5 December 2006

The Prime Minister has highlighted the significance of two reports that he received this morning from Health Secretary Patricia Hewitt in a speech to the NHS Confederation.

He described the reports as "a compelling and vivid account" of the programme of hospital service improvement that the NHS is currently undergoing.

Read the speech

Thank you. I am delighted to be here with Jill, and with David and with Patricia of course, and good luck David - I think you may need it.

But what you say is actually extremely important, which is that the inaugural¹ meeting of the PCT Network within the Confederation is important, but also is the fact that we are happy to give you the support in the work that you do because the future of the NHS will be developed in part through better commissioning, and the better you commission NHS services the better healthcare will be.

And look I think the biggest frustration² by far in getting across a balanced picture of the NHS today is the gap between people's personal experience of it, which is usually excellent, and their perception of it as a whole which is often negative. And the fact is that on any objective basis for all the challenges, and largely thanks to people like yourselves working in the NHS, the NHS is improving, often quite dramatically, in its treatment of patients, but it will only carry on doing so if like any other institution or business in the modern world it continues to meet the challenge of changing times. And I think the thing that is very obvious, but is worth saying, is that everybody knows that the services they receive and the services that they work for are undergoing processes of change, changes in the expectations of their customers, changes in technology, changes in working practice. It would be bizarre if the NHS alone of all institutions in this modern world did not also face those challenges of change.

And the important thing for us together is to try and explain why this change is happening, why it is necessary, why in the end it will be to the benefit of patients. And I think certainly David you have learnt a lot from your six years heading up a PCT, I mean I have learnt something from almost ten years as Prime Minister, which is that if the politicians do this on their own it is not nearly as effective or persuasive³ frankly⁴ as if we do it together, the people working in the service and the people responsible for overall policy. And there is probably no area of domestic policy changing more quickly than healthcare. The demands and requirements of patients are rising.  I am constantly struck when I talk to patients, and for example someone the other day was telling me that over the past ten or fifteen years they have had a pace-maker fitted, the first time they had it fitted they were staying several days in hospital, they were under general anaesthetic, the last time they had the pacemaker fitted it was done under local anaesthetic as a day case surgery. So you know these changes are perfectly⁵ natural and they are happening all the time.

The other thing of course that is happening increasingly is that technology is empowering us to deliver that change in a different way.  And I think the issue really today is not is there a change-free option, because there isn't, in the end, whatever we decide to do if we are going to keep the NHS vibrant⁶ then there has to be change, the question is what sort of change.  And I think the choice is this, either we shape the change to ensure that the principles of the NHS are preserved for another generation, or we let the change as it were shape the NHS but in a haphazard⁷ and random⁸ way.  If we just recall the NHS of ten years ago, waiting lists were well over a million, on an in-patient waiting list a quarter of a million people or more at any one time waited over six months. Many patients - I know, I used to receive letters when I first came into office from their relatives - used to die waiting for cardiac care. The length of time waiting for a cataract⁹ operation, if you remember that, was often over a year, sometimes two years.  On the out-patient list there were some 160,000 people who waited over six months and over 300,000 over three months. Cancer patients regularly failed to get to see consultants¹¹ for weeks after being told by their GP that they might have cancer, and Accident and Emergency Departments, all of us remember using it in those days, was often a disgrace and people could wait hours and hours for even the simplest treatment.

So I think people a decade ago were kind of asking not will the NHS work but could it work, I mean was it an inherently flawed concept almost that meant that it had to be dismantled¹²? And I think now that is not the question, now people accept it can be improved, the question is how.  Waiting lists are at their lowest level since records have been kept, the maximum wait on the in-patient list is down from 18 months to 6 months, cancer deaths have been cut, cardiac deaths have been cut and there are whole new services, NHS Direct, walk-in centres and so on.

Now a lot of this is about the extra money that has gone in, there is no doubt about that, the investment has helped, but actually alongside the money the single most important other dimension to this progress has been the fact that the system itself is undergoing change.  Now managing this system of change is incredibly difficult, there are different elements to it, we are trying to put greater choice in the hands of patients, we have got new suppliers, whether it is independent treatment centres, the Foundation Trusts as a different way of running hospitals, there are the new service frameworks, there is NICE, and then there are the changes we are making now in the primary care trusts, in practice-based commissioning and in the changes that we are trying to make at a local level to bring care closer to people.

I think the most difficult aspect of all of this is not simply trying to introduce these different systems, but trying to see how everything fits together and how we incentivise people, particularly you who are at the sharp end of this and have to take the most difficult decisions, to innovate¹³ and be creative in how you are giving patients care in a different way for today's world. So practice-based commissioning should reduce unnecessary referrals, but that won't happen just as a matter of course, it has to be managed.

