Well, thank you all. When I spoke last year there was about 27 people there. I don't know what you have been told I'm going to say! Thank you all for coming along.
I decided this morning that I just kind of wanted to have a conversation with you, rather than kind of delivering a pre-written speech. I told Victor this. He said it was a brave decision, in that slightly worried way. And I'm just feeling nervous, I met Andy Burnham. He said, "Are you doing a speech?" And I said, "I decided to have a conversation." Andy said that's good because it was in this very building several years ago in which Ed Miliband made a speech. He didn't use any notes. It was at a point when Labour's economic credibility wasn't great. He delivered a speech like this and forgot the whole economic section. And as Andy said, it was a complete disaster. So, I said, "Thanks Andy, just what I wanted to hear before I started to speak."
I do want to start by saying thank you for coming. I know with the junior doctors' action, it is challenging for people to make it here. We have heard there are 4,500 people here. It is a bigger event than last year. Amanda is here, we have the Secretary of State, and you will hear from Wes Streeting later on this afternoon. It's great.
I want to do one little bit of audience participation, which is the team at the Confed and the team at NHSE who have been working on this conference for months and months and a couple of weeks ago realised it was going to be clashing with this industrial action. They have had to address that and deal with it and a few speakers dropping out, but they have been a fantastic team and because of that we are having a great conference. I would just like you to thank the NHS Confed and NHSE team who have organised NHS Confed Expo.
More impact than ever before
The second thank you I want to make is to you; particularly to our members, who have worked with us over the last year. In what has been a really strong year in terms of the work of the Confederation, we have published more reports, held more events and had more impact than ever before. That is because of the contribution that our members make. Everything we do, we do for our members. Thank you for helping us to help you over the last year, in terms of the ways in which we seek to represent members' views and to help members to make practical change in the health service. And finally, to echo points that you heard this morning, thank you for your service, for getting through the toughest winter the NHS has ever experienced. For the progress that we are now able to make in relation to backlogs and key targets. And for setting incredibly stretching targets for the year ahead. We know that through the planning round leaders have stretched in terms of the performance targets and financial targets that they have set and that is brave. You know, we will be with you every step of the way and hope that we are able to achieve those ambitious targets we have set. So, thank you for that. As I said, speaking like this, chatting with you, I'm going to make eye contact with people. You know, it does feel a little bit nerve-wracking but, at the Confed we published a report responding to what our members asked us to do, we published a report on trans allyship last week and having dealt with the media and social media response to that, I have to say that has done wonders for my pain and risk threshold.
I wanted to mention that report because I'm proud that we did it and we responded to our members who wanted us to do it and also because I want to emphasise that one of the things we have a duty to do in the Confed, is to be willing to do things that are sometimes controversial. Whether it is talking about racial disparities and health outcomes, whether it is identifying the health impact and the impact on our staff of the cost-of-living crisis.
We know that you put yourselves on the line every day of the week as health service leaders and it is important that we as your representatives are also willing to take risks sometimes to say things that are difficult to say
Whether it is supporting the Hewitt review process and talking about the importance of the centre devolving to trusts. Whether it is working with the LGA to set up the integrated care partnerships forum to try to engage wider Whitehall in talking about health policy. We know that you put yourselves on the line every day of the week as health service leaders and it is important that we as your representatives are also willing to take risks sometimes to say things that are difficult to say. It is not easy for to you do a lot of the time. It is our job sometimes to do that.
Convening difficult conversations
But the other thing I want to say is that it is also the case that we don't always agree with each other all the time. I have come into the health service relatively recently. I have heard it said that sometimes in the health service what we say to each other is not the same as what we say about each other. Or as someone put it: what we say in the boardroom is not the same as what we say in the carpark. I think another important job for the Confederation, representing all parts of the health system in England, Northern Ireland and Wales, is to sometimes convene those difficult conversations. In the last year we've brought together leaders of acute trusts and systems to talk about how to make that relationship work and to discuss some of the challenges in making that relationship work. In our primary work, we have been really clear that we understand the huge challenges that primary care faces, but we are really clear that primary care needs to operate at scale. It needs to engage with places and systems - that is the future of primary care. We organised a forum for place leaders and in that forum we encouraged really honest conversations between colleagues in local government, the health service, the third sector, about how we make collaboration work and how we avoid the local blame game.
