Editorial Wednesday 30 November 2011: Michael Dixon speech to NHS Alliance conference

Welcome friends and colleagues to this fourteenth NHS Alliance Annual Conference.  I am delighted that so many of you have been able to make it here to Manchester on the day of the largest public sector strike for 33 years.  


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A particular welcome to those of you who are leading in Clinical Commissioning Groups and those striving to support them in Primary Care Trusts.  As the great survivors of endless Health Service change, please give yourselves a loud round of applause…..

Can we also give applause to our main sponsors Merck, Sharpe and Dohme and Abbott and all those who are exhibiting at this conference.....  Please visit their stands as, without their support and partnership, this conference would not have been possible.  

A final round of applause please as we welcome, for the first time, the Chairman of the National Association of Primary Care, Johnny Marshall…..  His presence today represents the new Coalition between the NHS Alliance and National Association of Primary Care, which will ensure that Clinical Commissioning Groups are fully championed and fully supported to achieve their purpose, especially over the next few months.  

When I arrived yesterday, they told me there was some bad news and some good news.  The bad news was that I would have to make a rather dangerous entrance.  The good news was that if anything went wrong, the man from Médecins Sans Frontières would be speaking after me!

Today, we stand as close as ever to achieving our mission of the past fourteen years.  Deliciously close, dangerously close, to creating a Primary Care led NHS, where frontline clinicians can lead with frontline managers.  An NHS which also involves its patients as full partners in improving population health.  This has been hard won but for future generations of clinicians it promises liberation on a grand scale.  

Allowing them to make a real difference to the services each patient receives and the health each enjoys outside the consulting room.  Only by extending the role of clinician from care of the individual to care of all local people, in this way, can we create a better, fairer and more cost effective health service.

Our duty now is to make sure that rhetoric translates into effective action.  The statutory status of Clinical Commissioning Groups should ensure that there is a real focus on localism, primary care and clinical leadership.  This was too often absent from previous attempts such as Primary Care Groups and Trusts or Practice Based Commissioning.  It will require the right seed and the right soil.  Clinical Commissioning Groups are, to be sure, the right seed.  But has the soil changed sufficiently to allow the germination of a thriving, clinically led, locally sensitive and primary care focussed NHS?  

Too many of you seem unsure that it has.  When I spoke to an audience of clinical commissioners here in Manchester, just two months ago, I asked who felt liberated.  Just one person put up their hand.

Now that is serious.  Because if clinical commissioners are not liberated then they are not commissioners in any meaningful sense.  

The week before last, I had over 30 emails from concerned CCG leaders.  Each told its own story.  Stories of commissioning support being imposed, of staff being appointed without consultation and of crucial meetings being arranged with less than twelve hours notice.  Too many stories of CCGs, even those with populations of 150,000-300,000 people, being told that they are too small.  Those poignant stories were supported by some pointed comment.   “I cannot believe the tactics used to keep the old PCT structures in place”.  “We are all meant to be on the same team and should be asking how we can - not hearing why we can’t!”  

It was because of stories and comments like these that the NHS Alliance/NAPC Coalition polled all CCG leaders last week to see if these problems were widespread.  Unfortunately, today’s results show that for 6 out of 10 leaders – they are.  So what can I say?  If things go on like this.  If the system continues to oppress our clinical commissioners.  Then every clinician, every manager and every patient will face the most terrible consequences.  

Localism
Because if we really want a locally sensitive NHS then, in future, there must be no “top”.  No “bottom”.  Just centre and frontline.  Both looking out to our patients rather than simply feeding the system.  It must not only be like that it must feel like that.  I do believe that the centre now genuinely wants to devolve power and responsibility.  
Today’s results suggest that it does not know entirely how.  Because we are talking here about a massive change in culture and relationships.  

When he heard about the fall of the Bastille, Louis X1V asked his advisors:- “Is this a revolt?”  “No Sire”, they replied, “It is a revolution”.  So too with clinical commissioning.  Our message to the NHS’s aristocrats, its Barons and its Knights, is quite simple.  We do not want to cart you off in the Tumbrills like those 19th century French aristocrats.  But if you allow clinical commissioners to become serfs in the new system, then we surely will!  

