Mr Lansley opened his speech by mentioning a text message he received from a friend living in France during the passage of the Bill. The message quoted the philosopher Schopenhauer: "all truth is ridiculed, then violently opposed, then accepted as self-evident".

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The NHS needed reform to focus on outcomes and patient self-care. Many of you have argued this for years, and I've heard you say this. At NAPC conferences in years past, I heard you say 'we believe in patient-centred care', so I can claim no originality at all. Many of you have sought this approach for years; you have seen false dawns. This time, reform is hapening and we will see it through

The NHS is more than a fixed point, more than bricks and mortar that become part of the furniture. The fixed point in the NHS is its values, the principles established at its outset, which have been incorporated into the NHS Constitution. Those values remain the same; but the service can and will change to meet changing needs.

The only reason I am so determined about this reform is that I can see the demographic tsunami that all of you can see, that will overwhelm the NHS unless it changes. I know many of you have been talking for years of the need to redesign pathways and services to meet rising demand.

In the 2006 deficit, the response was to cut budgets and rayiom care. new aoproach to innovate. NHS should never be run solely on bottom line: values to provide free and comprehensive service to provide best outcomes. send finite resources in the most effective and efficient way

People say these two are in conflict, but these are the things we must balance - to provide the right care at right time in right place - but you can be ethical and efficient. That means doing the best for the patient in front of you at the same time as doing the best for all your patients; two goals, pursued with the same vigour

Given these two objectives, the only way to do the best for individual and population is for those decision to be made by the same set of people, deciding for the individual and the collective. That's called clinical commissioning and those people doing this are you.

We need to move from the old system to the new, and I know it will be tough. We must think not only of immediate diffculties, but look again at the opportunities. Look at wider heath of population; social care and NHS integration for benefit of millions with care needs. We can only achieve the right level of care with radical thinking and radical actions. This means difficult decisions. It means delivering services differently than we do now; some in centres of excellence; some in people's own homes.

While rarely will care settings close down, many will change. That will be difficult. Hospitals with long-standing needs for change can't keep kicking the can down the road, and we will help their boards, giving them loans for the time and space to become sustainable and as I said last year, we will help those with PFI debts.

But help means not endlessly propping up those who cannot stand on their own two feet. I'm asking you as comisisoniners to do best for your patients; not to provide for deficits in the local health economy. That's our job, and in future, will be Monitor's.

This will take a few years, we will work with providers and Monitor.

I still intend that you start with no legacy debts. That will not be true of providers but I hope it will be for you commissioners

I know many in the NHS express scepticism of whether politicians back difficult decisions. National politicians should not lead the case for local change: you local clinicians should. Do that, and I will back you.

In the past, change failed to happen, but not because politicians lost their nerve: rather, because often the change proposed was not clnically backed or supported by evidence.

4 tests - local commissioners and public support, evidence of benefit; consistency with patient chocie.

NHS111 - technology more than 10 years ago identify your location from mobile, but put directory behind that of services.

Innovation on tariff, or teleheath: recently I met a patient with COPD who was now using telehealth - he had made 6 A&E visits in the 6 months prior to starting the new scheme, but was now managing his care at home and talking to the district nurse, who told me that she now visits far less often than she used to. NHS Gloucestershire roll-out of remote monitoring of patients and proactive GP support. Whole System Demonstrator published 45% fall in mortality rates, in BMJ last week

Innovation and change will define future of the NHS, led by evidence of what works. Not led by men in grey suits in Whitehall - not even this man in this grey suit.

The system must reward not ticking boxes, but improving outcomes.

The mandate is a simple document that will set this out, and it's essential we get this right, so please play your part. The mandate is how the SOS holds the system to account; it is not for telling you how you must do things but for describing what you need to achieve.

6 years ago, David Cameron and I said we do not want to tell you how to achieve. We will set stretching goals, leadership down to you. The mandate will be based around the outcomes framework, help people recover, have +ve experience of acre, treat respectfully.

We have to measure the right things. Currently, we're not measuring mothers' experience of childbirth - just infant mortality and complications. The patient survey only begins at aged 16; we don't know about children's experiences of care. People with learning disabilities can now feedback to service. Outcomes Framework will focus our minds, will enable clinicians to lead, not to be micro-managed from on high.

The NHS will remain free at point of use, not based on ability to care. The service must be clear about clinical effectiveness: I'm not asking you to offer services of poor or no value. We must move away from thinking that it's enough to hit a few narrow targets. People should have confidence on access but also on quality of care.

The mandate also aims to ensure a focus on outcomes for all, including improving the health of the poorest fastest. The better-off have longer and healthier lives. educe health inequalities of worst fastest. also must improve outcomes by better integrated care and support. Opportunity through HWBs to reach out across all services that impact: you often deal with housing or employment issues as well as health issues. Understand and impact wider determinants of health. Bring local authority and other groups together to make this happen. Having conversations and creating relationships that never existed in the past: Salford councillors and GPs had shared population and responsibilities, but had never met. Now you can; now you should.

This is a transition period, and I look to NHSCB to get as many CCGs as authorised as possible. set out regulations for CCG authorisation. a primary role for the NHSCB is to give CCGs support for authorisation and then to survive, enable you to be the local leaders you want to be and be as good as you can be.

There are some urban myths: about Board top-slicing your budgets, or being re-authorised every year. Wrong. Once authorised, you have authority to commission, while keeping in budget and delivering care to the mandate. Conditions will be transitional, not permanent. as we enter the summer, months ahead sense of momentum. system taking shape, people understanding how it works and where they fit. Authorisation next round applications, costs under control. GPs are already reducing referral rates, fewer emergency admissions.

Reshaping is not about primary care versus secondary care; but about understanding that we need to have community service primarily, supported by specialists

I know it's difficult, and change always comes with some friction, but encourage you to look ahead. Job you're motivated is only jib you have to do, improving people's lives by delivering better healthcare. Improve your own destiny and the health of your local community: efficient, excellent, equitable care. Look ahead to new NHS and changes you will lead

Schopenhauer said, "change alone is eternal, perpetual, immortal". You are leaders for the NHS and on behalf of your patients, and for their sake I wish you every success.