Health Secretary Andrew Lansley - speech to King’s Fund Leadership Conference, Wednesday 18 May 2011

Integration and Leadership

As the Prime Minister set out so clearly this week, the NHS faces some significant long-term challenges. An ageing and increasing population, increasing burden of chronic disease, rising costs of drugs and treatments, and growing, almost insatiable public expectations.

If we choose to ignore these pressures, if we stick with the status quo, then in the years ahead the NHS will face a genuine crisis. One that would threaten the core values of a comprehensive health service, available to all, free at the point of use and based on need.

This government will not allow that to happen.

But given the financial context, how to ensure the NHS is not only sustainable in the long term, but that it gets better? That it gives the people of this country healthcare that is consistently among the very best in the world?

I think the answer is straight-forward.

You put the right people in charge.

You make it crystal clear what it is they are trying to achieve and how they will be held to account.

And you then do everything in your power to support them in what they are doing.

Where they need extra powers or resources, as far as you can, you supply them. Where there are obstacles, you remove them.

That is what happens every day in successful organisations around the world. And it is what I want to happen in the Health Service too.

Leadership
Today is about leadership in the NHS. About what good leadership can do for patients and about how we can support and nurture current and future leaders within the Health Service.

Note that I say ‘leaders’ – not leader. For leadership in the Health Service cannot be about one person at the very top. The leadership style of Henry V on St Crispin’s day – the man on horseback- as dramatic and inspiring as it is, just isn’t appropriate for something as vast, as complex or as subtle as the NHS.

The Health Service needs far more than that. It needs leaders at every level, in every institution and in every profession.

And the people that I believe, first and foremost, should be leading the NHS are clinicians. GPs, hospital doctors, nurses, pharmacists, allied health professionals, scientists.

We need people in every area to step up to the plate and lead.

No profession can be left out if we are to deliver truly integrated, high quality healthcare for everyone in the country.

Managers
And when I say that, I include managers. But leadership and management are not the same. Some managers are leaders in the service now, like David Nicholson. Others will be leaders in the future – but not just because they rise up the managerial ladder. Management is one of the professional disciplines inside the NHS, but it is a support to clinical leadership, not a substitute for it.

Just so there is no confusion, I know that high quality managers are essential to the effective and efficient running of the NHS.

No fundamental change in any NHS organisation ever came about without the support of managers – people who are every bit as committed to the health service and to improving patient care as clinicians.

The problem is not the people, it’s the system. Managers are placed in an impossible position.

Too often in the Health Service, change is seen as a process whereby managers tell clinicians what to do. But why is this the case? It’s because people like me in government are constantly ordering them to do it.

So you end up with a top-down, command-and-control system with the Health Secretary driven more by that day’s headlines than the best interests of patients.

He then gets his officials to come up with some ploy that he can sell to the press, tells all NHS managers to carry it out and then claim to be saving the day.

Managers are then left to force it through on the ground – whatever the clinicians might think and whatever the consequences down the line for patients.

So you get new initiatives with exciting names. Policies that sound great, but amount to little more than hot air.

The result? Emasculated and frustrated clinicians, overstretched managers caught in the middle and patient care that is at the political whim of whoever happens to have won the previous election.

And over the years, the accumulated weight of countless...
• initiatives to implement,
• targets to meet,
• reports to produce
• and boxes to tick...
...means that the NHS isn’t managed. It’s bureaucratised.

Managers are no more free to run their organisations than clinicians are. Over these last seven years, it was as often managers who told me to get rid of the top-down culture as it was nurses or doctors.

And while those who work in the Health Service add “frustration” to their job descriptions from day one, it’s patients who lose out on the potential benefits of a truly clinically-led Health Service.

It’s been like this for decades. It cannot continue for another. It’s time that politicians and managers handed the controls over to the people who really understand the needs of patients and how to serve them best – to clinicians.

King’s Fund report
Today, the King’s Fund’s Commission on Leadership and Management in the NHS has published its report.

I very much welcome the report. It speaks to the same ambition that I have for the NHS. For a Service led from the front. An integrated NHS that is focussed on improving clinical outcomes and nothing else. A Service that is well managed, not overly administered.

I understand the caution around the size of reduction to the management and administration budgets. But most of these will come from the abolition of Primary Care Trusts and Strategic Health Authorities.

