Welcome to this year’s NHS Providers annual conference and exhibition. By necessity, our first ever virtual event. So please feed back on how you find it.
This event couldn’t happen without our commercial partners and I’d particularly like to thank Newton Europe, our main event partner. As the two sessions on their work in Cornwall and Birmingham will show, they’re doing some impressive work to support health and care integration at local level.
Can I please encourage you to support all our commercial partners and spend as much time as possible in the exhibitors area of our virtual conference platform.
Can I thank you for participating. I hope the virtual format, where you can dip in and out of sessions and return to them at any point over the next three months will help you get the most out of the next three days.
As for my opening address, I’ve created slides to help you follow the argument as I go. And please feed back your views on what you hear on the chat function.
Past, present and future
I want, today, to look at the past, the present and the future.
Given our reflect and recover theme I want to look back at the last nine months and reflect on what we’ve learnt.
I want to look at the task immediately in front of us.
And I want to look at two key elements of the future. The comprehensive spending review which, on current plans, will set the priorities and funding envelope for health and care for the rest of the parliament.
And the emerging NHS Bill that will seek to move us more rapidly and consistently to greater system working.
The past – the last nine months
So let me start with three reflections on the last nine months.
First, the debt that we, as a country, owe our frontline NHS workforce. And how we repay that debt.
Second, the way this virus has highlighted the inequalities in our country. And how we need to address them.
And third, despite what some have been arguing, the NHS never was a COVID-only service at any point over the last nine months.
The debt we owe our workforce
Thanks to our frontline staff, the NHS has achieved some incredible things this year.
33,000 beds for coronavirus patients and seven new Nightingale hospitals in less than a month.
New 24 hour crisis mental health services across the country.
Rapidly expanded ambulance and 111 call centre capacity.
And a huge growth in community service workload to safely discharge a large number of hospital patients using a new approach designed and delivered in three short weeks.
The nation owes a huge debt of thanks to frontline NHS staff for this, and all their other, work.
Coming to work and walking towards danger and risk, to care for others, whatever their concerns for their own health and that of their families.
Much of the focus has rightly been on doctors and nurses.
But we all know it’s been a huge team effort with staff from every part of every trust playing their role. Porters and pharmacists, psychiatrists and paramedics, podiatrists and physiotherapists. Procurement, estates, finance and HR teams. A collective team effort unprecedented in the NHS’ 70 year history.
And I’d like to recognise the effort of trust chief executives who worked with NHS England and Improvement on some of the difficult national level challenges we overcame and are still addressing.
Sarah Jane Marsh on testing.
Michael Wilson and Joe Harrison on personal protective equipment (PPE) distribution.
Mark Brandreth and David Probert on creating the nightingales and moving to online outpatient appointments.
Working with colleagues like Amanda Pritchard, Pauline Philip, Claire Murdoch, Cally Palmer and Matthew Winn, they showed there is a huge reservoir of skill and experience in the trust chief executive community that can be drawn on at national level.
The obvious question to ask when you incur is a debt is: “how do you repay it”?
My sense is that the best way to repay the debt to our staff is to create a sustainable NHS workforce model.
Asking those staff to do the right job, on the right terms and conditions, in the right working environment.
No longer asking them to go the extra mile and a half every single shift, every single working day.
A collective endeavour for all of us.
The government needs to fund and support the NHS to fill our current workforce gaps.
The government needs to fund and support the NHS to fill our current workforce gaps.
Trusts, in the words of the new NHS People Plan, need to make the NHS the best place to work.
And, as leaders, we must show, in all that we do, that the welfare of our staff really is our top priority.
That would be a fitting tribute and reward for what has been achieved.
The impact of inequalities
My second reflection is that, over the last nine months, two seismic events have shone a bright light on inequalities in our nation.
First we had COVID-19, with its disproportionate impact on people of colour. Then we had the murder of George Floyd, together with the Black Lives Matter protests it triggered.
Both exposing the invidious impact of health inequalities and of structural racism on our staff, our patients and our communities.
Structural racism is not new. But it is often misunderstood. These events are the latest in a series of ‘moments’ that have highlighted its all-pervasive and persistent impact. But this time, these events need to push us to take far-reaching action with a lasting impact.