So let’s start as we mean to continue.  With an equal relationship between the National Commissioning Board and Clinical Commissioning Groups.  Mutual annual appraisal of both by both just as the NHS Alliance/NAPC Coalition has suggested.  

In this new spirit of equality, what about the National Commissioning Board having to meet the same standards of accountability and transparency as CCGs?  Let’s ensure too that the disinterested voice of clinical commissioners themselves is part of the authorisation process of every CCG.  Then, when it comes to supporting CCGs, let’s make them the customers.  

That means choice of which PCT cluster might support them between now and 2013 and free choice of any support after that.  
Finally, as a long stop, Ministers must retain accountability and responsibility in making sure that we have got the right balance between the National Commissioning Board and CCGs.    

It was John Stuart Mill, who said:- “If things need reconstructing then there is no use in attempting to rebuild the “old” in the new plan”.  We must reject the disconnects of the past.  We must ensure that clinical commissioners are present and leading at all points in the system.  CCGs, the National Commissioning Board, the NHS itself will only survive if we can create universal ownership, action, commitment and delivery right from the centre to every frontline clinician.  If we could achieve that then it would be a revolution!

Primary Care Focus
Part of that revolution must be to create a much stronger focus on primary care.  All the research supports this.  Yet the NHS continues to over hospitalise its patients.  It continues, even this year, to spend proportionally less on primary care than secondary care.  Hospitals remain “the senior service”.  That must change too.  Those sterile debates on the power of clinical senates and the appointment of outside consultants on Clinical Commissioning Boards are the dying embers of a tired and sick old system.  Of course, it is absolutely crucial that primary and secondary care clinicians work together in creating this better NHS.  But restraining clinical commissioners with tokenistic gestures is just a sop to vested interest.  

At the same time, we, the new clinical commissioners, must also be ambitious.  Not only moving services out of hospital and reconstructing community services.  Like Torbay, where investing a million pounds in community services reduced hospital beds by 25% saved £2million overall.  We must be more effective, than in the past, where primary care and general practice are not as good as they ought to be.  We must also de-professionalise wherever we can.

Hand power to our patients.  Enable them to self care.  Encourage local populations, themselves, to produce better health.  Extend, for instance, the groundbreaking work of the NHS Alliance and Department of Health on co-production and our “HELP” project.  We have talked endlessly of these things but now, now, now, we have a real chance to make it happen.  

Transition
So much for our direction.  What about the transition?  I know these are difficult days for many of you.  Especially those of you who have worked in PCTs.  In many cases you have worked your hands to the bone and too often felt un-thanked and discarded – labelled unhelpfully as “bureaucrats”.  We must be sure that those who we will need to recreate the new order do not become casualties as we break through the old.  We must value and use every managerial or clinical talent we have in PCTs and GP practices to build our new liberated system.  

Because liberated commissioners will not succeed without liberated and talented managers.  

NHS Alliance will continue to support you during these turbulent times.  Whether it be through our weekly round up of news and advice, “Clinical Commissioning Connect”, which we launched this time last year, our new ACE website providing an interactive forum and practical help, our Commissioning Academy or our new accredited clinical leadership programme for CCG leaders.  

We will continue to show the enormous potential of clinical commissioning with pieces of work such as “Making it Better”, “Liberating Practice Managers” and “Breaking the Mould”, which we published recently.  Our Coalition with NAPC will now enable us, collectively, to do even more.    

Those Opposed to Clinical Commissioning
What about those clinicians, especially in primary care, who seem lukewarm or even opposed to Clinical Commissioning Groups?  Surely, we all want to improve the health of our local population?  Surely, we care about fairness?  Fairness in the use of resources.  Bridging the gap between good and bad services?  Between wants and needs?  Between the health of rich and poor?  If we care about fairness then the future of the NHS is also our business and clinical commissioning becomes a moral duty.  

Of course, of course, life is easier if we confine ourselves entirely to being individual patient advocate and forget the greatest good of the greatest number.  But “easy” does not mean “right”.  You do not reach the moral high ground by avoiding difficult decisions.  

