Dr Michael Dixon speech to NHS Alliance conference 2009

Welcome friends and colleagues to this 12th NHS Alliance Annual Conference. The best NHS conference of the year, of course, but only because you represent the very best of primary care.  The best managers, clinicians and non execs leading at the NHS’s frontline.

You are, as Miss Jean Brodie put it, “La crème de la crème”!  

The past
Twelve years and a General Election in the near future make it a good time to take stock for the NHS and NHS Alliance.  

Starting with the past, let’s pause for a second and celebrate our successes.

For the NHS, a considerable and necessary increase in funding has led to much-reduced secondary care waits and vastly improved care for patients with cancer and heart disease.  The NHS Alliance television team tell me that the opinions of people on the street, speaking about the NHS, were almost universally positive this year.  It is a far cry from years past!

Meanwhile, NHS Alliance has also gone from strength to strength.  We have established a new culture of frontline managers, clinicians and non execs working together. Today, we are bringing PCTs and practice based commissioners together as well.  Our messages of clinical leadership, localism and effective commissioning are now part of popular rhetoric.  Primary care has raised its game.  It can no longer be ignored.  Indeed, we are now the key to survival in a challenging economic climate.  

The present
And so to the present, where the NHS stands at a crossroads in so many ways.  As we await an election, people tell me of a feeling of “policy impermanence” with ministers and director generals of commissioning seeming to change almost as rapidly as the weather.

There is an ever-widening disconnect between the high ideas, the discussions and the resolutions in Whitehall and those who are struggling to deliver their best for patients at the front line of the NHS.

Clinicians, in particular, appear to be alienated.  Forget leading; far too many are not even engaged.  Commissioning, in the sense of radical redesign, is the exception rather than the rule - even after nearly twenty years of trying.  That enormous energy, enthusiasm and inventiveness for improvement that exists at the frontline is too often sapped by rules and regulations.

In short, whether you be a manager or a clinician, a group of practices or a PCT, you are probably succeeding in spite of the system.  All too rarely because it supports your aims.

Times of turbulence, indecision and impermanence are also times of great opportunity.  Charles Dickens, you will remember, started his “Tale of Two Cities”, describing the French Revolution, with the sentence, “It was the best of times, it was the worst of times”.  Times are bad financially, but primary care now becomes ever more important as the, the answer to how we create a more cost effective, more efficient, fairer and healthier NHS.  The World Health Organisation, no less, has produced the evidence for that.  

So it is time now for us to be a little more bullish about the things that we have championed over these past twelve years.  Today, we publish a challenging document “Sustaining the vision: how the NHS can survive the financial crisis”.

Today, also, we launch a dialogue with patients and people “Whose NHS is it anyway?”  One minute politicians tell us they are going to spend more and more on the NHS.  The next, it is a macho battle to see who can introduce the biggest cuts.

From now on, we want to inject a little common sense into the debate.  From now on, those who are commissioning, providing and receiving care at the frontline are to be part of the difficult decisions that need to be made.  

The future
And it is the future that I want to talk about next.  David Nicholson has frequently asked us to “make trouble”.  Today, David, we shall follow your advice.  Because you and we are all victims of a most fundamental dysfunction in our current system.  A dysfunction that continues to block all progress.  

It is really a disconnect.  In three parts.  Between the centre and the frontline, between secondary and primary care and between manager and clinician.

I may be wrong, but I believe that these disconnects started with changes introduced following a report for the NHS by Roy Griffiths, then Chairman of Sainsbury’s.  This created a fierce, forceful and top-heavy managerial hierarchy all the way down the NHS system.  If it was ever right, it is certainly no longer fit for purpose today.  

Because what we have created is an autocracy of senior managers at the top of the NHS.  Detached from the rest of us lesser mortals, particularly the clinicians.  Many if not most of this ruling elite have come from the acute sector, so it is little surprise that hospitals remain “the senior service”.  The consequence is all sorts of expensive and ineffective councils, boards and initiatives that do too little to support or meet the concerns of ordinary patients, clinicians and managers at the frontline of primary care.  

What does this system achieve?  It means that ministers and senior managers on the bridge of the NHS are able to press buttons labelled “restore financial balance” or “reduce secondary care waiting times”, and things happen.  The button labelled “increasing clinical engagement, ownership and leadership” doesn’t work because there is no connection to clinicians.  They are not part of this managerial hierarchy.  They were not meant to be.  

Meanwhile, the button labelled “localism” is permanently stuck.  Localism is, by definition, something that a centralist system cannot deliver and no wonder that David, in spite of best intentions, still finds everyone looking upwards not outwards.

