Michael Dixon’s Conference Speech
|November 19, 2012||Filled under Conference||
Welcome, friends and comrades, to this fifteenth NHS Alliance Conference. The conference of primary care for primary care by primary care. I am so pleased to see you all here! Today, your strong values, progressive ideas and supportive relationships are more important to the NHS than ever. Never more evident and uplifting than here, at this conference.
Today our fifteen year struggle to establish clinical commissioning is over. It is now a reality. Does that mean “mission accomplished”? A chance that we might return home to our neglected families and friends? Perhaps not yet. The lessons of the past, the imperatives of the present and the challenges of the future suggest that the battle may be far from won.
Lessons of the Past
First, the lessons. Perhaps my worst moment during the past fifteen years was a phone call late one evening in 2000 – on the eve of publishing our document “Implementing the Vision”. The Minister wanted his foreword removed from every copy. Why? Because we were the very first to suggest, in a discussion document would you believe, that the Government should consider creating an arms length body to which it would specify its requirements and then agree the necessary funding. Thus, to match expectation of the NHS with available resources. Twelve years later, last month to be precise, that arms-length body of Government – the National Commissioning Board – went live.
Last week, it received the new Secretary of State’s excellent liberating Mandate. Today’s heresy is tomorrow’s orthodoxy. Lesson one:- It can take twelve years to happen!
Lesson two came with the publication of our later documents “Engaging GPs”, “Engaging Nurses” and “Engaging Allied and other Primary Care Professionals”. No Ministers, no senior managers, no one “important” attended the launch of these pieces of work. We were told they were unhelpful. They raised issues that did not exist. Issues that did not need to be discussed. It was an attitude “at the top” so well expressed by Thomas Hardy (and how could I fail to quote him speaking in Dorset today) in his poem “In Tenebris”. “All’s well with us: ruers have nought to rue! And what the potent say so oft, can it fail to be somewhat true?” Of course, it can! Powerful vested interests rarely speak the truth. The main reason for the failure of NHS reforms to date has been the effective exclusion of primary care clinicians and patients from NHS policy and its implementation. Those at the very heart of NHS delivery that the Alliance has always championed and always will.
The third lesson of the past is that a passionate, determined and visionary force can eventually win the argument. That passionate, determined and visionary force of the last fifteen years is, of course, represented by so many of you here today.
The Imperatives of the Present
So to the imperatives of the present. The first is that clinical commissioning should succeed. That it should deliver better health and services for our patients. That will require great leading clinicians, great managers and great providers working with them.
So what of those harbingers of doom, who told us that we would be unable to find those leaders? That they would not want to lead. That they would not be up to leading. How wrong were they?
211 heroic men and women and very many others are now ready to lead and meet the challenges ahead. NHS heroes in every sense. Those leaders will need the wisdom of Solomon, the courage of Nelson, the determination of Mandela and the humility of Ghandi. That is because the lessons of the past tell us that a centralist, secondary care dominated system run by a managerial hierarchy will not relinquish its grip without a fight.
Those Clinical Commissioning Groups and their leaders will also need strong champions to give them headroom. That is why the commissioning arms of NHS Alliance, NAPC and NHS Confederation have come together as “NHS Clinical Commissioners”. With most Clinical Commissioning Groups being now full members, we can provide a strong unified voice for them.
It is a great pleasure therefore to welcome my fellow leaders of NHS Clinical Commissioners and partners in crime – Charles Alessi and Mike Farrar – who are here today.
From now on, anyone who wants to mess around with CCGs or their leaders will find themselves looking down the wrong end of the gun. A gun, this time, with three barrels.
Because this time, we will ensure that the ideals, that you fought for, actually happen. This time, there will be no replay of the broken promises of the past.
I hope and believe the NHS Commissioning Board will play an important part in this – perhaps as thanks for our role in its creation! It must become the “Grand Protector” of clinical commissioning and Clinical Commissioning Groups. Just as, in the early days of Locality Commissioning Groups, the Chief Executive of my local Health Authority told us that she was there to cover our backs and support our difficult decisions.
The current language of the Board is exactly right with phrases such as “assumed liberty” of CCGs. Those words must now translate into action. That is why last week NHS Clinical Commissioners announced that we will be undertaking 360 degree appraisal of the National Commissioning Board.
