Future of healthcare

Thank you very much,

I want to start by taking you back to the tail-end of a long and very hot London summer many years ago.

One night late at night, at a bakery in the City, a spark leapt out of an oven and ignited some nearby fuel.

London’s largely timber-framed buildings were bone-dry at that time. Tightly packed together in the narrow, unplanned medieval streets.

The year of course was 1666 and we all know what happened next.

When a system is hit with a big external shock it can be utterly devastating.

London lost a third of its buildings in the Great Fire, including its cathedral.

100,000 people were made homeless.

And the cost of rebuilding the city has been calculated in today’s money at 37 billion pounds.

But that same devastating shock can force people to find new and better ways of doing things.

The London Fire Brigade, the first insurance companies, building regulations that enforced access to running water, and of course Wren’s domed cathedral, the most ambitious public works project in the history of the city.

All of these have their origins in the nation’s response to the Great Fire.

And in that there is a lesson for us.

Because once again we have been hit with a terrible shock. A small spark that quickly turned into a global crisis.

Coronavirus has tested every single part of our infrastructure, giving us a new appreciation for what works and what doesn’t.

And once again, brilliant ingenious people have risen to the occasion.

Now it’s a long time since I’ve given this kind of speech.

And a long time since I’ve been in front of an audience.

And in these last few months, we’ve all been working every waking hour to lead the nation through the coronavirus crisis.

I am fully aware of the pain and suffering that this virus has brought to so many people, and we pay tribute to everyone that we have sadly lost.

Throughout this difficult time, we have protected the NHS, and in turn, helped protect us.

And that was thanks to the heroic efforts of many, many people.

This was a great achievement, in very difficult circumstances, but we know that we won’t have got everything right.

And that there will be lessons that we need to learn from this pandemic.

This includes what we’ve learnt both from our healthcare system and about it.

And today I want to step back from the vital work in the management of the COVID-19 pandemic.

That work continues every day, as we strive to keep this virus under control.

We can see a second wave emerging in Europe and we will do everything in our power to stop it reaching our shores.

However, today, I want to talk about what we’ve learnt about the health and social care system in this country.

How it worked during the crisis, and how it should work best in the future.

So first, what have we learnt?

Coronavirus has been a moment of exposure, of stark clarity.

Like sheet lightning on a dark night, it has suddenly and dramatically revealed our healthcare landscape in a way that we’ve never quite seen it before.

We’ve discovered things about our system that we could not have learned in normal times:

  • how it performed under conditions of severe, sustained nationwide pressure
  • the choices frontline professionals make if you give them greater freedom
  • what rules and structures are essential to the effective delivery of health and social care
  • and what are just a layer of bureaucratic barnacles that can be stripped away to streamline the vessel beneath

If you think about it, in terms of mobilising the resources of the state, the pandemic has been as close as you can get to fighting a war without actually fighting a war.

We achieved things that people never thought possible:

  • like building the Nightingale Hospitals in 9 days
  • or doubling ICU capacity to treat the most sick
  • or treating half of patients in outpatients and primary care online

At the same time, our brilliant scientists drove forward the first robust clinical trial to find an effective treatment for coronavirus.

And they are currently leading the world in the search for a vaccine.

Coronavirus has catalysed deep structural shifts in healthcare that were already underway:

  • telemedicine
  • data-driven decision-making
  • and working as a system not as atomised institutions

And just like a war it’s forced us to improvise new ways of doing things, some which will become permanent because they are better ways of doing things.

So for instance, before coronavirus, there were plenty of theories about how to transform health and social care.

In fact, the last 30 years is littered with top-down reorganisations and big-bang structural reforms, quangos and quasi-markets, and theories and pilots and reports and boards and commissions.

But something important has changed.

In the post-coronavirus world we don’t have to rely on theory.

Because we now have hard evidence how people choose to operate, under crisis conditions, when there is a novel and acute need to deliver.

We must learn from how the NHS and social care worked during the peak.

Both about what we must change. And critically, because so many things went right, we’ve got to bottle the best.

And this is in a way how I see my job and role as Secretary of State for Health and Social Care: not to impose some preconceived utopia that might look good on a management consultant’s slide deck but bears no relation to reality on the ground.

My job is to make the system work for those who work in the system, and work hard to make the system work: to free up, empower and harness the mission-driven capability of team healthcare.

So what do I mean by this? For an illustration of what I mean, come with me to Helsinki.

In Finland, town planners visit a park immediately after snowfall because the footprints reveal the paths that people naturally take.

