FIRST MINISTER’S SPEECH AT NHS CONFEDERATION CONFERENCE

11 NOVEMBER 2010

Thank you for inviting me to speak to you today. Let me start by paying tribute to what you and your staff have achieved over the last year.  You were instrumental in delivering the biggest and most radical reform of the NHS in Wales in a generation.

 

This was a big task, but one that lays the foundations for delivering higher quality care for patients, with single organisations now responsible for all health services within their areas.

 

Delivery:

You have delivered improvements to patient care.

• Many doubted that the 26 week referral to treatment target could be met – but NHS staff delivered it.
• Improved health outcomes for people with chronic conditions are being realised, with more integrated care provision helping to keep greater numbers of people out of hospital, live healthier, and be more independent.
• The 1,000 Lives campaign has improved patient safety and saved hundreds of lives  and in specialist services like renal services, there is improved access with more dialysis services closer to people’s homes.

 

Achievements like these are never easy, and they are testament to the commitment and professionalism of NHS staff.   Such achievements will no doubt become more challenging in future.

 

Challenges Ahead:

Last month’s Comprehensive Spending Review was the worst since devolution and the worst of all the devolved nations.  In real terms, the settlement amounts to a reduction of £1.8bn over the next four years.

 

Our Budget next year alone will be £860m less than this year and comes on top of the savage Budget in June.  This will no doubt be of concern to you in the health service.  Health spending comprises 40 per cent of the Welsh Assembly Government’s budget.   Next week, the Welsh Assembly Government will publish its draft budget for the next three years.

 

I can’t reveal the detail of that yet, of course, but let me make this commitment to you.  The NHS has, and always will be, a priority for the Assembly Government, and we are doing all we can to protect frontline services.

 

Now, that doesn’t mean that the NHS can afford to take its foot off the pedal in terms of looking for ways to work smarter.   I know that the NHS is already performing more efficiently than it did some years ago.

• The average length of stay in hospital for orthopaedic care and treatment, for example, has fallen by a whole day since 2005/06 and almost 5,800 fewer operations are cancelled annually compared to four years ago.
• Edwina Hart’s health reforms – streamlining the NHS from 32 to 10 organisations, removing the internal market – is making savings from the reduction of unnecessary and expensive transaction costs.
• Management costs are being reduced by £40million a year, with about £20million achieved by the end of this year.

The NHS will need to accelerate the impressive efficiency gains it has already made in recent years.  A theme of this conference is to go further and faster on chronic conditions management, reducing the strain on hospitals and delivering the integrated care systems that the NHS reforms are designed to deliver.

• The number of avoidable hospital admissions needs to fall faster through treating chronic conditions more effectively in the community.

• Reducing the average emergency length of stay for general surgery by a third of a day has already released 12,000 bed days – but we must go further.

 

Efficiencies are often interpreted – deliberately or not – as cuts.  But the fact is that increased efficiency and better public services go hand-in-hand.  A shorter length of stay is better for the patient, as well as being more cost-efficient to the NHS. 

 

The Welsh Approach:

In my speech to the Wales Governance Centre last week, I said that in England the approach has been to cut the budget, work in silos and leave services to make the best they can of it.  In Wales, helped by our scale and culture, we are building a joint vision and concerted action to achieve better outcomes for our communities.

 

We saw this distinctive approach in the way that public services and social partners came together to lead Wales out of the recession and we’re seeing this in health and social care.Yesterday, the Assembly Government published a progress report on how the NHS is delivering better chronic conditions management.   The report shows how different partners are working together to improve patient care.

 

Multidisciplinary teams are coming together to transfer more services traditionally provided in hospitals to primary care settings, such as diabetes services and rehabilitation clinics for respiratory, cardiac and musculoskeletal conditions.

 

In Carmarthenshire, for example, the total number of bed days for coronary heart disease were reduced by 35 per cent between 2008 and 2009, a cost saving of over £450,000.

 

There are other examples of where public services are working together.

• In Gwent, the Frailty Project is bringing together health and social care professionals to make sure patients have access to the right person at the right time, helping people remain independent by providing care in or closer to their homes, avoiding unnecessary hospital admissions and delivering efficiency savings of around £1million a year.

•  In Merthyr Tydfil, Rhondda Cynon Taff, Newport and Wrexham, local authorities, together with the Health Boards in their areas, will pioneer innovative Integrated Family Support Teams to strengthen support for vulnerable children and families.

