NHS Confederation speech

10 Apr 2025 11:36 AM

Speech given recently (08 April 2025) by Cabinet Secretary for Health and Social Care, Jeremy Miles.

Bore da gyfeillion. Good morning friends.

When I spoke at the NHS confederation conference last year I said I believed we needed to have two conversations with the NHS and the public. 

The first was how we needed a rapid improvement in the performance of the NHS to see and treat people more quickly. And secondly how we support the NHS to adapt to the challenges of today and tomorrow.

With a year to go to the end of the next Senedd, how do we tackle those two aims?

Performance is the priority

Let’s start with performance.

We have had an intense period of working together to drive down the longest waits. 

The number of over two-year waits have come down dramatically. We won’t have the final figures for another couple of months but health boards have assured me we will be pretty close to the 8000 figure which the First Minister spoke about.

The extra funding we provided has helped but the relentless focus on performing has been a huge part of the reason. 

I want to thank you all for the efforts that have gone into that. 

But we would all agree that the process has also shown us where the NHS absolutely needs to focus its energies better, if it is to improve performance sustainably – as the public rightly expects it to. 

I appointed a ministerial advisory group on performance and productivity in October under Sir David Sloman.

The group has now finished its work. We will publish the report and the actions we will take in response at the end of the month. There will be an opportunity to discuss our collective response to the performance challenge immediately after that. 

That discussion and what I want to talk about today will give us a route map for the year ahead.

The 5 key “change” priorities

So what do I want to talk about today? It’s the areas we all know we need to do better at if the NHS is going to be able to adapt for the future. 

It’s the five areas which cut across all that we do and touch on all aspects of physical and mental health for all parts of the population: 

The transformation of our health system is, simply put, a journey to more prevention so that we need less treatment. 

No health system anywhere can realistically cope with the growth in demand from an older population with more chronic conditions without a huge shift to preventative services. 

I have announced in the last few weeks a commitment to redouble our efforts to tackle the wider determinants of physical and mental ill-health, building on the work we have seen in Gwent - and making Wales a marmot nation. 

The year ahead will bring an extension to our screening programmes. 

But perhaps the most fundamental change we will need to bring about is an ability to identify proactively that group of frail and vulnerable people in our community who – if they don’t get effective care and support now – will probably end up needing long spells in hospital. 

We know how to help people when we know they need help. 

We need to be better at identifying them early and then intervening quickly. 

We made good progress before the pandemic in developing tools and systems to support GPs to identify this at-risk group, but progress has slowed.

Over the year ahead I want us to start to get back on track - so that we can catch up quickly. This is just one example of the sort of transformational preventative change we need – targeted, proactive care, helping patients stay well and helping the NHS cope with demand.

Shifting services into primary and community settings is at the heart of how we need to transform healthcare for the future. 

There is a broad consensus that this needs to happen, but we haven’t made the progress we need to. We know this is better for patients and better for the resilience of services too. So over the next year I want to start to build on our network of primary care clusters to begin to really develop and deliver our plans for a strengthened community primary diagnostic service.

We know too that we need to improve co-ordination and continuity of care, because it’s good for patients, it’s good for primary care and it’s good for the secondary care system. 

So we will shortly be launching a new initiative to support GPs to provide continuity of care with a quality improvement approach.  We will start with GPs identifying the most vulnerable patients who would benefit from seeing the same healthcare professional continuously. 

We will build on this over time so it becomes a routine expectation for everyone. This will improve outcomes for people with chronic conditions and help keep people well at home.

A service more focused on prevention and providing more care in the community is one which also puts the patient at the heart of the service as a partner in managing their physical and mental health.

But fundamental to being able to accomplish this is a digital NHS. 

We know that we have not gone far enough or fast enough to transform out healthcare system. This is holding us back. 

Over the year ahead, we need to deliver on some of the key digital enablers – expanding e-prescribing, launching the new maternity app and crucially launching the NHS app, which will put more power in the hands of patients. 

But we also need a bigger, open conversation about how we work more collaboratively across the system to bring about a step change in our digital delivery and move beyond the silos that we have allowed to develop. 