I want to encourage us to think about how we can mobilise to find a shared vision for the future of the health service
But in the rest of what I'm going to say, I'm not going to be talking about what we disagree about. I'm going to be talking about what I hope we agree about. I'm going to talk about five things - five shifts that if we were able to make them, would carry the NHS into our next period with real confidence. And I want to encourage us to think about how we can mobilise to find a shared vision for the future of the health service. This, I think is one of the imperatives we have. Why? Why do we need that shared vision? Firstly, because we have the 75th birthday. What better time to refresh, renew the story we have about the health service. Secondly, we have a general election looming. We know that in a general election, there is always a danger that the NHS becomes a political football. Or that the political parties try to outdo each other in their retail offer. And I think it is really important to encourage, in that debate, a focus on what really matters and a focus on the long term. And thirdly, I think it is important to have a shared vision because of the moment that we are at. We are at a moment when the opportunities for people to empower themselves in relation to their health, are growing every day. It is possible to find out more about your health. It's possible to monitor your health. It's more possible to diagnose what might be wrong with you. There is an ever-growing number of organisations seeking to sell us things to help us to take control of our health. Now, if we in the health service don't grasp those opportunities, if we don't empower ourselves, within the context of our commitment to equity, then what will happen is we will see an ever-growing divide between the healthy haves and the unhealthy have nots.
Five things we need to do
Let me talk about the five things I think we need to do. The first is: We need to have a health strategy, not just policies for the NHS. This is so obvious. Our country has become sicker and poorer. This is a kind of remarkable thing, for a person of my age. I have lived through all sorts of difficult times - the Winter of Discontent, the recession in the '80s - but we always felt when we got through those cycles, we would be better off and live healthier and longer lives. That has stalled over the last few years. We have to pick up the consequences of that.
...if we are to thrive in the health service, we need things to happen outside the health service
So, if we are to thrive in the health service, we need things to happen outside the health service. We know we can't succeed unless we sort out the terrible crisis unfolding in social care. We know that we need action on smoking, nutrition and on exercise and of course we also need action in relation to the social determinants of health: housing, employment. Yesterday I went to a fantastic primary care practice in Rusholme, just down the road, and spoke to a brilliant GP there and she'd looked hard at the data: that one-in-four of the people she sees, their problem is not actually a health problem, it is a housing problem. If we are going to tackle the issues we face, we need to do it within the context of an overall strategy to improve the nation's health. And unfortunately, when it comes to government, there is a disparity. We were promised white papers and a mental health strategy. And we are working with the strategies, and we want it to be as good as possible, but I don't see a concerted joined-up effort around health.
We need a national strategy
We need a national strategy to improve health. That is the first thing we need. The second thing we need is obvious. It is investment. We know the effect of the austerity decade: half the level of growth we needed to have over those ten years, we know the affect it had on us. We know that we went into Covid already vulnerable. Already with 100,000 vacancies, already with a crumbling estate, and we know that Covid hit us harder than it hit other health systems because of that. So, we are going to need several years, a decade of adequate revenue funding to be able to make up for that.
The Health Foundation estimates that by the end of that austerity decade we had fallen about £40 billion behind other countries in terms of our funding. That is revenue. The situation in terms of capital is even worse. Half the level of funding than is average in the OECD. That huge backlog that Richard Meddings talked about this morning; the difficulty of investing in digital in the ways we want to; and that lack of capital investment is a huge barrier for the amount of innovation that Amanda Pritchard talked about this morning. And of course, it goes without saying, workforce. We are finally going to see that workforce plan and it is going to be properly funded.
