Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, in June 2001.
It’s good to be back. With a renewed mandate for investment and reform in the NHS and with a very clear instruction from the British people to deliver real improvements within the NHS.
At the General Election there was a clear choice on offer: between putting public services first or putting tax cuts first. The public chose public services.
As you all know Mrs Thatcher featured prominently in the campaign. Ironically, the result of that election campaign has laid to rest the dogma that public sector investment is somehow bad for Britain. That dogma left a legacy of under-investment in our key public services. In transport, in education, above all else in health. The result of the general election is the clearest signal that the country has moved on.
People today recognise that if we are to have a fair society where everyone in our communities- and not just some – get a fair chance to succeed then we must build strong public services to set alongside a strong economy. There can be no such thing as a fair society – or a strong economy – if the education system is geared to success for some but not for all. There is no such thing as a fair society or a strong economy if whole communities are laid waste by the ravages of drugs and crime. Above all else, we cannot have a fair society or a strong economy if health care denies people help when they need it where they need it.
These are the public’s priorities. They are the Government’s priorities for this second term. And at the top of the public’s hopes for change – and top of their concerns too – is the National Health Service.
I have spent the last month, up and down the country, listening to what staff, patients and the public are saying about the NHS. I haven’t always visited the best places. I’ve seen the bad things as well as the good. Sometimes what I’ve seen and what I’ve heard has been encouraging. Sometimes it’s been more difficult. Wherever I’ve gone people have told it straight. And I’ve heard some home truths about what needs to change to realise our ambitions for the NHS.
Wherever I’ve been it’s clear people are impatient for improvement whether they’re NHS patients or NHS staff. So the stakes are high for all of us who believe in the NHS and in its fundamental first principles: care based on need, not ability to pay. A failure to deliver reform in the NHS will play directly into the hands of those who say that the NHS can never deliver.
It is important to recognise that the debate on the NHS has moved on. For years it was all about the need for more investment since for decades the NHS had suffered under-investment. Today we are putting that right. With funding growing at twice the rate of the past the NHS is now the fastest growing health service of any major country in Europe. And because sustained investment will continue throughout this Parliament the debate on the NHS is now very different from what it was just a few years ago. It is now about whether even with this enhanced level of resources the way we organise and fund health care in this country can ever deliver a modern patient-focussed service. And you only have to read the comment sections of some of the daily newspapers to know that waiting in the wings are those who say that the fundamental principles of the NHS cannot work and must be abandoned.
I believe those newspapers are wrong. I believe those politicians on the Right who advocate their cause are wrong. I have a different set of beliefs. I believe in the NHS – in its principles and in the people working in it. And I know that NHS staff can deliver, that they want to deliver – and are already beginning to deliver – the changes needed to redesign the services of the NHS around the people who use them.
We have a long way to go but a start has been made. Today the NHS is in transition. The foundations for change are in place. New structures – ranging from primary care trusts to the Commission for Health Improvement – will help deliver higher standards of care. The extra resources the NHS has long cried out for are finally bringing about expansion in NHS services. 67 new hospitals to be built. 3,000 GP surgeries to be modernised. Thousands of trained staff already in place and thousands more to come. In the next five years alone there will be 10,000 more qualified doctors. And by 2005 we will have increased the number of medical students by 57% – the biggest rise on record and a guarantee of expansion in doctor numbers for a decade or more to come.
Now is the time – with these foundations laid and a clear mandate for deliver – to up the pace of reform. Not because we can promise an overnight transformation but because we know that we need to deliver progress towards that transformation.
I make no apologies for the fact that the NHS Plan is unashamedly long term in its ambitions. There are no quick fixes and no magic wands. We cannot conjure trained doctors and trained nurses out of thin air any more than we can conjure trained scientists or trained therapists out of thin air. Expansion in staff and improvement in services will take sustained time and sustained effort as well as sustained resources. As we manage change we also have to manage public expectations. We have to carefully reconcile the legitimate demands of the public for faster improvement in the NHS with the reality of staff working under real pressure and services straining every sinew to deliver better care for patients.
This is not complacency. We know what needs to be done. And we have the plans and resources for making it happen. We will not pretend that every problem in the NHS can be solved in one fell swoop but nor should anyone pretend that during these next few years we cannot make substantial progress towards our longer term ambitions for the NHS. Our priority for this Parliament is simple: it not an avalanche of new initiatives. It is delivery. To deliver the NHS Plan.
There are four key areas where progress will need to be focussed.
First, on the conditions with the greatest clinical priority – cancer and heart disease and services for the elderly and those with mental illness. These will be our top priorities for investment and reform. Rehabilitation services to build a bridge between the hospital and the home. Prevention and treatment services that improve outcomes and tackle inequalities. By 2005 we will be spending an extra £1 billion a year on cancer and cardiac services alone. Our ambition is to give our country levels of cancer and cardiac care that are no longer behind the rest but up with the best in Europe.
