Paul Manning speech at BOA Annual Conference, 17/9/15

My name's Paul Manning - I'm a shoulder surgeon and also an executive at Circle Health, and
Clinical Chairman of Circle's Nottingham hospital.
It's really good to hear a discussion on politics - and to hear the range of views on the panel because I think all healthcare is political. It affects us all - and how it is structured and
provided is always going to be a political question.
I think I was invited me on to give a perspective from the independent sector. And in a
general election year, there has certainly been a lot of politics about the independent sector.
We've just had a Labour leadership election, and with Jeremy Corbyn now elected I think we
can cautiously predict that the role of the private sector in the NHS may just may be
something of a political issue.
Now my view is that a lot of what we have experienced in recent years is quite unhelpful.
We hear this word privatisation but rarely with clarity over on what it means.
We hear a lot about ideology but not an awful lot about outcomes.
We hear a lot about party politics but tend to ignore the roots of competition, choice and a
role for the private sector in some 15 years of EU and UK law, under governments of different
colours, led by civil servants and NHS leaders, often at a local level.
But that might be beside the point.
It might be completely irrelevant.
Because I think there might be something controversial in the next 5 years, to do with who is
providing care and how it is structured.
But it's far more interesting - and far more difficult - than public vs private.
That is how we approach the politics of change.
Think about the big picture. We all know the trends we are currently facing.
Demand is rising.
The pressure to save money has never been greater.

And I think we have yet to see patients really becoming consumers being every bit as savvy
and activist as they have in other sectors. But I think we will see that, and soon.
Advances in technology are astounding. We can carry out procedures we couldnt dream of 10
years ago. We have made it normal to be in and out of a theatre in a day for any number of
procedures. Were only seeing the start of what technology can do.
These trends demographics, funding, patient power, technology - mean change is inevitable.
We all know this. These trends are driving the 5-year Forward View, and leading current
policy, but it wont end there. They mean change in service delivery, in the models of care, in
an unprecedented need to innovate and to try new things.
The reason I think that this is the defining political challenge for the next 5 years is that
everywhere and always, change is controversial and change is political.
To illustrate what I mean, I want to take an example from one of Circles main
musculoskeletal contracts, in Bedfordshire.
Some of you may know this contract: its been one of the higher-profile prime provider or
prime contractor models in the country.
The situation before the contract was one we would all recognise.
MSK services were uncoordinated. It was more than common for a patient to attend a GP with
an MSK condition, and then get sent on to a consultant who might look at the patient and
decide that actually, physio was more appropriate. So they go back to the GP. And then on to
the physio. But then the physio decides they need an injection in the community. So back to
the GP. And so on bouncing between clinicians, none of them coordinating their decisions.
Thats bad for the patient. Its bad for clinicians, as its all but impossible to measure
outcomes with such a fragmented system. But its also extraordinary bad for taxpayers this
is a waste of money. Commissioners control the overall budget but there was no brake on
ever-rising spending.
The new set-up places Circle in charge of joining up the system.
When a patient presents with an MSK condition, the GP refers in to a specialist MSK hub.
They then refer to the right clinician, first time round.
Because we capture all referrals in our hub, we can measure outcomes much more
effectively. Weve been piloting a new MSK PROM with Oxford and Keele universities; we have

Eq5D for all physio. We can give GPs feedback on their decisions, educating them about
orthopaedic referrals.
We offer real choice, too: we call 98% of patients who come to us, talk them through their
choices, and they choose where to go so that providers can actively try and attract patients
through better service.
The change is better for patients, clinicians and the taxpayer.
In principle, it is a smaller version of the 5-year Forward View. It integrates services, allows us
to innovate and drive up standards. It is the future.
But its also controversial.
Many of you may know that Bedford Hospitals Trust refused to contract with us. They argued
that their orthopaedic income would drop, and that trauma services would be affected
because they cross-subsidised it from elective work.
The Bedford Labour party issued a string of press releases in the general election attacking
Circle.
It is fair to say that the Bedford contract has not been short of headlines in its first year.
Now, you might expect me to say that Bedford are just wrong.
But actually, while we are confident that our system is the right solution, we have some
sympathy with their position. Because theyve been forced by a tariff system into a corner.
National tariffs and funding decisions limit their choices.
We find ourselves in a crazy situation where were trying to make the whole system more
joined up more coherent better for everyone. But a trust is, quite rationally, incentivised
to do the opposite.
In the end, I think we have got to a better place with Bedford, precisely because we appealed
to that bigger picture, and we had commissioner support, and together we are working to
both implement our system, and protect trauma services.
But the Bedford case-study shows us that anyone trying to do the right thing should also
expect politics and should expect change to be difficult.
And this shows us the difficulties of confronting those enormous challenges that the UK faces.

It shows that we should be far more interested in whether doctors, the media, politicians and
the public line up for and against change, than whether they troop out the tired clichs about
privatisation good or bad. Thats the real question.
Will we fix the real problem proper, fair tariffs for orthopaedics in a way that allows us to
recognise, deal with but ultimately move beyond the objections of providers like Bedford?
And that allows us to get on and change the system for the better?
And theres a question for us, as surgeons . Are we going to help or hinder change?
These are the questions that will define this parliament. And I think they are best summarised
as how do you do change? How do you do things differently and make them better?
That is the major political dynamic for the next parliament. And it's one that is much more
complex - and much more difficult - than the debate weve been used to in the past year.
For the next five years, its not public or private. It's the reformers and the roadblocks.
I know which I choose, and which Circle wants to be.