Each year, we will collect appraisals from each Clinical Commissioning Group of the National Commissioning Board and local office. From these appraisals, we will produce a national report, which we will share with the National Commissioning Board and then we will publish the results with proposals as to how things might be improved. That is because there can be no “same old” in the relationship between the centre and the new clinical commissioners. No reversion in type from “Grand Protector” to “Grand Inquisitor”.
What applies to relationships between CCGs and the Commissioning Board applies equally to everyCCGin its relationship with frontline practices and clinicians.
That was the other missing link of the past. Clinical commissioners, as the second imperative, must now work as hard as possible to ensure their frontline clinicians are motivated, effective and (dare I say it) happy in their new commissioning role.
Those GPs, nurses and other clinicians have legitimate concerns. Some feel that they have got too much on their hands already. Some think they will be blamed if resources and services are less than expected. Some fear that their relationship with patients will be compromised. Others suspect this is the beginning of widespread NHS privatisation. We must answer these fears. Explain and show how every clinician now has a real chance to make a real difference for every patient.
It was George Bernard Shaw, who said over a hundred years ago:- “Until the medical profession becomes a body trained and paid by the country to keep the country in health it will remain what it is at present: a conspiracy to exploit popular credibility and human suffering”. Clinical commissioning marks the end of that conspiracy, if there was one. A promise that clinicians will, henceforth, be able and committed to “keep the country in health”.
The third imperative is to ensure that patients and clinicians make as fearsome partnerships as commissioners as they do in the consulting room.
Partnerships that will enable local people and clinicians, in Clinical Commissioning Groups and Health & Wellbeing Boards, to shake the floor beneath the trembling feet of any centralist left standing! Because in future, patients and local people must be more than critical friends and co-planners, they must also become an intrinsic part of our system for creating better health and care.
So to the future. The first task of Clinical Commissioning Groups and their clinicians will be to redesign local services and health. To enable the frail elderly and those with long term disease to be looked after within their communities. To enable redesign that has so persistently failed to materialise under the old order.
To do this, clinical commissioners must become demolition experts. Removing the mines, the obstacles and the red tape that prevent them securing better services and outcomes. Enabling good providers to provide even better care and going elsewhere only when they can’t. We are already beginning to see this transformation – witnessed in our document, “Clinical Commissioning in Action”, published earlier this year.
Yet, however much we redesign our services, however cost effective we make them, we will eventually hit the buffers of unaffordable cost, deteriorating quality or reduced availability. That means we will need to think ever bigger, wider and more ambitious.
I will explain. In theUSA, life expectancy of the poor white population is already going down and, as always, we are set to follow them.
The NHS is not going to stop that with a few more smoking and obesity clinics here and there. By more tablets and operations. The National Health Service needs to become a National Health System with clinical commissioners, Health & Wellbeing Boards and those at the heart of delivery being catalysts of health on every street corner, in every supermarket, in every inner city, estate and rural village.
Public health will need to get its hands dirty. Every patient and clinician will need to play his or her part in improving personal health. Ensuring that resources are used to best effect. Maximising wellbeing and resilience. Breaking new boundaries.
Involving new legions of health trainers, health advisors, community workers and volunteers. Supporting local initiatives from fishing clubs inNewcastleto dementia friendly towns like Crawley. Initiatives that have all too often been ignored in favour of short term targets and cash strapped services.
Even that will not be enough. Patients will still remain over medicalised, over professionalised and over hospitalised. Then we need to ask ourselves: “Do we really want a fair and equitable health system?” If we do then we will need to re-engineer a totally new relationship between the NHS and the people it serves. A relationship that reflects and exploits that rich seam of goodwill and giving that lies behind the very idea of an NHS.
That will mean reigniting the altruism that lies beneath the skin of every clinician, however scarred by life’s events. Reinvigorating the professional ethic that wants to make a difference. Releasing that pent up altruism that is so endemic in the population at large. So visible among the Olympic volunteers. So visible every day in my own surgery – from the next door neighbour that brings in the elderly patient to the patient that encourages a sicker patient to go before him or her.
The NHS must become more than just a service – a consumer service. From now on, it must also be a partnership – a National Health Partnership.