The next summer, they go out and pave those paths.

They don’t sit in an office and decide where to put the path.

They watch where people go naturally and then they pave the way.

We too must pave the paths that people want to travel.

Because our healthcare system isn’t just complicated, it’s complex. It’s best led not by diktat but by mission.

And we are now at a critical moment in that mission.

We are carefully restoring our healthcare system. And as we do so, we must not fall back into bad old habits.

Instead, we need to take what we’ve learned, and build back better, capturing a culture that’s open to collaboration and change.

And I just want to dwell on this collaboration point. We saw collaboration like we’ve never seen before: between different organisations, different professions and between teams in different organisations.

And we saw things change. I mean really change. I’ve lost count of the times someone said to me since: “what would have taken months took minutes.”

In the heat of the crisis we saw a shared understanding:

  • that accepted truths or ways of doing things had to be challenged if they didn’t help
  • that the needs of the patient mattered more than the silos between institutions
  • and, crucially, that we value the contribution from everyone on the team

Now, throughout I’ve been talking to the people responsible for making the system work: from regulators to frontline staff, to leaders of trusts to local directors of public health.

And I ask what they think are the things we need to ‘bottle’.

In organisations as diverse as NICE, the Royal Colleges, the BMA, people come up with the same list:

  • collaboration: we work better when we work together
  • speed: it doesn’t have to take weeks and months to change anything, no matter how small
  • and innovation: that’s it’s not about coming up with the idea, it’s about having the backing and the permission to make the change

I couldn’t agree more.

So today I want to start a conversation about how we can put these values into action.

How we can capture a culture that lets our carers care.

And scythes away the red tape, attitudes and ways of working that stand in the way.

And to do this, I’d like to draw on 7 major, cultural lessons that I think we’ve all learnt over the past few months.

Lesson 1: value our people

The first is that we must value our people and trust them as professionals.

Now, it’s easy to say we should value people. But there are some hard-edged changes needed to make IT happen in reality in the NHS and social care.

Too often before the crisis, people were treated as numbers on a spreadsheet, when they’re the most important asset that we’ve got.

And when I say people, I mean all of our people: care workers, porters, cleaners, clinicians and leaders.

Everyone, of every background, in every part of our health and care system, has a contribution to make, and everyone needs to be supported to do their best possible work.

Now some of you may have heard, I love the story of JFK visiting the NASA space centre. He saw a janitor carrying a broom and asked him what he was doing.

“Mr President”, the janitor said proudly, “I’m helping put a man on the moon”.

This is what it means to be a mission-led organisation.

And we know what support for staff looks like in practical terms.

Because as well as that great outpouring of emotional support from the British public, the crisis brought real, practical help for the frontline.

Good food. Decent rest facilities. Someone to talk to about the most difficult experiences that frontline colleagues faced.

It shouldn’t take a pandemic.

All of this needs to become the norm for the NHS and social care: that we listen to our people and we look after them. Not just an emergency response to a crisis but all the time.

I am determined to make it happen.

We also learned that people do their best work when they’re trusted to get on with the job.

Don’t just take my word for it. Look at Admiral Nelson, one of the most inspirational leaders of all time.

When the British navy was heavily outnumbered at the Battle of Trafalgar, it was Nelson’s approach to leadership – the Nelson Touch – that proved to be decisive.

He worked hard to build an agreed strategy that everyone knew and understood – and then he expected everyone to use their own initiative to put it into place.

So, amidst the fog of war, while his adversaries were hamstrung, waiting for instructions from their admirals, transmitted by cumbersome flag signals, Nelson’s fleet knew what they needed to do, and they were trusted to work out how to do it.

Admiral Villeneuve, whose fleet was defeated by Nelson, said it best:

“To any other nation, the loss of Nelson would have been irreparable, but in the British fleet, every Captain was a Nelson”.

This is the mentality that we need. I want an NHS and care system that is full of leaders. Leaders at all levels. This is the principle embedded in the People’s Plan released today.

Everyone, at all levels, thinking like a leader and being encouraged to use their initiative and take ownership of their decisions.

And that means getting rid of what stands in their way.

I think it is vital to understand what happened when we made emergency changes so staff could focus on the crisis.

Take the GMC and NMC, who:

  • set up registers for extra healthcare professionals
  • and gave professionals the flexibility to postpone their revalidation
  • allowed students to continue their studies while at the same time contributing to frontline care
  • and most audaciously of all, gave clinicians from areas far removed from respiratory illness, for instance dermatology, gave them the confidence to work in unfamiliar COVID wards.

