This has been a busy year for the NHS.

Apparently I'm not allowed to use the word 'insane', so I have to say 'busy'. It's political correctness gone mad!

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Over this past twelve months, we’ve seen:
• breast and bowel cancer screening – expanding ahead of schedule,
• MRSA down 17% - C.diff down 15%,
• 19 out of every 20 women now seen by a midwife in their first trimester – up 8%,
• almost ¾ million more people accessing NHS dentistry
• national waiting times kept low – with the average time patients wait for their operations lower,
• And mixed sex accommodation – dramatically down by 83%.
The NHS is clearly failing. We must change it, urgently and completely.

All this in a year that saw one of the harshest winters in memory, and significant increases in demand:
• with over half a million more people treated in hospital,
• and over 100,000 more diagnostic tests year on year.
I am hoping you have forgotten that I said "it's not about inputs; it's about outcomes".

All this with spending up by just 2.2%, and while SHAs and PCTs have reported an overall surplus of over £1.3 billion.
And inflation running well above that. Lovely surplus! Isn't it great what top-slicing budgets can achieve?

During a time of change...
which I imposed
when every day brings new challenges...
which I imposed
the people of the NHS have – yet again – proved just how resilient, how dedicated and how determined they are to improve care for patients.

So I want to start by saying thank you.
And here is your P45. Shut the door on your way out.

The Pause
(Shall I do a 'comedy' pause here? And just hold it for, oh, a minute? Jenny? Bill?)

The last year has been busy for other reasons too.
Which I imposed

• We published a White Paper in July,
• we held a full statutory consultation in October and responded to it in November,
• and we published the Bill in the New Year,
And the White Paper and Bill were both fantastic.

But while we were pressing ahead, there grew an increasing perception among some people – too many people

Bastards. With your completely wrong perception.
– that the Bill could pave the way for things that they didn’t want.
You only went and read the bloody things!

At the same time, too big a gap had opened up between what was actually happening on the ground and what was perceived to be happening by the commentariat at Westminster.
Oh yes. It's journalists' fault. They're double-bastards.

We needed a way to reconnect, to reassure those with genuine concerns, and to learn from those already implementing the changes locally about how to make the plans better.
Andrew Cooper told the Prime Minister how badly we were polling on the NHS.

So in April we took the unusual step of pausing the progress of the Bill.

The Future Forum, under Professor Steve Field, enabled us to look again at the detail of the Bill and the issues related to it. Issues of implementation and things like education and training.

It gave us an opportunity to address head-on the concerns that people had.
Consultations on White Papers don't do that, you see.

Some were genuinely concerned about the impact of competition on the NHS.
Competition is of course an issue of implementation. Likewise top-down reorganisations. But I'm betting you won't notice.

That it would be promoted as an end in itself and not in the interests of patients.

We will not do this.

Competition will only ever be used as a means of improving care for patients. What matters is that we create a level playing field that allows the best providers to flourish.
Of course, if you sell off a playing field, it tends to get levelled by the developers pretty quickly.

Some groups of clinicians, like the RCN, were concerned that the make up of local commissioning was too narrow.
Hospital doctors are not yet tired of explaining to GPs how thick GPs really are.

The pause allowed us to ensure – rightly – that commissioning is about clinical leadership across and beyond health and social care, bringing people together to design better services.

And I know from the many letters we received from members of the public, that some people feared the Bill would undermine the values of the NHS.

I would never let that happen.
My backbenchers, on the other hand ...

But we have now, I hope, reassured people of our commitment to the fundamental values of the NHS – of healthcare for all, free at the point of need. And to strengthening the NHS constitution as a basis for what we do.
Changed the title and the font.

The pause gave us the opportunity to build a greater sense of ownership
by Comrade Sir David Nicholson
- essential for proper implementation.
of the Nicholson Health Service. Do you feel nice and liberated?

And it enables me to assure you that the Coalition Government is fully committed to the NHS and its modernisation.
Do you remember modernisation? Tony let us have that one for nothing!

The Future Forum did a fantastic job. And I would like to thank all the managers who worked so hard to develop its recommendations.

They recommended that the pause should end.
Which is very clever. Because a pause that doesn't end isn't a pause, is it? It's death.

It has.

But that doesn’t mean we’ve stopped listening.
To Paul Bate

And on Monday I will discuss with members of the Future Forum what implementation challenges they might help us with next.
Like defining integration.

Principles
(I thought I'd just mention an indifferent high street clothes shop, for fun.)

While there have been substantial changes, the guiding principles remain.
Did you notice how I was absolutely right all along, and all my critics were completely wrong?

