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Making a real difference: the 10 principles of reform

Before I'm consigned to the RCN's history books, I'm determined to make the most of opportunities like this: opportunities to speak to distinguished and informed audiences; opportunities to say the things that I believe need saying on the issues that I believe really matter. When it comes to issues that matter, they don't come any bigger than the reform of primary care. That's because:

  • Over 90% of all patient contacts begin and end in primary care.
  • The sector employs more than a quarter of a million NHS workers.
  • Its spending accounts for 75% of the entire NHS annual budget.

In fact, you could say that primary care is the NHS.
It is a fundamentally crucial time of challenge and change. As part of my contribution to the debate on the future of primary care, I'd like to do two things: the first is to unpack and examine the government's key primary care reform proposals; the second is to walk you through the principles that I believe should inform and underpin all healthcare reforms.

The government's primary care reforms
It's no exaggeration to say that UK healthcare is currently caught up in a riptide of change. And nowhere is that more true than in the reform of primary care. You name it, it's happening:

  • Patient choice.
  • Increased competition.
  • Payment by results.
  • Practice-based commissioning.
  • Primary care trust (PCT) mergers.
  • Strategic health authority (SHA) mergers.

That's quite a list. But there's one reform that I need to add, and it's a reform that I'd like to look at in a bit more detail. This is, of course, the greatly extended role for the private sector.
Now, before I go any further, let me spell out where the RCN stands in respect of private sector involvement in healthcare. Over 25% of RCN members work in the private sector. We recognise the quality care they deliver. We value the magnificent contribution they make. We support the use of private sector capacity where it's appropriate and in the interests of patients. But, while we acknowledge the importance of the private sector, the RCN also believes in the strength, the success and the long-term viability of our NHS: publicly owned, publicly funded and publicly accountable, universal, comprehensive and free to all, dedicated to making a difference, rather than making a profit.
That's our NHS. And, for close to 60 years, it has improved the health of our nation and transformed the lives of millions. That's why the RCN values the NHS. And that's why we want it to remain the central pillar of UK healthcare.
But, as mentioned, at the centre of the government's primary care reforms is a greatly enhanced role for the private sector, and the extent and scope of that role can be seen in their recent advert in the Official Journal of the European Union. This Department of Health advert invited tenders from private sector companies for a range of services and functions currently carried out by NHS PCTs and, contrary to some reports, it didn't simply put back office management functions out to tender. It went way beyond. In fact, the areas of NHS PCT work now out to tender include the following:

  • The assessment of health needs.
  • Deciding service priorities.
  • Service procurement.
  • Managing patient demand.
  • Disease management.
  • Developing care pathways.

The advert literally covers the A to Z of primary care services. Little wonder then that the wording the government use in the contracts for prospective private sector bidders is "end to end" services.
We should be under no illusions about how radical and far reaching these primary cares reforms are and, I'll be honest with you, I warmly welcome and entirely share the government's objective of modernising primary care in order to design flexible, integrated and responsive health services around the needs of the patient.
But I also have very serious concerns. I'm concerned about the breakneck pace of change. I'm concerned about the lack of full and proper consultation with major stakeholders and, as a nurse, I'm concerned about the practical implications for our NHS and for patient care.
Viewed alongside the government's wider reform agenda, the changes to primary care signal a major shift in policy. And, as far as I'm concerned, if you're going to shift policy, you need to do so in a way that's based on fundamental and enduring principles.

Ten principles of reform
I'd like to set out the 10 principles that, in my view, should inform and underpin all healthcare reforms.

  1. Reform should proceed from the starting point that treatment is free at the point of delivery and based on clinical need, not on the ability to pay. Now, I'm pleased to say the government have given the very welcome reassurance that the NHS will remain free, but I also believe that there is much more to healthcare reform than simply safeguarding this one principle, as fundamentally important as it is.
  2. Reforms must also ensure equality of access, universal coverage and quality patient-focused care.
  3. The need to support and sustain our NHS as the centrepiece of our healthcare system. Put simply, we must always reform in a way that's consistent with the values and the successes of the NHS.
  4. Reform should take place on a level playing field. In other words, private sector companies should never be given an unfair advantage over the NHS when it comes to bidding for services.
  5. Reform must deliver a strengthened duty of partnership for all those organisations delivering NHS services. As a nurse I believe that those in need of treatment should never have to shop around for care in a marketplace where clinicians and providers compete for patients and resources, and that's because, as a nurse, I know that the health, and ultimately the life, of patients depends on cooperation and collaboration.
  6. Reform must enhance the democratic scrutiny which currently underpins our healthcare system. Our health service is a public service funded by public money, and that means it must always be publicly accountable.
  7. Reform has to provide a place at the top table for nurse leaders, both in the commissioning and in the provision of services. That's because, when it comes to the modernisation of the health service, nurses know where we need it, why we need it and how to make it work. Actually, it's our nurses, not our politicians, who are the real change-makers. We're the ones who deliver the reforms, we're the ones who turn policy into reality.
  8. Reform must never result in a two-tier workforce. I don't care if nurses work in the NHS or in the independent sector - we are one nursing family. And that means the pay, pensions, terms and conditions of every nurse have to reflect this reality.
  9. Reform of healthcare must always be evidence-based because it's literally a matter of life and death. That's why we need to pause for breath and pilot for evidence. It's also why all new policies should be accompanied by a fully costed implementation and rollout plan. Only in this way can we assess and analyse the likely impact of proposals. Only in this way can we be certain of making progress and improving care.
  10. Reform must be always accompanied by meaningful consultation. It's our health service, and we all have a right to shape its future. So the government have to talk to and work with patients, staff, the public and the organisations that represent them. The plain truth is that without the expertise, skills, cooperation and support of this country's healthcare stakeholders the reform train would hit the buffers at high speed. And that's in the interests of nobody.

I've spoken to you today about reform. I've highlighted the key features of the changes to our primary care sector and I've walked you through the 10 principles that I believe all healthcare reforms should be based on. In doing all of this I hope that I have shown that reform matters. It matters for our healthcare system, for our nursing profession and for the patients we care for. In truth, it matters for every single one of us, and that's because, at some stage in our lives, we - or those we love - will need to call upon the services, the skills and the compassion of nurses and other healthcare professionals. So it's absolutely crucial that we get the reform process right and, as the world's largest nursing union, the RCN stands ready and able to play its part in doing just that.
What does that mean in practical terms? Well it means that where reform delivers, we will support it, but where we have real fears about its impact on patient care, then we will stand up and speak out.
Today I've tried to send a message to ministers and managers, government and trusts. It's a message that says the RCN is not anti-reform, we are pro-patient. It's a message that says nurses have the skills, knowledge and experience to design and deliver sustainable and workable reforms. And it's a message that, loudly and clearly, says if we work in partnership we can transform our health service for the better. If we work in partnership, we can make a real difference to real people's lives.