Perhaps it jars for me with my white, privileged, middle class, background, to be addressing these issues. But it is my business. Just as I think it is yours.
We need an honest conversation about racism. The fact that it exists in our society, and in our NHS and that, without that honest conversation, we can’t move forward.
It’s an uncomfortable conversation where many of us, as white leaders, are not sure how to proceed. Where we worry that we may say or do the wrong thing. Where we can feel like we are treading on egg shells.
But we can be encouraged by the public leadership of chief executive colleagues like Patricia Miller, Raj Jain and Roisin Fallon Williams who have set out very clearly what we now need to do.
Lots of us like to measure, use data, ‘size’ an issue. It’s important.
But, as Raj and Patricia have argued in a blog they wrote for us, for positive change we need leaders who are culturally competent and can demonstrate inclusivity in all that they do. Not just talk about it, measure it or describe it.
Mindsets have to change. Not just the numbers.
Mindsets have to change. Not just the numbers. It’s important it’s “not just more words”. We need concrete action. At pace.
And it’s not just cultural competence, it’s cultural interest. Ensuring colleagues from minority communities are fully valued. To enable them to feel psychologically safe.
Alongside tackling racism, we need to think more broadly about health inequalities.
That, to quote Michael Marmot, health is closely linked to the “conditions in which people are born, grow, live, work and age and inequities in power, money and resources”.
And we need to make tackling those health inequalities a much more central part of what we do.
Owen Williams, the chief executive of Calderdale and Huddersfield, has led an important piece of work identifying eight immediate actions that need to be taken in this space. I commend them to you.
The reality is that, in many local health and care systems, it’s often trusts who drive change. Who have the depth of management resource, the analytical capability, the sheer heft, to make things happen.
If we are to truly tackle health inequalities, this issue has to become as important to trust leaders as the size of waiting lists, the daily performance statistics or progress with cost improvement savings
We have to put our shoulder to the wheel. Deploy our resource to drive change. Lead this agenda with local partners. That’s a big shift from where we are now.
The NHS was never a COVID-only service
My third reflection is that it’s been frustrating and disappointing to hear the NHS described as providing a COVID only service over the last nine months.
Some of this is about people wanting to highlight the importance of a particular specialty or condition.
Some of it, less excusably, is about private sector businesses or those with a vested interest trying to drum up business or raise their public profile.
Some of it is those who, for ideological reasons, want to attack the NHS model.
But a lot of what’s been said is just plain wrong.
The NHS never provided a COVID-only service.
The NHS did have to prioritise patients on the basis of clinical need, as it always does, to cope with the first COVID-19 surge. Some treatments were delayed. This was disruptive and distressing for those patients. And, for some of those patients, this will have a significant impact.
But hospitals only formally paused non-urgent services for a fortnight, between 15 April and 29 April, when the impact of the virus on the NHS was at its peak.
Even at the height of coronavirus, for every one COVID-19 patient in hospital, there were two non-COVID inpatients being treated for other conditions.
Even at the height of coronavirus, for every one COVID-19 patient in hospital, there were two non-COVID inpatients being treated for other conditions.
Between April and June more than three million urgent tests and checks were provided and 3.6 million people were treated in A&E. The NHS continued to deliver, on average, 1,800 babies every day.
Mental health, community and ambulance services carried on providing broadly the same full range of services to their patients and service users throughout the pandemic.
Mental health trusts, for example, were in contact with 282,000 children and young people in April 2020 – the highest monthly figure on record.
Ambulance services took more than 1.7 million calls between April and June.
And, during April, the peak month of the pandemic, more than 16 million GP appointments still took place.
So we need to be accurate and precise in how we describe the impact of treating COVID patients on broader NHS services.
Running down the NHS by implying that it stopped providing normal services is unhelpful.
Pushing inflated scare stories about how big care backlogs might grow is unhelpful.
And giving patients the impression that the NHS has to shut up shop for ordinary treatment when COVID strikes is particularly unhelpful and could, ultimately, cost lives.
The present
That brings me to the present task.
Many of the same people who have described the NHS as providing a COVID-only service now seem to be implying that the NHS is dragging its feet in restoring service volumes to their pre-COVID levels.
