Opening speech to NHS Providers annual conference 2018

Chris Hopson profile picture

09 October 2018

Chris Hopson
Chief Executive
NHS Providers

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 Newton Europe and Hempsons and our strand partners Teletracking. I’d also like to thank both Salary Finance and the NHS Leadership Academy who are delivering our breakfast sessions tomorrow morning. And can I please encourage you to support all our commercial partners and spend as much time as possible in our exhibition which you’ll find in exchange hall.

The NHS Leadership Academy session will be launching our new joint document From Clinician to Chief Executive which looks at how we can enable and encourage more clinicians to become CEOs. I urge you to get a copy from the NHS Providers stand that you’ll also find in exchange hall.

Can I also thank you for coming. I know how busy and stretched you are and how difficult it can be to take time out. But I hope you will find this event a timely and valuable opportunity to review challenges, develop and share solutions, and network with colleagues.

The longer view – the incredible achievements of NHS providers

This is my seventh annual conference and exhibition speech. We spend a lot of time in the NHS making year on year comparisons. But sometimes the longer view is more illuminating. So I thought I’d start by looking at what’s been achieved over the six years since I delivered my first speech, comparing what providers delivered in 2017/18 to what was delivered in 2011/12.

It’s a pretty extraordinary story of impressive performance, innovative treatments and improved clinical approaches to cope with rapidly rising demand. Better quality care for more patients despite the pressures the NHS faces.

In August this year, for example, ambulance trusts handled 230,000 more calls than they did six years ago… a very impressive 32% increase.

Mental health and learning disability trusts have led the world in introducing a new regime of outcome standards designed to improve treatment across early intervention in psychosis, increase access to psychological therapies and extend psychiatric liaison services in acute hospitals. There’s impressive work being done to increase access to specialist perinatal and eating disorder support and improve mental health crisis care, working with partners in the criminal justice system.

In our hospital A&E departments, we’re seeing 2.2 million more people every year, a 10% increase on six years ago. Of those patients, we’re treating 180,000 more each year within the four hour standard. Acute hospitals are now admitting 900,000 more people with emergencies each year, an 18% increase compared to six years ago.

It’s a similar story in elective surgery and cancer. Hospitals are seeing a million more patients within the 18 week standard than they were six years ago. GPs are now referring 830,000 more cancer cases to hospitals each year, an extraordinary 75% increase compared to six years ago. And 23,400 or 24% more are treated within the 62 day standard than six years ago.

Provider sector achievements – not just a numbers game

And it’s not just a numbers game.

As the CQC’s annual state of care reports have shown, all types of provider have, over the last few years, continuously improved the quality of patient care they offer. There are now 18 trusts rated by the CQC as outstanding – one ambulance trust, four mental health or community trusts, five specialist trusts and eight acute hospital trusts. Every single year since the new CQC inspection process got properly going, the number of providers with an inadequate or needs improvement rating has dropped and the number of providers with a good or outstanding rating has increased. The quality of patient care is quantifiably improving.

And just in case we thought all this was about running harder within the existing model, it has been providers from Northumbria and Nottingham and Birmingham and Solihull to Frimley who are playing a major role in developing new models of care.

At long last, we are beginning to get proper national recognition of the vital role that community services play. As the Kings Fund has argued, they are often leading the way in rapidly improving care for patients by bringing primary and secondary care together and health and social care together.

And we shouldn’t forget that providers have also led difficult changes to the pattern of services. There are more than 3,000 people who simply wouldn’t be alive today had it not been for the establishment of hyper acute stroke units in London and regional trauma centres across the country over those last six years.

Delivering despite the financial squeeze and workforce shortages

Even then, that’s not the complete picture, because providers have delivered all this at the same time as the longest financial squeeze in NHS history. And one of the biggest workforce shortages in NHS history.

If the 2011/12 NHS frontline budget had increased at the same annual real terms rate as it had between 1948 and 2010, the 2018/19 NHS frontline budget wouldn’t be £128bn, it would be £154bn. £26bn or 20% bigger. In fact, we’ve only been able to consistently balance the total NHS budget because providers have realised an estimated £15bn of savings over the last six years.