Chronic¹⁴ disease can often these days be managed in primary care, but again that won't happen just naturally, it has got to be a system of change that is put in place for it to be done. The elderly can be looked after at home, diagnostic tests and minor¹⁵ surgery can be carried out nearer to home where patients want it to take place, all of that is true. And earlier today, as you know, Patricia received two reports from two of her national Clinical Directors, that is George Alberti and Roger Boyle, and what they offer is a compelling and vivid account of change and why it is necessary, but also why it is difficult.

If we take Accident and Emergency, 18.5 million people go to Accident and Emergency every year, very few have life threatening conditions.  Major emergencies only affect about 10% of people, most people would actually be better served by care that was closer to home. At the moment if you have a pressing medical need you end up almost inevitably¹⁶ in Accident and Emergency, but in the light of the changes in medicine we need to do better than that, we need a diverse set of institutions, GP out of hours services, pharmacies¹⁷, social service, mental health teams, minor injury units, walk-in centres to treat the range of different needs.  Lots of people for example who come straight to A&E would for a variety of reasons be better treated elsewhere. For example paramedics can administer life saving drugs to heart attack and stroke victims on the doorstep.  If you have a stroke at 2.00 am in the morning you want to go to a centre with access to a CT scanner 24 hours a day. For the life threatening emergencies a specialist is needed at once.  If you have a rupture¹⁸ of the major blood vessel¹⁹ for example you need an experienced vascular²⁰ surgeon with access to 24 hour laboratory services and radiology. The right care for strokes is now to have a CT brain scan within three hours, followed by aggressive rehabilitation²¹ with thrombolisus (phon) in appropriate cases, but that level of expertise²² can't be offered everywhere.

That is why it makes sense, alongside local provision to create specialist centres of excellence²³ which have 24 hour consultant¹⁰ cover and access to state of the art diagnostic equipment.  Therefore alongside that specialist emergency care, we can then offer a quicker and more immediately appropriate service, the patient gets a more specialised service, in most cases closer to home, this can range from immediate²⁴ telephone access to information assessment²⁵ and advice on self care or the best place to seek further help, through to home visits and access to centres of care.  There will be many more paramedics and nurses trained to treat people at home and stabilise the patient's condition for longer journeys. And people will then have a shorter stay in hospital because the initial care received will be more specialised.

The reason therefore for all of this change in the end is the best reason there can be, better treatment for the patient, and of course this means at times the way capacity is provided may be changed, and I don't minimise either the difficulty or the importance of that. But we do need to make the case for these changes, and in that task I hope clinicians themselves will become ambassadors for change and improvements.  What this means in each locality frankly is a lot of it will be up to you in the PCTs and working alongside local clinicians you will be the main organisation²⁶ developing these new improved services in your locality. We, the politicians, have to back you when you have the courage to make those changes, and we will, and you need to have the confidence to make the argument for service improvements.

Now I don't under-estimate for a moment the difficulty of all this. As I often say to people, and I was saying this to the head teachers and deputy heads that I was addressing at a conference in Birmingham last week, the most difficult thing in any walk of life is to make change, there is a natural in-built resistance to it. On the other hand, I think what most people realise is that once you get through the process of change and out the other side, it is remarkable²⁷ how what was going to be the greatest disaster and catastrophe²⁸ ever to hit the world suddenly becomes part of the normal way of doing things. And the real reason why I think now is the right moment to do it is that for years and years, and certainly when we first came to office, there was a real problem with under-investment in the Health Service, there is no doubt about that, but on the other hand sometimes that became a kind of excuse for not facing up to the need to reconfigure and change the system itself. 

There has been substantial investment in the past few years.  Now I am the first to be aware that no amount of investment is enough, as it were, and there are always going to be financial difficulties and financial constraints²⁹, but the truth is within any given resource there is always going to be the need to change the service in order to meet the challenge of the changing times in which we live.  This is particularly true in healthcare, which round the world at the moment is undergoing a big process of change. When I sit down with other leaders in Europe or outside of Europe and we get round to domestic politics, healthcare is one of the biggest issues in the United States, it is a major issue at the moment in Germany, it is a vast issue in France where their health service has been in severe deficit³⁰. There is not a single country round the world of a modern developed nature where this is not a major issue.  It is perfectly obvious why - people are living longer, more diseases can be treated in better ways and people's expectations are infinitely³¹ higher. When the NHS was first started people thought it was fantastic that you got free healthcare. Today people want free quality healthcare, and what is more they want it, as someone famously said, at the time they want it, in the place they want it, with the person they want. 

