30 April 2007
The debate over the service had now moved on from one about its very survival as a tax-funded universal healthcare care, the PM told an audience of health experts and professionals at the King’s Fund in London.
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Niall Dickson, Chief Executive Kings Fund:
Well a very good morning and welcome to the King’s Fund. We are delighted this morning to welcome the Prime Minister, the Secretary of State, the Chairman of the British Medical Association, the Chief Executive of the Long Term Conditions Alliance, the Policy Director of the NHS Confederation as well as many other leaders and leading lights in our Healthcare system.
Now after you have heard from me I am going to ask each of the four representatives to give their perspectives before the Prime Minister responds, and then I will open it up to you for questions and comments. There will be a separate briefing for the media immediately afterwards.
On the last 10 years of the Health Service under New Labour,10 years of significant change which will be remembered for the unprecedented levels of funding which will leave health spending in this country at or around the average for the EU. If that is maintained over the next few years then I guess the excuse which we used to have that the problem with our healthcare system was that it was under funded will no longer apply. I guess everyone in this room will have their own perspective on the government’s record. For many in this room it is based on direct experience and expertise.
Our assessment here at the Fund is that there have been significant improvements in key areas, but there have also been missed opportunities and more important there are serious challenges and really quite difficult decisions ahead.
We can probably all, I think, agree that since 1997 the twin objectives for reform in England have been to increase the responsiveness of the health service to patients and to improve efficiency. To achieve this the government has used a variety of levers and incentives, lubricated with that additional investment. Some of these levers have been top down and centrally imposed including targets and regulation against national standards. Others have attempted to foster efficiency through incentivised payments. Others still have sought to energise local innovation through devolved management, and latterly we have seen the introduction of market forces and patient choice.
In pursuing these approaches this administration has not been so different from other governments across the developed world, each of whom has faced similar challenges, so just before we embark on our discussion let us remind ourselves of a few facts to set it in context.
The NHS has enjoyed real terms average increase annually of 6.4% in real terms since 1997, that compares with 3.4% as the historic figure between 1949 and 2000. In spite of that a minority of NHS Trusts have found themselves in serious financial difficulty, and others have struggled to manage within the resources that they have been given. The underlying financial weaknesses within the system are now being addressed, but I believe that it is also acknowledged within the system that this could and should have been tackled earlier. Hindsight, even for us I have to say, is a wonderful thing.
The drive is now on to reduce reliance on hospital-based care where the evidence suggests it can be better done either in specialist centres or in the community and to reduce unnecessary admissions by better management of long term conditions. Again though some would argue that the impetus has come late in the day, as have attempts finally to make commissioning fulfil its potential.
Significant progress has been made to make the system more accessible. The long waits for elective treatment in the past have gone, a real achievement. The target to reduce to 18 weeks the time from referral to treatment from 2008 may well be achieved although it is ambitious and it will be a considerable challenge to NHS organisations.
They promised more clinical staff and they have delivered more clinical staff. 25% more nurses, 53% more consultants, and 20% more GPs. But there are still questions to be answered about the level of productivity gains and benefits for patients from both additional staffing and the above inflation salary rises.
There has been big investment in building and renewing the NHS estate. 84 new hospitals in operation, 25 under construction, but again serious questions remain over the way the capital programme has been paid for, in particular the long term cost of some of the larger PFI projects, and whether some of these facilities can be adapted to changing patient care.
You can sometimes measure success by sustainability. If you have a change of government, does this reform stay in place? Well the National Institute for Clinical Excellence and the Health Care Commission, or something like them, will survive. We do now have a more coherent approach to setting standards and assessing quality and safety. National Service frameworks too have helped to drive up standards. At the same time we are still some way from measuring what this service does and in using clinical outcomes to drive the system.
How good is the Service? Well in the latest assessments for the Health Care Commission overall 4% of NHS Trusts got the highest rating of excellence for a quality of service, 36% were rated good, 51% were rated fair and 9% were rated weak.
The system has certainly struggled with hospital acquired infection. The number of deaths may be low but the impression has been of a service that has responded slowly and in spite of recent falls in cases of MRSA there remains concern at the continuing rise of Clostridium Difficile.
Mixed results too on public health where much was promised. Falls certainly in deaths from heart disease and cancer but rising obesity and stark inequalities in health status between different groups remain.
Patients with recent experience of the NHS continue to value it highly and they tend to be much more positive it has to be said than the public as a whole. Staff in the NHS are not necessarily unhappy in their work but the failure to engage them and to take them along this reform journey remains one of the greatest worries and the greatest challenges for the future.
And today I must say we do not cover social care, the oft forgotten sister of health care. It has fared less well than the NHS and now has to concentrate help on those in dire need.
There are perhaps two ways of looking at the last 10 years either as a series of sort of disconnected changes sometimes pulling in different directions and at other times indeed coming full circle. Regions were abolished and have now been reinvented, the internal market and fund-holding scrapped, now we have the market and practice-based commissioning and so on. But there is another way which is to see some continuity and a set of changes designed to reform a provider dominated public service and which is going on in other countries and will have to continue here. The scope of reform has been ambitious, the pace of change fast, significant gains have been made in priority areas although in other areas it is less hard to actually reach a conclusion and there is less hard data on what progress has been made. Although the government launched this 10-year plan in 2000, the really big money did not start flowing perhaps until 2003 and some of the reforms are still, it has to be said, at an early stage of implementation.
So there is a brief overview. I am delighted now to welcome the first of 4 perspectives before we give the Prime Minister the opportunity to respond. So can I ask you to welcome Nigel Edwards of the NHS Confederation.
Nigel Edwards, Policy Director NHS Confederation:
Thank you. That was such a comprehensive review, I am not entirely sure what there is to add but I shall try.
When I joined the Confederation in 1999, I spent most of my first year on the Today programme talking to the broadcast media about the crisis in the NHS. The world feels completely different today and the NHS does certainly feel a great deal better and although there are very big issues that are still in the media, many of those are, while serious, much less life-threatening for the NHS than they were in 1997 to 2000.
The argument about whether the NHS should be tax funded or whether we should be having social insurance or insurance top-ups has to some extent I think been dealt with. I dare say it will be back, but at the moment there is now a consensus on that. I had a list of policy innovations that we like and I think it is also worth saying that while there has been very widespread concern about targets they have had on a number of occasions really quite unfortunate and unintended effects. In a few key areas, particularly around waiting, they have been noticeably successful, but clearly not sufficient in terms of how to get the system to change.
