Speech: 23 January 2012, Lord Howe, ENT Surgery: Commissioning for the NHS, Royal Society of Medicine

Lord Howe speaks at the Royal Society of Medicine.

This was published under the 2010 to 2015 Conservative and Liberal Democrat coalition government

The Rt Hon Earl Howe

Thank you Alec [Fitzgerald O’Connor, President, Otology Section, RSM].

It’s a pleasure to be here at the Royal Society of Medicine among such distinguished company.

The suggestion was made that I should speak today about the progress of the Health and Social Care Bill, about its passage so far through Parliament and where it goes from here.

I am more than happy to do that - indeed I can bore for Britain on the subject, but if you don’t mind, rather than give you a blow-by-blow account of the trials and tribulations of the progress of the Bill through the Houses of Parliament, I would rather talk more about the impact of the Bill and our programme of modernisation more widely.

Because - this is a bill that - once it attains Royal Ascent, hopefully sometime in the late spring or early summer, will lead - I am certain - to a more patient focussed and clinically-led National Health Service.

Clinically led, because of the way in which we want power to shift from the centre to enable and empower clinicians like you - working with your counterpartsin their specialities and disciplines - to design and deliver good patient care.

In fact from the beginning, everything we have done has been based upon three ideas - three principles:

  • First, to put patients much more in control of their own health care through genuinely shared decision making.  For patients to feel that ‘no decision is made about them, without them;
  • Second, to judge success not on the basis of inputs or throughput or process - but on outcomes.  And around that to build a culture of innovation, evidence and evaluation that drives the pursuit of ever higher quality care for patients;
  • And, third, that in order to deliver the best care, we must empower the NHS staff whose responsibility it is to give that care.  For the NHS to be truly clinically-led.

These principles remain as strong today as they were when the Coalition first took office.  Some of the detail may have changed.  Some of the wording may have evolved.  But these ideas, of patient control, clinical leadership and a focus on outcomes, these have stayed precisely the same.

The fruits of our data

Even without the Bill having completed its passage, we are already seeing, these principles feeding through to better, more efficient care.

In December 2010 and again this last December, we published the NHS Atlas of Variation.  I hope you all will have seen it.  It certainly makes for fascinating and provocative reading.  It’s one of those documents you pick up and then find it hard to put down again.

If you haven’t seen it, it sets out 71 clinical quality indicators in a series of maps.  Each map shows clearly how every PCT in the country compares with every other.

The maps cover everything from emergency admissions of children with asthma to the proportion of people who are able to die at home.

The point of the Atlas is not to point the finger, to say that one PCT is bad and another good.  It’s there to help clinicians get an idea of just how well they are performing against their peers and, where they could be doing better, to help them improve.

Now, we’re only into the second year of the Atlas, but already we’re getting a taste of what is possible.

Warrington is an excellent example of this.  There, the new Warrington Health Consortium, an aspiring Clinical Commissioning Group, was under considerable financial pressure - on course for a £15 million deficit in this financial year.  And, on several indicators in the first Atlas, they were classed as an “outlier” in terms of clinical care.

So they used the Atlas to find the PCTs that were delivering more effective care.  They reviewed their approach and made significant changes.

Now not only do they expect to end this financial year in surplus, they also expect to see rapid improvement in areas like mental health, trauma care, respiratory and musculoskeletal care.

This is what’s possible when you focus on outcomes and put clinicians - doctors, nurses and other health professionals - in charge.  It’s a perfect example of how better quality care can also prove more cost effective.

What’s happening in Warrington - and in many other Clinical Commissioning Groups across the country - is not down to some top-down instruction from Whitehall.

It’s down to people like yourself taking the data and doing something about it.  Working with colleagues across the NHS and often far beyond it, to really make a difference.

Repeated across the country and across the specialisms, I believe this has the potential to transform care in England.  It’s about giving professionals that sense of autonomy and freedom to bring about change.

I know that ENT surgery has an impressive record of innovation and achievement.

  • tissue engineering and stem cells for replacement airway surgery,
  • auditory brainstem implant surgery to help patients with total hearing loss,
  • and balloon sinuplasty, with huge potential to increase day case rates.
  • A thousand cochlear implants every year with a similar of bone-anchored hearing aids.

And there’s more to come, with…

  • University College London’s Biomedical Research Centre which is pushing the boundaries of ENT with the NHS Newborn Hearing Screening Programme.
  • And the National Biomedical Research Unit in Hearing taking forward its work on tinnitus, paediatric audiology and paediatric cochlear implantation.

But I also know that ENT and audiology services face significant pressures.

  • Over a million first time referrals every year;
  • Over three million GP ENT consultations;
  • And a referral rate that’s growing at about 8% every year.  A trend that isn’t about to reverse itself as the population ages.

These pressures will not be met by centralising power in Whitehall.

We need all Clinical Commissioning Groups to take the same approach as Warrington.  Looking at the data, looking at the evidence, taking control talking together and working together, across professional boundaries.

The most recent Atlas of Variation contains two maps that focus on hearing loss.
The first shows an almost 5-fold variation [4.7] in the rates of hearing assessments conducted across the country.

Now much of this can be explained by differences in the local population, but not all of it.  And even where it is population differences, it is a wake up call that more needs to be done.

The second map a more than 3-fold variation [3.3] in the mean time from referral to assessment for hearing tests in newborns.

This sort of data can kick-start an evidence-based process of reviewing just how good services are in your local area.  Identifying problems and working with others to find the solutions.

So, again, its about clinical leadership and a focus on outcomes.

And with adult onset hearing loss and tinnitus identified by the National Quality Board for potential inclusion in the library of NICE quality standards, this is an exciting time for audiology.

But if you remember, there is a third principle.  Putting patients in control of their own care.

Last month, we published another series of maps.  These maps show NHS patients which services they will be able to choose, with their doctor or medical professional, from any qualified provider from April this year.

Here in Wimpole Street, we’re within the boundaries of NHS North West London PCT Cluster.  Within this cluster, patients will have this choice for diagnostics, for continence services and, like many areas across the country, for adult hearing services.

In fact, more PCT Clusters - covering 90 PCTs - have decided to give their patients a choice of hearing services than any other service.

This means that patients with hearing loss who are referred by their GP will be able to choose from any provider that meets the necessary quality requirements, be that a local hospital or a provider on the high street.

Choice, yes.  But it’s more than that.  It’s the opportunity for patients to discuss and decide with their GP or other healthcare professional the right course of action for them.  To take ownership of their own condition, and - to benefit from new, responsive services.  Genuine shared decision making.


Many things have been said about the Health and Social Care Bill.  Often generating more heat than light, I’m afraid to say.  But what most, if not all people can agree with are the principles of our reforms.

Principles that are already making a difference to the quality of care available to patients in the NHS - from Wimpole Street to Warrington.

The next year or so, with the assent of Parliament, will see the passing of the Bill and the creation of the new organisations that will lead healthcare in the future.

Clinical Commissioning Groups, Health and Wellbeing Boards, Public Health England and the National Commissioning Board.

But actually the names on the brass plates on the front of buildings will be less important than the relationships developed within and between the people in them.

With better data and a focus on outcomes, with patients in control of their care through shared decision making and with the right people in charge - clinicians, not politicians - this will represent a historic devolution of power and resources away from Whitehall.

It will also be the time when the NHS is finally set free to fulfil its full potential for the people it cares for.

Thank you.

Published 23 January 2012