That, again, is simply not true.
NHS staff are going as fast as they can. Approaching the task of recovering service volumes with the same commitment, ingenuity and pace they brought to the first phase of COVID.
Creating COVID free diagnostic hubs with portable MRI and CT scanners on industrial estates.
Standing up remote care models using digital technology across a wide range of mental health and community services.
Designing and implementing a new 111 first urgent and emergency care pathway to keep patients safe and reduce overcrowding in emergency departments.
And it’s working. Really well.
The problems is that the data lags.
The monthly NHS performance statistics data in these areas is well over a month old.
As those of you with access to the real time data know, thanks to the amazing work of our frontline staff, the NHS is actually recovering services incredibly quickly.
When we see September’s data on 12 November, the NHS will be reporting yet another significant leap in performance. At a national level we will have delivered the stretching targets that were set for that month.
But some people just don’t want to hear that, or report it, because it doesn’t suit the argument they want to make.
So what of the winter task ahead?
That task is significant.
In a worst case scenario, we face a perfect storm of a full second COVID surge alongside normal winter pressures at the same time as going full pelt to recover services and process care backlogs.
At a time when, on the other side of the coin, staff are really tired and in danger of burning out as our new survey, released today, shows.
And some trusts are losing up to 30% of capacity due to the need to keep patients safe by separating COVID and non COVID patients.
But we also need to recognise that the NHS is, in many ways, in a much stronger position than we were in the first phase of COVID.
We understand this virus, and how it works, much better.
NHS clinical teams have developed rapid learning on risks such as blood clotting, wider organ damage and mechanical ventilation.
Treatments are more focussed and outcomes have dramatically improved. Your chance of surviving if you have COVID and are hospitalised has now risen across Europe from around 65% to above 80%.
We’ve got tried and tested escalation plans and reserve capacity like the Nightingales in place.
We’re not heading suddenly into an uncontrolled peak with little or no idea of what the infection rate is or where the hotspots are, as we were in the first phase.
We’re in a much better place to carry on with normal patient care at the same time.
I don’t want to minimise the risks if we do hit that perfect storm but the obvious question is what do trusts need to navigate the choppy waters ahead?
There are six things.
First, a robust and effective testing regime. We set out in a new long read last week the 12 tests NHS Test and Trace will need to pass to deliver the service required this winter.
Second, security of supply and distribution on personal protection equipment. We welcome the new PPE strategy announced last week which shows how much good work has been done in this area over the last few months.
Third, flexibility and extra support, if needed, on finances. NHS England and Improvement know there are significant gaps in second half finances in some trusts, particularly for those with large amounts of non NHS income. And we need government to cover all the extra costs resulting from any unexpectedly large second COVID surges.
Fourth, we need realism on what can be achieved if we do hit that perfect storm. Trusts will have to juggle a range of different priorities and do all they can to avoid delaying care. But we must not place an impossible burden on our staff.
Fifth, trusts need to be left to get on with it, as much as possible, in collaboration with each other and system partners. Continuing that sense of local empowerment from the first phase.
Sixth, government, local politicians and the public must be willing to adopt appropriately tough local lockdown measures wherever the virus is spreading in a way that could jeopardise the NHS’ ability to cope with demand over its most busy period.
No-one can predict exactly what will happen this winter. Whether it will be a perfect storm, a severe gale or a heavy wind.
We do know, though, that trusts and their frontline staff will do all they can to provide high quality care to all who need it.
The future
So what about the future? I want to talk about two issues. The forthcoming comprehensive spending review and the proposed new NHS Bill.
The comprehensive spending review
It’s important to remember the financial context before we hit COVID-19.
The NHS had been through a near decade of the longest and deepest financial squeeze in its history.
Between 2010 and 2018, NHS funding grew by an average 1.5% a year in real terms compared to the long term average since 1948 of 3.7% a year.
That meant the NHS was unable to grow its capacity to match the rapidly growing demand it was experiencing.
If funding between 2010 and 2018 had grown in line with the long term average since 1948, the NHS would have had an extra £25bn to spend in 2018.
Think what a difference that could have made.
The impact from the loss of that funding has been all too predictable.
Growing demand for treatment has consistently outstripped capacity.
