#NHSP16 opening address

29 November 2016

Chris Hopson

Hello, good morning, and welcome to the NHS Providers annual conference and exhibition. Our flagship annual event and the single biggest gathering for provider board members in the NHS calendar.

This event couldn’t happen without the support of our sponsors and I’d particularly like to thank our overall event partners: DataFlow Group, Hempsons and Newton Europe.

Can I please also encourage you to spend as much time as possible in our exhibition which you’ll find in hall 3, just next to registration.

Providers deliver

It’s great to be together to remind ourselves of why we’re here. To deliver fantastic care to patients and service users 24 hours a day, 365 days a year. As part of the NHS – one of the greatest collective creations in our history. And the institution, according to Ipsos MORI, that makes us most proud to British, ahead of the royal family, the armed forces and the BBC.

This is my fifth speech to our annual conference and exhibition. A recurring theme of all five speeches has been the need for a balanced judgement on how well the NHS is doing. That seems particularly important this year because the strategic context has deteriorated even further and the challenge is even greater. Indeed, many of you tell us the challenge is now the greatest in a generation.

What impresses us most is the unrelenting commitment, from board to ward, to provide outstanding care for patients

I recognise that but we must avoid the challenge overwhelming us.

Alan Milburn, our first annual lecturer, reminded us of the importance of balancing the language of challenge with the language of opportunity. It’s vital that we retain a sense of agency. An unwavering belief that we really can make a difference, however tough the environment may be. That we are accountable for delivering the best possible quality of care to patients in our local communities and we can continually improve the quality of that care. That while providers can be shaped by the more challenging national context, there is a huge amount provider boards can do to shape the service they deliver locally.

Dame Gill Morgan, our chair, and I have stepped up our member visit programme over the last year. What impresses us most is the unrelenting commitment, from board to ward, to provide outstanding care for patients. That’s why I wanted to start by reflecting on the fact that when NHS providers are given a reasonable task with proper support, extraordinary things can and are being delivered for patients.

Compared to five years ago:

It’s providers who are leading the move to new care models, providing better care closer to home:

It’s provider chief executives like Sarah Dugan of Worcestershire Health and Care and Rob Webster of South West Yorkshire Partnership who, in the majority of the 44 footprints, are taking the lead in creating much needed sustainability and transformation plans.

And look at what’s being done on the money:

So, as we face that greatest challenge in a generation, it’s important to remain confident of our ability to deliver when we’re set a reasonable task and are appropriately supported and funded to deliver that task.

It’s why, when you read this new State of the NHS provider sector report that we are launching at this conference, it deliberately sets out both the challenges the sector faces and what we are doing to successfully meet those challenges.

And, for the avoidance of doubt, I think it’s perfectly compatible to argue on the one hand that the NHS is facing its biggest set of challenges in a generation whilst, at the same time, argue that trusts continue to deliver extraordinary things for patients that we simply don’t hear enough about.

Patient safety

There’s another area where we’re also making important progress.

Being secretary of state for health is an interesting job. You can use the role to persuade an NHS with an enormous reach and power to do things differently. Jeremy Hunt has used his term of office to focus on patient safety and quality of care. That focus has, on occasions, proved uncomfortable for the provider sector since we provide the vast majority of complex care. A light has been shone into dark and difficult corners. There has been a degree of challenge that, on occasion, providers have struggled to respond to. But I think we can all agree that important things are beginning to change and have already changed.

I think we can all agree that important things are beginning to change and have already changed

We now have a robust CQC led inspection regime that underpins quality by providing an independent and objective assessment of the quality of care provided in each institution. And look how far that regime has come in the last three years. It’s moved from being an object of concern and ridicule to being a genuinely useful source of evidence. I know it has its frustrations like the level of factual inaccuracies in first draft reports and the time taken from inspection to final report. But I have lost count of the number of provider chairs and chief executives who have described their CQC reports as “some of the most valuable consultancy advice we have received”. And I know from my visits that many of you have used that advice to improve the quality of services you provide.