All this whilst significantly reducing the inpatient bed base. There are now 9,000 or 6% fewer overnight inpatient beds, despite England’s population having grown by 4% from 53 to 55 million over the last six years. That bed reduction has been achieved thanks to NHS trusts pioneering and rapidly rolling out a whole range of new treatment approaches including:

  • The growth of hospital ambulatory care which has massively reduced patient length of stay
  • A much wider range of complex treatments provided by community services in patients’ homes such as the use of IV drips
  • The rapid expansion of see and treat rather than convey in the ambulance service
  • The continuing shift from inpatient beds to community services in mental health
  • And the introduction of the 111 telephone triage service.

All this at a time when the total NHS workforce has only grown by 9% compared to the 18% growth we’ve seen in emergency admissions. If we’d grown the 2011/12 NHS workforce at the same rate as the growth in emergency admissions, we’d now have an extra 90,000 much needed staff posts.

And all this has also been delivered at a time when our local government and other public service colleagues have been under huge pressure. Huge pressure on social care. Huge pressure on public health budgets. And huge pressure on the wider determinants of health like stagnant real terms wages over a 10 year period.

It all adds up to an extraordinary story doesn’t it? The longer view is illuminating!

The incredible efforts of frontline staff

As we know, this is all thanks to the incredible efforts of frontline NHS staff. Hundreds of thousands of doctors, nurses, therapists, porters, health visitors, psychiatrists, paramedics, dieticians, clerical staff, pathologists, radiologists, medical secretaries, midwives, psychologists, paediatricians, receptionists, housekeeping and estates staff… the hundreds of different professions that come together to make the NHS what it is.

As you consistently tell me on my trust visits, these frontline staff have never worked harder and their discretionary effort provides the rocket fuel that powers the NHS and delivers the extraordinary achievements I’ve talked about.

And yet, and yet.

Trusts locked into a debilitating cycle of public failure due to unrealistic targets

We have this incredibly frustrating paradox – that whilst providers have been improving the quality of patient care, developing new approaches to cope with rising and more complex demand, treating record numbers of patients within the constitutional standards, realising near record levels of savings, and whilst frontline staff have never worked harder…

Providers have now missed all the key performance standards for three years in a row and performance across the A&E, elective surgery and cancer standards is amongst the worst it’s been since those standards were introduced.

Whilst frontline staff have never worked harder, providers have now missed all the key performance standards for three years in a row and performance across the A&E, elective surgery and cancer standards is amongst the worst it’s been since those standards were introduced.

Chris Hopson    Chief Executive

The sector has consistently missed the financial targets it’s been set for each of the last four years. Mental health, learning disability and community trusts cannot provide the service they know their patients and service users need because demand is so far ahead of capacity. And whereas six years ago, the vast majority of providers were meeting all their performance and financial targets and realising the 5% surplus needed for future investment, now that’s the rare exception and nowhere near the rule.

The provider sector seems locked in a permanent cycle of debilitating public failure against its performance and financial targets. Debilitating because however hard staff seem to work and however much they achieve, the trust sector can’t deliver the performance and financial task that has been set. Debilitating because the prevailing public narrative is one of constant failure. Debilitating because it enables critics to imply that the failure is due to providers under performing and not doing as well as they should, which is patently untrue.

The importance of the new NHS long-term plan

That’s why the new NHS long-term plan to be published in November is so important. It will, of course, set out the long-term ambition for the NHS – what the service can deliver for the extra investment the government has made.

But equally important, it provides an opportunity to reset the current performance and financial framework. To enable the provider sector to return to sustainable success. To enable the average trust performing well to consistently and sustainably meet its performance and financial targets. To enable frontline staff and trust leaders to feel, once again, that their efforts are being properly reflected in a positive public narrative about how well the NHS is doing.

Whilst much of the current work on the long-term plan is concentrated on all the new commitments our politicians and national system leaders will want to make, it’s vital that we don’t lose the opportunity to create the performance and financial reset the NHS frontline so desperately needs.

Chris Hopson    Chief Executive

Whilst much of the current work on the long-term plan is concentrated on all the new commitments our politicians and national system leaders will want to make, it’s vital that we don’t lose the opportunity to create the performance and financial reset the NHS frontline so desperately needs.

What providers need from the new NHS long-term plan

So, as the NHS finalises the long-term plan over the next few weeks I want to set out what I believe the provider sector needs in that reset.

