Alan Milburn – 2001 Speech to the CNO Conference

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, to the CNO Conference in November 2001.

It is a great pleasure to be here today with people who are leading the process of reform and improvement in the NHS.

Wherever I go in the NHS it is no coincidence that where reform is taking hold nurses are often in the lead. NHS Direct – led by nurses. NHS walk in centres – led by nurses. Nurses, midwives and health visitors – leading reform in primary care, hospital services, rehabilitation, maternity services. Nurses were modernising NHS services before it became fashionable.

That’s true because nursing values are NHS values. Caring. Compassionate. Professional. Dedicated. The needs of the patient at the core of all you do. Everything we do has to preserve and promote these values. Our programme of reform and the nursing profession’s guiding values are as one – they are about redesigning the NHS around the needs of patients. That is what reform must mean – tearing down the barriers between health and social care, removing the demarcations between NHS staff, ending the old ways of doing things that stand in the way of more patients getting quicker, higher quality treatment.

Reform and innovation is taking hold out there. It is important that we harness it and that we evaluate it. I know there have been concerns about the level of investment going into nursing research about what works best for patients and what does not. So it is a pleasure to be able to tell you at the outset that I have decided to spend over £6 million over five years on a new programme of research to support the delivery of high quality evidence-based nursing and midwifery care.

Much of what I want to say today is about the greater role that I believe nurses can play in delivering improved services for patients. But I want to try to locate the contribution that I believe nurses can make – and are making – in the context of the wider reform programme taking place today in the NHS.

I want to start by thanking you for what you do, day-in, day-out, on behalf of patients. I know nurses – whether it’s in the community or in hospitals – are working under very real pressure. You are on the front line of many of the major challenges which face our country today – addressing the problems of poverty and deprivation, a growing elderly population, growing public expectations too.

Meeting these challenges must sometimes seem like a Herculean task. Sometimes there is scant thanks for what you do. And yet just a few months ago when people faced the choice in this country between short term tax cuts and long term investment in public services, the country backed public services and they backed the people working in public services. I think we should all take heart from that.

People have learned a harsh lesson over the last 10 – 20 years. Today people know a fair society, where everyone in our communities and not just some get a fair chance, can only be built on the sure foundations of a strong economy and strong public services.

We all know today we are a long way from having public services to match Britain’s position as the fourth largest economy in the world. We know too that the public are deeply impatient for change. Some commentators, some politicians even, say public services can never deliver, that private provision is the only answer.

I say that on grounds of efficiency and equity that view is wrong.

The NHS is the fairest way of providing health care to our people. It is based on the right principles – of care being available according to the scale of your need not the size of your wallet. But I say with equal firmness that failure to deliver reform in the NHS will prove the cynics and the doubters right. Reform has to deliver NHS services that are more responsiveness to the people who use them.

People grow up today in a consumer society. Services – whether they are private or public – succeed or fail according to their ability to respond to modern expectations. People today exercise more choices in their lives than at any point in history. Many can afford to walk away from public services which fail to command their confidence. People will no longer tolerate second rate services, dirty wards, waits of 18 months for an operation or 18 hours on a trolley. That’s why there is such a huge effort going on to redesign services from the patients point of view. To get waiting times down, make services more flexible and more convenient for the people who use them. To provide easier access, round the clock.

These big changes require big reforms:

To put in place for the first time national standards and independent inspection to monitor them.

To provides incentives to reward good performance and help to correct poor performance.

To devolve power to frontline staff in frontline services to encourage diversity and local creativity.

To change how services are organised and how staff are employed so that the needs of the patient always come first.

To give patients more choice including through greater co-operation between the public and the private sectors.

These reforms aren’t easy. Reform is high risk. In the NHS today there is a huge programme of change taking place. There is a lot of weariness and I know there’s quite a lot of wariness. But I believe passionately that the risks of reforming are far less than the risks of standing still.

The stakes are high for the health service. 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. 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.

The debate today is 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.

I believe there are good grounds for optimism. For a start the investment is going in with the NHS today the fastest growing health care system of any major country in Europe.

People – staff as well as patients – sometimes ask where the money is being spent. Aside from on staff – including the thousands of new staff the NHS is employing today – it is going on providing better services to patients. For example, waiting times of over twelve months for a hospital operation have fallen by 13% in just one year. Cancer patients are being seen by a hospital specialist within two weeks when they used to have to wait months. There are 3,000 more heart operations, over 150 more chest pain clinics, 17% more cardiologists. Prescribing cholesterol-lowering drugs is up by over one third. We are spending over £250 million on new drugs for conditions such as cancer, heart disease, dementia and arthritis. Free nursing care has started. 7 million callers a year are being helped by NHS Direct nurses. 40 nurse-led Walk in Centres are now open. 1,000 GP surgeries are being improved. Thousands of new intermediate care beds and places have been established. The biggest hospital building programme in NHS history is underway. This year for the first time in thirty years there are more beds in hospitals. The programme we outlined in the NHS Plan is on course to be delivered.