The criticism that the NHS has not delivered the productivity improvements it should have I think maybe reflects that we were perhaps not as honest as we should have been about exactly how bad the state of the NHS was just before the new money arrived, and what the effects of the under-investment that David Wanless identified as I remember £230 billion over 30 years was the cumulative effect of that under-investment. So a lot of work needed to repair the infrastructure and perhaps that wasn’t fully acknowledged, and maybe the money came a bit fast. A bit earlier and over a bit of a longer period perhaps in retrospect, which is a wonderful thing, perhaps would have been helpful. But nevertheless the NHS now is in a much better position than we could have hoped for in 1997 or even 2000 and in England at least we have a policy which is now much more convergent with the rest of the developed world in particular moving away from the very peculiar position that the UK has of having such direct state control and ownership of its hospitals and other health care providers which we have been somewhat off the graph with.
Perhaps one lesson that we learn is of course that no good deed remains unpunished in this world and even a positive story recently for example that 95% of Trusts have improved their mortality rates was reported as an unacceptable postcode lottery, and while the patients are happy, the public are much less so and our staff even less.
So rather than get into a retrospective …[inaudible] too much I would just like to think about what some of the lessons are. The first is I think a better narrative about what the reform is about. Whatever you are doing, whether it is top down or whether it is market, the staff needs a better story and to some extent that is not just the government’s responsibility, obviously it is the responsibility of local leaders.
The disruption caused by frequent reorganisation is easily underestimated, and particularly if you start the reorganisation before you have finished the last one. And again the NHS itself is very keen on reorganisation, it shows something of an addiction to it. It is to some extent easier than actually talking to doctors about changing care, but perhaps not as productive. So policies need time to be implemented and to bed in before we decide that they have failed. They also need probably better planning and costing and there is some work that we need to take from what we have learned. The big issue of course is that even a small error in a national system becomes a very big deal. So there is perhaps even more of an onus on us to get it right and the interactions in very big systems are very difficult to spot and understand. But the system has got a habit of relying on hierarchy and there is a danger that de-centralisation simply means that, as we have seen a bit in Wales, that the next level down the system says now we have got the power, there is no more devolution, it sticks there. So the front line feels very little difference. And I think this is a problem because the centralised chain of command is not just inappropriate for a complex organisation or series of organisations like the NHS, it has a debilitating effect on the governance and initiative of local organisations. And there has been a bit of a tension in the department about whether or not we are using a new system or whether we are we are trying to resort to the old mechanisms.
So the reforms have got us to a point where we have improved the NHS but in doing that I think we have revealed some rather interesting cultural issues that need to be dealt with.
In the story the Life of Pi there is a sequence in which the cages of the animals are left open and none of them leave. I would just ask you to hold that metaphor in your minds for a minute. The animals bit is perhaps the least important bit here. But the point is saying that you are devolving is not enough, we need to find a way because many of the problems that we now face around getting a clearer sense of local direction, being much more focused on the needs of patients, thinking about the detail of care delivery, systematising care, and making services more integrated which is a key issue and one in which I fear that in some ways we are going in the wrong direction, that is going to require really high quality local leadership, and in particular clinical leadership. Now the department can help by talking about outcomes, patient experience, safety, creating higher reliability, quality directed services but the rest of those require local leadership and if there is a lesson over the last 10 years it is that we need to create that space to allow that to happen and in particular to hold back the zoo keepers who might be tempted to rush to help.
Thank you.
Peter Carter, General Secretary Royal College of Nursing:
Good morning everybody. When Niall went around the table just now and introduced everyone he inadvertently, I am sure, missed me off and I sat here thinking hang on, have I walked into the wrong room here.
I was very pleased when I got the phone call last Thursday morning to have the opportunity to come and speak to this audience and looking around there are a number of people that I have worked with for many years during my NHS career. So just very briefly, for those of you that don’t know me, and many of you won’t, up until 14 weeks ago I was an NHS trust chief executive for nearly 12 years, so I like to think that what I am about to say comes from a position not so much based on the last 14 weeks in the Royal College of Nursing (RCN), but from what I was doing for 12 years and a lot longer as an NHS manager elsewhere.
Well I want to start by first of all commending the government. When the government came to power in 1997 and in the build up a lot was said about their commitment to the NHS and as is the way of these things there was some cynicism and a lot of people saying well let’s wait to see. What is undoubtedly true, the government were true to their word, they have more than doubled investment, there are more nurses, there are more doctors and there have been significant improvements. And I just want to give it from my perspective.
The performance on waiting lists and waiting times is commendable. I never thought that I would see such success in that area. Cancer, heart disease, mental health, the trust that I was responsible for was a large mental health trust in north west London and the very welcome National Service Framework for Mental Health was an initiative which began to catch up and fill gaps that in the preceding 20 years had been left. And I saw significant changes, crisis resolution, assertive outreach, early intervention. But on top of that the trust that I was responsible for were beneficiaries of literally tens of millions of pounds worth of capital. We had over 100 sites and during the past few years we have had new builds, refurbishments at a level that I never thought that I would see, and it has truly been impressive and as I say the government is to be congratulated for that.
Pay has improved, no question about this, pay has improved right across the piece. However for nurses, and that is the job that I am now responsible for, it is still a fact that the average nurse earns £24,000 and it is the lowest paid of the professional groups, and that is the sad reality, even though nurses have done well.
So what is the current situation? Well there is a sense of crisis in the NHS. The deficits issue has really been quite brutal over the past year, 18 months maybe to two years. The number of redundancies, who would have envisaged on the back of doubling investment that we would be talking about redundancies and literally the thousands of posts that have been frozen.
Last week the Royal College of Nursing received an invitation to attend a meeting this week with a University Trust in the centre of England where they have issued a consultation document setting out that a further 500 posts may have to be lost, and nearly 200 of those posts will be in nurses and midwifery grades. We see junior doctors protesting in central London, 12,000 marching. Last year 70% of newly qualified physiotherapists couldn’t get jobs.
Now I was given a brief for 5 minutes and I will stick to it, but why have we ended up in this mess? Well in 5 minutes I couldn’t possibly go there, but I want to give you one perspective and this is something I feel very clear about. In 1997 there were 100 health authorities and to different levels they agreed to different levels of maturity and overall I thought, and so did many of my colleagues, that that was working. I believe the government was given wrong and poor advice to go from 100 health authorities to 303 primary care trusts (PCTs). We saw this massive expansion in NHS bodies and there was no impact assessment. Were there sitting on the shelf a spare 200 and plus people ready and waiting to be PCT chief executives, or directors of finance, or commissioners, there simply was not the talent there. And what I and my colleagues saw, and whilst we saw many good appointments, far too often we saw people being promoted prematurely. I saw directors of finance who were third in line at health authorities becoming finance directors and they were not ready for it. I saw careers ruined. I saw one particular colleague who was in a neighbouring health authority who was extremely good but was possibly 10 years away from being a chief executive, and he was promoted, and we were astonished, and 2 years later he lost his job. And what was the net effect? First of all that massive expansion in PCTs, just the setting up and running them, sucked in hundreds of millions of pounds per annum, and then the double whammy was that so many of them were not up to it and their investment plans and their monitoring was such that they lost control. And so we have all these anecdotes of a PCT suddenly finding £9 million worth of unpaid invoices, we suddenly find plans being put forward and rushed through without people properly thinking it through. And the net effect of this is within a few short years what happened? We have gone from 303 PCTs back to 152. That on its own demonstrates that was a failed policy.