Despite the best efforts of frontline staff treating more patients than ever before, many patients have not received the care they need and that NHS staff wanted to provide.
The government response was to commit to a welcome, five year, average 3.4%, real terms annual increase in the core NHS England budget until 2023/24.
Compared to what had gone before, and to other public services, that was a generous settlement.
But we all argued at the time that it barely kept up with demand. It didn’t allow the NHS to recover performance. And it certainly didn’t pay for the transformation that was needed.
So although some tried to present that settlement as a bonanza it was, in reality, just a return to long term trend NHS funding growth. Well, actually, 0.3% short of that.
And it left two important gaps.
No long term capital settlement despite a rapidly growing bill for backlog maintenance and a crumbling NHS estate.
And no long term settlement for education and training and public health budgets despite a strategic commitment to tackle the NHS’ workforce shortages and improve the focus on prevention.
Since that announcement in June 2018, two important things have changed.
The government was elected in December 2019 with a series of major new NHS manifesto commitments. Expanding the nursing workforce to create 50,000 new nurses. And a new NHS building programme.
I always disliked the description of 40 hospitals, because the NHS isn’t just about acute hospitals, important though they are. And the near absence of mental health schemes in this weekend’s announcement shows there is now a real problem that must be addressed quickly.
The second change is that we now have the extra costs of COVID-19. It’s a long list. The need to recover care backlogs. Rapidly growing mental health demand. COVID rehabilitation. PPE and Test and Trace. And, on top of that, one, possibly two, years of lost cost improvement programme savings that were a fundamental part of making the NHS books balance.
This is why NHS funding has now become so crucial.
It is impossible to see how the NHS can deliver the Long Term Plan, meet the manifesto commitments and cover the costs of COVID-19 on the current NHS funding settlement.
All three elements of NHS funding – the capital budget; the non ringfenced wider departmental budget that includes NHS education and training spending; and the core NHS England revenue budget; all need revisiting.
I recognise the pressures on public expenditure. But we have to avoid what the Prime Minister calls his “have our cake and it” approach and pretend the NHS can cope with all these pressures on its current budget. It can’t.
And all of this, of course, is before we turn to the most pressing problem of all – reform of our social care system.
COVID-19 has clearly shown the unacceptable cost of neglecting our social care system and leaving it in an unsustainable state.
The government has recently said it cannot commit to a social care plan before the end of the year because it will require a huge amount of political collaboration that will take longer than the next few months.
But that’s the whole point. We elect our politicians to tackle the difficult issues. For two decades they have failed us deeply, consistently and unacceptably by promising to sort the crisis in social care and then failing to do so.
I don’t want to sound too alarmist. But I do want to explicitly link the state of crisis our social care system has now reached with where the NHS now is.
All of us who work in the NHS are passionately committed to the fundamental principle that lies at its heart –care provided to all who require it, free at the point of use, based on clinical need not ability to pay.
Our taxpayer funded model is rightly the envy of the world. For the equity it brings. For that sense of collective endeavour. For that moral purpose. All of which motivate our frontline staff to do extraordinary things. The model that had millions of people clapping every week.
But the success of that model depends on a fundamental contract between the NHS and those who pay for it. That our citizens will receive the right quality of care in return for the funding they provide.
That requires a sustainable and stable system that can provide the right quality of care every day of every month of every year.
Yet before COVID-19 arrived, the NHS was in danger of heading for the slippery slope of unsustainability down which social care has tumbled with ever increasing speed.
NHS demand, like social care demand, outstripping capacity, with access to care becoming more constrained and pressures on quality of care steadily growing.
NHS staff, like social care staff, being asked to do more and more to cover that growing demand / capacity gap.
NHS finances, like social care finances, failing to keep up with growing demand.
And COVID-19 has now increased those pressures.
Having driven social care into crisis by failing to fund it properly and sustainably, we must avoid driving the NHS into a similar fate. And we must rescue social care from its current state of crisis.
That is why the government has to get the comprehensive spending review right.
The future of system working
The last nine months have reinforced the need to move rapidly to greater and more consistent system working. In our recent survey, 92% of you told us the COVID pandemic has greatly accelerated collaboration.