I know there is a long way to go. There are very real problems to set alongside the real progress being made. Patients wait far too long for treatment. Staff shortages. Dilapidated buildings. Outdated equipment. Decades of neglect have taken their toll on the NHS and indeed on people work in the NHS. Only a fool believes that decades of neglect can be reversed in a few years of investment. The NHS Plan is not for one year or two years: it is for ten years.

So it really is time that we had a bit of balance in the debate about the NHS. Not only is the glass half full and not half empty – it is being topped up. No one should fall for the fallacy that unless we solve every problem in the NHS no problem is being solved at all. We know in these next few years we must deliver improvements and by working together we will deliver.

Delivery crucially depends on one million NHS staff. Without you it simply will not happen.

That is why we need more nurses at the frontline – in primary and community services as much as in hospital services. We’ve made a start. Nursing vacancies – while still too high – are falling. There are 17,000 more nurses working in the NHS today than just four years ago. And there are 20,000 more to come.

The cuts in nurse training that took place in the 1990s have now been reversed. Indeed, there has been a 40% increase in nurse and midwifery university places. Applications for nursing degrees are up by over 80%. And I can report today that the latest figures show that the number of nurses who left the NHS but who have now returned is well over 9,000.

We’ve turned the corner on nurse recruitment. But we can’t have people coming in through the front door and leaving by the back door. Retaining nursing staff must now be the priority.

A fairer deal on pay will play its part. We do need a fairer pay system for rewarding nurses and other staff for the enormous contribution they make to patient care. Negotiations are going well and I am determined to press ahead with final negotiations on all elements of the new pay system. The aim will be to complete this work as early as possible next year so that a final agreement can be reached as soon as information on future NHS resources are available. Following consultation by the NHS trade unions, this will enable us to begin the process of implementation during 2002/3.

Providing we can reach agreement, many nurses will be significant gainers from the new pay system we envisage. In the meantime we will continue to target extra help to aid both recruitment and retention including in those parts of the country where the cost of living is highest.

More pay alone will not do the trick. The truth is we will not be able to get more nurses at the NHS frontline unless we offer more support at the frontline. By offering nurses more flexible employment, as every NHS employer will have to do within the next few years. By using the £100 million we will save as health authorities and regional offices are abolished to invest in extra childcare to help nurses balance their family and their working lives.

As an organisation – throughout the organisation – the NHS must now focus on removing those barriers that stand in the way of nursing staff being able to use all of their skills to improve services for patients.

Our reform programme for the NHS has at its core an absolute determination to harness the commitment and know-how of staff to improve care for patients. Where nursing staff have been given their heads they have delivered far-reaching change. I see that wherever I go in the NHS.

Matrons empowered to get the fundamentals of care right for patients. Hundreds of nurse consultants now in post. Reforms which have used nursing skills to make same day tests and diagnosis the norm and not the exception. Reforms which have cut waiting times for dermatology treatment from months to days by putting nurse consultants and GPs in charge of providing the service. Reforms which have used the skills of nurses to speed up treatment for cancer patients. Reforms which have allowed nurses in accident and emergency departments to assess patients and so cut waiting times for treatment.

These reforms – alongside the investment in more nurses, more doctors, more skilled professionals – are about using skills to best effect, with care delivered by teams and with flexibility around the needs of patients. These reforms are breaking through the old demarcations. They are liberating the skills of nurses to transform services for patients. What is happening in some places now needs to happen everywhere.

The people at this conference today are central to this reform programme. Your job is to empower nurses to deliver patient-centred care. You already have some the authority to do that. Now I want top give you more authority still.

A year ago the Chief Nursing Officer published her ‘Ten Key Roles for Nurses’ in the NHS Plan. She set out the functions that appropriately qualified nurses should be allowed to perform to improve care for patients. In the best places nurses have been allowed to take on these new roles. In too many places they have been stopped from doing so.

In my view it is just absurd that in some hospitals nurses can order x-rays while in others they can’t. Or that in one hospital nurses can discharge patients but in a neighbouring one they can not. Limiting nurses roles and holding back nurses talents not only makes nurses and doctors the losers. The patient loses out.

For too long there has been a vicious cycle where the NHS has not been able to perform to its full potential because it has failed to support staff to perform to their full potential.

Today I can tell you how we intend to change this situation so that nurses everywhere are able to use their skills to the full. The key will be the modern matron. Matrons will champion the interests of the patient within the hospital so matrons must also champion greater power for nurses within the hospital.

