‘Clare thank you very much. Thanks for that introduction and thank you for the invitation and the opportunity to be with you again this morning.
‘I’m glad to be back with you. The RCGP conference did not appear on the agenda of my predecessors, so I am very glad to be with you again this year to further reinforce my view that general practice is at the heart of improving health outcomes.
‘Over this summer the world of general practice lost one of its brightest and best. Barbara Starfield from the Johns Hopkins Bloomberg School of Public Health. She knew the intrinsic value of primary care.
‘As she put it, and I quote her, “there is lots of evidence that a good relationship with a freely chosen primary care doctor, preferably over several years, is associate with better care, more appropriate care, better health and much lower health costs.”
‘I think we all learned a great deal from Barbara’s work and her work helped me to understand the fundamental importance of primary care.That is why I have been so determined to place so much emphasis on primary care as we modernise the NHS.
‘Let me start today where I finished last year. I said to you then, as I do now, that for years GPs had been telling me “if only they would listen to us we could do it so much better.” Well as I said, I am now listening to you and I do want you to do it better. At the heart of doing it better for patients is for clinicians to be at the heart of commissioning.
‘That is a central principle of the White Paper we published in the middle of last year. Remember there are three central principles. I think on all the evidence, we share these central principles. For clinicians – the heart of commissioning. For patients, the principle of shared decision making and “no decision about me, without me.” And for all of us, a focus on outcomes not processes.
On health inequalities
‘Let us start with one of the acid tests of modernisation. What are those outcomes we are looking for? One of them must be the impact on reducing health inequalities. If you are poor you are more likely to get cancer, you are more likely to suffer from cardiovascular problems, you are more likely to develop diabetes. Across the board, if you are poor, you are more likely to become ill and you are more likely to die early from that illness.
‘Tackling that inequality is one of the Government’s highest priorities and part of a focus on fairness and social justice that goes far wider than health alone. We want to help all people to live longer, healthier and more fulfilling lives. But we want to improve the health of the poorest, fastest. That is why the Bill will, for the first time, place an obligation on the Secretary of State and other NHS bodies to seek to reduce health inequalities and maximise the benefits that people take from health services.
‘Breaking the link between poverty and ill health must be spliced into the DNA of the NHS at all levels. Too often people in the most affluent areas get the most and best provision relative to need, what we call the inverse care law. So in better off areas it’s easier to access a GP and there are more GPs to access than there are in poorer ones. There are far more hip and knee replacements carried out in better off areas than you would expect, and far fewer in less well off areas.
‘All too often it’s those with the sharpest elbows and the loudest voices who benefit first from improvements in NHS care, rather than those who may actually have the greatest need.
‘That is why we are developing the inclusion health programme. Seeking to drive improvements in health outcomes for groups with especially acute needs, like the homeless. I’m pleased to announce today that as part of this programme we have asked the RCGP to lead a piece of work that will look closely at embedding inclusion health in general practice, providing GPs and new CCGs with a practical support to improve their understanding of the needs of particularly vulnerable groups.
On patient choice and variation in NHS care
‘I believe one of the ways we can make a real headway on this issue [health inequalities] is in giving patients more choice. Choice, properly applied, drives up quality. If everywhere care was uniformly good we wouldn’t need choice, but across the NHS quality varies.
‘There is a five-fold variation in PCTs in the proportion of diabetes patients receiving the 9 care processes recommended by NICE, a four-fold variation in emergency admissions for under-18s due to asthma. Death rates from bowel cancer surgery can be as low as less than two per cent or as high as over 15 per cent. Whether a disabled child has the right electric wheelchair depends far more on where they live than what they need.
‘I know everyone would prefer it if their local hospital or community service was as good as the best in the country. But after more then six decades of trying, stark variation remains the norm. We could condemn people to the arbitrary availability of what is on their doorstep. Or we could give them a choice to help drive up quality.
‘I remember my predecessor John Reid about 7 years ago, who instituted the programme developing the programme of patient choice for elected surgery. He was right about that and the reason he did it was precisely because of this inverse care law. He said if we want to democratise choice, we have to make choice instrumental to the process of referring patients so that patients themselves participate in decision making. He believed in the democratisation of choice and so do I.
On Any Qualified Provider
‘The last Government started the process of patient choice for elective care back then. I believe we can now give patients the right to choose the best, most appropriate, most convenient care for their needs more widely. And give them that choice at the moment that matters – at the point of referral. That is why we are introducing, in a phased and controlled way, the Any Qualified Provider model of commissioning.