So it is no surprise that frontline clinicians and patients get ignored; an excellent “Out Of Hospital” policy and White Paper never gets implemented; managers and clinicians continue to distrust each other; and the NHS and its patients get a bum deal.  No surprise, to be more specific, that personal care and continuity are insufficiently valued and that the work of patients and clinicians is interrupted by everything ranging from inappropriate central targets to overcomplicated forms.

After all, this was a system based on the retail trade and designed for selling baked beans - not the complexities of personal care and relationships.  Consequently, we measure and performance manage things that don’t matter and clinicians fail to voice, effectively, things that do.  Perhaps this is why poor care continues to go undetected.  Albert Einstein said it all - “Not everything that can be counted counts.  And not everything that counts can be counted”.  

That is why we must now dismantle this system.  We must allow clinicians and managers to lead together at all levels from primary and secondary care, with 360 degree performance appraisal at every level - just as we discussed last year.  To create a centre that is connected and accountable to the frontline – every bit as much as vice versa.

Practice based commissioning, World Class Commissioning, clinical leadership, radical service redesign, a cost-effective NHS – none of these things will ever really happen until clinicians, practice based commissioners and PCTs are fully connected and fully emancipated within the NHS structure at all levels.  In future, leadership must be “owned” by all of us.  Our work, published today, suggests how we might do this.  

The market
That brings me to the market.  We are in danger of creating a market that is both too weak and too overbearing.  Too weak because we have applied goggles and earplugs to our commissioners.  I am not only talking about the constrictions of national targets and priorities, national contracts and the National Institute for Clinical Excellence.  I am also talking about the very rules of engagement themselves.    

Why, for instance, is it quite legitimate for a PCT to commission out-of-hours providers, alternative provider general medical services and most other primary care services taking price into account?  Then the same PCT has to accept a fixed price, when it comes to purchasing secondary services?  It sounds like a fix!

In Japan, the tariff system has been used to contain costs. In this country it appears, if anything, to have inflated them. With coding errors running between 5% and 10%, it is no longer fit for purpose.

As money runs short and where a provider can provide services of a similar quality but at a much lower price, why on earth should the taxpayer and the patient not benefit?  Payment by Results weakens the negotiating power of the commissioner in its current form and should, in future, be regarded simply as a maximum.  Furthermore, we must enable PCTs and practice based commissioners to set cash-limited budgets for their providers so that they can keep a handle on expenditure.

I should add right away that I am no fan of tenders or time and money being spent on deciding who to commission from.  We need a system, described in previous Alliance reports, of “co-operative commissioning”.  This is tight, sharp-edged commissioning, where you start with your current provider; exert leverage on price and quality; and then go elsewhere if the provider cannot deliver or is failing to listen.  It was good to hear the Secretary of State describing exactly the same aspiration at the King’s Fund a few weeks ago.  Another document published by us today explains how this might work in practice.  

Because there is also a danger that we may go for too much market and render the NHS bankrupt.  A free market requires excess capacity.  That is expensive.  If you don’t believe me then just look at the US experience of competing corporates, which results in a very costly, unfair and inefficient system.  Because a full-blown NHS market turns the patient, who was simply a tin of beans in the old system, into a pot of gold in the new.  A pot of gold that everyone wants part of.  Not, sadly, for the patient’s sake but simply to get his gold!

Of course, there is a problem with this language, whether we label patients as tins of beans or pots of gold.  It is that it fails to account of just about everything that really matters in health and healing.  

I am not just talking about relationships, compassion, care and altruism.  They matter very much.  They are the real foundations of the NHS.  But I am also talking about hard economics.

It has been estimated that the vast majority of care that keeps our elderly patients out of hospital is provided by friends, relatives and communities for free.  Most of our own personal health is created by ourselves and those around us.  Where does this fit in the business model?  On the NHS’s ledger sheet, its capital is described in its buildings, its hospitals and its concrete.  These are not the NHS’s most important capital.  

That is its people, its goodwill, its commitment and, most of all, its mutuality.  It is the bit that makes us all want to work in the health service to start with.  The bit that brings you here today.  We can forget about these things and create a market that revolves around financial gain but we shall create a less caring system.  One that responds only to money.  One that is less cost effective because we will have ditched all that goodwill, commitment and mutuality.  Indeed, I fear that we may be half way down that road already.

And there is an even more pressing argument, why we must not allow markets to separate professionals and patients into providers and consumers.  That is because health creation is a partnership between people and professionals.  It is all about creating healthy communities.