So it is that changing expectation along with the changing nature of the service and the treatments that are available pose a huge challenge. And sometimes what we need to realise is that this is not something unique to this country, or indeed unique to you as the people leading the PCTs, this is the world in which we live.

But the great thing is we do have I think the right components³² and framework for change now and what we have got to do, bit by bit and piece by piece as we work together is to make sure that change works for the benefit of patients. I genuinely believe the best is yet to come, more lives saved, stopping more pain and distress³³, treating patients better, making sure the National Health Service is as an institution the pride and envy of the world, as indeed it should be because of the standard of care we do provide for people and recognising that none of this will happen unless we have collectively the courage to remain steadfast³⁴, to see through the process of reform and change and to make the alterations³⁵ in the way the service is provided in order to meet the challenge of the modern world.

And let me just say I fully³⁶ know how difficult it is for all of you but I congratulate you on the work that you are doing. Sometimes perhaps you don't hear it enough from us, we are very grateful for the work that you do, what you are doing at the moment in the National Health Service I think it is one of the most exciting things happening in our country today.  It couldn't happen without you and without your commitment, so I thank you for that, and as I say together I am sure we will manage to do it.

Question and answer session:

Question:

Perhaps more importantly for my question I am chairing a network of Primary Care Trusts throughout the whole of Manchester, east Cheshire and the High Peak which on Friday will reach the conclusion of a two year consultation³⁷ period which will lead to significantly better services for children and women and their families. And that will result, whatever we decide on Friday, that will result in some reconfigurations and some accusations³⁸ that some services will be closing. And I am confident after the talk we have heard from the Prime Minister that we will get the support from yourself and from the Secretary of State, the reconfiguration will have lots of the elements that you have already described as far as A and E is concerned. Our fear is that we won't get the support from our local politicians, some of them will be members of your party, some of them may be members of your government, and our fear is that that will undermine the process and that is a real concern for us in taking our reforms forward.

Prime Minister:

It is a very fair point, and the trouble is when change happens everybody assumes that the change is either made for the worst of motives³⁹ or alternatively it is just bound to make the service worse. And I think in relation to children's services, again I think some of the stuff that we have done today on Accident and Emergency we could usefully do there because as I understand it, and I am not an expert at all obviously, but if you think about your child being unwell, in fact provided you can get the emergency treatment that is necessary actually you would want that child to be treated in  specialist state of the art facilities, and I think the move towards those facilities which you see going on right round the country, we have to make that change on clinical grounds. And you know I have said to my own back benchers as well as Ministers, if we are not prepared to back people making these difficult changes then in the end two things will happen: first of all they will feel that they can't make them, in which case we actually let patients down in the name of protecting patients; but secondly⁴¹, we will get to a stage two or three years down the line when we face the electorate⁴² again when people will say well for all the investment that has gone in, is this really 21^st century care that you are giving us? And you know that is the challenge of political leadership and I entirely⁴⁴ accept what you are saying, all I can say is you know my message to my own people is have the courage to back the change and realise it is better to get it through and get it done, because once it is done a lot of the difficulty will fall away.

I had a situation where I saw some people the other day and they were complaining about local cancer services for young people and the idea that those should be sort of regionalised, and they obviously didn't want to change the provision they were very familiar with. But in the end what I found helped was that a clinician who was present simply said to them look, this is highly specialised treatment today, you are better maybe making the additional journey and getting the highly specialised treatment than getting local treatment that inevitably isn't quite of the same standard. And I think particularly for example where you explain to people that it is like any other job, if people who are working in a particular locality don't get the substantial flow through of patients and get the experience in treating all sorts of different aspects of a particular disease or condition, then actually they are less qualified⁴⁵ over time. It is the same as  in any other walk of life. But I agree with you, it is difficult and you are right to say the challenge is as much to us as it is to you, but I feel this is a one-off chance for the Health Service to prove it can make these changes and if we fall down this time I think people's consent for a taxpayer-funded NHS in the way it is at the moment will diminish.

Chairman:

And perhaps one of the things you should throw back to us is what can we do at a national level through the PCT network to help you deal with people in the party and to give information that would actually help you as politicians manage what is a very difficult situation at local level. So perhaps that is something, David, we can take on board to think how we can help.