Similarly, and let’s just look at London, we had one London office, we went to 5 strategic health authorities, 4 years later we are back to one London office and in the interim period money has been wasted and planning has been neglected.
As an NHS Trust Chief Executive I am very proud to have been an NHS manager. NHS management is a highly complex job, also it is a similar job to politicians in the sense that everybody has got their favourite anecdote as to where it goes wrong and most of us, and I am looking at some of my NHS trust colleagues over there, we all go to dinner parties where you have to endure your favourite anecdote as to why the NHS is so bad, and so on and so forth. But I was very proud to be part of that community, but what is so tragic is this, my whole career in the NHS is actually 38 years, I have never ever seen so much money come into the NHS, but sadly in some areas I have never seen so much money wasted and that is an absolute tragedy, it is a tragedy for the public, a tragedy for the NHS, I personally think it is a tragedy for the government because they were true to their word.
Very briefly, the future. Well I do believe the NHS will have a long and successful future, but I do think there are some inherent flaws and one of the major flaws is the issue to do with the way Foundation Trusts are set up to compete with each other. We have to get out of this mindset that the way forward is to compete and take business and services from each other, what we have to get back into is more over-arching strategic planning where neighbouring trusts, neighbouring PCTs talk with each other about what the needs are at any given time for a local health community. Without that you will end up with this market mentality of dog eat dog, and remember where you get winners you get losers and that I believe will be unacceptable in the long run. So over-arching more strategic planning and getting into a mindset where you have to accept, and the Royal College of Nursing are very clear on this, you have in most of our major cities a configuration of hospitals that emanate from the mid-late 19th century. That has to change and within the College we are clear that that will result in major hospital closures, in centres closing down and a realignment of the way in which service provision is made. Properly planned, that can be done without job losses, without a sense of chaos, but if you have got people competing with each other planning is done in secrecy, planning is done without an over-arching overview of what is needed.
So in conclusion, and I will say it again, overall I believe the government is to be commended but to end up in a situation where particularly some of the lowest paid people are now having to endure the offer of a pay of 1.9 is sadly unacceptable and you end up with a situation, instead of 10 years on us feeling a sense of real improvement and moving forward, you now end up with various staff groups feeling highly disaffected. It was unavoidable but I still think there is a way forward in which we can avoid this.
Thank you.
Jim Johnson, Chair British Medical Association:
Good Morning Ladies and Gentlemen and to this largest gathering of the usual suspects that I have ever seen first thing on a Monday morning.
The brief is to talk about the lasting impact of the last 10 years of government and challenges for the future, and I will stick rigidly to that and try not to repeat what other people have said.
Number one, undoubtedly a much better basis of funding for the NHS. We are now on the same level, or we will be by next year, as the rest of western Europe. I don’t sense a great deal of appetite to go much above the 9 or 10% of GDP, the only country that has significantly done that is the United States of America and I don’t think that is a healthcare system that any of us would wish to emulate.
Has the NHS improved? Well undoubtedly yes and we have heard all the ways that if you could just take a snapshot of now and a snapshot of 10 years ago there is clearly a lot of improvement both in numbers of staff, waiting times and so on. I think when you are working in it it is very easy to see what is the matter at the moment and more difficult to take the long view about how things have improved.
Are we getting value for all this extra money that has gone into it? Well probably not. Economists tell us that there isn’t a healthcare system in the world which couldn’t be made more efficient and there couldn’t be a lot more patient care got out of it for the amount of money that is being put in, and certainly it doesn’t seem to an awful lot of us that the increasing investment has so far yielded everything that it might do.
One of the most difficult problems that we have to tackle, and this is on to the challenges bit, is that by the year 2050, unless there is some terrible plague or something, there will be 2 people going out and earning money and paying taxes to look after every 1 person who is entirely supported by the state. Now that means they have not just to provide the money to support them, they have actually got to support them too, there isn’t anybody else. This is an impossible situation and this will affect certainly my children when they are a year or two older than I am and it is something that I think has got to be tackled by very, very difficult decisions like you know working until you are 70 and so on. It is very difficult for a government with a 5 year term to concentrate on really difficult and unpleasant and unpopular decisions that are going to affect you 20 - 30 years down the line, but we have got to start planning for when there are 2 people working to support 1 person, totally supported by the state, much sooner than when we get to the problems.
The NHS changes of choice and …[inaudible] provision and payment by results are well bedded in but remain highly controversial. The most unpopular with healthcare workers, not least doctors, is …[inaudible] provision, and it remains so. Probably the most difficult for the service in terms of making it difficult to run is payment by results. In essence it is a very just way of encouraging productivity, but in practice it is difficult and it is difficult because the way it is done is too crude to actually work. You know if you are a private sector company repairing people’s hernias and closing at 5pm every night, by definition you can only repair the hernias on people who are fit enough to go home at 5pm, so the NHS picks up the difficult cases. That is not wrong, that is right, that is what the NHS does best. What is wrong is paying them the same amount for each case. So unless we can sort things like this out, criticism will continue.
What about the doctors? That is what I am here I suppose to talk about. Well they are better paid than they have ever been, they work shorter hours than they have ever done, as we have said the NHS is improving, so they are very happy. No, they are angry and frustrated, as are nurses and as are the rest of the workforce. The Financial Times yesterday reported that talks between the employers associations and the unions had now reached impasse and industrial action in the summer seemed much more likely.
This is nothing to do with morale, this is anger and frustration. I attended a very difficult junior doctors’ conference on Saturday which was so angry and frustrated….[inaudible] that the doctors were actually turning on themselves, they spent the entire morning on a no confidence motion, which was defeated. But it is a measure of the anger and frustration going on out there.
I don’t want to labour this point, I probably already have done, but the real point I am trying to make is that if you are one of the guys trying to run the NHS it must be sub-optimal to have your entire workforce against the policies, and if we are looking at how to go forward that must be the absolutely number one issue I would say.
