Speech to Primary Care Trusts

5 December 2006,The Prime Minister has highlighted the significance of two reports that he received this morning from Health Secretary Patricia Hewitt in a speech to the NHS Confederation.,He described the reports as "a compelling and vivid account" of the programme of hospital service improvement that the NHS is currently undergoing.,Read the speech,Thank you. I am delighted to be here with Jill, and with David and with Patricia of course, and good luck David - I think you may need it.,But what you say is actually extremely important, which is that the inaugural¹ meeting of the PCT Network within the Confederation is important, but also is the fact that we are happy to give you the support in the work that you do because the future of the NHS will be developed in part through better commissioning, and the better you commission NHS services the better healthcare will be.,And look I think the biggest frustration² by far in getting across a balanced picture of the NHS today is the gap between people's personal experience of it, which is usually excellent, and their perception of it as a whole which is often negative. And the fact is that on any objective basis for all the challenges, and largely thanks to people like yourselves working in the NHS, the NHS is improving, often quite dramatically, in its treatment of patients, but it will only carry on doing so if like any other institution or business in the modern world it continues to meet the challenge of changing times. And I think the thing that is very obvious, but is worth saying, is that everybody knows that the services they receive and the services that they work for are undergoing processes of change, changes in the expectations of their customers, changes in technology, changes in working practice. It would be bizarre if the NHS alone of all institutions in this modern world did not also face those challenges of change.,And the important thing for us together is to try and explain why this change is happening, why it is necessary, why in the end it will be to the benefit of patients. And I think certainly David you have learnt a lot from your six years heading up a PCT, I mean I have learnt something from almost ten years as Prime Minister, which is that if the politicians do this on their own it is not nearly as effective or persuasive³ frankly⁴ as if we do it together, the people working in the service and the people responsible for overall policy. And there is probably no area of domestic policy changing more quickly than healthcare. The demands and requirements of patients are rising.  I am constantly struck when I talk to patients, and for example someone the other day was telling me that over the past ten or fifteen years they have had a pace-maker fitted, the first time they had it fitted they were staying several days in hospital, they were under general anaesthetic, the last time they had the pacemaker fitted it was done under local anaesthetic as a day case surgery. So you know these changes are perfectly⁵ natural and they are happening all the time.,The other thing of course that is happening increasingly is that technology is empowering us to deliver that change in a different way.  And I think the issue really today is not is there a change-free option, because there isn't, in the end, whatever we decide to do if we are going to keep the NHS vibrant⁶ then there has to be change, the question is what sort of change.  And I think the choice is this, either we shape the change to ensure that the principles of the NHS are preserved for another generation, or we let the change as it were shape the NHS but in a haphazard⁷ and random⁸ way.  If we just recall the NHS of ten years ago, waiting lists were well over a million, on an in-patient waiting list a quarter of a million people or more at any one time waited over six months. Many patients - I know, I used to receive letters when I first came into office from their relatives - used to die waiting for cardiac care. The length of time waiting for a cataract⁹ operation, if you remember that, was often over a year, sometimes two years.  On the out-patient list there were some 160,000 people who waited over six months and over 300,000 over three months. Cancer patients regularly failed to get to see consultants¹¹ for weeks after being told by their GP that they might have cancer, and Accident and Emergency Departments, all of us remember using it in those days, was often a disgrace and people could wait hours and hours for even the simplest treatment.,So I think people a decade ago were kind of asking not will the NHS work but could it work, I mean was it an inherently flawed concept almost that meant that it had to be dismantled¹²? And I think now that is not the question, now people accept it can be improved, the question is how.  Waiting lists are at their lowest level since records have been kept, the maximum wait on the in-patient list is down from 18 months to 6 months, cancer deaths have been cut, cardiac deaths have been cut and there are whole new services, NHS Direct, walk-in centres and so on.,Now a lot of this is about the extra money that has gone in, there is no doubt about that, the investment has helped, but actually alongside the money the single most important other dimension to this progress has been the fact that the system itself is undergoing change.  