Patricia Hewitt:

I think that is very helpful Jill.  If you don't mind I will just add one other comment to Ian's  question because my understanding is you have put huge effort into involving your local Overview⁴⁶ and Scrutiny⁴⁷ Committees, local councillors, others in the community and also your local Members of Parliament. Now if I can give you an overview of how we handled a different difficult reconfiguration, and that was Calderdale and Huddersfield where they went through a consultation on changing maternity⁴⁸ services and paediatric services, absolutely driven by the fact that the clinicians were saying they could no longer staff safely  adequately two consultant-led obstetric units, very controversial proposals. It so happened in that case there were two Labour Members of Parliament supporting the decision, because that was where the single unit was going to be, two Labour Members of Parliament opposing it because they were going to have a midwife-led unit but no longer a consultant-led unit. Now that particular reconfiguration was referred to me by the Overview and Scrutiny Committee, they made a very strong case for a reference and I asked the independent reconfiguration panel to take a look at it.  Peter Barrett and his colleagues did a very careful and thorough job, went up, talked to a lot of people, were crystal clear in their judgment⁴⁹ that the clinical case was overwhelming for this change. They recommended some additional changes, more midwife provision, particularly in the disadvantaged areas of Huddersfield, a bit more work on the transport issues with the local council and so on, and on that basis I was absolutely clear we would support 100% that reconfiguration. All the Members of Parliament have now recognised, the decision has been made, it has been made on clinical grounds, it is the right decision, they will back it and help get the implementation⁵⁰. And I think that is one example of how you can take some time and effort, but you can mobilise political support even for things that are very, very difficult indeed, and there were plenty of marches in the street around that particular issue.

Question:

Can I first of all say Prime Minister we are very very grateful that you have found the time to be with us, so on behalf of the PCTs can I really thank you for coming here. And this follows on from the Secretary of State and her top team meeting us in September, so it actually feels that although 85% of patient contact in the NHS is in primary care, both of you actually being here makes us feel valued because really I think we have made huge progress, but we have got a huge agenda to do.  Can I also thank you and the Chancellor⁵¹ and all the Cabinet for the huge sums of money that you have put into the Health Service because I think it has been, I was going to say a leap of faith, I don't think it was a leap of faith, I think because you both strongly believe in a publicly funded NHS is why you did it and we want it to succeed because my biggest worry is that the electorate think that we haven't got the value for money out of all this huge investment. We have made huge progress, we want to do more, and what we really want to do is work with the government, we are up for it, we want change, we want to transform our Health Service but we need your help. I would like to make four suggestions of what we can do, and that is really to do with hospitals and acute care. There is no incentive⁵² for acute hospitals to transfer care out into the community financially, and particularly with Monitor which tends to measure them on finances and not on delivering with other NHS agendas. So my first suggestion is there needs to be some tie-in of somebody asking Monitor what have you as a Foundation Trust done in terms of improving the health economy?

Chairman:

OK, if we leave it at that, we have one question.  Now I was told and I am very bad, as many of you in the audience know about following instructions, not to allow statements, but I thought that was actually quite a good statement to start with because I suspect that actually the two people sitting here very rarely have people who say thank you, and as a doctor who cares about wellbeing, I thought it might be good for you to start the day with a bit of wellbeing.

Prime Minister:

It can only get worse.

Chairman:

But there is a question in that which is about how do we align⁵³ the incentives⁵⁴ to actually genuinely get hospitals committed to this vision we have of out of hospital care?

Prime Minister:

I will leave you to deal with the really technical part of that, but you see I think one of the things we have got to realise, in a sense almost to give ourselves confidence, is the enormity of the task we have engaged upon and to realise that as we progress in making these changes there will be adjustments along the way. And one of the things you have raised is one of the points we were talking about at our last NHS stocktake, which is you have got to be careful that you don't get incentives that collide with each other in the service, so that some incentives are to pull the care out of the acute sector⁵⁵, then the acute sector has an incentive to keep it there. Right, we have got to find a way of managing that situation because the basic construct of reforms for me is this, it is to build up over time, greater patient input⁵⁶ into the service that they receive, it is then to have practice-based commissioning and the way that you work as PCTs with an incentive to get the care into the Primary Care setting insofar as that is appropriate closer to the patient. It is then to make sure through payment by results that actually you know what money you are spending and that hospitals have an incentive to make sure that they are offering a good service. And it is then within the overall framework to try to make sure therefore that you are keeping care as close to people, getting the care in the most appropriate setting, and having the patient and those at the ground floor of the service you know driving the change. 