The task of trusts is to provide outstanding care to the communities they serve. To do that, they need the right national framework and the right support. They need an achievable annual operational and financial task that’s properly prioritised. And they need a clear national plan to deliver the transformation the NHS so desperately needs. The right framework, the right support, an achievable day to day task, proper prioritisation and a transformation plan.

It sounds motherhood and apple pie doesn’t it? But, for the avoidance of doubt, we must be clear that, at the moment, providers feel that many parts of the current national framework hinder rather than help:

  • They don’t feel they’re getting the support they want and need
  • The day to day operational and financial task they’ve been set has not been achievable for some time
  • What they’re currently being asked to do has not been realistically prioritised and exceeds the frontline capacity available
  • Whilst we have a good vision for how the NHS should transform, we don’t have a clear plan or the necessary funding to deliver that vision
  • And, as a service, we remain confused and inconsistent about how we balance a focus on individual institutions and a focus on local health and care systems.

The five things trusts need from the long-term plan

So, let me go into more detail about what trusts need from the reset in the long-term plan. I want to talk about five things. How, working together:

  • We get greater realism on the growing and more complex demand trusts are now facing
  • We get rapid action to address current workforce shortages
  • We get a realistic day to day operational task
  • We get a clearer plan to deliver much needed transformation, including the transition to integrated local health and care systems
  • And we get a new relationship between national and local system leaders.

Being realistic about the increase in demand

Let me start with the growing and more complex demand trusts face.

It is, of course, the responsibility of trust leaders to provide outstanding care however much demand increases. That’s the job of any team leading a healthcare provider in any advanced Western economy with an ageing population. Indeed, it’s a sign of progress and a cause for celebration that our population is living longer – that’s the whole point of healthcare, isn’t it?

But there are a number of things our national system leaders can do to help trust leaders as they grapple with this knotty problem of rapidly rising, more complex, demand. At the moment we seem to have this weird disconnect where we all talk about the demand bulge the NHS will have to face as though it’s three, five or ten years hence. As the figures I used at the start of my speech illustrate, that demand bulge is already here. We’re already experiencing it. And, as the House of Lords select committee on long term sustainability pointed out last year, our health and care system is simply not planning well enough to meet that demand bulge.

Shifting to new models of care will be key. The NHS can’t afford to build another 40 district general hospitals to cope with the extra demand it now faces.

But there is a challenge here, a challenge that was brought home to me on a recent visit to the Isle of Wight. If you want a window on the pressures that an older population will bring to our health and care system, the Isle of Wight is as good a place as any to see them. I had a fascinating conversation with the senior A&E staff in the hospital, struggling to cope not just with the extra numbers of people they were seeing but the increasing complexity of that demand. Rapidly growing numbers of frail older people with multiple co-morbidities that absolutely required a high quality of acute care. So whilst they recognised that there were significant numbers of patients fit for medical discharge on the hospital’s older people’s wards. They were also clear that their A&E department and linked services would have to expand to cope with these higher levels of complex demand. We will need more care closer to home but we will also need more acute care. It’s both not one or the other.

So what do providers need from the long-term plan?

Above all, we need realism on the size, scope and nature of the demand challenge our NHS faces. And we need that realism reflected in all our plans, priorities and performance oversight. We need much better longer term planning that takes a ten year view of how demand will grow and change. And we need to start developing concrete long term plans, health system by health system, on how we will tackle that demand.

We need a strategy that provides as much care as possible as close to home as possible and ensures that we actually make the required investment in community services rather than just talk about it. A strategy that delivers the focus on prevention that the NHS so frequently espouses but just as frequently seems to elude us. But a strategy that also recognises, as the Isle of Wight demonstrated, that more acute hospital care will be needed.

There are some early examples of where new care models are starting to flatten the demand curve. But the mistake comes when national leaders turn those encouraging early examples into a hope, a wish and a consistent, system wide, planning assumption that is massively over ambitious and cannot be delivered.

Providers need realistic annual planning assumptions that reflect the demand that trusts will actually see, not the level of demand national leaders would like them to see. With an appropriate margin for error and more rapid growth than we were expecting.

Providers need realistic annual planning assumptions that reflect the demand that trusts will actually see, not the level of demand national leaders would like them to see.

