Thank you.
This draws directly on from David's presentation, where he talked about the Call to Action.
One of our prime duties in the legislation of course is to promote a comprehensive NHS,
and that is not just for now, that is into the future.
That is what our strategy process is about.
I will not go through the paper in detail, nor the Call to Action itself, because I think
when we launched it last Thursday it got a good deal of prominence and, indeed, quite
a lot of support for its approach.
I do want to just pick out four points.
Inaction The message at the heart of the Call to Action
analysis is that doing nothing is not an option.
I know the Institute for Fiscal Studies have just published their latest report on the
economic outlook, and they are reinforcing some of the messages in the Call to Action
about the state of public finances going forward, that they are not going to suddenly open up
and become much easier, much more generous.
I think in a number of the debates we have heard around that and around other long term
economic projections, people have identified a set of trade-offs for public services.
Are we going to look to reduce entitlements?
Are we going to look to increase charging?
Are we prepared to drop standards in particular areas?
NHS England in its Call to Action is saying none of those are acceptable options to us;
they do not fit with our values, they do not fit with our mission for serving patients
and population in this country.
So, that leaves us in a place described by this piece of work, which is: we need to be
able to identify the right changes in the interests of patients, in the interests of
communities, and be able to bring about those changes at an accelerated rate.
Methodology That leads, I think, to the second point I
would draw out, which is how you would go about that, and I think that is only through
a process of really honest, open engagement and involvement.
So, while we have set out the analysis last Thursday, that is just the start of a process
we want to see right the way across the country, where our partners in health and wellbeing
boards, where patients, the public, voluntary groups and charitable groups are all deeply
involved in sharing with us their understanding of what great health systems should be looking
like over the next five to ten years.
It is through that process of involvement and engagement that I think we will be able
then to respond more swiftly maybe than the health system has been able to do previously.
Support I think the third point that gives me quite
a lot of confidence in this is the nature of support that we have had from many of our
partners nationally.
So, I know in the paper which we wrote a little bit before we published the Call to Action
itself, we name check a number of our national partners; in the final tally, every single
one of the health system partners signed up.
They wanted their names to be associated with this work, but also local governments represented
by local government association and I think, really importantly, the clinical commissioning
groups across the country through their representatives.
So, this is a very broadly owned mission to identify a vision for the NHS in five to ten
years.
Future This leads to I think my last point, which
is that this will not be just about interesting ideas and good conversations; this will lead
to planning, and we will a traction which will help us actually deliver those changes.
That is both at the level of clinical commissioning groups and health and wellbeing boards where
we will be looking through the end of this to come up with real plans for change.
Similarly, for us as the NHS England commissioner for the way we commission primary care, for
the way we commission specialised services, for the whole range of work we can do around
incentives and financial change, but also in the area of transparency and that whole
relationship between citizens and service that Tim and his team, I think, are leading
in really quite an innovative and exciting way.
We will be setting out real plans for how we make that real over the next five years.
Therefore, I would commend this to the Board, and I would note that this is just the start
of a very significant process of engagement over the coming months.
Q&A Malcolm Grant: Thank you, Bill.
I think all the Board recognises that this is essential but that also it will be a very
tough exercise.
We have got a very good consensus around us for the case for change.
Maintaining that consensus as we go through to examine new options is going to be a real
challenge.
It is going to be essential, I think, that we engage clinicians and front-line delivery
people right across the NHS to help us to envisage this because it will affect how the
whole service looks in 10 years.
It will affect what we can do for the public.
It will affect the empowerment of patients.
There is a huge emphasis on prevention and the public health agenda that is all tied
in together.
What it does most of all is disrupt the existing set of expectations.
It is not a structural change.
We have to work within existing structures, but we also have to be able -- as a Board,
I think -- to ensure that there is sufficient commitment and stability over time, so that
people can see a direction of travel, a convergence of support around that, if we are to have
any chance of maintaining the highest quality healthcare system in these adverse financial
circumstances.
Let me invite comments, if I may, from members of the Board.
Moira Gibb: Malcolm, thank you.
I think David made reference to other healthcare systems, as it were.
Is there going to be an international perspective to this work, and are there examples?
Often when the NHS is discussed, it is terms of not comparing well.
However, I think it compares very well.
Are there examples of what has happened in other places that we will bring into this
discussion?
Personally, I think it is quite difficult to consider myself as a patient in these circumstances
rather than in any other capacity, and to think differently unless you can see examples.
Giving people opportunities to see what is happening and how things have changed elsewhere
might be very valuable.
Bill McCarthy: I think that is absolutely right, Moira.
I have two points on that.
I think probably the most respected think tank who compare different health systems
is the Commonwealth Foundation, which is based in Washington.
They take a number of the developed nations.
They look at the health systems and they try to compare against a set of criteria: efficiency;
effectiveness; quality; outcomes.
Consistently, the NHS rates very highly.
It has been in the top two in the past three comparisons they have done.
To an extent, that is great news for us.
That really does validate us on the excellence across the NHS.
However, we do know that there are elements where we can learn.
A Lancet article several months ago compared some of the outcomes in particular clinical
areas where we can improve and we must improve.