We have greater transparency of data – more of it, higher quality, and covering a much wider range of areas including, these days, CCG performance.

I’m particularly pleased that, at last, we now have better and more transparent data in mental health to underpin the commitment to parity of esteem. Performance data against three important new mental health access targets. CCG finance data that definitively shows what we have long argued – that despite all of your hard work, the extra promised investment in mental health is not consistently reaching the frontline. 

Providers are creating a culture of learning from mistakes. The number of incidents reporting severe harm between October 2015 and March 2016 has reduced by 16% compared to the same period three years ago.

There is also now much greater emphasis on the importance of listening to families when things go wrong and explaining what has happened. And if you want one of my favourite stories of the year, read Shaun Lintern’s HSJ report on 4 November of the reconciliation meeting between James Titcombe and one of the midwives implicated in his son’s death.

What could be more powerful than James, after all that has happened to him and his family, saying: “After eight years I feel I can hand over the responsibility to the trust now. It feels for the first time that the trust owns what happened to Joshua, they understand it, and they accept it. I don’t feel I am at odds with the trust any more.”

Fantastic leadership from Jackie Daniel, the trust chief executive. Just one example of where provider leaders are genuinely leading important change in their trusts.

So I did want to particularly recognise the advances that have been made in this area and I wanted to acknowledge and welcome Jeremy Hunt's personal leadership on these issues.

Frontline staff

It is, of course, frontline staff who are responsible for providing outstanding care to patients all day every day. We succeed or fail because of the commitment and discretionary effort of NHS workers from porters and healthcare assistants to consultants and managers.

And I wanted to use this speech to highlight the importance of supporting frontline staff as the pressure mounts.

There are some worrying signs.

The staff survey results show that the number of staff feeling they have experienced harassment, bullying or abuse from other members of staff has jumped from 14% in 2011, already a high figure, to 25% in 2015. The number of staff experiencing work related stress in the previous 12 months has jumped from 29% in 2011 to 37% in 2015. The 2015 staff survey also shows that only 75% of black and ethnic minority believe that their trust provides equal opportunities for career progression, 13% less compared to their white counterparts.

We succeed or fail because of the commitment and discretionary effort of NHS workers from porters and healthcare assistants to consultants and managers

And we know from the junior doctors’ dispute that many junior doctors feel they are not properly supported to give of their best in what is a crucial role. In the words of one junior doctor: “Is the new junior doctor contract safe? On paper yes…But in practice? In practice there has been no groundwork laid for the expanded roles of educational supervisors, no realistic investment in the guardian role in many trusts, and the financial pressures on hospitals right now are mounting. I simply cannot see hospitals having the will, the manpower or investing the resources to make this work”.

Unfair perhaps, but illustrative of a gap in trust that provider leaders need to fill.

These are, of course, issues within our direct control. They’re not a 'nice to have'. They are core business, translating directly into reduced patient deaths, better quality of care and an improved bottom line.

As we all know, the strongest predictor of outstanding or special measures in CQC ratings is the engagement of staff. Where the people we work with believe they are valued and can influence what happens then they have the space to excel. When they feel disengaged, disempowered and disenfranchised, patient care suffers. This is the environment and culture provider leaders can directly affect, irrespective of the harsh world outside…As I saw when I visited Western Sussex Hospitals’ staff conference a couple of months ago. One of the 10 trusts rated outstanding by the CQC, their senior leadership team has prioritised support of their staff as a key trust value and a key priority. And it really showed.

Congratulations to Marianne Griffiths, their chief executive, who last week was recognised as the HSJ’s chief executive of the year. It was no surprise that the judges’ particularly cited her personal, highly visible, leadership style and commitment to supporting her staff.

The challenge we face

Which brings me neatly to the challenges we now face and how we meet them.