Or look at the CQC’s Emergency Support Framework.

The CQC adapted their traditional inspection-based model of regulation to the new reality, using data and feedback to identify problems in real time.

And where there was a problem, working with them to have ‘honest conversations’ and provide ongoing advice and support.

Now when we made those changes the sky didn’t fall in. On the contrary.

The NHS was protected. Patient safety was protected. And crucially frontline staff felt empowered.

But empowerment is not just about giving people the freedom to make decisions.

It’s also about requiring them to make those decisions.

If you give people responsibility, they will act responsibly.

So we cannot, we will not, revert back to before. The GMC, the NMC, the Royal Colleges, the Academy of Medical Royal Colleges, the CQC, NHSE, we are all together on this mission.

The regulators and our NHS and care colleagues excelled during the pandemic, showing their ingenuity, their resilience and their versatility when it mattered.

And over the coming weeks they will be building on the action they’ve already taken to put this agenda into practice – for the long term.

Today the NHS published the latest part of its People Plan.

And aligned to this vision of an empowered culture where leadership at all levels supports every single NHS employee to reach their potential.

This is all about building that culture of trusting people to use their professional judgement, to do the right thing, instead of seeming, appearing to assume someone will do the wrong thing unless they have layers of management peering over their shoulder.

Together we’ll build a system of distributed authority, where decisions are made as close as possible to where the information is, with everyone working right at the top of their skill set and qualifications.

Where people feel empowered and encouraged to crack on with improvements, instead of having good ideas blocked by bureaucratic inertia.

And in a world where multi-morbidity is increasing, where we encourage and celebrate generalist skills, as well as supporting those who want to specialise.

Frankly, we employ some of the most compassionate, brilliant, intelligent, mission-driven people in the world in our health and social care system.

Why stop them from doing their best? This has to change.

Lesson 2: bust bureaucracy

That brings me to the second lesson.

Supporting a culture of collaboration and change by busting bureaucracy.

Now, we shouldn’t beat ourselves up too much.

The latest OECD data shows that we only spend 2p in the pound on administration in the NHS, compared to, for example, to 6p in France, and 8p in the USA.

But the crisis proved that there’s more bureaucracy that our healthcare system can do better without.

That barnacle-like encrustation of rules and regulations.

And I can see people smiling and I know everybody is thinking about some particular, frustrating, illogical rule.

It has been disempowering to many brilliant, highly motivated frontline staff who just want to get on with caring for patients.

Now, first, a caveat. Healthcare is a risk-based business, and many of the rules exist for good reason.

Of course they do. High-quality rules are the tramlines of high performance.

We know that checklists save lives, we know that professional standards must be rigorous and exacting. Clear standards are necessary for a disparate system to function.

In the crisis, we imposed some clear, high-level rules, around infection control, for example. And tech standards are vital for interoperability.

Done best, high-level, mission-based standards support people to deliver within them.

Done best, the centre sets clear tramlines, and holds the frontline transparently to account for delivery.

Kennedy set NASA the goal of getting to the moon by the end of the sixties. He did not specify what alloys the rocket should be made out of.

We need a framework that encourages local initiative in service of the overall goal.

Again the pandemic forced us to decide which rules and processes were essential to the NHS mission and which were getting in the way of that mission.

Sometimes it’s just an encrustation of decisions made over time, like the regulations which required thousands of pages of information from doctors who want to move here from Australia, which have been removed.

Other times, it’s how the law is over interpreted with layers of gold-plating.

Our information governance rules are a good example of the latter.

Complex, confusing advice leads to over-cautious interpretation. For instance, without changing a jot of the law, early in the crisis NHSx issued radically simplified new guidance to support new ways of working.

This guidance, information governance guidance, was on one page, and targeted at every single front line professional – not just at Information Governance experts.

For example, we it made clear that it’s fine to use secure messaging services like WhatsApp to share information with colleagues or patients where the benefits outweigh the risks.

And we made it easier to link the primary care records of millions to the latest data on coronavirus.

Helping us to do the world’s largest analysis of coronavirus risk factors.

This work normally would have taken years, but thanks to our new framework for processing data, it went from proposal to execution in just 42 days

I can’t tell you how many people at all levels have begged me never to go back.

And it worked because the emphasis was on enabling, on how people can safely share information rather than an emphasis on restricting.