Our digital journey has been marked by under-delivery and increasingly challenging relationships. 

Digital transformation should be integral to every single decision we make. It is everyone’s responsibility but we each have a different role to play.

I have tasked Digital Health Care Wales (DHCW) with rapidly improving its capacity to plan, manage and deliver digital projects in our system. 

We will provide it with the support it needs.

We need more confidence in the national expectation and capability in digital than we do today. But equally, we need a much greater commitment to collaboration and joint working between health organisations than we have seen. 

There is no room for empire building, or difference for the sake of it. 

We need a clear sense of the national direction of travel, and the requirements necessary for a coherent national system so that choices can be made in all parts of the system whether to develop, commission or buy off the shelf in a way which contributes to that integrated national plan, rather than making it harder we to achieve it. 

We need to make real progress this year. There will be an opportunity to explore this further at the digital summit in May.

An NHS which delivers more services regionally is one which delivers its fragile services more sustainably and its high-volume services more efficiently.

Ultimately this means better outcomes for patients. 

There are some good examples but we haven’t done enough regional collaboration.

I want the year ahead to bring about a step change in regional working. 

We have seen in recent months how effective regional cataract services have been in the south east. So our improvements in planned care must focus on regional solutions to give patients the timely access to quality care they deserve. I will say more about this later.

And lastly, leadership and our NHS workforce. 

Effective leadership at all levels and in all parts of the system – clinical and managerial – is fundamental to improving the performance of our NHS.

Our ability to create the right culture and motivate our workforce is how we create the conditions for high quality, efficient care to thrive. And continuously developing the skills of leaders and the broader workforce should be a basic expectation of working in the NHS. 

Over the year ahead, I want to boost the support we provide for leadership skills in the NHS – so we have more leaders able to lead with compassion, creativity and ambition for improvement. 

We will take steps to strengthen operational and clinical skills through targeted training in the most critical areas of the service, through NHS skills academies which we will launch in the coming months.

Five key priorities to improve access and services.

In a way, you might say these priority areas are nothing new. 

Five key priorities where there is broad agreement on the direction of travel, good for patients, good for services. 

So why have we struggled to achieve these goals? 

What’s standing in the way? How are we going to make sure that we have a better chance of transforming the NHS in the way we need to? 

What’s standing in the way and what’s going to change?

The starting point in any discussion about the challenge of changing the NHS is the pressure of resources. 

This is real. 

The year ahead is a better one than we feared with more funding from the UK Labour Government, and more capital especially which has been a challenge for a long time given the approach to investment – or I should say non-investment from the previous UK Governments. 

Although the next year will be better it will still be tough. We cannot make up for fourteen years in one year.

What we can do is make sure that we are using every pound we get to the best effect. 

At the moment we can’t yet say that. 

Like most healthcare systems across the developed world, Wales has a huge productivity challenge and in spending resources in ways which don’t always deliver the greatest benefit. 

Let me be clear, this is emphatically not a call for our staff to work harder. I’ve seen with my own eyes countless examples of our NHS staff going far beyond what we should expect, in order to care better and do more for their patients. 

That’s not the problem. But we do have a system which in too many cases confounds and frustrates what our staff know needs to happen.

I look forward to the recommendations from the ministerial advisory group in this area. This is an opportunity – and I know we will all pursue this energetically over this coming year.

But no one in this room believes the challenges we face are just about funding. 

We cannot simply expect that budgets can respond to what has become an unsustainable demand for resources.

The imperative to put services on a sustainable footing is immediate. 

To do that we need a new way of working.

We have become a system which is too reliant on managing up and down and isn’t co-operative enough.

A system quicker to point the finger than to grasp the nettle, and where our aversion to risk too often stifles our appetite to be better.

The answer I believe lies in a fresh approach to three key aspects of the way we run the NHS in Wales: 

What do I mean by that? 

All too often, there are no consequences for under performance. In my short time in the role, I have been met with the equivalent of a shrugging of shoulders when I have challenged people on why a budget has been blown or a target not met. 

This is fundamentally unacceptable. We will not tolerate a culture of impunity when commitments are not met.