Now managing this system of change is incredibly difficult, there are different elements to it, we are trying to put greater choice in the hands of patients, we have got new suppliers, whether it is independent treatment centres, the Foundation Trusts as a different way of running hospitals, there are the new service frameworks, there is NICE, and then there are the changes we are making now in the primary care trusts, in practice-based commissioning and in the changes that we are trying to make at a local level to bring care closer to people.,I think the most difficult aspect of all of this is not simply trying to introduce these different systems, but trying to see how everything fits together and how we incentivise people, particularly you who are at the sharp end of this and have to take the most difficult decisions, to innovate¹³ and be creative in how you are giving patients care in a different way for today's world. So practice-based commissioning should reduce unnecessary referrals, but that won't happen just as a matter of course, it has to be managed.,Chronic¹⁴ disease can often these days be managed in primary care, but again that won't happen just naturally, it has got to be a system of change that is put in place for it to be done. The elderly can be looked after at home, diagnostic tests and minor¹⁵ surgery can be carried out nearer to home where patients want it to take place, all of that is true. And earlier today, as you know, Patricia received two reports from two of her national Clinical Directors, that is George Alberti and Roger Boyle, and what they offer is a compelling and vivid account of change and why it is necessary, but also why it is difficult.,If we take Accident and Emergency, 18.5 million people go to Accident and Emergency every year, very few have life threatening conditions.  Major emergencies only affect about 10% of people, most people would actually be better served by care that was closer to home. At the moment if you have a pressing medical need you end up almost inevitably¹⁶ in Accident and Emergency, but in the light of the changes in medicine we need to do better than that, we need a diverse set of institutions, GP out of hours services, pharmacies¹⁷, social service, mental health teams, minor injury units, walk-in centres to treat the range of different needs.  Lots of people for example who come straight to A&E would for a variety of reasons be better treated elsewhere. For example paramedics can administer life saving drugs to heart attack and stroke victims on the doorstep.  If you have a stroke at 2.00 am in the morning you want to go to a centre with access to a CT scanner 24 hours a day. For the life threatening emergencies a specialist is needed at once.  If you have a rupture¹⁸ of the major blood vessel¹⁹ for example you need an experienced vascular²⁰ surgeon with access to 24 hour laboratory services and radiology. The right care for strokes is now to have a CT brain scan within three hours, followed by aggressive rehabilitation²¹ with thrombolisus (phon) in appropriate cases, but that level of expertise²² can't be offered everywhere.,That is why it makes sense, alongside local provision to create specialist centres of excellence²³ which have 24 hour consultant¹⁰ cover and access to state of the art diagnostic equipment.  Therefore alongside that specialist emergency care, we can then offer a quicker and more immediately appropriate service, the patient gets a more specialised service, in most cases closer to home, this can range from immediate²⁴ telephone access to information assessment²⁵ and advice on self care or the best place to seek further help, through to home visits and access to centres of care.  There will be many more paramedics and nurses trained to treat people at home and stabilise the patient's condition for longer journeys. And people will then have a shorter stay in hospital because the initial care received will be more specialised.,The reason therefore for all of this change in the end is the best reason there can be, better treatment for the patient, and of course this means at times the way capacity is provided may be changed, and I don't minimise either the difficulty or the importance of that. But we do need to make the case for these changes, and in that task I hope clinicians themselves will become ambassadors for change and improvements.  What this means in each locality frankly is a lot of it will be up to you in the PCTs and working alongside local clinicians you will be the main organisation²⁶ developing these new improved services in your locality. We, the politicians, have to back you when you have the courage to make those changes, and we will, and you need to have the confidence to make the argument for service improvements.,Now I don't under-estimate for a moment the difficulty of all this. As I often say to people, and I was saying this to the head teachers and deputy heads that I was addressing at a conference in Birmingham last week, the most difficult thing in any walk of life is to make change, there is a natural in-built resistance to it. On the other hand, I think what most people realise is that once you get through the process of change and out the other side, it is remarkable²⁷ how what was going to be the greatest disaster and catastrophe²⁸ ever to hit the world suddenly becomes part of the normal way of doing things. And the real reason why I think now is the right moment to do it is that for years and years, and certainly when we first came to office, there was a real problem with under-investment in the Health Service, there is no doubt about that, but on the other hand sometimes that became a kind of excuse for not facing up to the need to reconfigure and change the system itself. ,There has been substantial investment in the past few years.  Now I am the first to be aware that no amount of investment is enough, as it were, and there are always going to be financial difficulties and financial constraints²⁹, but the truth is within any given resource there is always going to be the need to change the service in order to meet the challenge of the changing times in which we live.  