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David [Prof. David Haslam, Conference Chair], thank you for that introduction.
I am glad to be back with you again.
I understand that the RCGP Conference did not feature on the agenda for my predecessors…
So I am glad to be here again this year, to further reinforce my view that General Practice is at the heart of improving health outcomes.
Over the summer, the world of General Practice lost one of its brightest and best. Barbara Starfield, from the John Hopkins Bloomberg School of Public Health.
She knew the intrinsic value of primary care.
As she put it, “There is lots of evidence that a good relationship with a freely chosen primary-care doctor, preferably over several years, is associated with better care, more appropriate care, better health, and much lower health costs.”
I learned a great deal from Barbara’s work, and her work helped me to understand the fundamental importance of primary care.
That’s why I have been so determined to place so much emphasis on primary care as we modernise the NHS.
Importance of GPs
Let me start today where I finished last year.
Then, I said to you that for years, GPs have been telling me, ‘if only they would listen to us, we could do it so much better’.
As I said, I am now ‘they’, and I am listening to you. And I do want you to do it better.
At the heart, then and now, of ‘doing it better’ for patients, is for clinicians to be at the heart of commissioning.
And you share the view that shared decision making - of “no decision about me, without me” - and a focus on outcomes and not processes must also be the cardinal principles of NHS modernisation.
Let me start with one of the acid tests of modernisation its impact on reducing health inequalities.
If you’re poor:
• You’re more likely to get cancer
• You’re more likely to suffer from cardiovascular problems
• You’re more likely to develop diabetes
In fact, across the board, if you’re poor, you’re more likely to become ill and you’re more likely to die from that illness.
And tackling it is one of the government’s highest priorities, and part of a focus on fairness and social justice that goes far wider than health alone.
We want to help all people to live longer, healthier and more fulfilling lives. But we want to improve the health of the poorest fastest.
That’s why the Bill will, for the first time, place an obligation on the Secretary of State and other NHS bodies to seek to reduce inequalities in the benefits that people obtain from health services.
Breaking the link between poverty and poor health must be spliced into the DNA of the NHS at every level.
Too often, people in the most affluent areas get the most and best provision, relative to need. The so-called “inverse care” law.
So in better off areas, it’s easer to access a GP, and there are more GPs to access, than there are in poorer ones.
There are far more hip and knee replacements carried out in better off areas than you would expect. And far fewer in less well off ones.
And all too often, it’s those with the sharpest elbows and the loudest voices that benefit first by improvements in NHS care, rather than by those who may actually have the greatest need.
This is why we are developing the Inclusion Health programme, seeking to drive improvements in health outcomes for groups with especially acute needs, like the homeless.
And I am pleased to announce that - as part of this programme - we have asked the RCGP to lead a piece of work that will look closely at embedding Inclusion Health in General Practice.
Providing GPs and new Clinical Commissioning Groups with the practical support to improve their understanding of the needs of particularly vulnerable groups.
One way I believe that we can make real headway on this issue is by giving patients more choice.
Choice, properly applied, drives up quality. If everywhere care was uniformly good, we wouldn’t need or want choice.
But, across the NHS, quality varies.
• There is a 5-fold variation across PCTs in the proportion of diabetes patients receiving the nine care processes recommended by NICE;
• A 4-fold variation in emergency admissions for under-18s due to asthma;
• Death rates from bowel cancer surgery can be as low as less than 2% or as high as over 15%;
• Whether a disabled child has an appropriate electric wheelchair depends far more on where they live than what they need;
• And the Eastbourne Wound Healing Centre successfully treats complex wounds in an average of 6-weeks, even when their average patient comes to them having suffered with that wound for over three years.
I know everyone would prefer it if their local hospital or community service was as good as the best in the country. But after more than six decades of trying, stark variation remains the norm.
One could condemn people to the arbitrary availability of what’s on their doorstep, or we can give them a choice, to help drive up quality.
Building upon the work of the previous government, who introduced patient choice for most elective care, we can give patients the right to choose the best, most appropriate, most convenient care for their needs.
And to give them that choice at the moment it matters - at the point of referral.
That is why we are introducing, in a phased and controlled way, the Any Qualified Provider model of commissioning; to give patients that choice.
It will also do away with the long and costly tendering processes that take up so much of commissioners’ valuable time and energy. Moving from competition on price, to competition on quality.
Under this method, all providers will offer their services at a common price. Meaning they are all competing solely on the quality of that care.
Now, this clearly won’t work for everything. Nobody would suggest choice for emergency or ambulance services.
But there are a range of community and mental health services where there are likely to be significant benefits from offering patients a greater choice, so long as the service is integrated around them.
This isn’t all going to happen over night. We’ve listened to what you have said, and to what the Future Forum has said, and we will phase this in over time.
And you will not be doing this by yourselves, but in partnership with the communities you serve and with the new Health and Wellbeing Boards.
Quality and Accountability
We know that better data means better quality in the NHS - for patients, for their specialist clinicians and crucially for you - both as their GPs and as the future commissioners of those services.
And today as part of our commitment to an open NHS I can announce eleven new areas of medicine whose outcomes for patients will be audited, monitored and regularly published in the future. These will include COPD, prostate and breast cancer.
From December, we will pilot the publication of clinical audit data to detail the performance of clinical teams.
This will then be rolled out across England from April next year.
This means there will now be forty areas of medicine involved in national clinical audits.
This data will mean patients can make better informed choices. It means specialists can compare themselves with the best and learn the lessons. And it means you can commission services from specialists who have learned those lessons.