Health is the fastest growing marketplace, and we could be major players
When we talk about investment, and when we make the case for investment let's remember it is investment. Too often people talk about spending in the health service as if it is pouring money into a bottomless pit. It is an investment. Health is the fastest growing marketplace, and we could be major players. Within local communities like this in Manchester, the health service is a massive employer in terms of investment, and procurement. And of course, if you don't get your health and care system right, it has a massively impact on your economy. Look at the inflation figures, everyone is worried about inflation, part of what drives inflation is labour shortages. Why do we have labour shortages? Because we have millions of people who are not working because of their health and care needs.
Investing in health
When we don't put money into the health service, it has a huge impact on the economy. So, we have to talk about investing in health as an investment for not just the health service, but for the whole country. The third thing we need to do, is we need to start to deliver on something we have been talking about for many years but haven't achieved. That is that shift, that proportionate shift of investment in the health service, upstream, into primary, prevention, services based in the community, in people's homes. We know how important that is. We know that unless we do that - and by the way it is acute leaders who say this to me as much as everybody else, - we are just caught on the hamster wheel of meeting demand when it presents at the front door of the hospital. But yet again, we are not necessarily going in the right direction. The government has cut public health funding year after year. We have fewer GPs. A lot more hospital consultants but fewer GPs. So that we are not doing that. We are not investing upstream. And we have to do that. We will not have a sustainable health service unless we are better able to use the money in different ways, in terms of prevention and support and support in the community. So how do we do this? We know it is hard. Because we have been talking about it for a long time and we haven't done it.
Just like Patricia Hewitt called for a commitment to prevention in her report, so we need to be accountable, nationally and at system level, for achieving that shift of resources upstream
So, I think two things: I think firstly we have to say that we want politicians to say that it is a national target. Something we will report on, be accountable for, we want to achieve that shift of resources. Just like Patricia Hewitt called for a commitment to prevention in her report, so we need to be accountable, nationally and at system level, for achieving that shift of resources upstream. And secondly, a kind of, the other side of this is that we need to support those practical initiatives that are starting to make this happen.
Care coordination systems
So, one of the things I have become really enthusiastic about, going around the country, is care coordination systems. These start with an acute problem: how do we reduce the number of people coming to A&E? How do we get people out of hospital quicker? But when I go to the places doing this best - I was in Wolverhampton a couple of weeks ago, for example - you have a war-room of people from different agencies, from different disciplines, working together, taking calls from the ambulance service; working to deal with that issue there and then. Identifying where there are gaps in the communities. Starting to think about how we need to fill those gaps. Using the opportunity of virtual care to develop different kinds of pathways. Working together, starting to look at the data, thinking about how it is we can intervene earlier with the people who are most likely to be ending up ringing an ambulance because they feel they have an emergency. And to me, when I see that, that is collaboration in action. That is integration and collaboration in action. So, to get that upstream support you have to support the momentum of initiatives like that, that are starting to practically shift those resources into the community and into prevention.
The fourth thing we need to do, and I have stolen this phrase from Cathy McLean, we need to invert the pyramid. I think it is great.
The NHS is committed in their operating model to devolve. I'm pleased that today we see the government's response to the Hewitt review and whilst, as Victor said earlier, it doesn't give us everything we want, there is a commitment to go further to reduce the amount of targets and the number of over-specified and overregulated funding pots. So, it is good to see that. I understand there will be a new NHS mandate announced and hopefully that will go in that direction.
Now, there is a gap, however, between the trick of devolving and the actual experience people are still having within the system. So, we have got to go further. And at heart I think this is a cultural challenge. Too often in the NHS, when we talk about accountability, what we think of is accounting upwards to the people who are in control above us. So, the accountability that NHS England has to DHSE, that systems have to NHS England, etc, etc. We need to reverse that and talk about accountability being what you owe downwards.
