process is a home for this in the NHS and the way that we can implement the best and brightest ideas across the service.
As the Prime Minister said: ‘Don’t hold back – be innovative, be radical, challenge the way things are done.’
And you will be listened to – every serious idea will be considered and the most promising ones will be taken forward.
Conclusion – clinical leadership
I believe these changes will empower patients and clinicians. They will even empower good frontline managers. And they will disempower top-down bureaucracy.
But the critical issue is this: what will you do with these freedoms and responsibilities? That is a question of leadership.
I remember the profession’s anger over Modernising Medical Careers and the Medical Training Application Service (I was on the march). The problem was that the profession wasn’t involved – the engagement was only skin-deep. It wasn’t owned by you.
So on taking my reforms forward, on publishing better information, on listening to patients’ views, commissioning services and achieving better health outcomes – we won’t be pronouncing the answers from the centre, you will have a responsibility to lead.
Because, in liberating the NHS and empowering you to do your jobs, we are not offering a one-sided deal.
In return, I expect you to embrace these new opportunities and assume your rightful role as clinical leaders.
In removing targets, the public need to see a clear improvement in the quality of care that you are providing.
In giving you clinical freedom, I ask for responsibility for efficiency and effectiveness too.
And in announcing the new quality standards today, I need to see a positive response – their potential will only be fully realised if the whole system aligns around them.
Let me be clear: I am not trying to turn doctors into managers, but leaders.
That’s how we’ll bring about a new culture of responsibility across the service.
That’s how we will create the stronger, freer, fairer NHS that I’ve described this morning.
That’s how we’ll empower you to achieve outcomes for patients that are among the best in the world.
Health secretary Andrew Lansley Health secretary Andrew Lansley