Ivan Illich, the great iconoclast, said that the greatest improvements in health would come about not because of any technological invention but because we had managed to improve the ability of patients to help themselves.  Our patients are self-organising beings, who can be motivated by themselves or others, who can accept personal responsibility and who often want to work for the good of the community?  Too often we talk about patient needs and wants and too little about patient abilities and responsibilities.

And the problem is that: if we simply view patients as consumers.  As no more than the objects of hungry health traders.  And the NHS’s role as no more than encouraging, commissioning and regulating those hungry health traders.  Then we will have completely lost the essence of what the NHS stands for and, more important, what it can achieve.  Especially in difficult economic times.    

So we need to aim for something better.  Something between bureaucratic centralism, which constricts the  market so that commissioners cannot do their jobs and providers become complacent - and market fundamentalism that allows it to become so rampant that the NHS becomes uncaring and bankrupt in every sense.  This middle way starts with local communities and focuses on their health.  It is an NHS that sees care as being about people and relationships.  

Which builds on those personal relationships between frontline clinicians and their patients to develop productive collective relationships between local people, clinicians and managers – not a system that fractures them.  A new order that celebrates and cultivates goodwill and altruism.  An order that will recreate that sense of collective ownership and mission.  In short, a national “co-production” service – NHS Mutual.    

The future of primary care
At the beginning of this year, our national executive chose two priorities.  The first was integrated commissioning – how we bring practice based commissioners and PCTs together and enable primary care commissioning to thrive.  The second was integrated provision – creating a horizontally integrated system of primary care provision that brings primary, secondary and social care together.  

In our current work with the Nuffield Trust, we are trying to blend those two themes and explore how a future National Health Service can develop a “Local Health Service”.  One that is clinically led and owned, and is based upon practices and the registered list.  One that is responsible for population health, has real teeth, real budgets and as integrated commissioner and provider, is responsible for “make or buy” decisions.  The “Deal” that we propose would remove the blocks to integration, while keeping those most important things such as personal care, continuity and relationships.  

Conclusion
So I say to you in all seriousness, our time - primary care’s time - has come!  

It is a time to trust.  To trust those practice based commissioners, who want to innovate.  To trust that they will create more cost effective health and care.  Time to better recognise those PCTs that are encouraging them and make it more difficult for those, who are not.  
It is time to better value those armies of the unrecognised and disenfranchised within the NHS.  Those  who are its very backbone.

Primary care clinicians and managers – of course - but particularly those forgotten armies of practice manages, non-execs and allied professionals, which NHS Alliance has championed and without whom a complete vision of a primary care-led NHS can never happen.

It is time for us to surpass that challenge to “cause trouble”.  Time for decisiveness, determination and, most of all, action.  It is time for us to call the bluff of all those who talk about clinical leadership, but do not mean it to happen.  Time, that is for leadership of clinicians with managers.  Not simply clinicians becoming managers.  That means changing the culture – even more than the structures.

It is also time that we look to our own selves.  Particularly those of us who are clinicians.  The restrictive practices, the complacency and, yes, the greed, which has been caused by a system that over emphasised financial reward.  A system that ignored those burning fires of care and compassion and wanting to make a difference.  Fires that I know lie within the hearts of all of you, who work in this great NHS.  If we are to become the agents and leaders of change then the revolution must start within ourselves.  Courage and sacrifice we will need in abundance.  These are the price of leading.  Of making a better world and of making our own working lives more fulfilling.  

Lead we shall; and our documents, published today, represent the first shots of a new NHS frontline revolution.  The stakes are high.  The very sustainability of the NHS lies in the balance.  

So, this time, primary care – that is you - will not take “no” for an answer.  It is time to kick down those doors.  Time to abandon a quiet life in the middle of the road.  As Aneurin Bevan put it in 1953.  “We all know what happens to people who stay in the middle of the road.  They get run down!”  Let’s avoid becoming tomorrow’s “road kill”.  We will no longer support a system, which systematically ignores primary care, its clinicians, it managers and (worst of all) its patients.

So I shall end with questions.  To politicians – “Do you have the courage to challenge and change a system which must be changed if it is to serve its patients and those who work within it? “  To the power brokers – “Are you prepared and willing to share that power and work in proper partnership with frontline clinicians and managers so that we can achieve better health and care for our communities?”  

Finally, to you valiant frontline clinicians and managers.  “Are you hungry and determined and selfless enough to lead?  To create a new order and to save the NHS at this difficult hour?”  If you are, then these two days in Manchester will prove to be truly historic.  Let’s debate and plan.  “All for one and one for all” – as always at Alliance conferences.

Then we shall leave.  We shall surmount the barriers.  And we will create a truly primary care-led NHS - together.