Now that is the construct but it is massively difficult, you know this is a piece of change engineering that is absolutely enormous. And it is therefore very important I think, and you can see this reflected actually in the changes that we made in the PCTs, that there will be adjustments as we move along, we would expect this, for something like payment by results it would be utterly⁵⁷ ridiculous to think if you were just going to introduce the system it was all going to work as absolutely as it should and you were never going to have to make changes to it. There will be adjustments continually that are happening but the important thing is that the purpose of the change is to move away from a centrally driven performance-managed system, which has the advantage that you can lash⁵⁸ the change through the system, but has the disadvantage that it squeezes out the creativity and innovation and ability to be flexible. The idea is to switch from that system over time to change that is self-sustaining, so that if there is an innovation you want to make as a Primary Care Trust, you have an incentive through the system to make that change. 

Now I think how we manage that is going to be really, really difficult and we shouldn't be in the least bit surprised that there are these issues that arise about the way the incentives work, or that we have to sit down in partnership⁵⁹ together based on experience as the system comes in and make changes along the way. And that is the best way to make this thing work because at each stage of this you will learn lessons on how you are implementing⁶⁰ it, we learn lessons as policy-makers. I think one of the important things that we do in this whole process is not to be either ashamed or worried of saying to the public in a sense look there will be changes in the way the system works as we make progress, there will be things that you experiment with and think 'well actually I don't think that is the right way to do it, let's look at a different way of doing it'.  And you know we have got to get to the point where we are unafraid to do what any other institutions or certainly major businesses would do as a matter of course, which is continually to re-evaluate the change process that you are putting through. The point that you raise is absolutely right, you have got to make sure that the incentives within the system don't rub up against each other. And I think this question, particularly with the acute sector, of how we make sure that they are not in a contrary way pulling care into the acute sector that doesn't need to be there, is one of the prime things that we have got to sort out.

Patricia Hewitt:

Yes. Normally on the technical stuff there is clearly more work we need to do on the  tools we have given you as commissioners⁶¹ to reduce the emergency admissions and challenge excessive lengths of stay will help, but we will also reinforce this direction of travel. We have already said over time we will move the acute tariff⁶² to best practice because by basing it on average cost it is inflated⁶³ by those hospitals who are keeping a patient with a hip⁴³ fracture in for 30 or 40 days when the average in the best hospitals is 10 or 11. Start moving it down towards 10 or 11 and that is a pretty dramatic incentive for acute hospitals to become a great deal more effective and it will release the money you need to improve other services.

On the Monitor point, which we discussed at the meeting in September, as you know I have asked for a meeting with some of the people in the department, some of the Primary Care Trusts, a couple of Foundation Trusts and Monitor itself, just to look at how we get right the balance between the autonomy of Foundation Trusts, which is very important, and we have signalled of course recently that if they want to apply to you to provide some services in the community themselves, you know they are free to do that as well, but we have to balance their autonomy with the cooperation that is needed right across the health economy to ensure that the whole system is in balance and doing the best for patients.

Chairman:

I think that is really important and I think that is really helpful, because you know one of the things when we go out to our membership on a regular basis is this issue about innovation, people want more space to innovate and that can only come from the local level, but it also comes with permission to sell. You know industry recognises that if you put in innovation, about one in five innovatory⁶⁴ things will succeed. We are actually succeeding on virtually everything we have put in, which probably means we have quite an opportunity to try harder and to be more innovative⁶⁵ as long as we can accept the risk that goes with that, and I think that is a real positive encouragement to everybody in the room to be thinking differently out of the box with political support.

Question:

I used to run a small non-governmental organisation whose aim was to help support the alleviation⁶⁶ of poverty in some of the poorest countries of the world. We had a very difficult job, we were tackling some of the world's most difficult problems, we were not well paid, we were always short of money, we never knew what was going to happen next and we were full of optimism and energy. And when I joined the NHS I was really surprised to realise in this wonderful organisation which is fully funded and has a huge amount of national support and respect, and love actually, that it was full of people who were anxious, grumbling⁶⁷, resistant⁶⁸ to change, and what I want to know is what is the Department of Health and the NHS Confederation going to do to help us to change this mentality⁶⁹ within our own staff, because they are the people who must bring about the change, they can't do that whilst they are full of pessimism⁷⁰, and also they are the chief ambassadors to the public. It is from our staff that the messages about what is going on is coming, so what we need, we are aware of all this, what we need is help, advice, support and leadership from you, and we will give it locally of course.

