Niall Dickson, chief executive of the NHS Confederation, gave the closing keynote address on the first day of Confed17 on Wednesday 14 June. In it, he told an audience of more than 1,000 NHS leaders that there is a chance to reset the clock, and think through what can be achieved in the months and years ahead.
His speech follows:
Thank you for being here.
We know it’s difficult to find the time to attend conferences such as this – but to lead you need time to reflect, to test out ideas, to compare and exchange views.
And that is what I hope these few days can provide for all of us.
In my first few months in this role, I’ve started to go round and meet our members and what I am going to say now reflects what I have heard. The Confederation will reflect your concerns – that is what we are here for.
I have been reminded in this of what remarkable things are being achieved by the NHS. We will hear later about the amazing response to the attacks in Whitehall, Manchester and London Bridge – this was the health service at its best and as one Chief Executive in Manchester pointed out, we are stronger than those who seek to harm us.
This is an opportune moment for our NHS – partly because we are at the dawn of a new, if fragile, UK parliament. For this surely is a time for our political leaders to pause for thought. There is a chance here to reset the clock, and think through what can be achieved in the months and years ahead.
Robert Burns’ oft quoted dictum or plea has never seemed more pertinent: “O wood some Power the gift tee gie us To see oorsels as ithers see us!”. At all levels, we need to put ourselves in the position of others and rise above sectional interests – the divisions between acute and community, between community and primary care between primary and acute, between health and social care between publicly provided NHS care and that which is provided by the independent and voluntary sectors. In their different ways, these schisms have blighted health and care services for too long and we now have a chance to put them aside.
I want to start though by reflecting on where we have got to. The last five years have seen the largest increase in our population since 1945. More people obviously means more health need. Yet, funding growth in the period from 2009 has been lower than at any time since the health service was founded.
And that is before we consider the astonishing and wonderful story of ageing.
Between 1995 and 2000, there were 100,000 more people aged over 65. Between 2000 and 2005, there were 300,000 more. Between 2005 and 2010, there were 650,000. Between 2010 and 2015, the number of old people in the UK grew by more than 1.3 million.
We have seen a step change in demand.
The surprising part of this story has been the resilience of the NHS – the fact that in spite of record demand our national health service has coped and, throughout the UK, has continued to provide good care to millions.
The positives and the reason to celebrate (if not to be cheerful) are worth repeating. As the health secretary has pointed out, we have record cancer survival rates, we have the biggest expansion of mental health in Europe and we have some of the highest dementia diagnosis rates in the world. Hospital acquired infection, once the scourge of our system, has been tackled leaving us with among the lowest rates in Europe. And the proportion of patients who say their NHS care is good has risen by 13 per cent in the last four years.
But the strains are also evident. Waiting lists and times are rising, access to GPs is becoming more difficult and all over the country, patients are stuck in hospital beds not because they are sick but because there is nowhere for them to go. Nor can we deny the thousands in need of mental health support who are being denied the care they need or kept waiting for too long. The system IS doing so well in so many ways, but too many patients are already being let down.
It cannot be right that for a child with significant mental health issues to wait up to six months for specialist help. It cannot be right that we turn our backs on the amazing achievement of an 18 week maximum wait, or go back to a world where hospitals are routinely operating at 91 per cent bed occupancy.
So what is to be done? Everyone here knows that we are presiding over a service that is gradually becoming unsustainable. And unless we act now, it will deteriorate further. As a society, we desperately need a national conversation to agree a vision for the future of our health and care services, a conversation that recognises the scale of the coming challenge.
There will be another million people over 65 by 2020, then another 1.3 million on top of that by 2025 and a further 1.7 million by 2030, with the over 85s set to double within 20 years.
We know the strength of feeling among the public about our health and care services – that was evident in the election campaign. Yet the level of debate was poor and the scale of the challenge was not addressed.
There is an opportunity for politicians across the political divide at least to recognise the need to put both health and care on a more sustainable footing.
Of course, we cannot ignore the vulnerability of the new UK administration and how far its room for manoeuvre may be constrained. The distraction of Brexit and the constraints of parliamentary numbers mean that government may be tempted not to take bold decisions and tackle crucial issues such as social care.
However, these constraints may present an opportunity. This Government will have to work differently, finding areas of common agreement on the issues that matter most to the electorate. This clearly includes the NHS and social care.
Our message to the politicians is that when it comes to the NHS, we have to stop launching life rafts and start fixing the ship.
There are three fundamental challenges – money, transformation and workforce.
On the money, the message is simple: we do not currently have the resources to deliver what the public expects. In England, health spending per head has been flat since 2009 and has fallen slightly elsewhere in the UK while demand has risen inexorably.
Per head spending in England was in fact due to fall over the next few years, so we should at least be grateful for some action on this from the election campaign. NHS spending in England over the next five years is set to rise from the planned 0.8 per cent increase a year to 1.2 per cent. That is a long way from the 4 per cent that has sustained the NHS over its history and, even that left us behind many other comparable health systems.