NHS England and Improvement are currently working on the next phase of policy development here. And the government is working on an NHS Bill looking at what legislative change might be needed to speed up system working.
I have some worries.
Thinking that it’s structural change that drives greater collaboration. When it’s actually on the ground leadership and organisational culture that matter most.
Spending too much time discussing structural and legislative change, just when we need to be recovering care backlogs, tackling COVID-19 and supporting our staff.
I also worry that national leaders take a top down view of these things. A focus on top down performance management, money flows and accountability.
So I want to take a bottom up view. What’s needed to deliver high quality patient care at the frontline.
I’d then like to propose six key principles to guide us.
Eight years after joining the NHS, I remain struck by the complexity, difficulty and importance of the work that NHS trusts do.
The range and complexity of services provided.
The number of staff, professions and care delivery locations involved.
The large amount of money involved, with some trust budgets well over £1bn a year.
The huge level of clinical and financial risk managed on a day-to-day basis.
Working within a complex legislative and regulatory framework.
All, rightly, under intense public scrutiny from a range of stakeholders with strong views about how a key local public service should be delivered.
And where a trust is often one of the largest employers and key drivers of the local economy.
It is precisely because of this size, complexity and risk that we need robust governance, leadership, accountability and assurance sitting close to where this activity takes place.
We thought long and hard about this and decided some time ago, rightly in my view, that the unitary trust board is the right approach.
Nobody, particularly after Mid Staffs and Liverpool Community, would pretend this approach is perfect.
But, by and large, it works well.
And it does allow flexibility. For trusts to come together in mergers, alliances and group models. To work in collaboratives. To create different models with primary care and social care to integrate services.
I know some will see this as being wedded to an old vision of big, burly, ultra competitive, foundation trusts worrying about nothing other than their own success.
That was always a caricature.
We all now recognise that collaboration, not competition, is the order of the day.
That improving the health of the whole population that trusts serve and reducing health inequalities require all parts of a local health care and system to work together.
That no trust can be an island.
That we must now rapidly move to greater system working, no if’s, no but’s.
So can we please stop pretending that pointing to the importance of the unitary trust board in overseeing the complexity of frontline secondary care delivery is harking back to a bygone era where Foundation Trust status is all that counts.
It isn’t.
The argument is that the unitary trust board, underpinned by law, is the right governance mechanism, at the right level, on the right footprint and population size, to oversee the delivery of complex, high risk, front line care.
And that we cut across, or cloud, that clarity of governance, accountability and assurance at our peril. For example, by turning systems into an all powerful quasi strategic health authority tier, as some have argued for.
And that anyone who wants to change such a fundamental sheet anchor in our health and care system needs to demonstrate that what will replace unitary trust boards will work effectively.
The task for me is to how to marry up three things.
Moving rapidly to more effective and consistent system working.
Ensuring we have the right structure from a top down perspective - the right money flow, regulation and oversight.
But also guaranteeing, from a bottom up perspective, robust and effective governance, accountability and assurance over hugely complex frontline care delivery.
The last of those is the dog that hasn’t really barked in the debate we’ve had on these issues so far.
That’s why I’d like to offer six principles that should guide us in the debate on future system working. They’re not a final proposed solution. But they do offer clear criteria against which to judge emerging solutions.
First, the power to command and decide needs to be vested as close to possible to the issue that needs to be decided. And accountability for decisions needs to lie in the same place.
Whilst those at the top of the NHS may want to reserve powers for themselves, robust and effective NHS structures need to be built from the bottom up not top down. In a word, subsidiarity.
Second, good governance of public services requires effective challenge, openness and transparency.
Executives running public services need appropriate challenge from non executives representing the citizens that pay for the service and to whom it is provided. Decisions need to be open to clear public scrutiny.
Third, we need complete alignment between strategic intent, statutory base and how we run our health and care system day to day.
We could ask sustainability and transformation partnerships (STPs) and integrated care systems (ICSs) to be voluntary strategic planning forums, in which case they need no formal statutory underpinning.
Or we could ask them to exercise formal accountabilities. In which case those accountabilities must be clearly defined, underpinned in law, and they must not overlap with the accountabilities exercised by other organisations within a system footprint such as trusts and clinical commissioning groups (CCGs).