Prime Minister:

Yeah!  I think part of the problem, which I notice in many other walks of life, is that what is demoralising for people is when they are working in a service and they actually think they are working very hard and doing a good job, and there is a negative impression given of the service the whole time. The trouble is you know it is like some head teacher who berated⁷¹ me the other day and said:  "Why don't you get some good publicity⁷² for all the good things that are going on in the schools?"  And I said:  "Look Madam I would be starting a lot further back down the chain than the head teachers if ever I was able to do such a thing."  And I think the thing that we have got to do is twofold, we have got first of all to get across a balanced picture, you know of course there are tremendous challenges in the Health Service but actually there is a lot of really good stuff that is going on out there and we have got to try and proclaim that and we have got to do that together. And the second thing is, just to return to what I said earlier, about giving people a sense that actually what they are engaged in is immensely ambitious and difficult but extraordinarily⁷³ worthwhile, because it is very difficult and it is very challenging. And what you are doing, as I say, there are, Jill was just saying a moment or two ago about business people, funnily enough I had a business person the other day say to me, who was a highly successful entrepreneur in the country, and he just described how he had tried to make some change in his business that involved about 3,500 people and what a complete nightmare it was to try and do it, and it had all been very very difficult and they had a terrible time and so on and so forth⁷⁴. And he said to me, he was actually saying to the group of people who were leading the change with him, imagine what it must be like for these people in the Health Service, you know dealing⁷⁵ with so many people. And so I think part of it as well is just giving people a sense, (a) that it actually is improving as a service and we should be proud of the improvements that are made;  but (b) there is something very exciting about making change. And I think the other thing obviously is the work that you do at a local level. You know we can support you but in a sense if you are giving that strong and confident message that will reflect itself I am sure in the people that work in the Health Service.

Mr David Stout⁷⁶:

Can I add, what the Secretary of State said earlier about allowing us to make decisions at a local level is part of the answer to that, because if our staff feel all the time we are being told what to do by someone up there, it is very hard to get that sense of ownership and belief because they don't feel they have got it. And I think if we, in partnership with government, can make decisions genuinely at the local level, which we are engaging our own staff in, and as I said earlier telling the story convincingly for the case for change, I think they are willing to do it, it is just we need that space to get on with it, and then I think it is up to us as PCTs to drive that change through at a local level.

Chairman:

The NHS, only the police have a workforce⁷⁷ more dissatisfied than the NHS despite all the wonderful changes that are going on, and it has to be one of the top priorities. The other thing I think we are bad at, and I think it is something we should engage in dialogue, is how when we are making major change do we invest some of the resource, not into the patient care changes, but into changing the staff. And we are very bad at doing that because the NHS and every manager wants to spend every penny they can on direct patient care, and therefore some of the things that would make it possible to produce the change, we don't do because we see that as the use of a penny that isn't going on a patient. And actually that may be very good in the short run, but in the medium term it doesn't produce change, so we ought to be thinking about how we make that investment for change around our staff. And we have done it, you know when we closed the large mental institutions we did a wonderful job in terms of training, in changing our staff, in the attitudes of the management, and we need to revisit some of the successes of the past and be proud of what we have done.

I am going to take three questions now because there are a lot of people who want to ask questions and I want to get through as many as I can.

Question:

I think everything that has been talked about is very much supporting, and we have got examples of where we have changed emergency care and really moved things forward.  My question is really about the strength of levers because I think we are all aware of the challenges we face and I think that clinical leadership has been touched on and I think it is there but we massively need to increase that and make sure it happens because it is absolutely correct, having good clinical leaders will make things happen. The other issue is the strength of lever, for example practice-based commissioning is regarded as a key lever of the reform, but I think it needs to be significantly strengthened and really be powerful for it to make the difference, otherwise it will be seen as a lever but not really having the bite at the end of the day. The other issue is about responding to changes in the system, for example we talked about the incentive of payment by result, I mean there are lots of examples, for example if a patient stays in A and E an extra 15 minutes it counts as an extra admission and suddenly the hospital is charging 50% extra admissions, and there are lots of these that obviously clinicians can spot, but we have got to be able to change systems fast enough otherwise the system cannot change because it is frozen by that perverse⁷⁸ incentive. Thank you.

Question:

Devon I think has the distinction of being the largest territory, if not the largest population among the PCTs, so we are very exercised about keeping in touch with our grass roots. And this is a question really about accountability, and there are two distractions⁸⁰ I have come across in my short stint⁸¹ so far as a chairman. The first distraction⁷⁹ came shortly after the Labour Party Conference when it was being suggested that PCTs were quangos and didn't bear enough accountability to their local population, and on the third day of my chairmanship I was interviewed on the local branch of the politics show pointing out the existence of Overview and Scrutiny Committees, and I am a great fan of the County Councils and their ability to scrutinise services across a broad spectrum⁸², but I am curious about whether there is confidence among senior politicians that the partnership and the mechanism⁸³ of joint⁸⁴ commissioning between the County Councils and PCTs is one which they see as robust⁸⁵.