As well as feeding in some of that data and analysis, we are proposing this autumn to
bring together what we are calling a symposium of some of the expert think tanks and some
other organisations who have experience of working both in this country and abroad, and
bringing them together into one place to describe -- from that experience and learning -- what
they think a great NHS might look like in 10 years' time.
We think just bringing some of that thought leadership and this exchange of ideas would
be a really good way to challenge us at the time that we are doing our own planning.
Naguib Kheraj: I have just two comments, Bill.
I thought the document was excellent.
I think that setting out the really big things that need to be addressed to make the whole
equation work is really critical.
There are two things I wanted to make a point about.
The first is: how do you translate this?
You talked about the things we may do over the coming month.
The concern I have is that we have a debate about the long term but we do not have actions
that we are taking that take us on a path for the long term.
Over the course of the next six months, what will actually do with this?
The second point is related to that.
If we now look at every decision we are taking that is incremental -- for example, if we
are looking at next year's plans in different areas -- how do we already start to take on
Board the direction of travel in the decisions we make?
That is something I am struggling with.
Bill McCarthy: I think I have probably got the same answer to both of those questions,
Naguib.
I will be quite cartoonish in this because it would not be fair everywhere but at times
in the NHS we have planned very incrementally.
We have thought how things are now, what the next year's money will look like, how we can
make some improvements, keep our heads above water, and we are always looking at that short
term.
The idea here is that we put that planning into the context of where we want to be in
five to 10 years' time.
That will only really make a difference if we connect it back into our planning processes.
While we will have the vision, we will have the challenge and we will have the question
of how services should look five to 10 years out, we will follow that up with the proper
planning cycle.
We will be working with people to say, 'if that is where you want to be, what are the
steps you are taking next year, and what are the steps you plan to take two years out?'
We would expect pretty hard, specific actions, backed up by the commissioning intentions
and by the sorts of collaborations with partners that will be needed to bring about the change.
This is not just about a theory of vision some way it out.
It provides the context against the really specific planning to get there over the next
few years.
Naguib Kheraj: With that course of action, the two things that strike me are that usually
when you make big changes either you have a combination of having to spend more in the
short term to create the change that enables you to do something differently, or in order
to do something differently or shift resources, you have to do less of something else.
Do you have concerns about those two things?
Is there an investment to create the capacity or a reduction in something in order to do
it?
Bill McCarthy: Paul may wish to comment, but I would be very surprised if that strand of
work, which we have called Financial Incentives for Change, did not get feedback both nationally
and also our local partners which says, 'we are not sure they the right incentives and
the right mechanisms to promote and support change at the pace we need.'
I would have thought that is an area in which we would need to be quite innovative.
Paul Baumann: I think I would just make two links for you, Naguib.
One is to the incentives and business model strands that we are doing, where we will really
give some thought to the specific question you ask, which is: what is the transitional
cost to get from where we are today to where we want to be, and how do we make the funds
flow to do that?
Much more concretely, and without wishing to bring forward an agenda item that comes
later in the meeting, there is the response to the Spending Review which, in my mind,
has brought forward very much the very focused discussion we need to have about how we make
that transition, how we use investment money and -- first of all -- how we create investment
money.
If I can just signal forward to that agenda item, I will directly address the topic that
you have raised in that context.
Malcolm Grant: Okay, may we return to Naguib's point when we reach that item on the agenda,
because the Spending Review is a spur for carrying out some of this work.
Victor Adebowale: I have a question.
First of all, I would like to welcome the fact that you are making a particular effort
to hear the voices of people who generally are not heard in consultations like this.
Naguib's point is that you can stop doing something, you can do less of something or
you can radically change and redesign something.
I was just wondering what you think the appetite is for that, and how we are going to know
that those voices that are not normally heard are actually influencing the outcome?
Bill McCarthy: My view is that NHS England absolutely has that appetite and that flows
directly from analysis that tells us that if we do not pursue some fairly radical redesign
and change in the interests of patients and communities, and particularly those that have
not perhaps fared so well in the past and are at risk of being left out, then we get
into that debate which in our values has been very unpalatable.
It is absolutely not where we want to go, which is: what do you pare back on or what
standards are you prepared to compromise on?
I think this is a very clear statement that we are into that area of compromise and cutting
back.
We are into the area of radical change in the interest of patients.
Ed Smith: I would just back that up by saying the whole design of this looking five to 10
years out, and the stakeholder participation that is absolutely integral to the success
of this, should enable us to really reimagine parts of this.
It is going beyond redesign to reimagine the whole construct of how service is delivered,
because the frontline and the consultation processes will start to bring some of that
out.
Victor Adebowale: I think we will find out what commissioning actually is, rather than
what it has been.
I think it is a very powerful intervention.
Malcolm Grant: I think that has been very interesting.
Thank you, Bill.
We will expect you to come back to the Board on several occasions over the coming months
with updates and also real engagement by all members of the Board, and non-executives as
much as executives.
This is something that we all own and that we all wish to succeed.
May we then turn to item five on the agenda?
Again, this is another hugely salient issue for us, which is: the Patient and Public Voice?
I am going to invite Tim Kelsey to introduce the paper.