Chris Hopson    Chief Executive

Being more realistic than we have been this year when, to choose just one example, trusts were asked to plan for 2.3% emergency admissions, despite the fact that last year emergency admissions increased by 3.7%. And what’s happened? In the first five months this year, emergency admissions have grown by 6.1%, nearly three times the rate the planning guidance suggested they would.

In short, the reset in the forthcoming long-term plan must avoid the over ambitious demand assumptions that accompanied the Five Year Forward View. Over ambitious assumptions that led to an undeliverable provider task over the last few years.

Treating short term workforce shortages as the crisis they have now become

The second area the reset needs to focus on is how we move a lot more swiftly and decisively to address the workforce shortages providers currently face.

You just have to read the Health Service Journal to see how serious these problems have now become. Over the last three weeks, there have been stories of:

  • More A&E departments having to close due to lack of staff
  • A district general hospital having to consider stopping all its elective activity due to lack of staff
  • Mental health out of area placements in some parts of the country, that we are working so hard to reduce, increasing due to lack of staff.

It is, of course, the responsibility of trust leaders to ensure their trusts have the right workforce with the right skills in the right place to consistently provide outstanding care. But they need the right national framework.

The long-term plan will, I am sure, chart the long-term course for growing our workforce; providing our staff with a reasonable workload; making the NHS a great to place work; and addressing the issues around diversity and a unhealthy bullying culture that currently scar the face of our NHS.

I also hope the long-term plan will propose a structural solution to the hopeless split in responsibilities for workforce issues between Health Education England, NHS England, NHS Improvement, the Department of Health and Social Care, the professional regulators such as the GMC and the NMC, and organisations like NHS Employers.

But this is not enough. We do need to avoid hyperbole. But hasn’t the time come to treat the workforce shortages providers now face as the crisis they have now become?

Dealing with a crisis requires a degree of urgency, co-ordination and focus. Dealing with a crisis brings all the relevant players into a single space to develop new solutions at pace. Dealing with a crisis means being willing to consider approaches that might carry a degree of risk but are clearly better than the steady state alternative. Isn’t this what is now needed?

Every single trust leader I talk to only sees this problem getting worse before it starts to get better. The latest quarter one data from NHS Improvement confirms that – with vacancies growing by nearly 9% from 98,000 to 107,000 in just one quarter. And a forecast that vacancies will continue to grow for the rest of the year.

Yes, of course, we need the right long term strategy like ensuring we grow our domestic supply. But isn’t now the time for short term crisis measures like:

  • The arms length bodies and trusts coming together to work out how we can provide short term incentives to encourage those who have left the NHS to return to work
  • The government and the NHS coming together to work out how we can, for a short period, bring in significantly more staff from overseas
  • The NHS and the government coming together to solve the pensions cap issue which is robbing us of so many experienced senior leaders and experienced medical staff that we can ill afford to lose
  • Local systems coming together to plan where temporary changes to current patterns of service are needed, before those services become unsafe and literally have to be shut overnight
  • Regulators, trusts and professional bodies coming together to work out how we can quickly give other staff groups, particularly the new roles we are creating, some of the clinical permissions that can currently only be held by registered doctors and nurses.

These are potentially challenging ideas. But I suggest them in the spirit that we have to move with much greater purpose and speed to address current workforce shortages.

An achievable day to day task, honestly based on where we start from

Let me turn to the third area where the reset needs to focus – giving providers a deliverable day to day operational and financial task. I don’t envy Simon Stevens and Ian Dalton in their task of drawing up the new long-term plan. There are too many demands for too little money.

It is right to be ambitious to deliver improved outcomes, particularly in areas like cancer where the NHS lags our European neighbours. And mental health where the level of unmet need is simply unacceptable. We must invest quickly to improve the NHS’s shockingly under developed IT infrastructure.

The way our health and care system provide services is now unsustainable so we must fund the transformation we desperately need. But all this has to be balanced with giving trusts and frontline staff a deliverable day to day operational and financial task. And in setting that task national leaders must be honest and realistic about where we start from.

It’s not a great place. A recorded financial deficit of nearly £1bn and an underlying deficit of over £4bn. A £2.7bn backlog of high and significant risk maintenance and a total backlog of £5.5bn. Rapidly growing levels of demand we seem unable to cope with. The key performance standards being missed by some distance for some time. Widespread staff shortages, an overstretched workforce and a much needed lifting of the pay cap that now has to be paid for. All these shortfalls have to be addressed.