It will also mean health spending is likely to continue to fall as a percentage of GDP.
During the election, we argued that government should commit to setting a GDP target for health spending, thereby placing it on the same footing as defence and international aid. This would be a transparent commitment to fund our NHS, a visible benchmark which government can defend and which allows those who use and pay for the service to hold the NHS to account.
And a recognition that as the economy grows so too should our investment in health and care.
But what is the right level of funding and can we afford it? The Office for Budget Responsibility’s projection is that to meet rising demand NHS spending in England could rise at around 4.5% a year in real terms – the Nuffield Trust suggests this would mean spending at around £155 billion in 2022/23; nearly £31 billion more than this year.
But rather than politicians trading promises in billions, we urgently require an objective assessment of what the service needs both in the short term and over the coming decade. Such an assessment might not secure political consensus, but at least it would expose the scale of the challenge and the ensuing debate would be based on evidence not speculation. We also recognise the service would have to demonstrate that it is providing value for that investment.
But while more resources are necessary they are not sufficient. There is now agreement across the UK that without changing the way we deliver care, current systems are not sustainable.
That is the underlying message of the Five Year Forward View and its sequel Next Steps and we remain committed to this vision in England. In Wales, they have prudent healthcare and in Northern Ireland, the Bengoa Report – all these initiatives point to the need for a more joined up integrated future. The challenge will be how to get from here to there.
The Sustainability and Transformation Partnerships (as we must now call them) have proved extremely challenging. In part, this is because they require leaders to set aside organisational interests in favour of the system as a whole. That is much easier to promise than to deliver. And it is made more difficult because the regulatory and accountability mechanisms that govern providers and commissioners are not always aligned. They continue in law, and too often in practice, to be focussed on organisational rather than system performance.
And in reality the S can simply overwhelm the T – just trying to keep the system afloat is difficult enough without requiring it to transform. And it is made harder still because change requires clinical and public support. In hard pressed health economies, genuine attempts to create services based on new models of care can be viewed as nothing more than cuts designed to save money.
We might have hoped that politicians at local and national level would be more willing to back radical change and new models of care at the start of the political cycle. Yet, we must continue to make the case for reform even though the current levels of uncertainty could mean political courage is in short supply.
The opportunity for legislative reform has likewise been made more difficult by the parliamentary arithmetic. There is no appetite for a re-run of the Health and Social Care Act, regarded by its kindest critics as an unfortunate muddle. And given a hung parliament and the looming Brexit negotiations, we have to accept it will not be easy to secure health legislation. Nevertheless, there is scope for tidying up the current legal framework, in the absence of which NHS leaders and staff will have to keep coming up with ever more ingenious workarounds.
What we should expect and demand is that this is the moment for politicians and communities to engage constructively in shaping the future of local services. In exchange, our members will continue to show commitment to reform and to work with partners, not least local government, to redesign services to cope with the new demands of the 21st century.
This will include work to reduce clinical variation, rationalise acute services, merge back office functions, and eliminate delayed transfers of care and other blockages in the system.
And there are examples all over the country where this is happening. In Hounslow and Richmond, they have tackled delayed transfers in acute care and poor flow in community hospitals by redesigning systems to improve pathways in and out of rehab beds, by better communication and co-ordination and by dedicated social work to support discharge planning.
They have seen their CQC rating go from ‘inadequate’ to ‘good’ in ten months, improved average length of stay from 44 to 17 days – a reduction of 61 per cent, fewer beds while maintaining throughput and significantly reduced use of agency staff.
The goal has to be to create new forms of integrated services which use data to stratify populations, which focus relentlessly on managing demand by keeping people as healthy as possible in or near their own homes and which tear down the barriers that have blighted effective care in the past. It includes establishing a new compact with primary and community care, so that we ensure patients receive the right care in the right place at the right time. And it has to include valuing our staff, so that they are involved along with patients and communities in redesigning services.
As one of the digital gurus observed, the future is already with us. The vanguard projects are beginning to show what can be done with investment and support. Case studies published at this conference show that it is possible to improve performance against the four hour target, reduce the number of hospital stays longer than 14 days, reduce psychiatric admissions, triage thousands of calls without emergency services, and much more.
The Wakefield District vanguard has looked to support residents in care homes and those who might have to go into a care home. In one scheme, the percentage of tenancies terminated due to residents moving into residential or nursing care went from 38 per cent to zero since the vanguard’s support.
At the same time, we must also be wary of thinking we can simply apply the same approach in every area – what may work in one part of the country, may not work in another. And while it is vital that nowhere is left behind, we must recognise too that the pace of change will vary.
I have largely focussed on the challenges in England, but virtually all these issues are experienced in Wales and Northern Ireland. And there are lessons to be learned from all these different systems. As colleagues in Northern Ireland can testify, structure is not everything. Just having joint health and care organisations does not guarantee truly integrated services.
And the third major challenge? Securing the workforce to deliver what is required.