The second distraction is a rather specific one to Devon, is that we are working quite well with Devon County Council on formulating⁸⁶ joint commissioning, but we now have a request from Exeter City Council, which is seeking to become a unitary authority, to work with them as well on their future aspirations⁸⁷ for the commissioning of health and social care, and I would be interested to know whether there is a plan to amalgamate⁸⁸ the proposals of the local government White Paper and the patient-led NHS proposals.  Thank you.

Question:

I have to say that the RCN is very excited about the reform overall of care closer to home, we totally believe in it. And I am also excited about IT and I haven't heard much about it, but my understanding is we can't really get there without a good IT system that makes a difference and that nurses are wanting to be involved in that. But one of the realities is our training budgets are being slashed⁸⁹ and nurses are not getting away from the units and not being able to attain⁹⁰ their professional development, and so it is almost as though there is a freezing on that and it has something to do with the response to the deficits⁹¹ and balancing the books. And I think that when we are trying to work with the change to go forward and things happen that seem like it is reversing the change, that it is undermining it, for example the endangerment of specialist nurses who are keeping patients out of hospital, keeping them in the community, close to home, working with them, but they are in jeopardy⁹² of being lost. So those are the kinds of concerns that it seems like we are moving forward but that these issues then push us back, and it is just not clear about how we can work together to make sure those things are minimised and that there is a safety net for patients in terms of the changes that happen.

Chairman:

OK.  Maybe if we divide those up into two, because there is a cluster around clinical engagement, investment in training and development for clinical staff to make the changes happen, and then we have got this big question about accountability. So maybe Patricia, because I know this is something very important to you.

Patricia Hewitt:

Can I start, I will start with Beverly if I may, and just on the issue of IT which like you I am hugely enthusiastic about, I think it would be really helpful Beverly if we can work more closely with you and get the RCN and some of your members really making the case for something like the electronic patient record which will make an enormous difference to the quality, the speed, the safety of the care that we can give to patients, and that case needs to be made more strongly I think as we overcome some of the criticisms and worries about the IT programme.

On the issue about what is happening in some hospitals where as you and I both know specialist nurses are being asked to go back on to the wards⁴⁰ as part of what is often a short term set of measures designed simply to deal with financial problems, hugely frustrating⁹³ to everybody. But I think we do have to recognise that in the enormous growth that has taken place in the NHS finances over several years, and partly because we are still completing the necessary reforms to the financial framework so that everybody understands really clearly what the financial position is, and it is not hidden from sight by some of the brokerage and other devices that have been used in the past, in this process some organisations have overspent. And a few of our hospitals, even last year as the deficit was building up and up and up and becoming visible to everybody, they were taking on more staff, taking on staff they couldn't afford, and now having to make decisions that are incredibly difficult for all the staff to get back into financial balance. But I think what we have to do is to go on working together, both nationally and locally, to ensure that we support staff through those difficulties, we do more, and the Chief Nursing Officer is looking at this of course with modernising nursing careers, to support nurses who want to start their careers or retrain in order to work in the community, because clearly that is where a lot of the growth is going to come, but also to support staff where a hospital assigns possibly because of the other changes taking place like more daycare surgery, they need fewer acute beds and therefore fewer staff in some of their wards. And all these changes happening simultaneously⁹⁵ can be particularly difficult for frontline staff and we need to recognise that, we need to support them, we need to make sure that the hospitals with the biggest financial problems - the small minority - have the time they need to work through those problems, but we have to recognise the longer they take to sort themselves out, the longer somebody else has to compensate⁹⁶ by underspending themselves for the overspending that is continuing in that minority of hospitals. So being fair to everybody in all of this, as many of you know because you are contributing towards those regional reserves, the so-called top slicing, being fair to everybody is part of the very real difficulty here.

On Ken⁹⁴'s point about stronger practice-based commissioning, I completely agree, it is something you and I have discussed before. That was very much the thrust of the guidance on practice-based commissioning that we have just put out. I think it is one of the key challenges for Primary Care Trusts to support GP practices who are really up for practice-based commissioning, help them to make that happen and sort of support and challenge and develop the ones who aren't really signed up for it or really taking advantage of it yet.