I said that to you last year that, “patients must be at the heart of everything we do, not just as beneficiaries of care but as participants in its design”.

That still stands.
Because I am always right.

Last year I said that we need a, “rigorous focus on outcomes with the ambition of securing results and healthcare services in this country that are amongst the best in the world.”

That still stands.
Because I am always right.

Last year I said we must set professionals free to, “use their clinical judgement to do their jobs to the best of their ability and on the basis of the evidence.”

That still stands.
As maintenance of central performance management of the 4-hour A&E process target
clearly demonstrates Not only am I always right, I am never inconsistent. Apart from about top-down reorganisations, which are just an implementation detail.

And last year, I underlined the central importance of emphasising public health and modernising social care as part of a comprehensive set of long-term reforms.

That still stands.
Because I am always right.

Momentum
But my main message to you today is that, after the pause, it is now time to move forward and get on with improving services for patients.
Crouch! Touch! Pause! Engage! What do you mean, this isn't meant to be a rugby scrum?

Listening to GPs at pathfinder events or at the NAPC, I know that while our plans were in flux, some became less keen to commit to long-term changes. And some of them – some of you, I know – will have felt unsure about how to proceed.
You mean Comrade Sir David hasn't told you what to do yet?

Well it’s now time to regain the momentum.
Towards doing the wrong thing

To get back on the front foot.
Pleasepleasepleaseplease don't let them think about this line too closely. 'Get back on the front foot' ...

To focus again on the challenges we all face.
Which a system-wide top-down reorganisation is sure to make easier.

Pathfinders
And to underline that return of momentum, I am pleased to announce today the fifth wave of Clinical Commissioning Group Pathfinders.

The 35 new Pathfinders bring the total to 257, covering almost 50 million people, around 97% of the population in England.
Up from 150 to 297, and not done yet. That's cutting wasteful bureaucracy!

Some PCTs have already delegated budgets and commissioning responsibilities to pathfinders, and I hope the majority will by next April. By October next year, the NHS Commissioning Board will begin to establish full Clinical Commissioning Groups, delegating budgets to them directly. And by April 2013, Commissioning Groups will start to take statutory responsibility in their own right.

You will hear more on this tomorrow from David Nicholson
whose health service this now is

, but it will be the mission of the NHS Commissioning Board to help local commissioning groups to get up and running as quickly as is sensible to do so.

Only when commissioning is both clinically-led and local can it bring about the transformation so critical to meeting the challenges of the next 10 years.
Unless local clinicians aren't much good at leadership.

Challenges
And those challenges are great. As I see it, there are four major challenges facing the NHS, and facing you as managers
i.e. bureaucrats
• to increase productivity
• to improve patient care
• to reshape how care is delivered
• and to integrate care around the needs of patients.

The first then, is to dramatically increase productivity year after year.

We will do this by by providing better care.
No shit!
• By treating more people closer to home,
• By focussing on prevention as much as on cure – like in Sandwell, where the PCT and the local authority are working together to improve sexual health,
• by eliminating errors and avoidable harm – like maintaining a zero-tolerance approach to MRSA and c. Diff,
• and by integrating and streamlining care.

Making big savings must not be about crude cuts to services.

Not when it can be about making them better.
You can type this shit, but come on, I can't say it. Can I?

The second challenge is to significantly improve the quality of patient care.

I know people are generally satisfied with the NHS. But if people were only aware of the variations in the quality, they’d be shocked!

Just look at the report on palliative care by Tom Hughes-Hallet and the variations he highlighted.

The NHS can be so much better. You know it. I know it.
So let's have a top-down system-wide redisorganisation to prevent it from happening and increase the risk of ugly failures!

We need to measure more, to publish more, to incentivise more.
Which is why we stopped our funding to the health questions of the Social Attitudes survey

In the coming years, we will give England the most transparent healthcare system in the world.
We will stretch the bugger so thin, it's translucent.

As the Prime Minister said this morning, transparency is a central tenet of this government’s approach to improving all public services.
Which is one way to describe the widespread losses of patient data

Up to now, this approach has worked for waiting times.
yes, nobody gamed waiting times ever, did they?

In the coming years we want to publish far more data on clinical outcomes for public and clinical consumption.

Data like hospital mortality rates for bowel cancer surgery – published this year – rates that vary from less than 2% [1.7%] to more than fifteen [15.6%].

Every doctor, every nurse, every manager, every provider wants to be as good as they can be. In a transparent NHS, everyone will see just how good they are.
If they trust and feel ownership of the data and get it in a timely way.