The scale and nature of that challenge is widely shared so I won’t dwell on it. I think we’ve articulated it well over the last three months when we said there is now a gap between what the NHS is being asked to deliver and the funding available.

The evidence of the gap is clear:

And we have a series of workforce challenges that we are struggling to meet: staff shortages, an ever mounting pressure I’ve already referred to, and a workforce planning system that seems unable to match demand and supply or staff numbers to the available financial envelope.

Our statement eight weeks ago was regarded in many quarters as a usual piece of autumn statement lobbying. And a small part of it was. But it was actually something much more important than that. It was us, as your voice, saying clearly, for the first time, that providers simply cannot deliver all that they are being asked to deliver on the funding available. That is a really important statement for an organisation like ours to make. And I want to assure you that we didn’t make it lightly.

How we closed the gap in the past

So, if there is a gap what do we now do? Fifteen years ago we all know what the NHS would have done.

There would have been a private conversation behind the back of the bike sheds and providers would have been told by NHS system leaders to reduce workforce numbers, lengthen waiting lists, and restrict access to certain treatments, hoping that not too many people would notice. But over the last 15 years we have decided, quite rightly, that’s not appropriate for the NHS.

So we have reinforced the fundamental principle that a defined range of treatments should be available to every citizen, free at the point of use, based on clinical need. We’ve set clear, stretching, performance targets for the delivery of those treatments. We’ve enshrined these targets as formal constitutional standards in an NHS constitution. Whole system and individual institutional performance against those standards is now completely transparent and regularly and heavily scrutinised in the media. And delivery of those standards and the quality of care is inspected and enforced by the most rigorous and transparent inspection regime in the world.

As a result, when the pressure is on, there’s a whole load of things the NHS can’t do. Things that other public services have done when faced with similar pressures over the last six years. And things the NHS used to do when faced with similar pressures in the past.

NHS providers can’t stop providing a service to 450,000 people by changing the eligibility criteria as they’ve done in social care;

NHS providers can’t cut the workforce by between 15% and 25% as they’ve done in the armed forces and the police;

NHS providers can’t close 178 A&E departments as local government has done with its library service;

NHS providers can’t reduce opening hours for our ambulance, crisis mental health and community services, as has happened with leisure centres up and down the land;

NHS providers can’t alter the frequency of how often a service is provided as many refuse collection services are now doing by shifting to fortnightly rather than weekly collections;

NHS providers can’t degrade the quality of the service in the way the chief inspector of prisons argues is now happening in the prison service.

So when we make the comparison between the NHS and other public services, it’s not just the demand and cost increases that we should be pointing to – the 20% increase in NHS demand and cost between 2010 and 2015, higher increases than any other public service. We also need to clearly point to the fact that the NHS is currently constitutionally unable to change its service in the way that other public services have done.

When we make the comparison between the NHS and other public services, it’s not just the demand and cost increases that we should be pointing to. We also need to clearly point to the fact that the NHS is currently constitutionally unable to change its service in the way that other public services have done.

As Jonathan Michael, one of our most experienced former provider chief executives put it: “Most of the levers that we used to use to balance the triumvirate of finances, quality and operational performance have gone. You could increase waits to help manage the finance, or slightly alter things on quality. But each of them has now been nailed to the floor by regulation or legislation”.

This is a key part of the dilemma we now face. It’s not simply that the NHS can’t deliver what is expected of it. It’s that the NHS can’t deliver what it is formally and constitutionally required to deliver. And if we fail to deliver the impossible, that failure is plain and transparent for all to see. So it really isn’t just a question of provider boards trying harder, being more imaginative and transformational, or just doing what local government, the police and prisons have done.

Three broad paths and rights and responsibilities

So what does happen now?

We have three broad paths:

You know our view. We believe the government should increase funding. And if it won’t, it has to honestly accept the consequences – that the NHS can no longer deliver what is being asked of it and the offer has to change. That view is underpinned by a clear sense of the respective rights and responsibilities of the government, NHS system leaders and us as providers. 