Only if we can do that can we maximise the co-production between clinician, patient and population and de-professionalise and de-medicalise wherever possible and appropriate. Can we release a spirit so common in our churches, our schools, on our lifeboats and in our fire service. Not common enough, when it comes to health. Only if we can develop this new social contract between patients, people and professionals, managers and the service, can we begin to reach the holy grail of “Health Creating Communities”. And thus maintain the vision of a service that is free at the point of delivery.
That will mean re-writing the NHS constitution. A better and more honest balance between rights and social responsibilities. Otherwise the harridans and harpies of “me first”, “don’t care” and “it doesn’t matter because it is all free” will destroy the spirit and the reality of our NHS.
The Future of NHS Alliance
That is the debate we must start at this conference. What will primary care and the future NHS look like? Next March, we will gather together all the words and aspirations of this conference and the conversations that follow from it to produce a piece of work, in partnership with the Nuffield Trust and King’s Fund, that will lead the future. A manifesto for that future.
Standing on the brink of this brave new world has helped us, at NHS Alliance, to clarify our own vision for the future.
I have been proud to have been chosen to lead the NHS Alliance for the past fifteen years but what of the next fifteen? Put simply, you could say we have dealt with commissioning .It is now time to look at provision. Because excellent commissioning relies on excellent provision. These ambitious reforms will only deliver if we can successfully harness the enthusiasm and commitment of frontline clinicians and managers and the wider providers of services within primary care. In future, as NHS Alliance, we want to represent the people and the organisations, whose services commissioners will be proud to commission .
In our new role, NHS Alliance will continue with the same values, the same determination and the same passion. “A force to be reckoned with” as described by at least three previous Secretaries of State. Championing innovation and patient involvement. An NHS that is fair (as we said in our very first manifesto) to patients and fair to those who care for them. Promoting integrated primary care, tackling inequalities and emancipating our members. So much so that every member, whether individual, practice or primary care provider, will be free to decide what membership fee to pay depending upon what a member thinks we are worth. Symbolic of the new culture and behaviour in the NHS that we mean to create – illustrated in the new NHS Alliance badge with its partnership logo. Details of all of this are in your conference bags.
So today, whether you are an individual manager or clinician. Provider or commissioner. You carry a very heavy burden. To overcome the ill health, the unhappiness and all the other negative effects that our current system creates. The deprivation, abandonment, bullying and abuse. The stark architecture, chemical substances and moral pollution. The violent video games, trash food, existential disconnect and near-zero attachment. The feral over-class greed, mindless TV, loss of hope, control and attachment. The isolation and the exclusion.
As a National Health Service we must now go beyond being simply a repository for the downstream consequences of all of these. Just patching people up. As a National Health Partnership we can begin to do something about them!
To do that, we will need to renew our passion and determination. Create an NHS, turned National Health Partnership that will restore a sense of human worth. Then a sense of meaning and hope. A health system that “cares” rather than simply “does”. That makes healthy supportive communities out of alienated and fragmented ones. That spreads the word that giving is better for your own health and for everyone else.
These things will not happen as a result of central edict or regulation. They must bubble up and explode as our own message of exasperation and liberation. Part of a new unstoppable relationship between clinicians, managers and local people.
All committed to the health of their communities. A health revolution that will never see the voice of patient or frontline clinician ever ignored again.
We will not achieve this by the banging of little fists. In the words of T S Eliot, we must leave behind “The conscious impotence of rage”. Also in his words, we must have the strength to face the moment to its crisis”. I am not a poet but even I know that “We must or we’re bust”.
In the same poem, Eliot finally challenges us to ask “Do I care? And do I dare?” That is the question facing each and every one of us now. We must overcome the apathy and fear among our fellow clinicians. Together, we must seize power against the broken promises, the silly orders, the cant and the cynicism of the past. We must regroup and become unstoppable, progressive and terrifyingly positive. A force for real reform that makes a difference – not just “re-disorganisation”. A force that will reignite that rage, which enables radical things to happen. The force we created, when we fought and won the argument for clinical commissioning.
That is the revolution the NHS now needs. That every patient needs. A revolution that will fully enable clinical commissioners to re-design their local services. A revolution that will re-energise local health and create healthy communities. A revolution that will re-engineer an entirely new relationship between our people and patients, our managers and our clinicians.
We must do all these three things together. We must do them now. We can and we will. Then and only then. Perhaps, at long last. We can go home!