Across the public services, similar reductions in administrative costs are required. In the NHS, we can see how we can achieve this by changing the shape and burden of administration, not just the numbers of administrators – not keeping the system the same and asking fewer people to run it, but reducing the scale of administration alongside the cost.

By handing power to clinicians and by ending the constant micro-management and over-burdensome performance management of the NHS, much of this work will no longer be needed.

Where I fully agree with the report is in the vital importance of high quality leaders and managers. The gains made in recent years must be maintained and built upon. Every NHS organisation and provider must take their staff development role incredibly seriously, especially new entrants from the charity and independent sectors.

I’m keen to continue the excellent work of the National Leadership Council. Just last week, I announced that we would fund a further 60 Fellows as part of the Council’s Fellowship programme, developing tomorrow’s leaders from all parts of the Health Service,.

Every one of whom will make their own individual mark on their local NHS, and collectively make a real and lasting difference to the level of leadership within Health Service as a whole.

The King’s Fund report says that the NHS needs a national focus on leadership and would welcome a national leadership development centre.

I am now considering the idea of a national centre. I know there are some interesting and novel schemes already running. For example, the innovative programme at UCLH, which has drawn on models of leadership from the armed services. We’ll respond to this and the other recommendations once the listening exercise has closed.

Outcomes
I said at the beginning that if you want to achieve success in an organisation you first have to put the right people in charge. But that’s not all. You then need to be clear about what they are trying to achieve and show them how you will hold them to account for that.

So let me ask you a simple question. What’s the NHS for? We all know when we see it: supporting childbirth; promoting good health; treating illness and injury and promoting recovery; care for those with chronic illness; care when dying.

But if this is what the NHS is for, why have we never measured in a systematic way how well it’s achieving these aims? Of course, these things are not always easy. But they are worth the effort.

What is the gain if you treat people in a shorter period of time if the quality of the care and the quality of the outcomes were to be poor? Too often we measure the success of the Health Service by the number of units it processes, not by how well it improves people’s lives.

So from now on, I want all parts of the NHS to be judged on the clinical outcomes they achieve. We published the Outcomes Framework in December to help all clinicians to pull in the same direction.

• Reducing avoidable mortality;
• enhancing recovery after treatment;
• improving the quality of life for people with chronic conditions;
• maximising safety and cutting the number of infections;
• and continually improving patients’ experience of their own healthcare.

To flesh out the detail, NICE is developing a library of condition specific Quality Standards. These will mean that, over time, every clinician – and every patient – will be able to see just what excellent care really means and judge whether they are receiving it. These aren’t targets by another name. They state what should be achieved, not how clinicians should achieve them.

As General Patton once said, “Don't tell people how to do things, tell them what to do and let them surprise you with their results.”

And because all providers of NHS care will be aiming for the same high quality outcomes, I, the NHS Commissioning Board, General Practice Consortia, local authorities and, most importantly, patients themselves will be able to hold providers to account for delivering that excellent care.

Integration
And more often than not, delivering excellent care will mean delivering integrated care.

But unfortunately, the NHS is not particularly good at integration. What it is good at is episodic care.

If you’re young and relatively healthy but fall ill with a specific disease, or have a particular injury, the Health Service is excellent at taking you in, making you better and sending you on your way.

The problem with this is that the vast majority of the people the NHS looks after don’t fit that description. Most of today’s patients are older and with one, or often more than one, long-term condition.

So you have the typical example of an older person with terminal cancer, having to rely on her daughter to coordinate care between her GP, community nurses, hospitals and social care because they can’t quite seem to join up the dots by themselves.

And what about the many who don’t have someone to fight their corner? What happens to them?

The needs of patients are too often not catered for by the strengths of the Service. The result is that, far too often, care today in the NHS is fragmented.

A patient with COPD might be treated by her GP, by a pulmonary specialist, and by a community nursing team.

• Three separate groups of people to contact,
• three separate sets of forms to fill in,
• and three separate notes to keep track of.

All this with the patient in the middle, often the one who has to try and coordinate their own care between them.

Or look at end of life care. At the end of their life, most people want to die in their own home. But the fact is that most people actually die in hospital.

