Health secretary Andy Burnham explains the thinking behind his recent assertion that the NHS should be ‘our preferred provider’, setting it against a wider future of ‘re-engineered’ services - and a renewed sense of purpose among staff
The next decade in the NHS will look and feel very different from the one just ending.
Where existing NHS services are delivering a good standard of care for patients, there is no need to look to the market
Where once it was all about building up capacity and getting more people through the door, all thoughts are now on getting more for the public out of what we’ve got. So, an era of expansion is about to give way to an era of re-engineering.
It’s a very different challenge, and we need to recognise that doing it successfully will require a different approach. That means building on our reforms of the last 10 years, but refocusing them for the new times we are in. It means more choice, more empowerment, more autonomy for the frontline, better focused on the new challenges of a more preventative, more personalised and higher-quality NHS.
The scale of today’s challenge is no less daunting than the mountains that faced us in 1999. It’s possibly harder. But, far from approaching it with a gloomy outlook - or a sense that the good times are over - my argument is that this is the moment of greatest opportunity for the NHS. In recent speeches I have sought to expand this through three core points:
First, that rather than retrench or retreat, the NHS can make further progress in the next decade. It has gone from poor to good and, because of that, has put itself in a position to go from good to great.
For me that means two things: a more preventative and more people-centred service.
Second, if we are to make that kind of progress possible - and release the savings to pay for it - there will need to be more reform, not less. Any suggestion that there can be a “go slow” on reform is straightforwardly wrong. But where there was much focus on organisational and process reform in the last decade, the next will have to see much more change in the shape of services on the ground. Any politician who spends the run-up to the election denying this point is not credible.
And, third, while we need more reform, the kind of approach that takes you from good to great will need to be very different from that which took you from poor to good. Top-down efforts must give way to a bottom-up approach - principally led by empowered patients and engaged staff. It means taking patient choice further, such as our plan to abolish GP practice boundaries.
It also means making the radical mindset shift of linking payment to quality and patient satisfaction to get the focus where it needs to be.
What this all points to is the need for a radical redesign of services and patient pathways, as set out in the 2006 white paper Our Health, Our Care, Our Say, which was, arguably, a little before its time. That document shows the route to the financially sustainable, high-quality and people-centred services the new era demands.
The last decade has essentially seen the expansion of the traditional hospital-based model of providing healthcare. Our collective challenge in the next decade is to re-engineer that traditional model.
That is essential if we are to realise the Darzi vision for a high-quality and preventative NHS. However, refashioning existing provision is also potentially a far harder task than bringing in additional capacity.
It means winning the hearts and minds of public and staff so that it is change they can believe in. It means change being led by staff rather than being imposed from above.
It is for this reason that we will need to find more engaging, less polarising ways of making change happen in the NHS than we have in the past. Clearer rules about managing change are needed so that everyone knows where they stand and what is expected of them.
Why does this matter? Because failure to find a better approach to reform could mean change doesn’t happen as quickly as it should, or that change is howled down by protest, and that would risk the NHS slipping back when it should be moving forward.
This is the context for why I have chosen to be clear that there are times when the “NHS is our preferred provider”. We need clear rules through which services can be challenged or changed in a range of scenarios. This is necessary as we expect primary care trusts to challenge poor performance more, not less, in the coming period.
In essence, “preferred provider” status amounts to a chance to improve to the new quality standards that will be required. Where existing NHS services are delivering a good standard of care for patients, there is no need to look to the market. We need to remember that it matters to staff that they work for the NHS. Its values are inspiring and that brings an added public value.
For this reason, I do not believe it is sensible to be agnostic about provision: where it is good, the NHS should remain our preferred provider. This has always been the government’s guiding principle, but in this period of increasing change I think it is right to be absolutely straight about it.
But “preferred provider” doesn’t mean tolerating poor provision simply because it is NHS provision. In the end, it is quality that matters. If existing providers are failing - or if they can’t or won’t meet new standards - they should make way for those that can or in some cases be taken over. There should be a clear, staged process with a timetable for improvement leading to open tender. Where PCTs are commissioning new services, or significantly redesigning existing services, then they will be expected to engage with a range of potential providers before deciding whether to issue an open tender. Where services are genuinely new we would expect an open tender on the “any willing provider” principle.
These decisions will be made locally and we will not choose to exclude either NHS or private providers on grounds of ideology - quality must always come first. If commissioners want to redesign services, those new demands should be clearly spelled out and the NHS, where there are good providers, given a chance to rise to the challenge.
Clever commissioning in my view does not needlessly destabilise good provision. But nor does it let poor provision drift on. The Care Quality Commission’s annual health check found many of the organisations ranked as weak last year received the same ranking this year. That is not acceptable.
Our approach will mean more challenge, more improvement. Far from meaning less independent or third sector provision, we will focus the potential benefits of external providers where we need them most - on improving underperforming services and on bringing innovation, where they can, in new services such as the new GP-led health centres we are setting up.
I welcome the diverse provision we have in today’s NHS. The independent and voluntary sectors have an important role to play in helping us rise to the challenges of the new era. If we are serious about quality and we challenge underperforming services in the ways I suggest, then it is possible that their role will increase rather than diminish.
The logic underpinning this approach is that re-engineering existing provision is a new and more difficult challenge for the NHS. Going from good to great will mean the NHS working harder to engage and empower staff in this improvement journey. It was possible to move services from poor to good with top-down levers. Greatness can’t be mandated.
Such is the scale of the productivity and efficiency challenge that building a sense of common purpose will be crucial. It is why I said in my recent speech to the King’s Fund that, alongside patient satisfaction, we should more systematically measure and publish staff satisfaction data.
This next decade in the NHS has the potential to be the most exciting in its history. For the first time it starts with a large budget close to the EU average, with the heavy lifting on waiting times behind it, and with the high-quality services that every professional aspires to provide within our reach.
The NHS can be a great service by 2019. But it means finding common purpose - firm ground under the consensus of the next stage review - and taking people with us on a challenging journey.
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