We need to avoid asking STPs and ICSs to exercise formal accountabilities like allocate capital, receive revenue incentive payments or hold trusts and CCGs to account for their financial performance if they don’t have the legal power or infrastructure to do so.
Fourth, health and care services are delivered on a range of different geographic footprints of varying population size.
Many integrated services are best created at neighbourhood and place levels, far below STP or ICS level, where those services can be truly shaped to meet local need.
Equally, ambulance and many mental health services can only work effectively and efficiently on a footprint much larger than individual STPs and ICSs. And the same applies to many specialised hospital services.
Many patient flows and provider collaborations work across, not within, STP and ICS boundaries.
We must not artificially shoehorn all service delivery into a single system level footprint. We must be rigorous about what is best done, and should only be done, at system level.
Fifth, the opportunity presented by systems is to bring all the different elements of a local health and care system together.
To integrate health and care, better manage whole population health not just treat illness, and reduce health inequalities.
System working has to enable all relevant organisations to these missions to equally participate in local systems.
In some STPs and ICSs we have been in danger of creating structures which are just about how we run the NHS. System leaders, CCGs and trusts talking to each other about NHS issues.
In a way that excludes, marginalises, or just plain bores, key partners we need to include, missing the opportunity here.
Sixth, we need to ensure maximum efficiency and best use of resources.
For example, avoiding going from a structure with two layers – Monitor and TDA and trusts, to one with four – NHS England and Improvement; NHS England and Improvement regions; systems in the form of STPs and ICSs; and local trusts. Do we really need four finance and workforce teams where previously there were two?
We can find the right answer here.
But we need to meet all three objectives – a rapid move to more consistent system working; the right top down accountability, regulation and oversight; and the right bottom up leadership, assurance and governance of front line care delivery.
NHS Providers
Before I finish, a few words about NHS Providers.
It’s been an extraordinary nine months for us too.
We realised, very quickly, there was a large and potentially dangerous communications gap emerging.
A clear need for an authoritative, evidence based, voice to calmly explain how you were tackling the biggest health challenge for a generation.
Acknowledging the problems you faced but keeping them in appropriate proportion.
We’re pleased that, judging by feedback from stakeholders, the media and, most importantly, from you, our members, that we filled that gap successfully.
But, and this is the whole point of an effective membership organisation, we couldn’t have done it without you. It was your information, your evidence, your data that enabled us to play that important role.
The posts on our real time WhatsApp groups; the responses to our surveys; the rapid replies to requests for data. They were all essential.
And it was your membership subscriptions, which provide more than 80% of our income, that gave us the independence and freedom to speak truth to power. To point out where the government was getting it wrong and where you needed more support. Whilst also recognising that we are, and always be, part of one NHS team.
I’d like to take this opportunity to thank our staff team who have performed their own brand of heroics over the last nine months.
Both individually and collectively they’ve consistently gone way beyond the call of duty.
10,000 individual pieces of media coverage.
400,000 individual page views on our website, with traffic at twice the levels of the same period last year.
40 different briefings and major reports.
12 select committee submissions, three oral evidence sessions and 17 parliamentary briefings.
All done from home.
It’s been a huge effort.
And we look to the future with real excitement and enthusiasm.
Because, just as your world is changing as we move to system working, our world is changing too.
A new focus needed on how providers can help bring health and care together at neighbourhood, place and system levels.
New thinking needed on how providers can lead the moves to whole population health, reducing health inequalities and a greater focus on prevention.
New relationships needed with colleagues in primary care, social care, local government and the voluntary and independent sectors.
Whilst continuing with the core work representing the provider sector, that you tell us we do so well.
Watch this space as we consult with you on our plans to develop NHS Providers in these directions over the next few months.
Final thoughts
Let me finish by saying that I think our health and care system has been through the most astonishing nine months in its history.
Our staff have done some incredible things.
The NHS has met the biggest challenge it has faced since its inception head on.
There are some things we would now do differently.
But I think we are entitled to a degree of satisfaction at what’s been accomplished so far.
Whilst recognising there are clearly more trials and, possibly, the most difficult days ahead.
Enjoy the rest of the conference and thanks, again, for joining us.