The government has the right to set the NHS budget wherever it wants to. It is our responsibility, as the provider sector, to stick to that budget, however difficult it may be, realise efficiencies, improve productivity and stretch every sinew to deliver the best performance possible within the budget that is set. 

But it is also the government and the NHS system leadership’s responsibility to set the NHS a delivery task that is achievable and matches the financial envelope. 

In Jim Mackey’s welcome and sensible words [and i won't do a Geordie accent]: “I am not going to ask you to deliver anything that’s impossible”. Stretch is fine. Aggressive stretch is tolerable. Impossible to deliver is not.

If the task that is set is impossible, the NHS frontline has the right to point clearly, first privately, and then publicly, to that impossibility.

This is where we now are.

The government has said there will be no more money. The government and our system leaders have said that the NHS still has to deliver everything that is currently being asked for. That is why I am repeating today what we said eight weeks ago – there is a gap between what the NHS is being required to deliver and the money available. We cannot deliver everything that is being asked for on the funding provided.

The risks of the gap

The NHS frontline will, of course, do all we can, as we have always done, to provide the best possible service. We’re not going to suddenly stop doing all the extraordinary things we do for patients.

But the gap means the NHS is now running a higher level of risk. I want to set out that risk as clearly, calmly and objectively as possible. I am forever being encouraged by journalists and twitter campaigners to shroud wave, exaggerate and use emotive language in speculating on what might happen next. I always resist, not least because it’s vital we retain public confidence in the NHS.

But I do see four main risks.

The first is that the service the NHS provides is now starting to deteriorate.

I’ve never bought the argument that the NHS will collapse or that performance will go off the edge of cliff. As we argued eight weeks ago, I think that, instead, we will see a long slow inexorable decline and all the gains we made between 2000 and 2010 will slowly dissipate. We can already see this starting to happen. Waiting lists for operations are lengthening. People are waiting longer in A&E. The CQC has said that they are “starting to see some services that are failing to improve and some deterioration in quality”. We know that CCGs are starting to restrict access to some treatments. And I cannot see how, without more funding, we can avoid social care falling into crisis. Surely it’s better to do something now than follow the example of the prison service, and have to come back later when the damage has truly been done and the task of rebuilding is so much greater.

A second risk is that the service is becoming much less resilient. When you run a system under as much pressure for as long as we have been running the NHS, it becomes much less able to absorb the shocks that any health system has to absorb. The winter flu outbreak. The closure of a couple of local care homes due to a CQC inspection or a provider going out of business. A few experienced GPs retiring and being replaced by more risk averse locums or new partners leading to sharply higher referral rates.

It’s easy to think that, in our system, power flows one way - from system leaders with position power down to frontline leaders. But it’s so much more sophisticated than that.

Given the capacity levels at which we are now permanently running our hospital, ambulance, community and mental health services – capacity levels unheard of in Germany, France, Spain and Italy – these small shocks now risk destabilising local health services. It’s no accident that we have seen some precipitate drops in A&E performance in particular hospitals on particular days. Drops that have a clear and demonstrable negative impact on patient experience and patient safety. Many are traceable back to that lower level of resilience and an inability to cope with shocks that five years ago could have been absorbed but now can’t be.

The third risk is one I’ve already talked about, that the pressure on staff and leaders becomes intolerable.

I am struck by how many chairs are worried about the pressure now being loaded onto provider leadership teams. And how many chief executives are worried about the pressure now being loaded onto frontline staff. The discretionary effort of our staff is the rocket fuel of the NHS. We also rely on a steady stream of our staff being willing to step up to leadership roles. We risk both if the job becomes so difficult, so pressurised, so relentless that it becomes undoable or unattractive.

And finally there is a fourth, more intangible, risk. I worry that the invisible bond of mutual trust and faith between the government and NHS system leaders, on one hand, and frontline leaders, on the other, is starting to fray.