This is particularly true in healthcare, which round the world at the moment is undergoing a big process of change. When I sit down with other leaders in Europe or outside of Europe and we get round to domestic politics, healthcare is one of the biggest issues in the United States, it is a major issue at the moment in Germany, it is a vast issue in France where their health service has been in severe deficit³⁰. There is not a single country round the world of a modern developed nature where this is not a major issue.  It is perfectly obvious why - people are living longer, more diseases can be treated in better ways and people's expectations are infinitely³¹ higher. When the NHS was first started people thought it was fantastic that you got free healthcare. Today people want free quality healthcare, and what is more they want it, as someone famously said, at the time they want it, in the place they want it, with the person they want. ,So it is that changing expectation along with the changing nature of the service and the treatments that are available pose a huge challenge. And sometimes what we need to realise is that this is not something unique to this country, or indeed unique to you as the people leading the PCTs, this is the world in which we live.,But the great thing is we do have I think the right components³² and framework for change now and what we have got to do, bit by bit and piece by piece as we work together is to make sure that change works for the benefit of patients. I genuinely believe the best is yet to come, more lives saved, stopping more pain and distress³³, treating patients better, making sure the National Health Service is as an institution the pride and envy of the world, as indeed it should be because of the standard of care we do provide for people and recognising that none of this will happen unless we have collectively the courage to remain steadfast³⁴, to see through the process of reform and change and to make the alterations³⁵ in the way the service is provided in order to meet the challenge of the modern world.,And let me just say I fully³⁶ know how difficult it is for all of you but I congratulate you on the work that you are doing. Sometimes perhaps you don't hear it enough from us, we are very grateful for the work that you do, what you are doing at the moment in the National Health Service I think it is one of the most exciting things happening in our country today.  It couldn't happen without you and without your commitment, so I thank you for that, and as I say together I am sure we will manage to do it.,Question:,Perhaps more importantly for my question I am chairing a network of Primary Care Trusts throughout the whole of Manchester, east Cheshire and the High Peak which on Friday will reach the conclusion of a two year consultation³⁷ period which will lead to significantly better services for children and women and their families. And that will result, whatever we decide on Friday, that will result in some reconfigurations and some accusations³⁸ that some services will be closing. And I am confident after the talk we have heard from the Prime Minister that we will get the support from yourself and from the Secretary of State, the reconfiguration will have lots of the elements that you have already described as far as A and E is concerned. Our fear is that we won't get the support from our local politicians, some of them will be members of your party, some of them may be members of your government, and our fear is that that will undermine the process and that is a real concern for us in taking our reforms forward.,Prime Minister:,It is a very fair point, and the trouble is when change happens everybody assumes that the change is either made for the worst of motives³⁹ or alternatively it is just bound to make the service worse. And I think in relation to children's services, again I think some of the stuff that we have done today on Accident and Emergency we could usefully do there because as I understand it, and I am not an expert at all obviously, but if you think about your child being unwell, in fact provided you can get the emergency treatment that is necessary actually you would want that child to be treated in  specialist state of the art facilities, and I think the move towards those facilities which you see going on right round the country, we have to make that change on clinical grounds. And you know I have said to my own back benchers as well as Ministers, if we are not prepared to back people making these difficult changes then in the end two things will happen: first of all they will feel that they can't make them, in which case we actually let patients down in the name of protecting patients; but secondly⁴¹, we will get to a stage two or three years down the line when we face the electorate⁴² again when people will say well for all the investment that has gone in, is this really 21^st century care that you are giving us? And you know that is the challenge of political leadership and I entirely⁴⁴ accept what you are saying, all I can say is you know my message to my own people is have the courage to back the change and realise it is better to get it through and get it done, because once it is done a lot of the difficulty will fall away.,I had a situation where I saw some people the other day and they were complaining about local cancer services for young people and the idea that those should be sort of regionalised, and they obviously didn't want to change the provision they were very familiar with. But in