• The new multi-agency teams, which are unique to Wales, are bringing together social workers, family workers, substance misuse professionals, nurses and health visitors, to work directly with families to protect and support vulnerabl
  e children.

 

These examples show the important role that social services play in achieving more effective joint-working across the interface with health.

 

We must therefore remain ambitious for social services, as well as for health, in the face of the financial challenge.  Social services will not be sustainable unless we are able to meet financial pressures and, crucially, the challenge of changing expectations, social pressures and the demands of an ageing population.

 

That is why the Deputy Minister for Social Services has commissioned a series of strategic reviews over the last 12 months.  These reviews will give us a way forward to meet these challenges.

 

Foremost of these is the independent Commission on social services which was established last year to consider the future delivery of social services over the next decade.  Its report will be published this month and our response will be outlined in a White Paper on social services in the New Year.

 

What the examples of partnership working I have outlined show is that we have a distinct approach to public services within Wales, a co-operative model that England finds hard to emulate.

 

Take the proposed health reforms in England in terms of GP commissioning for example.  The British Medical Association has said the proposals risk pitting GPs against each other in a market-based system which creates waste, bureaucracy and inefficiency.

 

Services will only improve if GPs can work with others in a co-operative environment.   Contrast that with the approach our health service is taking – an approach based on collaboration, not competition.   The model that we are following in Wales is essential if we are to successfully tackle the issues that cut across all public services.   Only by working across all public services to address the wider determinants which affect people’s health – factors like poor housing or educational attainment – can we make a difference.

 

However, the cuts will place real pressure on our ability to meet the needs of our population with the same high standards of service and care that we have developed over the last 10 years.

 

How NHS Staff can play a part:

So we need to consider every potential avenue to become more efficient while at the same time relentlessly pursuing the best possible quality of service.  The way to do that is to talk to staff at the coalface.  The NHS in Wales employs around 84,000 staff – around one in four of the Welsh workforce – which is why it’s crucial that we listen to them.

 

I met many NHS and social care staff on my tour of public services over the summer.

 

In England there is a sense that social partners and the workforce are somehow the problem, rather than the solution.  I see things very differently.  I saw first hand the enthusiasm and expertise at work in the NHS.  So there are tough decisions ahead, and these will inevitably impact on staff. We have to work with them to find a way through, because staff know better than anyone else how to save money – so that we can deliver the same or better quality services.

 

Just look at what NHS Wales staff have achieved over the last few years.

• The 26 week referral to treatment waiting time target – achieved every month since December 2009.  Incredible, when you think that just five years ago, 75,000 patients were waiting over 26 weeks for treatment and 12,500 waiting over a year.

•  The 31 day target for urgent cancer referrals – met for the eleventh month in a row with 99 per cent of patients seen within that time.

•  Ambulance response times – a year ago the subject of much criticism – but now the target for emergency responses to arrive within 8 minutes has been met for eight months in succession.

•  Delayed transfers of care – since September 2003 delayed transfers have reduced from over 1,100 to just under 550, a reduction of almost 50 per cent.

The NHS reforms are seeing a new set of behaviours where competition is being replaced by collaboration, joint working, whole systems thinking and, now that service delivery has improved as a result of targets being met, a greater emphasis on quality.

 

Targets:

The pros and cons of targets are the subject of much debate.  Today, there is a broad consensus for a move away from a culture of targets to systems that better measure the outcomes and experience of citizens.  Markets and targets go hand-in-hand.  Targets develop a culture which undoubtedly deliver benefits in the short term.  But they are exactly that – short-term transactional measures which in themselves will not generate sustainable improvement.

Targets had their place, when services in Wales had their shortcomings, but delivery is now much better than it was some years ago.  The next step is to improve the quality of care we provide.  So, as we move to a period of austerity, we need to get smarter about what we do and not simply seek to drive the system even harder by a target-driven culture.

 

Sustainable improvement can only be brought about by tapping into the enthusiasm and commitment of the whole workforce – the kind that I witnessed on my public services tour – to generate lasting improvement and innovation.

 

We need to have a greater emphasis on understanding what works well and give more autonomy to clinical teams and managers to tap into the full potential of their organisations.   Now that performance has been improved through targets, we need less command and control and centrally driven targets and give more freedom to staff to innovate and improve services.