And now we’ll work to simplify that guidance yet further, to make it yet more empowering.

Rest assured, this bureaucracy will not be coming back.

In fact in the future, I want us to go even further.

Lesson 3: better tech means better healthcare

That means lesson 3, better tech means better healthcare. We want to double down on the huge advances we’ve made in technology within NHS and social care.

Because it’s not really about technology, it’s about people.

It’s the child with cystic fibrosis who can have his lung capacity measured at home with a spirometer and an app instead of having to go to hospital, with all the risks that entails.

It’s the elderly care home resident, socially shielding for months, able to meet her new grandchild on an iPad.

It’s the local GP, already time poor, not having to spend time donning and doffing PPE because she can do her care home check-in online.

I know I’ve taken a bit of stick for making technology one of the central issues for the NHS.

Before coronavirus, there was a view advanced by some people, would you believe it, which held that anyone over the age of 25 simply could not cope with anything other than a face-to-face to appointment.

That video consultations, a technology by the way that’s been around for decades, was too modern and new-fangled for the NHS. Remember that?

That apps had about as much relevance to present-day healthcare as nanobot surgery and missions to Mars.

When it came to social care this attitude was even worse.

Take away their fax machines, people told me, and care homes would collapse.

Well all I can say is thank God we didn’t listen to the naysayers and that NHS Digital, NHSx and NHS teams right across the country, worked so hard on digital transformation.

Imagine if we hadn’t put the investment into broadband infrastructure so 99% of surgeries could offer remote consultations, virtually overnight.

Imagine if we hadn’t digitised prescriptions so people could get repeat prescriptions online.

Or imagine the massive pressure on NHS 111 at the peak of the pandemic if we hadn’t developed it also as an online service.

At a time when over 750,000 online assessments were carried out in just one day in mid-March.

Now, of course sometimes developing new technology is hard, and you have to have an attitude of iteration and of flexibility. But none of that makes it any less valuable.

So to promote collaboration and change, we need more transparency, better use of data, more interoperability, and the enthusiastic adoption of technological innovation that can improve care.

This crisis has shown that patients and clinicians alike, not just the young, want to use technology.

Just look at how many families, all different generations, kept their precious encounters going through parties on Skype and quizzes on Zoom.

And when it comes to their healthcare, whether they’re digital natives or digital converts, they don’t want to have to sit around in a waiting room if that service can come to them at home.

In the 4 weeks leading up to 12 of April this year, 71% of routine GP consultations were delivered remotely, with about 26% face to face.

In the same period a year ago, this was reversed: 71% face to face and 25% remotely.

Now of course there always has to be a system for people who can’t log on.

But we shouldn’t patronise older people by saying they don’t do tech.

The feedback from this transformation has been hugely positive.

And especially valued by doctors in rural areas, who say how it could save long travel times for doctors and patients.

So from now on, all consultations should be teleconsultations unless there’s a compelling clinical reason not to.

Of course, if there’s an emergency, the NHS will be ready and waiting to see you in person – just as it always has been.

But if they are able to, patients should get in contact first – via the web or by calling in advance.

That way, care is easier to manage and the NHS can deliver a much better service.

Not only will it make life quicker and easier for patients.

But free up clinicians to concentrate on what really matters.

The fourth lesson is about open borders

This crisis showed that we were at our best when we were looking outwards, drawing on ideas and expertise wherever they may be found – and that means the private sector too.

And that takes me onto the fourth lesson: the NHS needs open borders.

Better joint working between local authorities and the NHS locally to embrace the solutions that work.

They say there are no atheists in a lifeboat. Well, there are no ideologues in a pandemic.

Take testing for example.

If you’d have asked most people who’d taken a swab test whether they were part of pillar 1 or pillar 2 you’d have seen some fairly blank looks.

People don’t care who has provided the test.

They just want a test that’s easily accessible, that works and that they can have confidence in.

And I want to thank the teams – public and private – who put themselves on the front line every day to swab people at risk.

Restrict yourself to the false divide of public or private and you are only fishing for solutions in half of the pond.

As part of our response to coronavirus, we were able to call up the logistical knowhow of Amazon, the production lines of Burberry, the car parks of IKEA, and literal boots on the ground from the British Army.

The independent hospitals stepped forward and provided services to protect the NHS.

And the NHS worked side-by-side with them all as part of this incredible national effort.

One diverse, talented team, working towards a common goal.

And we were all better off as a result.

In the face of unprecedented challenges, our sense of enterprise and pragmatism is mission-critical to the success of our health and care system.