Second, primary care – the point of contact most patients have with the NHS. GPs and other staff are doing a good job under real pressure. That is why our priority has to be to increase the number of GPs as fast as we are able alongside expansion in nursing and other primary care professions too. And it has to be about getting extra investment directly to the frontline in primary care both to improve services for patients and to relieve pressures on staff. Together with the reform programme outlined in the NHS Plan – more specialist GPs, more personal medical services, a new GP contract – this investment will help give patients easier access to primary care services.
Third, emergency care – the point of contact patients most need to know is there for them when they require it. We will invest more in ambulance services, in accident and emergency departments and in expanding NHS Direct. We will also work to integrate these services so that better, faster care is there for patients. Far-reaching reforms and a better division of labour amongst clinical staff will, by 2004, have reduced average waiting times in accident and emergency departments to 75 minutes. Inappropriate trolley waits for admission and assessment will by then have been ended.
Fourth, cutting waiting times. The biggest concern about the NHS today is how long patients wait for treatment. It is frustrating for staff and distressing for patients. So building on what has been achieved to reduce waiting lists in our first term, our focus in this second term will now move on to reducing waiting times for treatment.
Today I can confirm that there will be no waiting list target but there will be a concerted drive to reduce waiting times. Priority will be given to those patients with the most serious conditions. Year by year the maximum waiting times for a hospital operation will fall from 18 months today to 15 months by Spring next year, then to 12 months and by 2005 it will be down to just 6 months. As staff expansion and service reform take hold average waiting times will fall lower still. And the same focus will get waiting times down for outpatient and for ambulance services too.
These are ambitious plans to improve the responsiveness of the NHS. Delivery here will rebuild public confidence in the NHS. It will also solve a real dilemma that confronts thousands of patients every year. Many people – particularly those who have a bit of savings – are currently forced to choose between waiting for treatment or paying for treatment. Many end up paying. However comforting that might be for some people it does not provide a solution for most people. Indeed there is a real risk that without support from middle income families public services will end up fulfilling Richard Titmuss prophecy: services for the poor which are themselves poor services. Our ambition as a country surely has to be to make the NHS a service of first choice not last resort.
We can have that ambition because of the expansion in staffing we are planning. 20,000 more nurses, 10,000 more doctors, 6,500 more therapists and scientists. We can have that ambition because we can deliver not just more staff at the NHS frontline but more support for staff at the frontline. More childcare support. More housing support. A new fairer pay system for staff.
Each year as the NHS grows so services will grow. But as NHS staff know better than anyone, our task is not to get the system to work harder but to get it to work smarter. To have an NHS judged not just by the quantity of services it offers but by the quality of care it provides.
This second term then is all about embedding far reaching reform in all parts of the health service and in social services too. Reform cannot be an optional extra. Investment alone cannot deliver the goods. It is reform that is the key to the improvements that we seek to unlock in the NHS.
Reform to reorganise services from the patient’s point of view – to make same day tests and diagnosis for example the norm and not the exception. Reform to overcome traditional demarcations between staff – to release the talents of nurses and therapists and relieve the pressures on doctors. Reform to break down barriers between services – to get health and social care working as one part of one organisation rather than competing organisations. And reform too which rejects ideological objections to the NHS working with the private sector – as well as rejecting ideological obsessions with the supposed superiority of the private sector – in favour of a modern relationship which best suits the interests of the NHS patient.
In this second term, reform in the NHS is not about abandoning the principles of the NHS. It is not about privatising NHS services. It is not about sidelining NHS staff. It is above all else about empowering frontline NHS services and liberating the talents of frontline NHS staff.
Our reform programme will have as its core purpose an absolute determination to harness the commitment and know-how of staff to improve care for patients. Where staff have been given their heads they have delivered far-reaching change. You can see that in the cancer collaborative programme where joint working between clinicians, managers and patients has already reduced outpatient waiting times by 50% and radiology waiting times by 60%. The collaborative principle and the collaborative process now need to be spread to all parts of the NHS.
I know that for some in the NHS, reform can feel like another burden to be confronted rather than a means of relieving the burden. There is real pressure on staff. It is hard to find the time to reform services. And yet when reform happens it is quickly seen as a help not a hindrance, to staff as well as to patients. GPs who have got waiting times for appointments down by changing how their surgeries are organised have found their working lives better not worse. In hospitals, doctors, nurses and therapists who have changed who delivers outpatient services have found greater job satisfaction not less. What we need now to do is to support more staff through the reform process. That is what giving staff protected time to improve their services is all about. It is what the Modernisation Agency and the Leadership Centre are all about. It is what Individual Learning Accounts for unqualified staff are all about. And in time it is what the new University of the NHS will be all about. All of this is about one thing: to unleash the tide of innovation that exists among staff in every surgery and in every hospital.
With a clear framework of national standards and policies in place from our first term this second term will be all about shifting the centre of gravity to staff at the NHS frontline. The NHS is a high trust organisation. It works on the basis of trust between patient and professional. In the way it is organised the NHS now needs to enshrine that trust. It needs to give more control to the NHS frontline. I don’t treat patients. I don’t provide GP services. I don’t manage NHS hospitals. You do. The NHS can not be run from Whitehall. Just as schools now have greater control so local health services must now be given greater control too.