Accountability is not strong enough in our system. 

I have been clear about the priorities I expect to be delivered. 

I published the NHS planning framework for the next three years in December – I kept my promise to you to focus on a smaller number of priorities and set out our key asks of the system.

There are 16 metrics and a list of enabling actions and a recognition that beyond that you have the flexibilities you need to prioritise. 

I want to be very clear, the quid pro quo of a more focussed set of priorities is that I absolutely expect them to be delivered. They will lead to better - and better value - services for the public. 

And I will publish each organisation’s performance against those metrics and actions. 

Where we provide additional funding for the NHS to deliver improved performance against agreed plans, if measures are not met, the funding will be returned. 

We are doing that now with the planned care programme. There are several examples where, despite the overall performance of the system, agreed commitments were not met. So funding will be clawed back so it can be put to use elsewhere. 

But I don’t want a system which is all stick and no carrot. 

I also want to look at how we can use funding to incentivise and reward organisations to improve delivery and productivity.

I talked earlier about the need to shift services out of hospitals and into the communities where people live. This is a vital part of avoiding emergency hospital admissions. 

As more diagnostic services and other work moves out of hospitals and into communities, resources and ways of working will need to move too. 

To increase accountability about how we allocate funding, as a starting point, I will expect all health boards to declare how much they spend on primary and community care this year and to define that. This will enable us to work towards a common definition across Wales, helping us be more systematic about how we make the shift. 

We have been too hung up in the past on the difficulties of definition, and allowed that to distract us from one of the most important strategic issues we face. 

That can’t continue.

The work to move more diagnostic services into the community is only the start. I want to work with you over the coming months to develop concrete commitments, with clear delivery steps and accountability measures for a systematic shift of services and resources into communities progressively over the next five years.

And I want to change the relationship we have with NHS leaders. 

I have already recast the objectives we set chairs to make them clearer and more focussed. And we will be rigorous in holding them to account. 

Less bureaucracy, fewer priorities, more clarity, more accountability.

Linked to this, we need a fresh approach to leadership in the system overall.

Wales has a huge advantage – we are small enough to run our NHS as one coherent system. You can literally get all the key leaders – Welsh government and the NHS - in one room to move forward together.  Larger countries would die for that. 

But we too often work in silos and we just don’t make enough of that advantage.

I’ve been impressed by the talent of our staff.  Not surprised.  But delighted, and reassured. 

Between us there is no shortage of good ideas, no shortage of energy and enthusiasm to do things better, to challenge ourselves. 

Some of the best meetings I’ve had have been when the most inspiring doctors, nurses and other clinicians, managers and other leaders in the NHS, come together in the room with my officials to solve a shared problem. 

We leave that room with the strength of collective resolve and mutual support, and we see the impact. 

This needs to become our usual way of working. 

That will challenge us to strengthen leadership in all parts of our system, and at all levels. 

Leadership must be about more than meeting our targets – essential though that is, but about articulating an ambition for how our services can be the very best they can be, creating the coalitions of change we need and empowering staff to shape the services they deliver.

When we met in November, I promised we would look at the role of the NHS executive. 

It plays a valuable role in driving value and sustainability and in providing detailed intelligence about performance and activity across the service. 

But with the benefit of two years of operation it is clear there are ways we can reform the executive so its work is better aligned with our priorities and expectations as we drive up performance.

So we will be refocusing the role of the executive over the next few months. 

We will strengthen the operational leadership of the executive to streamline the organisation, and ensure it has the capacity in the right areas and the mix of skills it needs to do the full range of things we expect of it. 

And we will do a zero-based review of its budget and funding to make sure resources are aligned with our more focused priorities. 

We will also strengthen the voice of clinical leadership in the system. 

It’s crucial for confidence, credibility and transformation. There isn’t a successful health service in the world where clinicians don’t have a central leadership role. 

Over the coming weeks we will look at how the executive can make a bigger contribution to that. 

The work of the ministerial advisory group has also highlighted the need to address this. I want to ensure there is clinical leadership able to align and refocus the work of the clinical networks and transformation programmes and to provide a medical leadership voice throughout, highlighting clinical excellence and innovation.  