Claire Chapman, the new and quite excellent director of human resources of the NHS, when I first met her when she was still on the induction programme I said: “What are your first impressions?” because as you know Claire came from Tesco, and she said: “The one thing that if you go round anybody in Tesco, the checkout person, the shelf stacker, by and large they believe that Tesco is on their side, they will have their grumbles and everything but they think the firm is on their side. You talk to people in the NHS and by and large they think that they are up there are against them.”
Now we have to turn that one round and I would propose that the only way that we can do that is for the day to day running of the service to be set free from political interference. Of course the policy has got to be set by Parliament and Ministers, the general direction of travel, but once you have done that let’s have the chief executive, and the chief medical officer and the director of human resources and so on answerable to an independent body, not the Ministers’ offices every day doing a bit of fine tuning. I really think that that might be one way to change the general tenor of how the workforce regard their management.
Finally, and to change the subject, I think the thing that this government has done which will have the most effect on the health of the people by a long way over the long term is the action that they have taken on smoking in public places. Now there was the odd wobble, the wheels came off now and again, but we got there in the end and I think in 50 years’ time this will be the greatest, it will out-do anything else that has happened in the last 20 years, this will have the greatest benefit of the health of the British people that we will see probably in our lifetimes.
Thank you very much.
David Pink, Chief Executive, Long Term Medical Conditions Alliance:
Good Morning. The advantage of coming up last after Niall and the speakers we have had is that I can go - chronic heart disease, cancer, waiting lists! Off. But I hope then I have got a few other points that are relevant and it would otherwise have been quite difficult to look at the last 10 years and the future in 5 minutes.
I am from the Long Term Conditions Alliance, which is an alliance of over 100 patient organisations and I want to speak about what has changed for patients. Patients need well motivated professional staff and some of those issues of course have been touched on so far, but ultimately the only measure of success or failure of our publicly funded NHS is what it does for those it serves - the patients and the public.
Over the last 10 years the term ‘patient centred’ has been used quite a lot, it fades in and out of fashion and of course it always started off as a bit of a joke term because why should Health Services ever have been anything other than patient centred. I am glad it is nowadays not just a politically correct rhetoric but it is something that is beginning to make a real different to our Health Services. In a way you could say me being here today is part of that. I think 10 years ago it would have been entirely unnecessary to have anyone speak from the perspective of patients about reforming Health Services.
So clearly the headline changes over the last 10 years, the milestones are those that we have already heard about and the only one of those that I particularly want to add to is the NHS Plan itself and I was surprised that it got so little mention. I think it was notable because the NHS is professional staff, the representatives of patient organisations and the government built a consensus around a way forward and that was embodied in the NHS plan. Of course I am sure that consensus was motivated and embodied in the increases of funding just as much, but I think it was very significant that we have that plan with those signatures attached to it.
I won’t review the statistics about the performance of the NHS since then because I think we have already had quite a lot of those and I can’t out-do those that have been said, but what I will say is that the first 5 years of the last 10 were characterised by an obsession with hospitals and with acute care. Now it might be that that was justified because of the years of under-investment that has been referred to and the appalling waiting lists for hospital treatment that had become a national obsession, you know a decent percentage of the total acreage of the national press seemed to be focused on waiting lists. But those sad days are now hopefully behind us and access issues around waiting lists and hospitals, we have seen huge improvements.
The more contentious areas have been the system reforms to the NHS and I don’t want to go into those in detail and about the arguments about the way the mechanisms work and whether they have improved or not by the experience to date, I would have thought we were too early to pass judgement, but I want to mention just one or two aspects. One, national standards and national systems for quality assessment and inspection have certainly been welcomed by patients and the public and those were one of the glaring holes in the situation we inherited 10 years ago and I think perhaps it is a measure of how …[inaudible] and successful they are that they are very rarely mentioned in any contentious way on days like today.
Choice, which is a far more contentious area, has actually been welcomed by patients as well but the market and system reforms that accompany choice mostly cause confusion for patients and are far less consensually accepted both within the service or without.
I want to move on though to the more patient centred aspect to it and for the last few years, the second 5 years of the 10 we are talking about, the government and the NHS have started engaging with a much more important question which is the fact that no amount of investment in improving hospitals and improving the access and quality of those hospitals can actually make the health of the people of England better in the long term. In fact the mindset we inherited from the ’90s and ’80s was completely absurd, we had a mindset where professionals, the press and the public actually thought that more and more hospitals and more hospital beds, and more admissions into those beds was the route to improved health in this country. Health and healthcare need to focus outside hospitals and I am pleased that is now beginning to happen. The long term conditions such as chronic heart diseases, diabetes, cancer, these are the principal causes of ill health in this country and of course they are the principal business of the NHS, whether we are talking about inside hospitals or outside, but what we need to realise is that the outcomes in all those conditions are determined by what happens outside hospital, hopefully before hospital care ever becomes necessary, and that most of that care outside hospital doesn’t even take place in any sort of NHS setting at all, it takes place in people’s own homes. The largest workforce for healthcare in the country is the ordinary people of this country and their efforts to manage and improve their own health.
So while health service commentators in this room might want to focus on the funding or the market reforms, PFI, Foundation Hospitals, I want to mention two other things which haven’t been highlighted this morning. One is the quality and outcome framework, now that gets lots of press coverage as well but most of that press coverage is about the new cars that doctors can buy as a result of the quality and outcome framework and that is not my interest area. My interest is that it is a major national programme that has turned the NHS’s attention to helping people monitor and maintain their own health, living with a long term condition, and it is very significant for that switch. And the other one I want to mention is the Expert Patient Programme. The formal training courses to help people manage their own conditions were largely developed in this country in the voluntary sector and then adopted by the NHS and I welcome the investment that has been made in the Expert Patient Programme. 23,000 people have received training so far, of course that is a drop in the ocean compared to the 17 million people with long term conditions, but it is a start. The other great significance of the programme is that it is an acknowledgement of the vital role that patients and their families have in improving their own health, and I am very pleased to see that the British Medical Association has supported the programme.
Looking to the future, investment matters, hospital services matter, the system reforms matter. For me the system reforms matter to the extent that their further implementation and stabilisation and embedding should help rather than hinder, but we shouldn’t become obsessed with them. More than anything we have got to make sure that we keep in our vision and in our hearts the fact that we have to be patient centred and this is a publicly funded health service for the population of the country and we must not become NHS centred in our thinking.
So all of the reforms and especially the choice reforms need to remain patient centred and their objective should be to strengthen the ability of people to manage their own health and that is a far more important objective in my opinion than any of the system reforming incentivisation systems.
What ordinary people living with health problems want is improved information, they want care plans to set out what they can expect from services and they want simple and fast access routes to expert advice from professionals when they need it. We have still got a long way to go on all three of those but I am pleased we are making some progress. But for information and care plans there is a long way to go. People’s expectations have changed over the last 10 years, but I don’t think people’s expectations are unreasonable and I would really fight against the notion that some people have that there is a great mass of completely unreasonable individuals out there and that they are just waiting to barge their way into the NHS and spend their time in their nice hospital beds.