‘It is to give patients that choice. It will also progressively reduce the long and costly tendering processes that take up so much of commissioners and providers valuable time and energy. Moving from competition on price to competition on quality, because under AQP all providers will offer their services at a common price, meaning they are all competing solely on the quality of that care.
‘The system won’t work for everything. No-one is suggesting choice for emergency or ambulance services. But there are a range of community and mental health services where there are likely to be significant benefits from offering patients better choice, so long as the service and the characterisation of the service that needs to be provided, is integrated around patients’ needs.
‘This isn’t all going to happen overnight. We have listened to what you and your colleagues have said and not least to what the Future Forum has achieved over recent months. We will phase this in over time and you will not be doing this by yourselves, but in partnership with the communities you serve and with the new Health and Wellbeing boards.
‘I was tremendously encouraged yesterday at the National Children and Adult Social Services conference where the leaders of health and wellbeing boards from all over England were coming together and saying how energised and enthusiastic about the opportunities to work with Clinical Commissioning Groups. The opportunity to talk literally about the health of their population, not just have arguments about budgets with PCTs.
On improving NHS data and National Clinical Audits
‘We know that better data means better quality on the NHS. Getting the health data there drives improvement for patients, for their specialist clinicians, and for you, both as GPs looking after patients, and as commissioners of services.
‘Today, as part of our commitment to an open NHS, I can announce 11 new areas of medicine whose outcomes for patients will be audited, monitored and regularly published in the future. New National Clinical Audits in areas including COPD, prostate cancer and breast cancer.
‘From December we will pilot the publication of clinical audit data to detail the performance of clinical teams. This will then be rolled out across England from April by next year. This means there will now be 40 areas of medicine involved in National Clinical Audits.
‘This data means patients can make better and more informed choices, means specialists can prepare themselves with the best and learn from lessons – we’ve seen in cardiac surgery and with stroke how National Clinical Audits can instrumentally drive up quality. And it means you can commission services from specialists who have learned those lessons, see the data and improve their services.
‘This information, along with the NHS provider staff satisfaction data, will help providers drive up quality and help you and your patients make the best decisions about care. This sort of comparative data will also help general practice improve, so I’d like to thank the RCGP for leading ongoing work to publish comparative data on the provision of services from GP practices due from December.
On the Secretary of State’s duty to the NHS
‘Under the new system providers will be accountable to CCGs for the quality of care they provide to your patients. CCGs will themselves be accountable to the NHS Commissioning Board for the outcomes they achieve. And of course the NHS Commissioning Board will be accountable to the Secretary of State, both through the mandate and for the delivery against the overall NHS outcomes framework.
‘Yes, the Secretary of State will still be responsible and accountable to parliament and the public for a comprehensive health service. That has never been in question. If it needs any further amendment of the Bill to put it beyond anyone’s’ doubt then we are happy to do that.
On practice boundaries
‘I also want to talk about an aspect of choice no doubt many of you would regard as very controversial – that is choice of GP practices. The last government proposed giving people greater choice of GP practice, you’ll recall that. They initiated a public consultation and the public said they wanted choice.
‘We also know the great majority of people want to choose a local GP practice. I’m clear that whatever we do, general practice must always remain rooted in local communities and that clinical commissioning builds upon this.
‘But there are a small proportion of patients who feel that the current system just does not meet their needs. People who have moved away a short distance but want to maintain their relationship with their current practice, people who find it difficult to see a GP because they are at work whenever their local practice is open to see them.
‘Tackling inequalities means making services more responsive to everyone’s needs. But the last government’s proposals on choice of GP practice didn’t take account of the practicalities of achieving that choice.
‘We will ensure that any progress is practical. We need to think carefully about how to manage home visiting, about how patients who don’t live locally to their practice can receive urgent care, and about how information is shared. We will make sure it is done in a way that will preserve the responsibility for CCGs for the health of their local population.
‘I want to make sure that we do respond to the needs and the expectations of the public. But I want to do it in a way that takes careful account of what is best for patients, particularly the most vulnerable patients, and in ways that are, in practice, effective.
On integrated care and tariffs
‘Of course, excellent care will often mean integrated care. We all know this but the reality is often the opposite, with health and care services not joining up around the needs of patients, of people stuck between competing demands, procedures and paperwork of the health and social care services.