 

The 1,000 Lives campaign is an excellent example of this.  Two years ago, every NHS organisation in Wales voluntarily signed up to the campaign to improve patient safety and the quality of healthcare.

 

As a result we have seen numerous improvements.

• There’s been a significant reduction in healthcare associated infections in critical care units.

• Ventilator associated pneumonias are now becoming a rare event, rather than an expected complication.
• And action taken to reduce bed sores, also known as pressure ulcers, has resulted in a number of wards going more than a year without a case.

 

These changes have made a real difference to patien
ts.  They have clearly saved lives and the efforts of staff must be applauded. 1000 Lives Plus, the successor campaign, will continue this work, and we need to build on this kind of staff engagement to accelerate the pace of improvement.

 

I am acutely aware that a move away from central targets may be interpreted as an excuse to slacken our commitment to service improvement and that waiting times no longer matter.  Far from it, these have been hard-won gains.

 

But given the significant improvements we have made over the last four years, it is now time to place a greater emphasis on the input that clinical teams, citizens and stakeholders can make to ensure that patients and their carers receive excellent services.

 

A good example of this is the development of intelligent targets – a target that is centred on the patient and is developed in partnership with, and owned by, clinicians in all professional groups.

 

• In stroke care, intelligent targets have made a real difference to the quality of care patients received.

• Significant improvements have been seen in the time from a patient being presented at A&E to their admission to a stroke unit -  along with an increased percentage of patients who are mobilised within 72 hours.

• Intelligent targets on stroke also go beyond just initial delivery – such as treatment and discharge of patients – to enhancing health outcomes such as longer term rehabilitation and care.

 

Expressing ‘outcomes’, rather than ‘targets’, also allows local services to reflect the geography and demography of Wales, and sets people free to develop excellence which is locally appropriate.   So building on the achievements already delivered, the aim in next year’s Annual Operating Framework, will be to have fewer targets for the NHS in Wales which promote health improvement and more integrated working between health and social care, which will ultimately drive better outcomes for patients.

 

And because improved health outcomes will be at the forefront of this new way of thinking, we will measure patient satisfaction and experience.

 

End

The NHS, was born in Wales, and is the pride of Wales.   I’m proud that the NHS in Wales has remained true to the principles of its founder, Aneurin Bevan, with services provided free at the point of need.   That’s why I’ve promised that universal benefits such as free prescriptions are here to stay.

 

Critics say that free prescriptions is a gimmick, a waste of money, and – most ridiculously – that it has resulted in an increase of over-the-counter medicines being prescribed to people on a higher income who take advantage of it to obtain medication such as cold remedies or teething gels.    

 

What utter nonsense.   Try telling a patient with asthma, heart disease or high blood pressure – who previously were not entitled to free prescriptions and are now able to live healthier, more rewarding lives thanks to the policy – that it’s a gimmick.

 

Too costly?   Surveys undertaken by the Citizens Advice Bureaux and the Office of Fair Trading show that if patients could not afford or were deterred from paying for the medicines they need, the long term costs to the NHS could be far greater in terms of avoidable hospital treatment.  So for me, the cost of free prescriptions is a price worth paying.

 

And research undertaken by Public Health Wales – which since 2003 has been tracking the trend in both the number of prescription items and selected medicines sold over-the-counter from community pharmacies – has found absolutely no evidence to back up the claim that it has resulted in an increase of over-the-counter medicines being prescribed.

 

There’s a wider issue here too.   The recently announced welfare cuts at UK level will hit Wales disproportionately hard given our historical legacy of poverty and vulnerability.  These actions risk pushing some of the poorest and most vulnerable in our communities below the poverty line.

 

A Citizens Advice Bureaux report, prior to the introduction of the policy found that 50 per cent of people who had to pay prescription charges reported difficulties in affording the charge and 28 per cent had failed to get all or part of a prescription dispensed during the previous year because of the cost.

 

Past experience has shown too clearly what happens when financial pressures are translated into all-round cuts in services – with those in greatest need often taking the biggest hit.   That is unacceptable.  As a nation, we have to do everything we can to narrow the equality gap, not widen it.   It’s that overarching principle of chwarae teg, fair play for all our people, on which the NHS was founded and which my Government is basing its priorities.

 

And I know that you as NHS staff who care for any patient, regardless of their background, will appreciate that principle more than most.

 

Thank you.