So I think it is important that we rebuild, if we have been starting to lose it, the consensus around those essential objectives for why we are reforming the NHS. I am not sure we need lots more policy for that, we have got a vast policy portfolio from the last 10 years and arguably more than any of us could have wished for.
And the last thing I wanted to mention is patient and public involvement because I think it is vital that despite the fact that there have been difficulties with the structural mechanism for patient and public involvement, that we do our best to make it work. Of course at the individual level it has always been part of the foundations of healthcare, it is about an individual sitting down with a professional and making shared decisions and having a partnership in care, but we need to make patient and public involvement work at the community level if we are going to devolve power for determining health service to commissioners, they have to have mechanisms which they use to engage with their local population, and I would argue that we need patient and public involvement at the national level as well and that there needs to be a clear ownership of the programme which is rooted in mechanisms for actually engaging people and listening to what they want to say.
Thank you.
Niall Dickson:
Thank you very much indeed David. Let me now invite the Prime Minister to respond to what he has heard this morning.
Prime Minister:
Good morning everyone. First of all can I give my thanks to the King’s Fund for organising and hosting this morning and also say to all of you who are working inside the National Health Service, thank you for the work that you do which is enormously appreciated not just by the patients that you serve, but by those of us in government as well, though it probably doesn’t always seem like that to you.
The other day when I was going round a Health Centre I got set upon by someone, which happens to me reasonably often when I am out, and she said to me “Why don’t you make the media publish something positive about the Health Service?” It took me a long time and she said “You are not saying anything” and I said “I am trying to frame a polite reply”. And the single most difficult thing, as we can actually see from the presentations this morning, is to get a sense of balance. It is hardest thing in fact in modern politics today actually, never mind in respect of the Health Care system, in other words what all of the speakers in various ways were saying this morning was that there have been significant, sometimes transformative, improvements in the Health Service but there are immense challenges.
There is not a single person who has spoken today who hasn’t acknowledged the significant improvements and the most important thing really, because I think personally this also impacts a lot on morale, is to get that sense of balance across and in a way that is the reason why it is quite useful to have a 10-year perspective. I mean in my often mocked comments of 10 years ago, 10 years ago today I think, about 24 hours to save the National Health Service, which is sometimes taken at its most extreme end that I said that within 24 hours the Health Service would be transformed, which was a bold boast even for those heady days, but actually what I was meaning was this, that 10 years ago I think the question was does the Health Service as an institution have a future and today I think the question is how do we improve the quality of that future? There is far less debate about whether the NHS as an institution can survive and I would say this is - I mean obviously I am in one sense, well in every sense party-free when coming to discuss the achievements or otherwise of the last 10 years - but what I think is undeniable is this, that in terms of waiting which was the problem in 1997 there have been real and transformative reductions and by the end of next year, if we succeed, then the concept of waiting as traditionally addressed in the Health Service will have gone.
Secondly in cardiac treatments, in cancer there have been major, major improvements. In terms of accidents and emergencies I think for many of the patients they get a completely different experience today than a few years ago. There has been a huge replenishment and rebuilding of the NHS stock and the patient experience, as I think next week’s Health Care Commission Report will show, the patient experience when you ask people what they actually personally have experienced inside the Health Service is immensely more positive than their general perception.
That said I think there are real challenges that remain. I think that there are things that we have got wrong as well as we have got right and just in this brief introduction I will try and talk a little bit about that. The other thing that is very important though in politics is and it is something I have learned over the last 10 years is that people will say “Listen to the people” and when you are a politician what you find sometimes is that they don’t always speak with one voice and so what happens when one group of people say this and another group say that and actually that is what the job is about and then you have decide the way forward. And I respect in respect of the reforms, I think it is true to say that in the first 2 or 3 years we did not push forward fast enough some of the reform agenda, although I always thought that dealing with reform before you dealt with the under-investment was going to be difficult, even with the investment it is difficult but in the absence of that it was even more so. I think there are fair points that can be made about the different reorganisations. I think that we obviously have a great deal of work to do in order to try and take people with us in the Health Service on these reforms.
However I personally think that the concept of a less, or non-monolithic, system of health care, greater competition, greater patient choice, the changes in terms of payment by results and practice-based commissioning and so on, I believe that those reforms and that framework will stay in place. I cannot see myself, any government, turning their back on that. And I totally understand, incidentally, the difficulties whilst you are putting through a process of change. And you are right of course, it is very obvious that we have to do far more to try to take people with us. That is certainly true. But I think if you were to ask any major corporation whilst they were going through a period of immense change how easy they found it to have people on side and I think they would say well that was the tough period and the real question in the end is whether the reforms are correct and once you are through them then people have a clearer understanding. I am just wary about this idea of an independent NHS Board and I will tell you why. If it is a means of making decisions, then I can kind of understand the point of it but I would be very worried if it became a means of avoiding decisions. In other words this idea that politicians that transfer power over to someone else who kinds of takes decisions objectively as opposed to us who are so immersed in subjectivity or wrong-headedness and all the rest of it. In my view the difficulty is in the end someone has got to take the decision, that is the same with running any organisation and who goes on the Board, what does it become, is it actually a driving force for change or is it actually a break on it. Well I think those are difficult questions. I think the issue to do with the competition within the system, again, I totally understand the concerns about that but truthfully when we started to introduce independent provider concepts and patient choice, that was when we started to get real and sustained falls in waiting and I just think there is a basic lesson here which is that in the end whether in the public service or the private sector, there needs to be a way, if the service isn’t good enough, for people making a different choice or having a different system in place.
Now I think these reforms are incredibly difficult. They are the biggest set of reforms - I think we would all agree on this - going through the Health Service since its inception but I cannot see myself that basic framework being changed and that is because ultimately I think the patient will tick those reforms as being essentially right, but that is obviously a big debate.
I think in terms of the challenges that lie ahead, I think again there have been some very fair points made. I think in respect of public health and the smoking ban, I should give a special thanks to Patricia (Hewitt) on that since it has to be said that there were some of who scratched our heads, sucked our teeth, and you know were a bit worried about the public reaction to what the civil servants thought was a bold and courageous move, which always terrifies you, but it was the right thing to do and I think it will leave its mark in time.
But I think in respect of public health we have got far more to do. I think in respect of social care that some of the same reform agenda is also important there as well. I think that in respect of mental health, although there have been major improvements I still think there is a lot of understanding we still need to get about the scale of mental health and how we deal with it, and of course there are obvious issues to do with hospital infections and so on.