And we will set out a new mission statement for the executive so its role is crystal clear. 

Put simply, it will do just two things and two things well: provide support to the NHS to deliver better service to the public and support for the Welsh government to hold the NHS to account. 

It will have a much bigger focus on working alongside NHS bodies, supporting them more directly with improvement and performance. And it won’t complicate accountability and communication channels. 

Leadership is not only national. It is regional and local too. 

Regional delivery requires regional leadership able to think, influence and lead outside the boundaries of an individual health board. 

We will therefore reorganise the work of the executive to create a dedicated regional delivery support function to work with health boards and trusts. 

And I have now issued a direction to establish a regional delivery board encompassing the three health boards in south east wales. The first project it is tasked with delivering is the new south east Wales centre of excellence for diagnostics and elective surgery in Llantrisant.

Progress on that project has been too slow, and there is no more time to lose – the new, more efficient ways of working, the cutting-edge facilities and extra capacity it will deliver are essential to how we transform the NHS. 

I want the board to ensure construction of the new centre starts before the end of the year.

And I expect to see similar rapid progress in the other regions. 

Clear leadership, a collaborative approach, a stronger clinical voice and a new impetus for regional working. This is the fresh approach that we need.

The third element to help us transform, is a more transparent system – open in the way it works and open to learning from itself and from others.

So we will build on the work we have done to make health board level data more accessible – I will task the NHS executive to publish more information about key performance targets, including:

We gather huge amounts of really powerful data but this is often underused. So I will publish a transparency statement in the autumn which will set out what data we will be making available and when. 

The public have a right to information which can help them to hold the NHS and the Welsh government to account. 

We need extra levers to increase the pace and ambition of change, and to stimulate change from the frontline, rather than top down.

Comparative data is a tool that has worked well for a long time in other aspects of our lives, but we don’t use enough of it in the Welsh healthcare system.

Our clinicians and managers want to provide the very best care they can.  If they see data which shows their service is lagging behind – or that they are in front of the pack – it can be a powerful incentive to make change happen, or to get even better.  

We need to make this common practice and empower NHS staff to take control of quality and outcomes for themselves by showing them how their services are performing. There is almost no limit to how far this needs to go. 

Wherever we have useful information on quality, outcomes and performance, we all need to see it and use it.

And I want Llais be able to draw on data more freely to strengthen its role. 

And from the Autumn, I will also be introducing an annual public accountability forum where I will meet with NHS bodies in public, as part of holding the NHS to account for meeting our priorities. This will help us increase confidence in the system of accountability by opening the doors to the NHS. 

Transparency is crucial to creating an open, self-improving culture. But it is not the end of the story. Openness is also about ways of working, an attitude of mind. A willingness to be challenged from within and outside. 

That is particularly important when it comes to giving the public confidence in standards of healthcare and the performance of health organisations. 

We have taken big steps to improve the transparency and predictability of escalation and de-escalation arrangements. This is important for the public but it is critical for health organisations. 

A clear understanding of shortcomings and the steps needed to address them in the escalation regime is the hallmark of a system focused on improvement.

The final step I am announcing today is an urgent review of the current arrangements with a view to making sure everyone in Wales can see how well their health board or NHS trust is working; that assessments of board performance are transparent and understood by everyone; that health bodies have proper grown-up conversations with the people they serve and have to explain themselves. 

We need strong independent bodies to make sure that we don’t get complacent or lose focus. 

We have a statutory duty of candour in Wales for a reason. Let’s live it.

In a democracy, and for a service as important as the NHS, this needs no justification. But it goes much further than that. 

Ultimately, the NHS improves fastest when every team becomes its own champion of change. Every NHS team I’ve met in the last few months wants to do better for their patients.  To do so, they need to know what is expected of them, have useful comparative data which shows them how they are doing and what good looks like. We need to celebrate those who challenge themselves to improve.

Access to treatment over the next 12 months

I said at the start that performance is priority.

Nowhere is the need for transformation more urgent than in delivering improvements to planned care. 