the end what I found helped was that a clinician who was present simply said to them look, this is highly specialised treatment today, you are better maybe making the additional journey and getting the highly specialised treatment than getting local treatment that inevitably isn't quite of the same standard. And I think particularly for example where you explain to people that it is like any other job, if people who are working in a particular locality don't get the substantial flow through of patients and get the experience in treating all sorts of different aspects of a particular disease or condition, then actually they are less qualified⁴⁵ over time. It is the same as  in any other walk of life. But I agree with you, it is difficult and you are right to say the challenge is as much to us as it is to you, but I feel this is a one-off chance for the Health Service to prove it can make these changes and if we fall down this time I think people's consent for a taxpayer-funded NHS in the way it is at the moment will diminish.,Chairman:,And perhaps one of the things you should throw back to us is what can we do at a national level through the PCT network to help you deal with people in the party and to give information that would actually help you as politicians manage what is a very difficult situation at local level. So perhaps that is something, David, we can take on board to think how we can help.,Patricia Hewitt:,I think that is very helpful Jill.  If you don't mind I will just add one other comment to Ian's  question because my understanding is you have put huge effort into involving your local Overview⁴⁶ and Scrutiny⁴⁷ Committees, local councillors, others in the community and also your local Members of Parliament. Now if I can give you an overview of how we handled a different difficult reconfiguration, and that was Calderdale and Huddersfield where they went through a consultation on changing maternity⁴⁸ services and paediatric services, absolutely driven by the fact that the clinicians were saying they could no longer staff safely  adequately two consultant-led obstetric units, very controversial proposals. It so happened in that case there were two Labour Members of Parliament supporting the decision, because that was where the single unit was going to be, two Labour Members of Parliament opposing it because they were going to have a midwife-led unit but no longer a consultant-led unit. Now that particular reconfiguration was referred to me by the Overview and Scrutiny Committee, they made a very strong case for a reference and I asked the independent reconfiguration panel to take a look at it.  Peter Barrett and his colleagues did a very careful and thorough job, went up, talked to a lot of people, were crystal clear in their judgment⁴⁹ that the clinical case was overwhelming for this change. They recommended some additional changes, more midwife provision, particularly in the disadvantaged areas of Huddersfield, a bit more work on the transport issues with the local council and so on, and on that basis I was absolutely clear we would support 100% that reconfiguration. All the Members of Parliament have now recognised, the decision has been made, it has been made on clinical grounds, it is the right decision, they will back it and help get the implementation⁵⁰. And I think that is one example of how you can take some time and effort, but you can mobilise political support even for things that are very, very difficult indeed, and there were plenty of marches in the street around that particular issue.,Question:,Can I first of all say Prime Minister we are very very grateful that you have found the time to be with us, so on behalf of the PCTs can I really thank you for coming here. And this follows on from the Secretary of State and her top team meeting us in September, so it actually feels that although 85% of patient contact in the NHS is in primary care, both of you actually being here makes us feel valued because really I think we have made huge progress, but we have got a huge agenda to do.  Can I also thank you and the Chancellor⁵¹ and all the Cabinet for the huge sums of money that you have put into the Health Service because I think it has been, I was going to say a leap of faith, I don't think it was a leap of faith, I think because you both strongly believe in a publicly funded NHS is why you did it and we want it to succeed because my biggest worry is that the electorate think that we haven't got the value for money out of all this huge investment. We have made huge progress, we want to do more, and what we really want to do is work with the government, we are up for it, we want change, we want to transform our Health Service but we need your help. I would like to make four suggestions of what we can do, and that is really to do with hospitals and acute care. There is no incentive⁵² for acute hospitals to transfer care out into the community financially, and particularly with Monitor which tends to measure them on finances and not on delivering with other NHS agendas. So my first suggestion is there needs to be some tie-in of somebody asking Monitor what have you as a Foundation Trust done in terms of improving the health economy?,Chairman:,OK, if we leave it at that, we have one question.  Now I was told and I am very bad, as many of you in the audience know about following instructions, not to allow statements, but I thought that was actually quite a good statement to start with because I suspect that actually the two people sitting here very rarely have people who say thank you, and as a doctor who cares about wellbeing, I thought it might be good for you to start the day with a bit of wellbeing.