As one CEO said during our regional meetings: “We have absorbed pressure through the goodwill of the workforce, but we are starting to creak”.
The number of advertised vacancies in England, Wales and Northern Ireland is growing year-on-year. Analysis from the RCN suggests there are already 40,000 registered nursing staff ‘missing’ in England. Currently, 21.5 per cent of GPs are aged over 55.
Nurses and doctors are having to work rotas with gaps that cannot be filled. We remain too dependent on agency staff. Doctors, nurses and other professionals who come here from other countries are critical to our success – one in three doctors working here was trained abroad. Put simply, the NHS would have collapsed long ago without them. They have brought expertise and insight and have enriched our health service and our country.
But for too long we have been over dependent on overseas recruitment – we have not trained enough of our own. Movement of healthcare professionals around the world is inevitable and positive, but it behoves an advanced economy such as ours to train enough for our needs, accepting that some will go at least for a while and we will benefit from others coming here in return.
The nature of training also needs to change. We have to prepare health professionals for the very different needs and expectations of the 21st century – a world in which professional boundaries will be more permeable and staff at all levels will need to be much more flexible. New types of worker should be encouraged and much better use of the skills of existing professionals such as pharmacists, GPs, specialist consultants, and community nurses.
We are now living through what Thomas Friedman described as the Age of Acceleration – it is not just that we face unprecedented change, but that the pace of change is faster. And in particular the impact of technology on social behaviour and political thought. This poses particular challenges for those who are responsible for education and training – there is little point in preparing the troops to fight the last war.
And that will mean not only training new types of staff to meet new and different needs. It means training and retraining our existing workforce for new roles and new challenges, recognising that their ambitions and aspirations will often be different from their predecessors.
We look forward to the workforce plan from Health Education England and there is a very obvious and immediate ask of government. We had a good session this morning on the potential impact of Brexit and the guarantees we need to secure as a health system in the upcoming negotiations.
The position of EU nationals in the UK needs to be dealt with at the outset. For all of us this is fundamental – we have seen already that uncertainty about the future is affecting the 60,000 staff from the EU, the inflow has already begun to dry up and those that are here fear for their future. That cannot be allowed to continue and will be an ongoing priority for the Cavendish Coalition led by the Confederation’s NHS Employers.
So, we need clarity on funding, we need political courage on transformation and a new approach on securing and supporting our workforce.
The political and financial environment in which we are all operating is difficult and uncertain but we can unite around a vision for a renewed health and care system. And as we approach the 70th anniversary of this great service we should celebrate the achievements of the past AND set out a vision of what can be achieved in the future. I do hope being here provides you with some headroom to reflect and a chance to share your good practice and learn from others. Transformation will be built on managers and clinicians coming together to agree a way forward and share ideas and lessons from what works.
At the NHS Confederation, we are committed to doing what we can to support you to meet the awesome challenges you face. Over the last year, we have led calls for government to address the crisis in social care which has hit NHS organisations hard, we have continued to engage national bodies about better and more coherent support from the centre and we have begun to do much more in bringing the different parts of the system together.
The success of the Confederation depends on engaging with our members and in the coming year Stephen and I together with the entire leadership team of the Confederation Group will aim to reach out to understand the challenges you face on the front-line. We believe that our ability to bring the whole system together will be crucial in the coming weeks and months.
Our Confed Group brings together networks and offices that represent different parts of our membership. This includes NHS Clinical Commissioners, NHS Employers, the Mental Health Network, NHS Partners Network and our offices in Wales, Northern Ireland and Brussels.
Confed17 a great showcase of this and we are proud that this is the established health conference for the service, but do not take this for granted. We made changes this year based on feedback from last year and we will keep doing this so please do let us know what you value and what we could do better.
I am enormously grateful for the support from our partners. Allocate Software have been a strong backers for some time and we’re delighted to have their continuing support this year for the whole conference week. Thank you also to NHS Digital, Optum, EMIS Health, HFMA, Newton Europe and NHS Professionals for their backing on the programme. I do hope you will give a bit of time to visit their exhibition stands to hear more about what they are doing, and indeed to go round the wide range of organisations in the hall who provide key services and support to the NHS.
We also have a fringe programme this year that runs straight after this session and first thing tomorrow morning. This will have more discussion on the big issues and if you can spare one more hour with us today, do take part – they are on the top floor.
Thank you for attending Confed17 and thank you to all our members for continuing to support the Confederation. We recognise times are tough and that we need to be keep changing to reflect your needs. In these uncertain times, more than ever, we need to be united and unambiguous – clear what our offer is to the British people and what we need to deliver it. Some of this will be uncomfortable and we must be honest about what can and cannot be achieved and what is needed to bring about the transformation to which we are all committed.
I am determined that over the course of the next year the NHS Confederation will become ever more responsive to our members and place you at the heart of everything we do.
I very much hope we can work together to achieve this.
CLICK HERE to watch the speech in full.
Source: NHS Confederation