Professional pride, patient choice and financial incentives will drive outcomes ever upward.
Don't ask me for the evidence.

The third challenge is to reshape NHS care.
Unless it's in a Conservative marginal seat. See Chase Farm.

More community based care – like how people in Whitstable no longer go to hospital for an endoscopy, they have one at their local GP surgery.

More specialist care in centres of excellence.

Like the new Centre for Surgical Reconstruction and Microbiology in Birmingham, which brings together trauma surgeons, research scientists and others from the military and the NHS – pushing the boundaries of major trauma care.

Every provider – especially hospitals – needs to take a deep and profound look at the services they provide and at how they provide them.

The best hospitals no longer think of themselves as a physical place – as bricks and mortar – but as providers of excellent health care.

Not so much a Hospital Trust, or a Mental Health Trust, but a Healthcare Trust.

Like Croydon Health Services, which provides both hospital and community services through a number of community and specialist clinics throughout the area.
Helped by the 'Croydon List' of procedures rationed by the PCT.

This flexibility makes adapting creatively to change far easier.

But change, even when clinically justified, will be difficult.
Kidderminster. Just saying!

People form a strong emotional bond to the places that may have saved their life or that of a loved one.

So it is incumbent upon us to make the argument for pressing forward.

Change must be – and seen to be – clinically, and never politically led.
See above re Chase Farm; also Epsom & St Helier

Of course, the NHS will always be political to an extent.
Tax funding does that, apparently

Government sets the overall budget.

And we’ve amended the Bill, reaffirming that Ministers are accountable overall, with a duty to promote a comprehensive health service.

But the political balance needs to change, with no more interference in the day-to-day running of the NHS.

Now I know there is a lot of direction from the top at the moment, but I want it to be a transient step towards a truly liberated NHS.
A transient step back on the front foot, that is

An NHS accountable to patients more than anyone else.
Welcome to the Nicholson Health Service.

For we know that where decisions are clinically led, based on the latest evidence, and where patients and the public have been properly involved in their planning and design, services will flourish.
As I assert it, so shall it be.

The fourth challenge is to cut bureaucracy and to integrate services around the needs of patients.

Last November, my father died. While his care was good and, with the support of the NHS community services and Marie Curie Cancer Nurses, he was able to have a ‘good death’, it was not without its problems.

While the people in the NHS he encountered looked after him extremely well, in the early stages the service as a whole was fragmented and uncoordinated.

At one stage, I couldn’t work out who was in charge: his GP, his oncologist, his palliative care consultant or the hospice?

There are too many hoops for patients to jump through.

Too many administrative obstacles for clinicians – and managers – to negotiate.
And more complex transactional commissioning and contracting will help with this. No, really.

All getting in the way of proper integration of services built around the patient.

You all know me as a critic of excess bureaucracy, of red tape, of an over-administering NHS.

And I know from long experience that many of you are among the most vocal opponents of excessive bureaucracy.

It must stop.

So we'll need a few clinical senates, Health And Wellbeing Boards and others to send back commissioning plans.

We can’t afford it. It stifles innovation. And it gets in the way of providing the best patient-centred care.

Importance of managers
Can't I say bureaucrats?
Without high quality management, we cannot hope to meet the challenges we face.
So we will cut it to 45% of the 2008-9 level by 2014-15.

Without good managers, we can’t achieve the efficiency gains so vital to the NHS.
So we are calling them bureaucrats for over a year now, as a motivational tool

Without good managers, we can’t take the leap forward we want in patient care.
A leap forward back onto the transient front foot. Obviously.

Without good managers, we cannot re-shape NHS services.
But we can certainly have a big old top-down system-wide redisorganisation.

And without good managers, we cannot create a streamlined, integrated NHS.

Modernisation is every bit as much about organisational leadership as they are about clinical leadership.
I said 'shut the door on your way out'! Bloody bureaucrats.

Conclusion
These challenges, these changes, will have a significant impact on each and every one of you. There is a huge amount to do, a huge amount to get to grips with.

I know this is a tough time for many of you.
Of course I do. I made it happen with my Grand Plan.

I understand the difficulty of the position some of you find yourselves in.
Bureaucrats.

But patients need you to keep at it. To do what is necessary to make the transition to the new system a smooth one.
Andrew enjoys cricket and emotionally blackmailing wasteful bureaucrats.

So it is time now to look these challenges in the eye.
How do you look a challenge in the eye?

To do what’s necessary to meet them.

To regain the momentum.

So I ask you to return to your organisations with one simple message.

The pause is over.

It’s now time to act.
as if this makes sense; method acting, preferably.

Thank you.
Bureaucrats.