Four years ago GPs through the fundholding scheme controlled just 15% of NHS resources. Today the GPs, the nurses, the patients and the local communities who run primary care groups and trusts control 50%. By 2004 they will control 75%. By then – if not before – two-thirds of existing health authorities will have been abolished. The NHS regional offices will have been abolished too. Power will have been devolved to frontline NHS services.
And I can announce today that in future resources will be devolved directly to frontline NHS services too. Within the next two years it is my intention to no longer allocate cash for local health services to health authorities. Instead it will be allocated directly to local primary care trusts so that they can decide how to commission services for the local communities they serve. I have heard from too many people too often in the NHS that resources have not been getting through to the frontline. Now I plan to give resources direct to those at the frontline.
This process of decentralisation that will now take hold in all parts of the NHS. I want to see a new culture of public sector enterprise in the NHS to rival the spirit of private sector enterprise which developed during the last few decades in our country. That requires more discretion over how local budgets are spent. It requires greater freedoms and more rewards for organisations which succeed. And it requires greater help and more support – rather than blame – for those which do not.
As standards and performance improve so greater autonomy will take hold. Good hospitals will get extra resources to help turn round persistently failing hospitals. And devolution to NHS organisations will be matched by devolution within NHS organisations. In hospitals ward sisters will have control over ward budgets. Matrons will have the power to fine cleaning contractors that fail to keep wards cleans. Hospital consultants and other senior clinicians will decide on how the new £100 million a year equipment budgets are spent.
The priority for reform will be to free the NHS frontline. Not a return to the anarchy of the market but a freedom to shape local services in this second term within the clear national framework of standards and accountability we established in our first term. With a reformed Department of Health doing only what it can properly do in an accountable public service. Providing the resources. Setting the standards. Holding the system to account.
That process will begin at once and it will provide an opportunity for every member of NHS staff to contribute to the programme of NHS reform. In every part of the country from this month through to the autumn health services will be conducting local modernisation reviews. Just as last summer there was a national programme to involve the NHS in drawing up the NHS Plan so this summer I want to see local programmes throughout the country to involve the NHS in implementing the NHS Plan.
The reviews will culminate in local three year action plans that set out the changes and the investment required to deliver the ambitions of the NHS Plan. These will be local plans for local communities. If they are to launch real change they will need be formulated by local NHS staff and local NHS patients. It will be for local managers to make that happen. But I will be writing to the royal colleges, the trade unions and patient groups urging them to ensure the involvement of their members on the ground.
This is a unique opportunity. For the first time in the history of the NHS staff and patients will be asked to help reshape and reform local health services in all parts of the country. It is a powerful symbol of our determination to put real power and real influence in the hands of those who use NHS frontline services and those who provide them.
Making reform happen will require not just a relocation of power to the NHS frontline but a change in the relationship between patients and frontline services. The culture of the NHS has to change. It has to be attuned to the times in which we all live. Services today have to operate for the benefit of the public, not the other way around. They have to operate on the basis of open information, not behave like a closed society. They have to enhance patient choice not deny it. These are big reforms. They form the basis of the NHS Plan.
In this second term of Government, our concentration will be on embedding the reform programme in the NHS Plan rather than an avalanche of new initiatives which sometimes follows the election of a new government.
Government alone can not change the NHS: real and visible improvement to patient care only happens – is only happening – because NHS staff make it happen. In this second term, NHS staff will be given the power, resources and responsibility to reform the NHS for themselves.
Increasingly, the NHS has a cadre of “public sector entrepreneurs” – committed to the principles of the NHS, driving through local innovation themselves, eager to see reform take hold across the health service. Our task is to engage these “public sector entrepreneurs” against the coalition of “eternal pessimists” – on both Right and Left – who view reform of the NHS as either a threat to the system or as being doomed to failure because the system itself has already been deemed to fail.
These eternal pessimists see every change, in whatever direction as always bad; every extra pound of extra investment as either totally inadequate or pointlessly extravagant. They see every new PFI hospital as a threat of wholesale privatisation rather than as an opportunity for staff and patients to experience new and better NHS facilities.
As we decentralise and devolve more power to the frontline, we have to empower these public sector entrepreneurs to show by example that the NHS can be reformed, that change can be real and visible for patients, that the health service is growing and that it is changing to meet modern patient expectations. By doing so we will prove the eternal pessimists wrong.
There is now a mandate for investment. But there is also a mandate for reform. There can be no veto on either investment of reform. Of course there will always be differences over detail and negotiations over contracts. But I believe there is a natural alliance between NHS staff striving to improve care for patient and the Labour Government striving for sustained investment, far reaching reform and devolution of power to the NHS frontline.
Our commitment – my commitment – is to work with all those who want to see the NHS succeed. With all those who know that it is not just sustained investment that the NHS needs by far-reaching reform.
This is the challenge ahead. It is a challenge we share. It is a challenge we can now meet. It will be most visible and most profound at the NHS frontline.