The next decade in the NHS: quality, not quantity

The time is fast approaching for Labour to articulate its new vision for a new era in the NHS – the service's seventh decade.

To work, it must be based on an honest assessment of the last 10 years – good and bad – and of the challenges that lie ahead.

It must be a clear and simple vision that strikes a chord with NHS staff at every level: right for the new era we are entering; responding to legitimate concerns; and speaking to their sense of professional vocation and belief in the NHS.

And it must be a vision that inspires patients, showing them a sense of ambition for what the NHS could be and how it could do more to improve and change lives.

I believe that, despite the brickbats, the NHS is in such a fundamentally strong position today that we have an opportunity to do all that.

If I had to sum up in a soundbite what the change of emphasis will be from this decade to the next, it would be this: from quantity to quality.

By this I mean it will be less about the need to drive up the quantity of care delivered and measured from the centre, and far more about the quality of that care as driven by empowered staff and the decisions of patients.

It will be less about further structural change of NHS organisations and more about the emergence of new partnerships at local level.

And it will be less about a preoccupation with services delivered in hospitals and more about the huge potential to develop primary care.

So, when does this new era start?

For the NHS, a break-point comes a year from now with its 60th anniversary and the point where key targets are expected to be met.

Much of the Government's change programme has been about increasing capacity and reducing waiting.

As figures we will publish on Thursday will show, waiting lists around the country are beginning to melt away as we make progress towards the 18-week target.

This is the end of waiting lists as we have known them. What better way to celebrate this milestone than with the lifting off the back of the NHS of that millstone of waiting lists that has been there for so long?

It is a rock-solid platform on which to build a vision for a new era and, more importantly, to fight and win the next Election.

That we are within touching distance of a goal many said was unachievable isn't the result of work in the last two years, but rather the culmination of the NHS reform programme over the 10 years of this Government.

But, unless you think this is all beginning to sound a bit complacent, it also explains the essence of our political difficulties on health.

In short, the service has made huge strides, but staff don't feel good about it. We are yet to realise political benefit from this monumental change that has been made to waiting times; but we are feeling the political costs.

Making change in the NHS has been a difficult and challenging process for everyone, particularly as we have entered the business end of the 10-year reform programme.

Out of necessity, much of it been driven from the centre – such as new targets, National Service Frameworks, and the central procurement of new providers – but over time the driving of any change top-down from the centre can be disempowering for those on the receiving end.

The reform programme has also challenged established ways of doing things. Where people were in a comfort zone, it has taken them out of it. In general, there has been increased pressure in the system to deliver improved standards.

It might all be good for the public but, not surprisingly, over time we have seen a growing resentment to central targets and cynicism about the performance management that comes with it.

It is also the case that the language of reform sounds very different on the NHS front line than in the comfortable confines of a Whitehall office.

To the politicians that conceived it, it's all about making the public NHS as good as it possibly can be, thereby securing public support for it.

For those on the receiving end, talk of reform can translate as a fundamental frustration or dissatisfaction with the very system itself.

If we are to get our vision for the next decade right, we have to be honest and understand why some people may feel this way.

But, we can also legitimately ask the critics of the reform programme to acknowledge that, without the concerted drive to improve services to the public, the political debate today about the NHS and its future would be very different indeed.

Talk is beginning to bubble up again from the Right of the need for fundamental change to the NHS model.

Doctors for Reform have called the idea of a universal, comprehensive NHS a "political mirage".

Tomorrow, the BMA consultants' conference will debate compulsory insurance operated by insurance companies – an idea gaining unexpected political support.

As the real Tory Party pours its heart out on grammar schools, so we hear again for the first time in a while the innate Tory distrust of the NHS in a a strongly-worded attack this week from the Cornerstone Group.

"It is time to get rid of this Stalinist system," says author Peter Bone MP. "The way forward is compulsory insurance. If the Conservative Party believes in a smaller state, lower taxes and better public services then a compulsory insurance system will provide this and bring this country's health service into the 21st century."

Despite the clever positioning, this view has a wider resonance in the Conservative Party.

But where is the evidence that the NHS is failing?

The Commonwealth Fund's comparative study of six health systems – UK, US, Canada, Australia, New Zealand and Germany – ranked the NHS top overall.

It found that the NHS combined the lowest cost per head with high standards of service and equity.

This ranking is a vindication of the Government's reform programme. In 2003 and 2004, it was ranked third. As the NHS has improved its scores on quality and patient responsiveness – the very objective of the reform programme - so it has been lifted it into first place overall.

That this 60 year-old universal, comprehensive service – still based on the idea that you only take out not what you put in but what you need – comes top of a comparative study of six advanced health care systems is truly amazing.

So, in setting out our vision of the future, we should be clear and confident at the very beginning that in this funding model we have something very precious.

It's always been seen as fair but now has added higher standards of patient responsiveness – a traditional weakness.

Our vision for the next decade must therefore be seen in the context of maintaining a comprehensive and universal service funded by general taxation, but it must also address misconceptions about our reform programme. In Payment by Results, Choice, Practice-Based Commissioning and Foundation Trusts, we have created a series of bottom-up tools that can be used by empowered NHS professionals to improve services.

In truth, the NHS today is between two worlds. It is in transition from a service principally run top-down to one where more decisions and priorities are set locally. But the two worlds are running together and pressure is being felt from both ends, hence the potential for confusion.