It’s easy to think that, in our system, power flows one way - from system leaders with position power down to frontline leaders. But it’s so much more sophisticated than that. Our system leaders have to earn the right to lead the NHS at system level, as for example, Jim Mackey and Ed Smith have done over the last 18 months. If we get into a position where the frontline feels it is being asked to deliver the impossible; where boards are being held to hard account for something they can’t achieve; where senior leaders are being sacked, not because they are under performing, but because they are inevitably falling short of an unrealistic goal, then I think some important bonds start to loosen.

So, taken together, these are big and important risks. We need to think carefully about how we manage them as we enter this period of heightened challenge.

What government and system leaders can do to help

As I near the end of my remarks, let me strike a more positive note. There are three things that the government and our system leaders can do to help providers in this more challenging context.

Better prioritisation

The first is that we have to be more realistic and ruthless on priorities.

At the moment, it feels like we have four different sources of power and authority in the NHS, each with its own set of priorities. 

An NHS Improvement that wants providers to deliver on the money, hit the performance targets, get the right CQC rating, realise efficiency savings and cut agency spending. 

An NHS England that wants providers to implement the five year forward view, co-lead their local system towards new care models, help create local system sustainability and transformation plans and implement the outcomes of the cancer and mental health taskforces and the maternity review.

A CQC that wants providers to deliver the right quality of care and guarantee the right levels of staffing in every setting.

A Department of Health that wants providers to move to seven day services, create a paperless NHS, and focus relentlessly on patient safety issues.

No one would quarrel with any of these individual priorities. They’re all important. But, as you can tell from the length of the list, taken together, this is far too large a collective set of priorities to deliver consistently and effectively. We need our system leaders to come together and agree a much smaller number of priorities, setting realistic trajectories for each objective. It would help if that was done in close collaboration with those who actually have to deliver those priorities on the frontline.

A clearer, more realistic, medium term plan

The second way the centre could help is a realistic medium term plan for the NHS.

The short-term plan to eliminate the provider deficit is on track. The NHS Five year forward view provides a sound, important, longer term vision of the transformation the NHS needs, including a whole system focus, new care models and a prevention revolution.

The bit that is desperately missing is a credible, realistic, plan for the rest of this parliament. A plan that sets out how we will close the gap at both national and local levels between what the NHS is asked to deliver and the funding available. A plan that, as the National Audit Office requested last week, is realistic, sustainable and properly tested.

The sustainability and transformation planning process offers the opportunity to create these plans at a local level. But as we have said elsewhere, it needs more time, better governance, greater realism about what can be delivered and genuine co-design with the communities we serve. And, talking of better STP governance, I hope you will pick up a copy of this report we’ve just written with Hempsons on that subject that we’re launching today. You can get a copy from both their stand and our stand in the exhibition area.

More support

The third way the centre could help is to provide more support. In times of trouble it’s so much easier for system leaders to grip and whip than support and enable. No one is asking to be excused from rigorous accountability. This is a key public service accounting for nearly 20% of public spending. But there are two cases for more support.

The first is an effectiveness argument. As NHS Improvement is beginning to show, support works better than grip.

The second is a moral argument. I’m struck by how many of our senior provider leaders find their roles exposed, lonely and increasingly impossible. We are asking good, honest, decent people to do jobs with huge complexity and difficulty under the most intense scrutiny.

I think all of us around them, be they system leaders, commissioners or organisations like ours, have a moral responsibility to support senior leaders in their roles as well as we can. So, in summary, if we are to manage the increased risk we now face, better prioritisation, a realistic medium term plan and more support would help.

NHS Providers

Let me finish by saying that it remains an honour, a privilege and a delight to lead your membership organisation and trade association.

I couldn’t be more pleased that our most recent member survey tells us you think we continue to do a great job on your behalf. If you haven’t seen the results summary, please pick one up from our stand in the exhibition area.

I promise you:

Have a good conference and exhibition, and thank you.