It’s part of the spirit of collaboration and change that we must bottle for the future.

Now we have made this huge step forward, we should never walk back.

Lesson 5: no trust is an island

Lesson 5 is that the system works best when it works as a system: collegiate, co-operative, collaborative.

As opposed to a series of atomised, fortress-like, rather lonely institutions.

The future of health and social care will be built by those striving to keep the population healthy, not just to fix the ones who are ill – just as is spelled out in our NHS Long Term Plan, and in our social care reforms.

This can only be done by the delivery of healthcare based on the needs of the population, not the design of the institution.

To deliver this type of care, systems will become the foundation stone of the future of the NHS and social care.

We have already seen local areas in England embracing system-wide working.

With more streamlined planning, bringing together clinical commissioning groups, providers and local authorities to plan services across an area.

These plans will of course help reduce admin costs, but that’s only half of it.

System working means better, less fragmented decision-making.

This is how people work when they really need results.

So we must work to break down the silos that exist between providers and trusts of all kinds.

Primary care, community care, pharmacy, mental health and acute trusts, the barriers between these services are decades old.

But they don’t work now.

Not in a crisis. And not in an age where ever more patients have the kind of long-term, complex conditions which mean they can’t just be bandaged up and set on their way.

The strict barrier between primary and secondary care goes right back to Lloyd George’s National Insurance Act of 1911.

Now I’m a great admirer of David Lloyd George but what was right for 1911 is not right for the 2020s and beyond.

The past few months have shown that there is another way.

During coronavirus, when many secondary care appointments were cancelled for those with chronic complex conditions.

Primary care clinicians were able to support them, using digital technology to take advice from consultants where needed.

So the best possible care could still be delivered in the community.

Pharmacies provided open-access support and care that is deeply embedded in the communities they serve.

Pharmacies showed just how much more they can do.

And this is the spirit that I want us to channel as we move out of this pandemic.

Collaboration doesn’t just mean inside the NHS either.

The NHS must be connected to the places they serve, coterminous with local authorities where the crisis has shown that councils and the NHS can work wonders when they work together.

Look at what was achieved with rough sleepers by working across the system, from housing to the NHS to public health, to protect the most vulnerable.

And then look at the acute response team. Take Thanet, a dedicated team of GPs, nurses, paramedics, AHPs and geriatricians that provide Thanet’s 61 care homes with assessments and advice on all aspects of old-age care.

Now during the pandemic, that model came into its own, with 7-day support so care homes and district nurses always had someone they could call if they couldn’t get through to the local GP.

Integration is not a silver bullet for all problems in healthcare, not by any means.

But what is clear is that once you think about the delivery of health and care as a system in a place it changes the conversation.

So money spent on a care package rather than in a hospital looks less like a loss to the hospital for example, and more like a better outcome for all.

There’s a stronger imperative to treat people in the right settings.

And data flows more easily.

So together we will build our future health and care with the system by default.

And this will include a financial and inspection approach that encourages and rewards collaboration.

And as we do this, we need to look beyond healthcare, at everything that makes us healthier and happier.

Recognising that access to a gym or a park can have just as great an impact on our wellbeing as a GP surgery or hospital.

We must move away from thinking about spending as an NHS pound or a Council pound.

But a Darlington pound or a Dudley pound.

We need local authorities and the NHS to plan and budget together, to work together, and to be accountable together to local people.

Lesson 6: accountability matters

We also need this collaboration at a national level too.

All of our national organisations have done exceptional life-saving work during this crisis.

The NHS has withstood the worst global pandemic in a generation…

PHE rolled out a diagnostic test faster than ever before in recent history.

And we saw the strength of the Union coming to the fore, with a UK-wide approach helping us to expand testing capacity…

Procure PPE for every corner of the UK.

And of course search for a vaccine that can help us return to normal life.

Just as we need a more joined-up, collegiate working on the ground, so to we need the same at the centre.

We’re making progress already, with NHS England and NHS Improvement now operating as a single organisation.

But our national healthcare institutions are too siloed, in many cases by law under the 2012 Act.

Huge amounts of energy are wasted managing the legally-imposed silos.

That’s why the NHS itself has proposed adjustments to join up services both nationally and locally.

Fortunately, there are many practical steps that we can now take.

Take just one example: we have many bodies: DHSC, NHSD, NHSE&I, PHE and the CQC all making separate information requests from providers, often for the same information.

It’s a huge burden, and Instead we should ask

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