When leaders have more autonomy and trust they are more likely to innovate
Accountability should be about - are you empowering and enabling those people that you are overseeing? Is the department enabling NHS England? Is NHSE enabling systems? Are systems enabling trusts? Are trusts enabling their clinicians, their managers? And this isn't just some kind of, you know, ideological commitment to devolution, the evidence is really clear: That where the centre of organisations are strategic and focused and not micromanaged, it has more impact. When leaders have more autonomy and trust they are more likely to innovate. Indeed, what we know about the best systems and the best organisations is that they have this characteristic: They combine top-down drivers of improvement - strategy, accountability, resourcing - with lateral drivers of improvement. That is, a culture of improvement that is about peer-to-peer support. Professionalism. And then bottom-up drivers, which is to do with being responsive to the public, to communities. That is what you get. That is the most dynamic system. At the moment, still, and as I say, it is great to hear the commitment from the department and NHS England, but it is too top-down to be as dynamic as we want it to be. So, supporting NHSE and supporting the department to a more devolved way of working is also a challenge for us in the Confederation. How are we part of that lateral effort to drive change and improvement? That is why I'm proud we are announcing this week a partnership with the Health Foundation and their Q network around improvement. We are doing more and more work on leadership development. We want to be a player supporting you, supporting our members in driving improvement and change in a health system which feels more dynamic and balanced in the way that it works.
But ultimately, if we are talking about empowerment - and this brings me to my fifth and final point - ultimately when we are talking about empowerment, what matters most is empowering the people that we serve. And that's why I think the fifth thing we need to agree about and to talk about, in the context of the 75th birthday, is a new social contract with the public. Seventy-five years ago the health service set out with a paternalistic medical model. We were the experts, the public were passive. We would cure them. That was the simple model. We all know now that it works very differently to that. We know the vital importance of patients feeling a sense of agency and control in their treatment. We know how so many of the things that are important to the sustainability of the health service, whether it is anticipatory care or patient initiated follow-up, or virtual care or shared care. They all depend on patients being partners with us. And I have just been reminded of this a few minutes ago. Remember during Covid, and at the heart of Covid we said - 'we must learn the lessons of Covid.' And, we seem to have forgotten that. Maybe it is Partygate or culture wars over lockdown, I don't know, but in Covid, millions of people, nearly everybody, made major sacrifices to protect their own health and the health of other people. People undertook diagnostic tests, at home. People, of course, went out and got vaccinated.
We realised, in order to make an impact in the most disadvantaged communities, we had to reach out to people who had reasons not to trust us
In the health service, basically leaders in localities were allowed to get on with it, to respond in the best way. We realised, in order to make an impact in the most disadvantaged communities, we had to reach out to people who had reasons not to trust us, not to have that sense of agency. So, we have to go back to some of that learning, as we think about how we empower people in the health service. So that new social contract is fundamentally about the fact that we need to offer more. And we need to empower more. We published a report with Google Health the other day about technology. People often talk about people being fearful of technology. Overwhelmingly, patients - and this included patients with long-term conditions - said they wanted to use technology as a way of supporting their care. But they also said they wanted to be involved in designing that technology, that it should be user-friendly, that clinicians should spend time with them explaining how it works. So, if we want a sustainable health service for the future and also the most effective health service, we need to change that conversation. At every level we need the public to understand that the health service cannot thrive and be there for them, unless it is a partnership between those of us who provide the service and between the public themselves. And if we get that partnership, that dynamic partnership, then, an enormous amount is possible.
if we can develop that social contract with the people, then we can achieve something amazing
Now I think if we do these things, if we have a strategy for health, rather than just policies for the NHS, if we get the proper, sustained investment that we need, if we can shift resources upstream and into primary prevention, community sections, if we can invert the pyramid to empower managers and clinicians to find local solutions and if we can develop that social contract with the people, then we can achieve something amazing. And that is that we can grasp those opportunities that technology is going to bring, is already bringing. Both opportunities for the personalisation of care, to empower people but we can do that while holding fast the thing people most care about, that is the principle of equity that lies at the heart of the health service. So, I think we need to take this 75th birthday opportunity to develop a shared vision, to communicate that vision with the public, to win that argument about what we need. And I think that if we do that, there is no reason, at all, why the NHS cannot, once again, be the best health service in the world.