That will cost money, frontline capacity and leadership focus. Money, capacity and focus we can’t devote to other priorities. So the NHS now has some really tough and difficult choices to make that cannot be fudged as we have fudged in the past.

If you look at the long-term plan from a Treasury and Number 10 perspective the whole point of allocating the money first is that the NHS has to rigorously, conclusively and definitively demonstrate that the plan matches the money.

The NHS can’t just produce a vaguely costed wish list and then lobby for that wish list to be funded. This has to be a carefully costed and properly programmed delivery plan that matches the funding envelope. No unfunded commitments, no over ambitious assumptions, no aspirational wish lists.

I recognise the political difficulties of telling taxpayers that a significant chunk of the extra NHS resource they will help fund through increased taxes has to go on filling the large gap that has opened up. Particularly when our national system hasn’t fully or honestly acknowledged the existence of that gap.

But we have to break the downward spiral of continued missed financial and performance targets in which trusts are currently trapped. It is, of course, the responsibility of trust leaders to stretch every sinew to deliver a challenging task set by national leaders. But, as the last four years have shown, no-one benefits if that task is beyond challenging and is undeliverable.

So, what do we need from the long-term plan here?

We will want to recover performance levels to meet NHS constitutional standards. Trusts spent the best part of the last decade achieving those standards. And they are the best proxy we have for the quality of patient care we should be providing. We may want to modernise and update the standards to reflect today’s clinical practice, but I’m yet to find anyone who wants to abandon the performance levels implicit within them.

But if we are going to recover performance to those levels, national leaders must be realistic about how much that will cost and how long that will take. The prime minister has made it clear that, over the medium term, no NHS organisation should be in financial deficit. National leaders must be similarly realistic about how long that will take and how much that will cost. Many of the biggest individual deficits are due to stubborn, long running, structural issues that will have to be addressed before those trusts can return to sustainable surplus. Recovering a deficit in a cold climate, with a squeezed tariff where the easy cost savings have already been realised, is also a much tougher proposition now than the warmer climate of fifteen years ago.

Over the last few years, national leaders have used over ambitious efficiency assumptions to make the money balance. The result, as the report on efficiency NHS Providers has released today shows, is that just as night follows day, an over ambitious efficiency target just leads straight to a larger provider sector deficit. So just as we need realism on the levels of demand the NHS will face, we need realism on how much efficiency can be delivered.

Taking all this together, we must also explicitly measure the overall provider ask – performance and financial recovery, efficiency, new commitments and transformation – against current provider capacity and capability, particularly current workforce capacity. There is a real danger here of asking for too many things too quickly when the NHS has too few people and too little money.

Chris Hopson    Chief Executive

Taking all this together, we must also explicitly measure the overall provider ask – performance and financial recovery, efficiency, new commitments and transformation – against current provider capacity and capability, particularly current workforce capacity. There is a real danger here of asking for too many things too quickly when the NHS has too few people and too little money. And it’s vital that the provider sector is fully involved in assessing whether the overall ask is deliverable.


So I’ve talked about demand, workforce shortages and a deliverable ask for providers. What do providers need from the long-term plan on transformation, my fourth area?

It is, of course, the responsibility of trust leaders to lead the transformation of their trusts and, working with local partners, to lead the transformation of their local health and care systems. If we carry on doing the same things in the same way, we will get the same results.

The good news is that, thanks to the work of the new care model vanguards and other pioneers over the last few years, we now know what changes we need to make. The challenge now is to consistently drive those changes at scale and pace.

The new care model programme has shown the power of creating powerful neighbourhood hubs that bring together primary care, community services, social care, community mental health services and some lower level acute services into a single, seamless, integrated, service, working 24 hours a day, seven days a week, and offering a single point of access. A service provided by a single multi disciplinary team using a single integrated care record and a whole population approach that identifies those most at risk with dedicated care co-ordinators to support those patients. Encouraging and enabling them to take more control of their own health and wellbeing with a strong emphasis on better prevention.

So, the long-term plan needs to set out how we will spread this approach at pace and scale.