This isn’t because of the high level of intensive, hospital based care they need.

It’s not because the people who work in the NHS don’t want to provide the very best care to their patients.

It’s simply because the system isn’t set up to provide the quality of out-of-hospital care needed to help patients die at home.

• The system of tariffs doesn’t encourage hospitals to do it.
• The people with the money, the PCTs, often aren’t aligned properly with clinicians.
• It’s hard for the voluntary sector – organisations that can add so much at the end of a person’s life – to offer their services.
• Patient experience and outcomes aren’t measured.
• And all too often, health and social care organisations just don’t join up.

But there are examples where people have joined together to beat the system. Since 2004, the Marie Curie Cancer Care’s ‘Delivering Choice Programme’ has taken a whole system approach to end-of-life care. Working across all those involved – the NHS, the voluntary sector, social services and carers – to provide 24-hour, patient centred care for those at the end of their lives.

The evaluation of the first scheme in Lincolnshire, carried out by the King’s Fund, found that deaths at home rose from 19% to 42%, while deaths in hospital fell from over 60% to just 45%. All the while being cost neutral.

Another important opportunity for joined-up services is in urgent care. Services are too often fragmented, varying in quality across the country and often confuse patients into using inappropriate services – like going to A&E rather than seeing their GP.

But by adopting new technologies to encourage greater self-care, by introducing the ‘111’ telephone number as a single point of contact for non-emergency care and by giving local commissioners the freedoms they need, we can change this.

We can deliver a properly integrated urgent care system that turns the NHS into a 24/7 service, and makes phrases like “out of hours” feel redundant.

Care needs to be organised not around the needs of a particular provider, but around the needs of the individual patient.

To have good care, care needs to be integrated.

Choice and competition
Another thing that is essential for achieving excellence is involving the patient in their own care. This means more than just explaining things to people. It’s bringing them into the decision making process. It’s giving patients a choice.

Now patients already have a degree of choice. They can choose the hospital that will carry out an elective procedure. Or at least they could if they were able to distinguish to any meaningful degree the quality of care offered by one hospital from another. But whether you’re going in to have an in-growing toe nail removed or for radical cancer treatment, if you don’t know how good a particular provider is, how can you – or your GP – decide which to choose?

And even if you look at the current overall hospital ratings, they won’t tell you how good their clinical outcomes are at the one thing that you’re most interested in – at the procedure you’re about to have.

So while patients today theoretically have a choice. In reality, it’s hardly a choice at all.

So is it any wonder that although almost all GPs maintain that they always offer their patients a choice, according to research by the by Anna Dixon here at the King’s Fund, less than half [49%] of them recall being offered one?

We need to offer choice where appropriate; but even more so we can make the framework for choice more robust. If you could see not only how good a hospital was, but how good a specific department or even a specific consultant-led team was, wouldn’t that change things dramatically?

That is when GPs and other clinicians can really draw a patient in to the decision making process. For with the right sort of information, choice becomes meaningful.

And patients will choose the care that offers the best results for them.
Last month the National Cancer Intelligence Network published, for the first time, mortality rates 30 days following surgery for bowel cancer. Across the country, the figure was 5.8%. Not bad, perhaps. But that national figure masked huge variation. From just 1.7% to 15.6%.

Now this doesn’t automatically mean that care at one place is necessarily better or worse than elsewhere. As you know, there will be all sorts of factors at play. But it does give clinical teams pause for thought. To ask the question, is there more that we can do? To look at those with the best performance and see if there are things that they are doing that we are not.

Making this information available to the public will also have an impact. Patients, with their doctor, will be able to make a more informed choice as to by whom they wish to be treated. And given the choice between one hospital with a very high survival rate and another with a lower one, which would you choose?

Integration vs. competition
Now choice, real choice, means that providers will be sometimes, in effect, competing for patients. They do now. Strengthening information and accountability will encourage all providers, however good they may be, to raise their game and to offer patients the best possible care.

No provider, whether from the NHS, charity or independent sector will be competing on price. As we extend tariffs prices will either be fixed for all providers nationally or locally by commissioners. The only way to distinguish yourself as a healthcare provider is to provide a higher quality service than everyone else.

But at this point, some people start to question whether competition isn’t utterly at odds with that other essential ingredient I’ve mentioned – proper integration of healthcare.