My final point, however is this, so I would say that the balance is there have been significant and transformative improvements, there are real challenges that remain, I think the essential framework of reform will remain in place but there are major issues for the future.
The final reflection I have got is this and I think this is important for all of us to recognise. There is so much change going on. This whole changing to day-case surgery is something that is a major feature. The way that paramedics operate today is completely different from some years ago. The fact that the primary care services can offer such a broader range of services today and the ways that disease and conditions are being treated. How people with long-term conditions manage their own conditions. I think sometimes we do not factor in enough for the public the degree to which the context within which our Health Service is operating is just being changed the whole time. And therefore it is in that sense a bit like a business operating in a global context where there are massive changes going on and therefore the business is having to adjust, and the thing that I think is really interesting and occasionally in my darker moments fortifies me is whenever I talk to any other leader around the world about their health care system, because we sometimes get the idea that we are the only ones who have got a challenge on this. Believe me, if you talk to anybody from outside, if you look at the debate inside the United States at the moment about health care, it is a major, major issue. In France it is a major part of their election campaign at the moment and of course their deficit is vast actually compared with ours and what is the problem. The problem is - and this comes down also to this issue to do with waste - if you take the American health care system, actually arguably that is a highly wasteful system of resources. You have many people without medical insurance but you also have I think a far higher proportion of GDP being spent on healthcare than any comparable country. You go and talk to business people in Germany and France where there is a social insurance system and they would be highly attracted by the idea that they move to a tax-based and funded system.
So I think the other thing that we should remember too is that this is an organisation of 1.3 million people, a budget of whatever it is, £90 billion or so. It is a huge task to run and manage that system and actually if you look back over this last decade it has got better, there are real changes happening, yes it is an enormous challenge but if I might permit myself in concluding a note of optimism and you know in my job you have to be an optimist but it is if you think about the challenges we face and where we think the service is heading now over the next decade, at least we are having an argument about how we improve it rather than how we prevent it from collapsing, and I think that is a real change, and it is a worthwhile change.
Thank you.
Niall Dickson, chief executive of the King’s Fund:
Thank you very much indeed. I am going to throw it open to questions in a moment. We have got a couple of microphones around. Let me just very briefly ask you to respond to reorganisation. Do you regret the number of reorganisations you have had to go through of creating 300 PCTs and then back down to 100, or creating 5 for London and then back to 1 because there is a lot of feeling, it feels a bit like organisational vandalism I think to some people.
Prime Minister:
I think the difficulty when we came in was that there was a lot of support for the idea of the Primary Care Group and then there was more interest in PCTs and so on and part of it is that when we were running a completely and very centralised system it made sense to do it in that way. As you then move to a different system, then it makes sense to change it and I mean obviously it is better if you have a minimum of reorganisations and I think a perfectly reasonable point was made about the multiplicity of them. However I think from where we were at the time it seemed the right thing to do to have the Primary Care Groups and it was only when you then started to introduce a different type of system you then made those changes. Would it have been better to have avoided it, well of course in retrospect but I think it would have been difficult at that time with the system that we had in place to have done it in the way that maybe now you might think.
Question:
I think one of the unsung stories of the last 10 years has been the growth in the influence and the strength of the third sector, particularly encouraged in terms of service delivery by you, Prime Minister. But I wonder how far that has gone in the Health Service. Despite the big role that we play in social care and palliative care in the prevention of ill health, the role as voice of citizen, I don’t think the Health Service takes that as seriously as it should and I think that is a challenge for the next 10 years. And I wonder why that is. And I think one of the reasons we have heard this morning because it is not regarded as central to what the Health Service does and I think that for some of us we are slightly bemused when we hear from doctors and nurses’ representatives. I am not underplaying the role of pay and conditions, but they have improved significantly and we wonder from outside when pay in social care is not as significant whether actually the true purpose of the Health Service is about the health of citizens and communities and not the pay of people who work in it.
Secretary of State for Health:
Well if I could make just a very quick comment on that I think what we are going to see, and we are already seeing in some parts of the country, is a real opening up to the third sector to social enterprises. A whole range of different kinds of not-for-profit organisations alongside the public sector and indeed the private sector which we have also been using for some years now and what we have done already, I have created within the Department of Health a social enterprise unit, working of course with the team at the Cabinet Office and as we get far more Primary Care Trusts working with local councils to bring health and social care together with a real focus on prevention and long-term conditions, the big challenges facing any health system, I think that we will find that in order to do that really effectively we are going to need a much bigger contribution from the social enterprises and the not-for-profit sector including organisations that have very deep roots in different communities, different user-groups, who are not always well reached at the moment by the traditional NHS.
Question:
One thing that has come through very clearly from all the speakers is human capital. We have had a lot of investment in buildings and in system reform, but for the future it is this human capital that we have that is critical. We have also heard from two of our speakers and at least two of our professional groups are rather disaffected and over the last 10 weeks I have had to absorb dismay, really anger, from one particular section and what has been lost is trust and I would like to know from the panel, and this is not a word we use very often, but how do you think, in order to take the reforms forward, we can restore that trust?
Prime Minister:
I think the only way in the end - because I have been through this a lot with various changes in public services - and my view is this that whilst the change is going through it is extremely difficult, because the person who argues that the change is a disaster will always be heard above the person who says it is not and I don’t want to introduce another controversial subject, but when I first went through both the Academy and Trust School reforms and reforms to University finance, the predictions of disaster were absolutely multiple everywhere. And they were unpopular. You wouldn’t have got polling results on any of them that would have been anything other than bad. But to be absolutely frank we introduced the University Finance reforms and now that they are there and through there is very little blow-back from them. I think in the end, how you do this and I am not saying we can’t do it better or we haven’t got to do it better, how you do it in a system that is as big and complex as the NHS is really, really tough. But I honestly do not believe you are going to get a reversal of the essential course of this which is towards a less monolithic system with greater patient powers and choice within the system and competition with providers.
Now how do you then get people through this. You get them through it and then I think people make a more rational assessment at the conclusion of it. Now I know that is not a very optimistic response but I have been through this so many times and I just think it is really tough whilst it is happening and what we have got to do is in a sense hold our nerve in it whilst trying to deal with the points that are reasonable, when people have got objections with certain changes in the system or obviously issues recently to do with contracts and so on but where I think there are perfectly legitimate points that we have got to take on board, but I think that for that essential structure of reform you have to do it or not do it, and I believe that it is best that it is done.
Niall Dickson:
So you actually think that we are going to reach some sort of sunny uplands, because there is a sense in which people I think in the Health Care System feel that it is like a Maoist revolution, whatever happens then it will be another set of changes that will be introduced again. You probably won’t be in charge but presumably at some point in the future you are saying you think it will be a bit calmer, at least on the reform side.