Prime Minister:

This is an issue that goes on, particularly in the Shire counties, all the time and I have got the same issue up in the north-east in County Durham. It is basically a matter for the local authorities to sort out amongst themselves, although we have certainly in my area we have been more keen on moving to a unitary situation. And I know it must be very difficult for you because then you get slightly conflicting lines coming at you, the trouble is, I will be absolutely open with you, some of these things at a local level are let us say difficult because in the end if you move to a unitary authority the question is what is the unit and that is a very very difficult thing to do.  I think what we have got to try and do is iron out any of the practical problems that come from that, and I also think incidentally that more generally what we have got to do is to say why it is important that good management and good commissioning within the Health Service was one of the reasons I wanted to come along today is to say we are actually proud of people who are managing commissioning in the Health Service, it is an important part of getting it right.

And there are just two points that I wanted to make in this regard. The first is, and I think this is partly in answer to the point that Bev is making, because at the moment it is very difficult, you are going through this process of transition and there will be difficult things that happen along the way. On the other hand, for the first time I think people are facing up to decisions and having to align their capacity with revenue streams ... and that is difficult to do. I think however what we have got to do is to make sure that as far as possible there is an alignment⁹⁷ between our long term goals and the short term measures that we take in order to get financial balance.  But you see one of the things that is really difficult about debating public services is that people, and this is something I have certainly learnt over time because frankly when I was an opposition⁹⁸ politician I would say a public service is not a business, you have got your public services here, you have got your businesses there and the two are completely different entities⁹⁹. And what I have come to realise is that it is true that public services have a different ethos and a different purpose than a business, what is not true however is that some of the same challenges do not affect the business and the public service equally and that actually how you manage in things like procurement¹⁰¹, in things like the efficiency of your through put, in things like how you handle workforce change, some of the challenges are actually identical and in exactly the same way that businesses can learn something about social and public purposes from public services, public services  I think can learn something of management practice and efficiency from business. And it is a very difficult thing to say to people because they immediately say oh you want to privatise everything, you are not, you are simply saying that if you are handling a procurement budget that runs into millions of pounds, whether you procure¹⁰⁰ it well or badly is a question that any business person would recognise.  And the point that Patricia is making about the electronic patient record, it is obviously sensible, indeed it is potentially an amazing opportunity for the Health Service to have a single electronic patient record. But how you then manage that process of change through the service is going to be massively difficult. But the IT implications of change in the Health Service are actually not totally different from the IT implications that face any major business.

And that brings me to the second thing, in answer to the point that Ken makes, and this is in a sense my closing plea to you today, is that one of the other things that is very difficult when you are sitting at the top of government is to get the feedback quickly enough, and for us then to respond quickly enough to it. Because the point that I was making earlier about how you adjust as you go along, I think the points  you  are making in practice-based commissioning need to be strong and need to have the clinical leadership. This is really, really important. And one of the things that we have often talked about in our stock-takes is the degree to which you have PCTs doing the commissioning, and then you have got GP-based commissioning and how those two inter-relate together, which have some quite tricky¹⁰² issues to do with that, when you come up against a snag that you feel we in the system we have designed have put in your way, we need to get that feedback as quickly as possible coming through so that we can make adjustments and changes. Because this question of the unbundling of the tariff, you know there were reasons why we did it in the way that we did it, but once you start to put the system in place you realise there is a real problem if you don't have that flexibility¹⁰³. So we have to make change. But the quicker you get this to us, and you shouldn't be at all afraid either as a PCT network within the confederation, of saying look here are the changes that you could make right away that would make a difference to the way this system works, and then it is our obligation frankly to respond to that. 

Now that is what I think is a sort of partnership approach to managing change. And I know this may come as a shock to you, but we don't deliberately¹⁰⁴ want to get things wrong.  You know it is one of the mistakes people often make about political leaders, they don't actually usually sit there and say how do we devise things that will make people's lives most difficult. It is usually because there is a difference between the information that we get, which is subject to all sorts of changes before it actually reaches you, and the people on the ground. And all the time what you have got to do with this, as I have learnt over the years, is to have it road tested by the people who are doing it. But that information needs to come back to us, and if it does come back to us all I can tell you is insofar as it is possible to make the changes and adjustments in line with the practice that you are experiencing on the ground, we will do it.

Chairman:

I am afraid, I know there are lots of you who want to ask questions but we have had 40 minutes of I think amazingly frank discussion with the Prime Minister and with the Secretary of State which I have certainly found very enlightening and I do think highlights how important PCTs are. 

But may I on behalf of all of you thank the Prime Minister and the Secretary of State for giving us their time this morning and being so open with us.  Thank you very much. 

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