That’s why I will be asking matrons in every hospital to report annually on how the 10 key roles for nurses are being implemented. I am going to ask them to produce an annual report which will go to their Chief Executives, who have the ability to remove organisational blocks to greater nursing influence. It will go to the Chief Nursing Officer, who will be able to remedy legal and professional blocks as well as identify variations between different hospitals. And most importantly, it will go to their hospitals new Patients’ Forum so that patients can see whether the necessary reforms have taken hold.

This is about allowing nurses to break through the glass ceiling that has for too long held them back. It is about unlocking the talents of nurses to improve care for patients. And there is one further development that I can announce today to help make that happen.

I am convinced we need more clinicians in key leadership roles throughout the health service. That is why I was disappointed to see the results of the survey of Nurse Directors we commissioned through the Modernisation Agency. Only around half of Nurse Directors who apply for Chief Executive posts get an interview.

The majority apply only once because they are put off by the selection procedure which, ironically, makes them feel that they are unsuitable for a Chief Executive post because they are a nurse. Often they play down their nursing role and clinical expertise, yet it is precisely that clinical insight and understanding of patient care that is the experience we ought to value most in our top people. It is precisely because nurses are closest to the patient in the NHS that we need nurses closest to the power in the NHS. Nurses need to be in positions of leadership right across the NHS. There must be no glass ceilings for nurses.

We have already made funding available to provide leadership development programmes for over 30,000 frontline nursing staff. I can announce today a new programme to develop nurses as potential Chief Executives. The programme will be specifically designed for nursing, medical and allied health professionals to put them on an equal footing to compete for Chief Executive posts. Next year it will provide up to 100 places for senior clinical leaders.

All of this is about one thing: to unleash the tide of innovation that exists amongst staff in every surgery and in every hospital.

In our first term, the Government established a clear framework of national standards and policies to help us address the postcode prescribing and postcode performance which existed across the NHS. With these in place from our first term this second term is 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 work in the GP surgery or the local NHS hospital. 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.

Last Friday, we published the NHS Reform Bill to ensure that by 2004 the GPs and nurses, patients and local communities who run primary care trusts will control three quarters of the total NHS budget.

By then 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. Cash for local health services 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. The NHS Reform Bill will mean resources going directly to the NHS frontline.

The government’s reform programme has to breakdown the monolithic structures of the NHS in favour of a more decentralised pluralist and responsive health service. A modern health service can not be run like an old style centralised bureaucracy but should instead devolve power and resources to frontline services and frontline staff. The advent of Primary Care Trusts – in which nurses must play a leading role – is the biggest devolution of power in the history 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. It requires greater help and more support – rather than blame – for those which do not. And it relies on you using your authority to innovate and develop new ways of delivering services to patients.

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. More qualified nurses should have the power to prescribe. Matrons will have the power to fine cleaning contractors that fail to keep wards cleans. In hospitals ward sisters will have control over ward budgets. In the community health visitors will have control over community budgets.

We need to go further still. Many hospitals already involve ward sisters and charge nurses in managing their ward staffing budgets. I can announce today that the Modernisation Agency, will over the next 12 months, lead a management programme to support the devolution of staffing budgets to those ward sisters and charge nurses in England’s hospitals who do not yet have that control.

An Audit Commission report on ward staffing, being published today estimates a typical ward budget for a cardiology ward at £560,000 a year. Within 12 months I hope all ward sisters and charge nurses will be in control of ward staffing budgets.

Ward sisters and charge nurses are best placed to know the day to day needs of patients and the hour by hour demands on staff. It is because they understand that they should be in control. They should be able to decide the mix of grades, the mix of skills, the mix of jobs they need on the ward. Patients on a ward, particularly the elderly and most vulnerable, need caring skills alongside clinical skills. Some feel that over the last few decades these caring skills have got lost. I believe it is time to re-emphasise them. That is why we have placed such a strong emphasis on cleaning up the wards, improving the food and introducing new jobs such as ward housekeepers to make sure that patients day to day needs are being met. Meeting patients’ needs will be enhanced by allowing ward sisters to decide the number and mix of nurses, care assistants and ward housekeepers. It will be the job of matrons to support ward sisters and charge nurses to discharge these functions.

After almost half a century of central control Whitehall must devolve NHS resources to the NHS frontline. To decentralise decisions to staff at the NHS frontline. To deliver better care for patients at the NHS frontline.

This is the programme of reform we are embarked upon.

It is a programme where local communities will have greater say over the local health service.

Where the health service is more diverse. Where services are more responsive to patients and where patients have greater choice over services.

Where public and private providers work together to deliver the core NHS principle – care that is free, according to need not ability to pay.

It is a programme where the power of nurses, as professionals, as practitioners, will be vital to delivery.

By working together it is a programme that we will deliver.