Prime Minister:
Well I think the basic framework will be in place but here is where I think one has got to give a warning to people. You know, this is the 21st century. There is no walk of life in which change is not going to carry on happening and if you get new treatments for diseases or new ways, for example, that people can manage their long-term conditions, you know the guarantee that life is going to carry on as it is, everyone is going to do the same jobs in the same way, I don’t think anybody and I don’ t think anybody around the panel would say that we could do that and therefore what I do think is you will be through, as it were, the essential structural change but, as you rightly say, it will be for others to do, but I think what we have got to get used to today is a process of continuing adjustment to change.
Secretary of State for Health:
But I think the difference, Neil, and I can comment on that, if you go round and talk to staff as I do in Foundation Trusts, you find a very different sense of an organisation that really has got control of its future. It doesn’t mean they haven’t got difficult decisions to make and they are working in many cases with Primary Care Trusts with local GPs, looking at how they move services out of that hospital. You have got Foundation Trusts looking at how they might become Community Foundation Trusts for instance. They are still changing but not constantly looking up to the Department of Health, in the way that several panellists rather vividly described, much more taking charge of what they are doing and thinking about how they do it better for patients. What has happened with junior doctors is a very specific problem. It should not have happened, we are sorting it out with the help of the Academy and the Medical Royal Colleges and the BMA and we will just work our way through those problems in order to ensure that the appointments and recruitment system is fair to junior doctors but also gives the NHS the right people in order to fill those training and non-training posts for the benefit of the patient.
Question:
I am glad you mentioned Foundation Trusts because on that point I want to raise a very specific question about public accountability. You talked about them making their own decisions. You talked earlier about the problems of actually trying to devolve decision-making down to other layers and passing the buck in decision-making terms but I don’t know if you are aware that a number of Foundation Trusts have closed their Board papers to the public. A Parliamentary Question about the matter and the Regulator said that this was perfectly acceptable. I raised this issue with Baroness Helena Kennedy who was quite shocked and I think this is a very, very worrying development.
Secretary of State for Health:
Well one of the things I am most impressed by actually in the Foundation Trusts has been the involvement of local people, patients and indeed staff members, as members and indeed as governors of the board. There will be occasions where any Board needs to have private …[inaudible].
Question:
Whilst everybody here has commended the improvements on waiting times, waiting lists and patient choice, we suggest that there has been some forgetting of the everyday issues of health care, not least dentistry. This week we will publish more research showing that the situation is not getting any better and in a number of parts of the country people are having very real difficulties getting dental care and are actually going without treatment as a result. Similarly our work last year on out-of-hours showed huge problems there in some parts of the country. And whilst you can say that this is Primary Care Trust responsibility and it is up to them to do it, who is holding Primary Care Trusts accountable when they are not up to the mark?
Prime Minister:
I think in respect of dentistry the big problem, and we have wrestled with this over the last decade, the big problem is you cannot force dentists to provide the NHS service so we tried to offer all sorts of inducements, we have increased the number of dentists to 1,500 but there is a problem if they decide that they do not want to do the NHS treatment. And I think the other problem, if I am absolutely frank about it, is that dental care is also changing enormously as well. The way it is being delivered, the type of dental care people are getting, it is just completely different, even in the last 10 years and certainly over the last 20 years it has been transformed. You notice this with your own children’s dental care. The dental care they experience and the dental care I grew up with they just seem to me two completely different worlds. But I agree we have got to make sure, particularly focused on those parts of the country where - and it is part of the country where there are significant problems - that we need to do far more.
On the out of hours I would say that I think in the end, again, you need to have a plurality of provision here. If we want to go down the path where we are going to have health care delivered at the times when people actually want it delivered, then obviously it is important for GPs to provide this care in the ways that people want, and many practices of course do, but we need to find ways also of encouraging practices to be open at the times that people really want them open, and that includes the times on Saturdays and so on and later into the evenings when most people actually want to, or maybe if they are working, when it is most convenient for them to come. Now I think in many ways the GPs’ services have improved significantly but I think it is very obvious, and I know, this is more anecdotally than not, of people who say their GP services are an awful lot better in the last few years, but also people who say we used to get the out of hours but now we don’t, so we have got to find some way of working that through.
Question:
The first thing, fluoridisation would be a very bold step, akin to smoking. Secondly, there are very good examples of out of hours service. We have one in Tower Hamlets, which we set up 10 years ago, run by local GPs providing exactly what you said and the challenge therefore is to see that that happens more widely. And finally can we have more of a hidden achievement which is what Patricia (Hewitt) touched on and that is the integrated community health care services. Now, I am from Bromley-by-Bow and we run a service which has 100 different things under one roof including a general practice. We run the park, the café, children’s centre. Angela Lennox, in your area, Patricia, has got a police station in her GP waiting room and has reduced the crime rate to something like one-fifth of what it was before.
Secretary of State for Health:
There even are examples of actually when you bring together all sorts of different things under one roof you provide real holistic health care to patients but the other hidden achievement of it is around bringing communities together and that to me is critical for us in the next few years, particularly in an area like mine, the most deprived area of the country, and of course with a very large Muslim population.
Question:
I am also a consultant cardiologist and married to a GP so that is where I am coming from. A couple of things, we have heard an awful lot about the past underinvestment in the Health Service and I think we have forgotten that the Health Service provided health care, it educated future doctors, it educated doctors in training and it provided a fantastic resource for clinical research which has put the UK where it is, or I might say was, a few years ago, at the forefront of prime medical research. I think you cannot underestimate the spectacular own-goal that you have done in disillusioning the medical and nursing workforces that provided that service on the background of the under-investment and, almost to a man and woman now, are upset and feel disillusioned about the environment in which they are working, and now that has been translated to the next generation of doctors. I think there is a huge job of work to be done about that.
But my main point really is that I have heard a lot about health delivery, about waiting times, about improvements, and I would have to echo the fact that in cardiac services things have improved enormously. Doctors were not against change, we wanted change. It was depressing telling somebody he had to wait 18 months for coronary by-pass surgery, so we are not against change. We wanted change. But I have heard nothing about how we are going to educate the next cohort of doctors in the new environment and I am finding it difficult to spend the British Heart Foundation’s money on high quality research because we have empty academic posts all around the country and that is getting worse because the next phase of junior doctors are simply not applying to do research. They are just too insecure about their futures.