The First Minister and I have been absolutely clear that improving access to care is one of the Welsh government’s absolute priorities. 

The public rightly want us – and you – to focus on that relentlessly. And they are entitled to have it delivered. 

In November, we put an extra £50 million into the NHS to fund health board plans to provide more outpatient appointments, more diagnostic test, more neurodevelopmental assessments and more operations to reduce the longest waits.

We are seeing the positive impact of that targeted investment and concentrated work as long waiting times are coming down.

Some health boards have been more successful than others – we still have too many waits of more than two years in north Wales and in Cardiff and the Vale, for example.

We have made positive progress but there’s a long way to go and we have to see sustained improvement month on month. 

In the year ahead we will continue to tackle long waits - and focus on reducing the overall size of the waiting list.

We will reset and reduce the overall size of the list by March 2026, bringing it back towards pre-pandemic levels.

It is within our grasp to reduce the size of our waiting list by as much as 200,000 pathways over the next year.

We will do this by tackling outpatient appointments in the most challenged specialities.

By March 2026, we will meet and maintain the eight-week target for diagnostic tests.

And throughout this year, we will continue the focus on reducing long waiting times. I do not want anyone to wait more than two years for treatment again in Wales.

There will be additional funding to do this. 

But let me be clear. 

I am not prepared to fund ways of delivering services which do not deliver the best patient outcomes nor the best value for money. 

We will be applying three principles to the planned care improvement funding for the next year.

I expect health boards to implement the enabling actions I have set out in the planning framework. These will help us deliver more effective services and health boards will need to demonstrate they are implementing the actions, or they will not access funding.

Secondly, health boards will only be able to access funding if they can show they are maintaining their core capacity in the relevant specialty.

Any additional funding deployed for core activities will be clawed back.

Thirdly, we will introduce a strengthened national and regional approach to commissioning independent provider capacity.

Given where we are today, using the independent sector is a necessary part of this 12-month transition back to a more sustainable and efficient NHS, if we want to drive down waits and the size of the list. 

Commissioning some capacity at a national level will enable us to be more strategic about where its deployed and ensure it is used to supplement and not to compete with the public NHS.

This is all part of our commitment to the public that we will deliver a stronger NHS. 

But we will go further in our commitment to the public.

We will introduce an entitlement for a patient to be told at the point they join a waiting list how long their wait is going to be. 

This will be information specific to them. 

And when the NHS app launches, patients will be able to track the time left until their treatment. 

In line with our 3Ps policy, health boards will help people to be in the best possible health and fitness to undergo surgery. 

And in future, patients will only be listed for surgery when they are fit enough to undergo and benefit from their treatment. This is much better for the patient - we know that people in optimum health are likely to recover from surgery faster, have fewer complications and won’t need to stay in hospital as long. 

And it is better for other patients on the list as it will reduce the number of treatments and appointments cancelled or missed, helping to speed up access overall.

This is our commitment to the public.

And what we ask the public is that you do all you can to prioritise and keep your appointments so, together, we make the best possible use of scarce NHS resources.

And this is really critical because currently we are losing huge numbers of appointments in the NHS – hundreds of thousands every year. 

14% of all outpatient appointments are lost because people do not turn up or cannot attend. 

That is not right, it’s not sustainable and it doesn’t help us make sure the public get faster access to the care they need.

So in future, we will provide patients with two offers of dates for an NHS appointment. If those appointments are not kept without a good reason, they will be removed from the list, so that their place can be taken by someone else. 

Every person’s circumstances will be considered, patients who are vulnerable, children will be protected but we want patients to keep their appointments or to cancel in good time so their place can be taken by someone else. 

I don’t want patients to have to wait longer because someone else isn’t keeping their appointments. We owe it to one another to make sure that appointments are available to those who need them and who will take them.

In closing colleagues, can I encourage us all to lift our sights. Let’s grasp the opportunity to make the changes we all know we need. 

I have tried to set out today not just the what but the how of change. It requires us to challenge and to inspire ourselves and those around us. But we all have a part to play in leading and delivering that change and to give the people of Wales the health service they deserve.