Six years ago, when I did my member visits, no one ever talked about primary care. Now everyone talks about how trusts can only provide high quality care with a robust, reformed, primary care sector effectively operating at scale in their local system. Again, we know there are lots of different ways of achieving this – modality type super-partnerships; effective GP federations; trusts acquiring GP practices as in Wolverhampton; trusts creating joint ventures with primary care as in Yeovil; or the new Integrated Provider Partnership the CCG, trust and GPs are seeking to establish in Dudley, to name a few.

The long term-plan needs to set out how we will spread these approaches at pace and scale. The new care models are also showing that there are rapid gains to be made by rationalising commissioning, making it more strategic and integrating health and local authority commissioning. They’ve also shown that devolving specialised commissioning to consortia of providers can, within a few months, generate enormous leaps in patient outcomes and cost savings.

Correctly sizing and configuring commissioning and the arms length bodies means the NHS can release significant amounts of savings – probably up to £1bn – for front line care. The long term-plan needs to set out how we will spread these approaches at pace and scale.

The Virginia Mason Institute programme with five trusts is demonstrating that the systematic adoption of improvement methodology can rapidly drive exactly the kind of staff driven, bottom up, change the NHS desperately needs. The long-term plan needs to set out how we will spread these approaches at pace and scale.

You can’t transform without investment and some element of double running. So the long-term plan needs to clearly out set how much transformation funding will be available when and on what basis. It also needs to change the financial architecture and incentives to match the integrated health and care system we want to reach rather than reflect the world of reducing hospital waiting times that we’ve recently come from. And it also needs to end the current confusion and uncertainty on the journey from individual institutions to integrated local health and care systems.

As we set out in our latest briefing on the progress of STPs:

  • Providers need greater clarity on the desired final destination
  • Greater clarity on what the NHS will do at each of regional, system, place and neighbourhood level
  • Greater clarity on how much variability between different systems will be allowed and desired
  • And greater clarity on how we navigate the legislative constraints that none of us want but all of us must acknowledge do actually exist.

A new relationship between national system and local leaders

Finally, my fifth area, providers need the long-term plan to deliver a new relationship between our national system leaders – the Department of Health and Care, NHS England, NHS Improvement, the other arms length bodies – and local leaders.

Of course, local leaders are responsible for balancing that trinity of finance, quality and access to provide great care to the communities they serve. But they can only do that if they have the right policy framework and the right support from national system leaders.

And, uncomfortable though this may be, the current relationship between national system leaders and local leaders feels too one way, too top down, too command and control rather than a partnership of equals. Too directive rather than genuinely collaborative and too much about national system level assurance rather than trust level support.

And, uncomfortable though this may be, the current relationship between national system leaders and local leaders feels too one way, too top down, too command and control rather than a partnership of equals.

Chris Hopson    Chief Executive

Everyone in the trust sector welcomes Dido Harding and Ian Dalton’s commitments to change this relationship. But, as we all know, changing large organisations so that everyone is aligned with a new top leadership approach, takes time, focus and clarity of purpose.

Six years ago I joined the Foundation Trust Network, not NHS Providers. I know that the foundation trust concept has become discredited in some places. And, of course, we all recognise that pursuing the success of the individual institution at the expense of the local system is yesterday’s model that is now firmly dead. But there were some key ideas behind the foundation trust model that are absolutely vital. We mustn’t throw the baby out with the bath water.

The most important idea is that local delivery of health services is just too complex to be run from Whitehall, Wellington House or Skipton House or their regional outposts. You can only manage annual budgets of up to £1.4bn, deliver services for populations of up to one million that have very different needs and lead workforces of up to 30,000 locally. Local trusts and, in the future, local health and care systems running local health services for local communities. Local trust boards and, over time, new local system governance mechanisms, being accountable for the delivery of those local services. Local leaders empowered to innovate and develop new ways of providing care, whilst working within a national framework.

I recognise that the NHS pendulum often swings between devolution and centralisation. The foundation trust model rightly gave the pendulum a strong pull towards devolution. But there is real concern amongst trust leaders that the pendulum is rapidly swinging back towards centralisation.

Take two areas. Chief executive appointment and remuneration and the creation of annual budgets and plans. It must be local chairs and boards who appoint their chief executives and decide their pay. Of course, trusts should listen to NHS Improvement views on who they believe would make the best chief executive and any national guidelines on senior manager pay.