Secretary of State for Health:
Look, there is a whole series of issues in that. There are the immediate issues around EMPAS and the application system and so on which, as I was just saying, we are in the process of sorting out. There are particular issues which have been developing I think for some time around academic medicine, and I agree with you that is absolutely fundamental to our strengths in clinical research and a much broader range of biomedical research and development and we are working on that with the Universities and with leading consultants as well. We have got the potential as NHS Connecting for Health rolls out, as we develop the electronic patient records and in the areas where there is adjusting introduced on a trial basis we are getting a superb response from patients who in many cases positively welcome the fact that there are electronic patient records there. We will have the basis potentially for Britain to be probably the best place in the world for clinical research, and therefore for the development of new breakthroughs. And that is what we want to do, it is what we are working on with colleagues in the scientific and academic community.
Question:
These academic posts will be filled then, is what you are saying?
Secretary of State for Health:
Well that is what we are working on at the moment because we want to get them filled this year. This is a longer-standing problem, it is not one that has simply arisen this year and we have got to look at why academic medicine has become unattractive and then just overcome those barriers. As I say, the potential that we have actually got here is enormous and it is why there is still a great deal of inward investment coming here rather into other parts of Europe for biomedical research.
Question:
Where else in the NHS do you think that competition and choice should be introduced. Given that this reform has no doubt added to the scars on your back, what advice would you give to your successor on how best to escape further injury?
Prime Minister:
Well I give up on that latter one since I don’t think it is possible really. He must take these decisions. I think that for example with the diagnostics you can see how it can make a difference. I think where there are under-doctored areas, then it can make a difference there too and I think in general terms once this system beds in there will be the opportunities, particularly as hospitals move to foundation status and so on, and practice-based commissioning becomes clearer in what it is achieving, I think there will be a system that operates without the market mechanism that is based on the wealth that someone has, but with the sense that there are alternative providers that are available and I just think that in any walk of life and system today you have got to have that. So I personally think that this will carry on and that is why I said in my introduction, I can’t really see that framework changing. And yes, I think it is rather difficult whilst we are doing it and just to pick up on the point that was made previously, I think there are real issues to do with medical research that we need to work very closely with you on and make sure that we overcome these issues and listen carefully - I am not saying that we don’t listen carefully to what people are saying about this, and it is a serious point. If you say well yes people don’t wait so long and they get treated better and so on but going forward there is a long-term challenge. We have got to be prepared to sit down and work those things through with people and actually I should say this, that although it is very natural that in a sense the management gets pitted against the professionals, actually on the agenda for change, on much of the work that we have done in relation to the national service frameworks and so on there has been very good co-operation and working between the professional associations concerned and the government but I just have this belief that here is a long term change, here and around the world, which is that just as the private sector moved over time to more customised services produced in a way that was far more flexible and adaptable, so the public service as a whole will move in the same direction and I think that that concept is not going to be dislodged because I think it is where people are today. And I think that one of the things that we haven’t really discussed much but I think is a huge factor in all this, is rising patient expectation. I mean I think people expect far more from the Health Service today than they did 10 years ago or 20 years ago. And a good thing too. Why shouldn’t they, especially when they are paying their taxes to fund it. But I think that you will find, and I am sure that this is a big pressure for example on doctors today, that you will often find, I know people when they go to see their doctor now first of all they visit the internet, and they are going in for a dialogue. They are not going in to be told this is what you have to do, and this is the world that we live in. Now personally I think it is perfectly acceptable, but I think it makes those changes inevitable and I think if you don’t want a few scars on the back, don’t do the job!
Niall Dickson:
I am just going to take one very quick final question and then I am going to ask each of you in one sentence your top priority going forward. Just one sentence each, and then we will wrap up.
Question:
Yes, this is a very quick question. I am very glad actually, Prime Minister, that you have pointed out mental health as being an area which needed a great deal more improvement. Certainly that is the evidence that we have and we would like to know how are we going to ring-fence the money in some way so that it is a soft target to raid the budget, the mental health budget, when there is a deficit, when the acute services need something. We are needing to look at how that can be retained and one thing that nobody has mentioned in all this is the importance of carers. Two for one are going to be looking after people. What is the government going to be doing to give them more than just a pat on the back, to actually giving them proper support, financial and otherwise.
Prime Minister:
Well I think, first of all, when we are through this very difficult financial period and Patricia (Hewitt) I think will be announcing shortly the funding for next year, we will see a clearer path forward on that and I think it is very important that we recognise the importance of mental health. I know that we have increased the funding, but I also know that the need there is huge and really only just I think being discovered in its full extent. And I think that the other thing that will be really, really important is to make sure that in offering the type of care that is important for people and this is where I think the third sector has a significant role to play as well, we again make that adjustable and flexible and give the patient as much power as possible over the type of service that they both require and desire. And I think in relation to carers in particular, obviously we are trying to increase the funding, and we accept that we have got to do more on that, but I think the other thing is this right to request flexible working. I don’t know whether people saw in the paper today, there was something about the reduction in nursery requirement because of people requesting more flexible working. Personally, I think we will still need the nursery places and that is for sure, but what is interesting is that right to request flexible working that I think you (Patricia Hewitt) introduced in an earlier incarnation and I think that what we thought would be quite minimally exercised has ended up becoming a major part of the way that employers work. And I think for carers, one of the most important things, because not all carers will want to give up their work and care full time or need to, is that we have far greater flexibility in the way that people are able to work and take time off and build their working lives around the needs that they have of their family, including carers.
Niall Dickson:
Very, very briefly because I will get all kinds of … and scars on my back if I keep you much longer, one sentence from each of you just on the top priority for the Prime Minister’s successor and the government going forward.
David Pink:
I think we should remove choice from being a battleground to being a ground where we collaborate and work together and there is no better area that I can think of than mental health. Their people should have access to the services that they want, which might include talking therapies, various forms of support for carers and so on but nothing holds us back from doing that. It is …[inaudible] that needs doing and I think the third sector has a role to play but I don’t think that competition is the most important issue.
Jim Johnson:
In the short term I would say without a doubt it is a matter of reconnecting with the workforce because that way you will get much more efficiency, and that is probably the only way to get more efficiency for the huge amount of money that we put in, and in the longer term I think we had better have a real public debate about this business of what happens in 30 or 40 years time when people are living much longer and the dependency ratio is going to be 1 to 2.
Peter Carter:
Well I was going to say reconnecting with the workforce, so I will move on to my next one which is this. Planning. The need to ensure that all the component parts, both statutory and non-statutory, are actively involved in planning developments in any given health community.
Nigel Edwards:
I think creating some space for local leadership, measuring them by the quality of outcomes, patients’ experience and any …[inaudible] focused on the patient being the customer rather than the Strategic Health Authority or the Department of Health.
Niall Dickson:
I am not going to ask the Prime Minister for any advice for his successor but I am going to ask you to thank, David Pink, Jim Johnson, Peter Carter, Nigel Edwards, the Secretary of State and the Prime Minister for coming.
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