I would like to explain not only why this is not the case, but why competition can actually lead to a far greater degree of integration than would ever be the case without it. And to do that I hope you will forgive me if we leave the realm of healthcare for a moment.

We live in a complex world where we take for granted the minor miracles of integration that we see and experience every day. Integration that is so seamless that we don’t even notice it.

Let me take just one example. I bet virtually everyone here today has a phone in their pocket or handbag. Some of you will have more than one. It might be a basic model where you can make calls and send texts and that’s about it. Or it might be one of the latest smart phones that can do just about everything bar the washing up.

Either way, you are enjoying the fruits of countless individual companies operating in a wide range of individual, highly competitive markets, all working together to deliver that one complex, ubiquitous product.

Mining companies, designers, chip manufacturers, haulage companies, marketing agencies, precision engineers, logistics companies, data management, network providers, warehouses and, finally, the place that sold you the finished product.

Each one competing fiercely for business at every step of the way. Each one successful in large part because of the high degree of integration they can offer with the other parts of that supply chain.

When organisations compete but don’t offer to integrate their services, the result is clear... they don’t get the business.

It is in the interests of every provider to offer the greatest possible degree of integration. Even with those they are competing directly against. Vodafone and T-Mobile both rely on common standards. Whether you have a Nokia, an iPhone or a Samsung, the same SIM card will work in all three.

The same can be true of healthcare. Only here we don’t call it a supply chain, we call it a care pathway.

Of course, the NHS isn’t a mobile phone. It’s infinitely more important than that. If things go wrong on your phone, you can’t make a call. If things go wrong in the Health Service, people’s lives are at stake.

Modernisation isn’t about competition. It’s about improving results for patients. It’s about building quality services for patients. It’s about extending information and choice. It’s about competition as a means to an end, not an end in itself. And it means ensuring that the service is patient-centred, not provider-centred.

I know the clinicians in charge of commissioning will demand nothing less.

Because it will be an essential element of every contract within the NHS.

Because they will be rewarded by the outcomes they deliver and they will be better if they are deeply integrated within the wider pathway of care.

So a hospital that doesn’t go out of its way to integrate its general surgery with community nursing teams and with local GPs will quickly run into problems.

The community dialysis provider that does not link up with specialist community nursing, with hospital renal specialists or with social care organisations will find it very difficult to convince commissioners to pay for their services.

And if nothing else, if they don’t prioritise integration, their competitors certainly will.

And in those circumstances where the best care is be provided by commissioning a single provider across the whole pathway, that’s allowed too. The Bill doesn’t prevent that. It will support that. This is about doing whatever it takes to produce the best outcomes for patients.

Listening
If we agree that the whole point of the NHS is to provide the very best outcomes for patients, then I believe we must have a fully integrated NHS that is clinically led and that gives patients a real choice.

I am very clear that this is what we must achieve, but I am also very open to views and ideas as to how we achieve it. To my mind, nothing is more important than getting this right. The law of unforseen consequences can play no part in NHS modernisation.

That’s why we have paused after the Health and Social Care Bill has left committee to listen and reflect on what people are saying and to see if there are things we can do – substantive things – that will mean that our ambition is matched by the reality on the ground.

The Bill is necessary not to give more power to the centre, but to give it away to clinicians. You cannot have a clinically led system without the legislation necessary to give them that lead. And if you want the NHS to be truly run from the bottom-up then you do at some point need the people at the top to let go the direct reins of power. That is what the Health and Social Care Bill is about.

Conclusion
I don’t want the future of the NHS to be determined by me or any other politician. I want it to be determined by the millions of choices made by millions of individual patients and by the healthcare professionals responsible for their care.

By local NHS and social care organisations working with local authorities and patient groups to bring cohesion and integration to local patient services.

And by the many thousands of clinical leaders in GP surgeries, hospitals, cooperatives and independent sector providers all across the country.

The government will put the right people – clinicians – in charge. We will make it clear what they need to do and how they will be held to account. And we can do everything possible to support them in this difficult role.

This is our vision for the NHS. A vision of an NHS led from the bottom-up. A vision that puts patient care above news headlines.

A vision that I believe in and that I fully expect to deliver outcomes that are consistently among the very best in the world.