The trouble is that the NHS today still has a 'permission culture'. It is the case that people in the service are beginning to feel the end of that culture, but they are responding in different ways. However change will accelerate and here I lay out eight ways in which I see that happening over the next decade:

1. The next decade will see a decisive move away from national targets and performance management.

The reliance on targets was right for their time. But now we should signal clearly to the NHS that, after the current set have been met, the era of the top-down target will end. Indeed, the 18-week target is a bridgehead to a new way of doing things. As an end-to-end goal, it leaves plenty of room for local freedom and innovation.

The dismantling of the top-down performance management machinery that comes with targets will open up the space at a local level for local priorities to be set. This isn't just talk. This year, there are no new national targets and, as a result, PCTs can pursue local priorities. My own PCT, for instance, will spend £6 million on a scheme called 'Find and Treat' – a serious effort to identify those living with poor health but not known to the system.

But it must go down deeper. This change in the balance of central-to-local must be felt by staff at all levels. We are looking to managers to make sure it is an empowering process, where staff set their own targets and lead local change. It will be world where we won't measure as much as we do now but we will measure what's important – for instance, clinical outcomes and patient satisfaction.

2. With the space for more decisions to be taken at a local level, steps will be needed to strengthen the local legitimacy and accountability of PCTs.

The individual elements of the new bottom-up, self-improving NHS are already in place. But, in this more local world, a piece of unfinished business is how to ensure that powerful commissioners, taking vital decisions for the community, have more local legitimacy and are better held to account. Direct elections to PCTs are an option, but I would prefer a solution that better engages Councillors and MPs in the day-to-day work of the PCT.

3. Stronger partnerships between local councils and the NHS will at last become a reality.

Around the country, the realisation is sinking in that the interests of the Council, the PCT and the acute trust are all bound up together – each has an interest in the other's success. A decade of change has perhaps led to organisations concentrating on their own game as they rise to the challenge. It has not necessarily created the climate where organisations can work across boundaries. That is changing but two specific steps will help. First, we need to create a more flexible financial regime. For instance, we should consider whether in a more integrated funding world the decisions of NICE should take more account of social care costs and other costs falling to the public sector. Second, we need to look at giving health and local government the same performance and inspection regime wherever possible.

4. There will be lots more emphasis on improving primary care services and the changes will be most marked here.

One of the quietest, yet potentially most significant, changes in the NHS at local level is the arrival of the new LIFT centres. Ironically, it is the very parts of the country that have traditionally had the poorest quality primary care who will first see how services can really change for the better.

LIFT-style buildings and services represent the future for many localities. But LIFT currently only covers half the country and we need to find ways of expanding its reach, particularly to more rural areas where partnership with local government could bring modern facilities for co-locating health with a range of public services - schools, children's centres, libraries and leisure facilities – that may struggle alone.

5. A change from the horizontal layers of hospital and GP services to new kinds of pathway-based services.

The 18-week target is fostering a better discussion between clinicians in primary and hospital-based settings. In the next decade, I expect to see this trend accelerate and new kinds of vertically-integrated services to emerge.

In this new NHS, what would stop the development of the Leigh and Wigan Heart Service or indeed the Leigh & Wigan Children's Health Service if that was the vision of local clinicians and it made sense clinically and financially?

So many of the services in the NHS are geared around adults and often the patient experience for children and their families is not great. A new type of children's service might involve a GP with special interest working with hospital-based paediatricians in establishing a community-based service out of purpose-built premises.

This service could accept GP referrals from across a locality and, as a principle, would seek to provide as much out of hospital as possible. It would have walk-in slots and offer home visits wherever possible. My guess is that parents of young children would find such a service very attractive and in a free-choice world it would be highly likely to succeed.

6. The decade ahead will see big changes in role of acute trusts.

We are not talking about the end of the District General Hospital. But it is the case that the days of people trekking in to a hospital site for all manner of routine services are ending.

Clever DGHs can already feel these changes in the wind and are working creatively and collaboratively with local commissioners to introduce new services. We may see big names expand their reach. Christie Hospital is already looking to take its excellent services into the communities of Greater Manchester. Hope Hospital is providing renal dialysis service out of a new LIFT centre in the middle of Wigan.

7. We are just at the beginnings of the idea of real choice in the NHS and personalisation of services

At a meeting last week of senior clinicians, I heard the claim that "staff don't want targets and the public don't want choice". The obvious question that follows: if there is no pressure up or down, who holds the system to account?

It is a complete nonsense to say people that don't want choice. It goes without saying that it is a massive improvement for the Wigan patients who previously travelled into Salford three times a week. I am sure there are more kidney patients in England who, through choice, would like to receive dialysis more locally. They do want choice, but one that is real and relevant to their life.

To those who see this as a politically provocative statement, let me quote from the pro-choice Minister for Health Aneurin Bevan at the Second Reading of the National Health Service Bill:

"There ought to be nothing to prevent anyone having advice from another doctor other than his own … An individual hears that a particular doctor in some place is good at this, that or the other thing, and wants to go along for a consultation. …. If the other doctor is better than his own all he will need to do is transfer to him and he gets him free."

8. Encouraging more responsible use of services will become an imperative if a free at the point use system is to be sustainable in a world of very different expectations.

I hope that buried within this we have the bones of the right package to take the NHS forward, learning from what we know about change in the NHS in the last 10 years.

But this vision shouldn't simply be laid down but formed through a proper debate and consultation on the next decade for the NHS involving staff and patients at all levels.

This could lead to the development of a new settlement for the NHS in its 60th year, perhaps expressed in a new Constitution for the NHS.

To allow real freedom at local level, it is vital to spell out what is binding on all, the values that won't change, and what represents the 'N' in NHS.

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