I know too that many people, especially primary care clinicians, are concerned about too much competition, too much privatisation and too much markets.  I share these concerns.  

There must be balances.  Of course.  But these concerns are poor reason to turn your back on clinical commissioning.  They are every reason to embrace it.  It enables us to make sure that our patients really do come first.  Not the ideology of markets, nor of competition nor the private sector.  

So, as clinicians, we must ensure that we are leading by joining and supporting Clinical Commissioning Groups.  We can then ensure that they are empowered to do the best for our patients.  

Because the NHS’ Rubicon is not about who provides health services.  We already have private providers, semi NHS providers, third sector and social enterprise – these are not new and have often helped the NHS to deliver.  It is about who makes the commissioning decisions and about what care is provided, how and by whom.  It is about making sure that our patients get the best - regardless of public or private.  

Those are the decisions that clinical commissioners and clinical commissioners alone will need to make.  If they are fully empowered.  If the NHS fully supports them.  If clinicians sign up to lead them.  Then and only then will the NHS be truly safe and sustainable.

Clinical Commissioning Groups
And finally, I want to talk particularly to those of you who are leading Clinical Commissioning Groups.  I know that some of you have felt a little beleaguered recently.  Especially during the “Pause”, when it appeared that your future would be decided by the hounds of political compromise and hyenas of vested interest.  But be sure.  We are now about to reach the point of no return.  Clinical commissioning is here to stay.  We must press ahead, impatiently without delay.  Because, as Matthew Arnold says:- “If we hesitate and falter life away, we will lose tomorrow, the ground we won today”.  

Upon your shoulders.  Upon your shoulders alone lie the task of making clinical commissioning the “Great Champion of the NHS”.  

You must claim sovereignty once you have been authorised and the NHS Alliance/NAPC Coalition will ensure that you can.  You must be empowered to decide what is best for your patients – not the National Commissioning Board, not Monitor, not the Senates, not anyone else!  You must do this as disinterested advocates of your patients and local people.  Able, as only clinicians can, to balance the good of the individual with the good of your whole local population.

Meanwhile, be sure to nurture your constituent GP practices, local patients and population.  You must be their creatures.  They must feel that you are their champion.  Guard against becoming the new overlords and barons.  Replacing one tyranny with another!  Lose your clinicians and you have lost the plot.  

T. S. Elliot reminds us that policy makers: “Constantly try to escape from the darkness outside and within by dreaming of systems so perfect that no one will need to be good”.  Clinical commissioning won’t deliver itself.  It will require an army of passionate, principled and determined individuals.  That is - you who are in this room and those who were unable to come.

Conclusion
In conclusion, as the nation’s future clinical commissioners, have no doubt.  You will face the most awful but crucially important ethical dilemmas.  You will meet unprecedented financial challenges.  Indeed, today’s industrial action is symbolic of difficult times to come.  You will be confronted by the demons of self interest, factional politics, ignorance, laziness and raw emotion.  You will be hated by all those who have fed from the gravy train of the current system.

You will need to be very strong.  Remember, power is never given.  Always seized.  We must use that power to extend ourselves beyond the ordinary.  Beyond the easy.  Beyond the expected.  To make the rules and even break the rules, when necessary.

To create something better, something visionary.  Something so magnificent that people will say:- “Why on earth did we let clinical commissioning wait so long?”  

Ghandi warned us:- “First they ignore you, then they laugh at you, then they attack you.  Then you win”.  You and your patients will win.

You will win because of your values, your integrity of purpose and your imagination.  You will destroy the harridans of inertia, the slaves of the ordinary, the gargoyles of doom and the naysayers.  Because you promise a new hope.  And they have no answers.

Yes, it has been a long and sometimes harrowing fourteen years.  But the fire is now well and truly lit.  This time, the barons won’t get us.  This time, the recidivists won’t block us.  No-one, this time, is going to block us.  Let this conference be a celebration of “break through”.  A preparation for our future.  A strong and unconditional message to the outside world “Clinical commissioners are ready to lead!”