‘We need to do better. That is why the bill will place new requirements on CCGs, local authorities and social care to work together with the leadership of the new Health and Wellbeing Boards to improve the overall health and wellbeing of their communities. That is why the NHS Commissioning Board will help create the right incentives, and remove the barriers to, integrated services.
‘By developing the system of tariffs through things like pathway-based tariffs, developing better model contracts that allow commissioners to contract for an integrated services, and by looking at system-wide issues such as access to patient information and information technologies.
‘I think it is what those of you involved in designing and commissioning local services need to have in front of your minds at all times:- how can we ensure that the service we commission not only gives us the right referral pathway but also give to our patients a service integrated around their needs and expectations?
On the Future Forum
‘We are grateful not least to Geoff Alltimes and Robert Varnum who are leading this work through the Future Forum. I think with Steve [Field’s] leadership the Future Forum has done tremendous work for us, and is continuing to do tremendous work. I think it is changing the character of how we can interact with the NHS and with the professions so that we don’t simply think up a proposal then put it out to consultation but actually it is much more of a co-production between us and the service.
‘That will be more important as time goes on as fewer and fewer of the decisions will be top-down. More and more decisions need to be made from the frontline.
On education and training
‘Finally let me talk about an area of real concern, namely education and training. The Health and Social Care Bill will reiterate the Secretary of State’s duty to ensure that the education and training is provided to the NHS but it doesn’t then go on to set out any of the changes in education and training. But the NHS Future Forum’s continual programme of looking with the NHS and the professions at how we can ensure that education and training meets the needs of the service in the future.
‘The NHS is only, and will only ever be, as good as the people within it and every single one of those is somebody who is the accumulated product often of years of training, of experience and ongoing professional [development]. As the NHS changes, so the system of education must keep pace. Maintaining high standards but also remaining relevant to the people and the organisations we serve.
‘The NHS Future Forum found broad support for proposals setting up Health Education England, greater provider involvement in education and training. But it also recommended how we could change the plans, including creating a duty for the Secretary of State to maintain a system for professional education and training. As well as them accepting their initial recommendations we’ve asked them to look at this are in more depth and report back in the Autumn.
‘In the meantime we’ve been working to get the process of revalidation right and I’d like to thank the RCPG for all of their work on this. We now have responsible officers across the NHS, helping drive forward our commitment to everyone having their full annual appraisal. Helping you to develop your skills and experience throughout your career.
‘There are also concerns over the role of deaneries. Postgraduate deaneries will continue through the transition until the end of March 2013 and become part of the new system. I want to say something about GP training. It is in all of our long-term interests – patients, public, policymakers – to ensure that the next generation of GPs get the high quality training they need. I know the current training schedule is tight, especially considering all the aspects of service a GP has to cover, including new responsibilities for commissioning.
‘I’m very sympathetic to the educational case for enhanced GP training, subject of course to it being considered through the proper process and I know many others are equally sympathetic. But we also have to be mindful of the impact on educational training budgets – those budgets have been maintained but are finite – so we need to make sure that we make the most of ever pound and that all of the changes are affordable.
‘Now I know that the delay in resolving this issue has been frustrating. I share that frustration and I’m pleased to see that progress is now being made. The case will be considered by the Medical Programme Board in the New Year who will make a recommendation to Medical Education England. They will then present a final recommendation to me. So we are moving forward, but it’s important that any decision we make is sustainable financially as well as the right thing to do for education.
On GPs holding ‘the power’ in the NHS
‘Let me finish. I want to underline what I think is perhaps the most important change modernisation can bring. From now on the real leaders of the NHS won’t be people sitting in offices in Whitehall or anywhere else. They will be people like you. So if you see something that is wrong, change it. If you have a good idea, do it. If you have knowledge or expertise that will help others, share it. From now on you will have the power, you will be the ones with the power, to change things in your communities.
‘The Health and Social Care Bill and the power it confers, the organisational changes taking place, all the drive for modernisation, will be fruitless if you do not take up the challenge to lead. So whatever your views about the Bill, or the Government, or the reforms, this is an opportunity for you to lead in your communities. To work in the best interests of your patients, to work in partnership with them and others to deliver the best healthcare you possibly can. As you do that, you will find that this Government, and the new system we put in place, will support you every step of the way.
‘Thank you very much.’