This information, along with NHS provider staff satisfaction data - taken from the NHS Staff Survey - will help providers to drive up quality and help you and your patients to make the best decisions about their care.
This sort of comparative data will also help General Practice to improve. So I’d like to thank the RCGP for leading the on-going work to publish comparative data on the provision of services by GP Practices, due from December.
Under the new system, providers will be accountable to Clinical Commissioning Groups for the quality of the care they provide to your patients.
Clinical Commissioning Groups will themselves be accountable to the NHS Commissioning Board for the outcomes they achieve.
And of course, the NHS Commissioning Board will itself, in turn, be accountable to the Secretary of State. Both through the Mandate and for delivery against the NHS Outcomes Framework.
And yes, the Secretary of State will still be responsible and accountable to Parliament for a comprehensive health service. For me, that has never been in question. And if it needs further amendment of the Bill to put it beyond anyone’s doubt, then we are happy to do that.
Choice of GP Practice
But I also want to talk about something you would regard as more controversial, choice of GP practice.
The last government proposed giving people greater choice of GP practice.
They initiated a public consultation. And the public said they wanted choice. We know from numerous surveys that people do want to be able to choose their GP practice. We also know that the great majority of people will always want to choose a local GP practice.
I am clear that, whatever we do, general practice must always remain rooted in local communities - and that clinical commissioning builds on this.
But there is a small proportion of patients who feel that the current system just doesn’t meet their needs.
People who have moved a short distance but want to maintain their relationship with their current GP.
People who find it difficult to see a GP because they’re at work whenever their Practice is open to see them.
Tackling inequalities means making services more responsive to everyone’s needs.
But the last government’s proposals on choice of GP Practice didn’t take account of the practicalities of achieving this choice.
We will ensure that any progress is practical and think carefully about:
• how to manage home visiting,
• about how patients who don’t live locally to their practice receive urgent care
• and about how information is shared.
And we will make sure it’s done in a way that preserves the responsibility of Clinical Commissioning Groups for local populations.
I want to ensure that we respond to the needs and expectations of the public. But I want to do it in a way that takes careful account of what is best for patients, particularly the most vulnerable, and is practically effective.
Of course, excellent care will often mean integrated care.
We all know this, but the reality is often the opposite.
Of health and care services not joining up around the needs of the patient.
Of people stuck between the competing demands, procedures and paperwork of health and social care services.
We need to do better.
That’s why the Bill will place new requirements upon Clinical Commissioning Groups, local authorities and social care to work together within the new Health and Wellbeing Boards to improve the overall health and wellbeing of local communities.
It’s why the NHS Commissioning Board will help create the right incentives and remove any barriers to integrated services, by:
• developing the system of tariffs,
• developing better model contracts,
• and by looking at system wide issues, such as access to patient information and IT.
And it’s what those of you who will be involved in designing and commissioning local services need to have at the front of your minds at all times.
**Education & training **
Finally, let me talk about an area of real concern for many of you - education and training.
The NHS is only, and will ever only be, as good as the people within it. And every single one of those people is the accumulated product of years of education and training, experience and ongoing professional development.
But as the NHS changes, so the system of education must keep pace. Retaining its high standards but also staying relevant to the people and the organisations it serves.
The NHS Future Forum found broad support for our proposals - setting up Health Education England and greater provider involvement in education and training.
But it also recommended how we could improve our plans. Including creating a duty for the Secretary of State to maintain a system for professional education and training across the health service.
As well as accepting their initial recommendations, we’ve asked them to look at this in more depth and to report back later in the Autumn.
In the meantime, we’ve been working to get the process of revalidation right, and I would like to thank the RCGP for all of their work on this.
We now have Responsible Officers across the NHS, helping to drive forward our commitment to everyone having a full annual appraisal - helping you to develop your skills and experience throughout your career.
There are also concerns about the role of deaneries. Postgraduate deaneries will continue through the transition until the end of March 2013, before becoming a part of the new system.
And I want to say something about GP training.
It is in all our long-term interests - patients, public and policy-makers - to ensure that the next generation of GPs gets the comprehensive and high quality training they need.
I know the current training schedule is tight, especially considering all the aspects a GP has to cover, including their new responsibilities for commissioning.
I am very sympathetic to the educational case for enhanced GP training - subject, of course, to it being considered through the proper process - and I know that many others are too.
But we also have to be mindful of the long-term impact on education and training budgets. These budgets have been maintained but are finite, so we need to make sure that we make the most of every penny and that any changes are affordable.
I know the delay in resolving this issue has been frustrating. I share your frustration. But I’m pleased to see that progress is now being made.
The case will be considered by the Medical Programme Board in the New Year, who will make a recommendation to Medical Education England in the Spring. They will then present a final recommendation to me.
So we are moving forward. But it is important that whatever decision we make, it is sustainable financially as well as the right thing to do educationally.
Before I finish, I want to underline perhaps the most important change that modernisation will bring.
From now on, the real leaders in the NHS won’t be people like me. They’ll be people like you.
• So if you see something that’s wrong: change it.
• If you have a good idea: do it.
• And if you have knowledge or expertise that can help others: share it.
From now on, you will be the ones with the power to change things in your communities.
The Bill and the powers it confers, the organisational changes taking place and all the drive for modernisation will be fruitless if you do not take up the challenge to lead.
So I want all of you - whatever your views are of the Bill, or of the government or of our reforms - to lead in your communities.
To work in the best interests of your patients, to work in partnership with them and with others to deliver the best healthcare you possibly can.
And as you do that you will find that the government, and the new system, will support you every step of the way.