But, in the end it is local leaders who are accountable and they must be free to make their own appointments and decide what those senior leaders should be paid. It must be local leaders who decide what their annual surplus or deficit should be and, in so doing, strike the balance between quality and money. That must, of course, be in discussion with NHS Improvement and NHS England. But, in the end, it must be local leaders who decide what is deliverable and what is not; what is safe and what is not. It is local leaders who have the most and the best information. It is local leaders who understand the needs of their local communities. It is local leaders who have to own the local delivery task and carry the can if things go wrong. Either we trust them or we don’t. Either we give them the rights to lead local services and then hold them responsible or we don’t.

If NHS Improvement and NHS England make these decisions and impose them on local leaders, we dangerously blur accountability. We risk the sense of local ownership of a very difficult but important delivery task and we stifle the energy, innovation and drive that is vital to achieving that task.

So, providers need the long-term plan to commit the new NHS Improvement/NHS England joint venture to work with local leaders to agree how the key processes like senior appointments, budgeting and performance management will actually work. To commit the soon to be appointed new regional directors, to work with local leaders to develop an agreed set of behaviours we will all adopt when working with each other, with mutual respect at their heart. To commit to a proper, formal, forum for regular detailed dialogue between national system leaders and local leaders. To commit to full and genuine co-creation of the big policy decisions like the direction of local system working. To commit the arms length bodies to a systematic programme of gathering feedback and learning on the processes that lie at the heart of that national system/local leader relationship. Annual planning; the special measures regime; capital prioritisation and allocation; regular performance and finance management and information collection; transaction approval; the support offer to trusts; senior leadership appointment, development and remuneration. So that these processes work equally well for both local and national leaders.

If we want trusts to continuously improve by being brilliant listeners to the patients they serve, we need the arms length bodies to do the same with the local leaders they say they want to support.

Brexit and the spending review

Let me start to wind up by saying that we need to avoid overloading the long-term plan with unrealistic expectations that cannot be met. There are other things that need to happen too:

  • The government needs to avoid a Brexit that damages the NHS
  • It must ensure the NHS has the capital, public health and training budgets it needs when the next spending review completes its work
  • And, above all, it absolutely must develop a robust long-term solution to social care.

In the words of one trust non-executive at a recent NHS Providers member dinner with the Local Government Association: “Now is the time for men and women of good conscience to stand up as one and say ‘we cannot carry on like this with social care, something has to be done’.” I couldn’t agree more.

So it isn’t just about the long-term plan. But that long-term plan does present an important opportunity. If it is honest about the demand challenges, quickly tackles current workforce shortages, sets an achievable frontline task, brings clarity on how we will deliver transformation and creates a new relationship between national system leaders and frontline trust leaders based on mutual respect... Then you, those frontline leaders, can do what you do best. Provide outstanding care to the patients you serve.

NHS Providers

Let me finish with a brief reflection on NHS Providers using the six year context I started with. I am immensely proud of what we have achieved over those six years. We now have every single trust in membership. We have become a powerful and effective voice that speaks truth to power. We have become a trusted and influential system partner helping to generate effective solutions like the Aspiring trust chief executives programme. We have massively expanded our support offer from our networks and briefings to our development programmes and this conference and exhibition. The full range of our development offer, by the way, is now set out in a new publication you can collect from the NHS Providers stand in the exchange hall. We have built a professional organisation with real strength in depth and a fantastic team that it’s a privilege to lead.

I became the NHS Providers chief executive because I thought frontline trust leaders with incredibly difficult jobs deserved and needed more support from a world class membership organisation. So nothing gives me greater pleasure than to see in our latest member survey that 99% of trust chairs and chief executives are satisfied with what we do; 98% believe it’s important for your trust to be a member and 99% would speak positively of NHS Providers.

Thank you for your support, thank you for coming and I hope you enjoy the conference and exhibition.


The annual conference and exhibition 2019 will take place on 8-9 October in Manchester Central. Find out more on the annual conference website.

About the author

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Chris Hopson
Chief Executive

Chris Hopson is the chief executive of NHS Providers. He joined in September 2012 after a career in politics, commercial television and the civil service. Read more

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