Alan Milburn – 2001 Speech to the Fabian Society

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, on 21 October 2001.

Nye Bevan’s shadow hangs over every health secretary, especially Labour secretaries. He was the architect of a care system based on values community, solidarity, and belief that we achieve more together than ever can alone.

Our commitment to the values of NHS binds today’s generation Labour Ministers Bevan generation. And yet our pride in creation last century must not stand way its necessary re-creation for this century. attachment has too often been structures when it should have values. end do change with times. endure over time.

Bevan’s greatest success was not to overcome the intransigence or conservatism of those opposed to creating the new NHS, enormous though that achievement was. It was not to forge a particular structure for the NHS because as Bevan himself later conceded there may have been better ways of organising the new health service. It was neither of these things. His greatest achievement was to build a national coalition behind the values of the NHS. A system based on need not ability to pay, free to all and available to all. A system which removed the fear of becoming ill and having to face the doctor’s bill. The boldest ever attempt to break the vicious circle where poverty brought illness and then illness brought ever greater poverty. These were the right principles then. They remain the right principles now.

But Bevan’s was a structure forged out of the experience of war. It took a particular structural form – state ownership through nationalisation. After all the Second World War had been won by a society committed – after five years of total war – to the notion of collective action to solve national problems. People had made sacrifices in their own lives – many of their own lives – in pursuit of the common good. During the War the values of solidarity and the actions of the State converged. The State was the focal point for the solidarity of the British people.

Conscription meant that everyone had to take common risks. Rationing was treated the same.

And this approach worked. We won the war. And when Labour peace same was applied. took on big national problems by creating institutions. Coal Board – to take over a failing industry. British Transport Commission railway system. Health Service care

In 1948 there were 1.334 voluntary and 1,771 municipal hospitals. A confusion of different systems. No clear standards. No national planning. The NHS brought order out of chaos. It provided the basis for the first time in our history for a national system of health care.

And yet it was far from perfect. Indeed elsewhere in Europe governments, many of them socialist or social democrat, forged institutions which favoured greater community ownership over state ownership. Here in Britain centralised control still means, in Bevan’s famous phrase that when a bedpan is dropped the noise reverberates throughout Whitehall.

Indeed throughout the last two decades of structural upheaval in NHS essential post-war structure top down control has remained largely intact. result been that too often governments have defended interests as a provider services when they should focussed on patients consumers services.

It is right of course that there should be national accountability for the workings of our country’s health care system. For fairness sake there should be clear national standards applied across all parts of the country. It is right too that government should allocate resources to ensure that NHS cash meets health needs.

But beyond that I believe the old top-down model of the 1940s cannot deliver in the twenty first century. Vesting control at the centre has diminished control where it counts – in local communities where local health services interact with local people. In the modern age that will no longer do. For public services to command public confidence today they have to give greater control and more choice to the people who use them,

This is the key challenge we face in government as go about our fundamental task for this second term of reforming great public services: how to reconcile maintenance equitable access all with greater choice individual. policy education example, give parents more school and diversity provision within a framework rising national standards.

In health I believe we can best meet this challenge in three ways. Firstly by reforming the NHS to deliver improved and more responsive services to match modern needs. Secondly, by ensuring patients have more power and greater choice over services. Thirdly, by empowering communities to have greater involvement with local services.

First then modernising health care. People grow up today in a consumer society. Services – whether they are private or public succeed fail according to their ability respond modern expectations. Bevan’s was an era where expectations among the were lower, deference institutions and professions greater. exercise more choices lives than at any point history. Many can afford walk away from which do not command confidence. one nation Britain cannot be built on two tier care but failure deliver big improvements NHS will if we careful inevitably make case for

The way NHS services were provided in Bevan’s generation simply will not do for this generation. People no longer tolerate second rate services, dirty wards, waits of 18 months an operation or hours on a trolley. That why there is such huge effort going to redesign from the patients point view. get waiting times down, make more flexible and convenient who use them. provide easier access, round clock. Alongside problems today progress.

The record investment and far-reaching reforms we outlined in the NHS Plan are beginning to bite. For first time there is a sensible relationship between public private sectors expand care available patients. clear national standards means implement them. real incentives reward good performance alongside help end poor performance. getting health social working together rather than against each other.

And yes, progress takes time. The problems remain in the NHS but today the NHS is the fastest growing health service of any major country in Europe. This year there are 3000 more NHS heart operations. Prescriptions for drugs to prevent heart attacks are up by a third on last year. People with suspected cancer, who used to wait for months to see a specialist, are now being seen within two weeks. There are more beds in hospitals this year for the first time in thirty years. New hospitals, more staff, new equipment – are all coming through at record rates.

But investment alone will not do the trick as today’s Audit Commission makes very clear. Making progress is not just a question of resources but of reform. So whilst we will invest
£100 million to reduce waiting times in A&E that must be accompanied with organisational improvement in individual departments and management change across the hospital.

At the heart of public concerns about NHS is sense that its services are simply too indifferent to needs patients. Staff and patients alike up against a system feels much like 1940s. confidence demands fundamental change not just in level investment but culture today – put parents pupils first schools hospitals surgeries.

That brings me to my second point: a health service designed around the needs of patients must give more power patients. Better education, greater leisure opportunities and easier access information mean that people today are less likely accept passive role as recipients care. Crucially meet’s expectations, NHS, true its values, offer not just fairness but choice.

The NHS has always been strong on fairness but weak choice. It was born into a world where everyone given the same rations. In top down model there rationed care, capacity shortages and culture of paternalism, strove for equity population at expense choice individual. Today we have an opportunity to reconcile As expands its capacity, our task – make investment reforms necessary over months years ahead – is demonstrate that can expand without compromising equity.

That is why we say choice in health care should not be about forcing patients to pay for their own care. privatising NHS services. It expanding capacity and reforming can only happen with a greater plurality of provision through longer-term relationship between the public, private voluntary sectors providing more patients.

In other words what we must not do, as we seek to embed choice within the values of the NHS, is to abandon equity. We must not throw the baby out with the bath water. Let me give you an example. Some commentators argue that patients getting access to hospitals only via GPs limits choice. The truth is, however, our list-based GP system is not only genuinely envied abroad, it enjoys high satisfaction levels among patients at home. It brings major health benefits through continuity of care. It engenders high levels of trust between patients and professionals. And it manages the 90% of common illnesses better and cheaper than a hospital ever could.

But even here we need to make changes get a better balance between choice for the individual and fairness society as whole. Patients can already choose their GP but there is limited information about choices open them. improve on that by ensuring primary care trusts available people in local community they serve availability of services, specialisms female GPs, alongside data waiting times other aspects performance. provide bigger range services cater different lifestyles choices. More GPs who specialise treating particular diseases. NHS Direct advice treatment. Faster surgery appointments. walk centres where lack instant access.

Crucially, modern GPs should not just be gatekeepers. They should be navigators, guiding patients through the system and helping them make informed choices about their care. And here there is much more we can do to improve choices for patients. When we abolished the internal market in the NHS we restored GPs’ rights to refer patients to different hospitals. In most places though there is only one local hospital. That is why we have to raise clinical standards and cut waiting times in every hospital. From all the evidence I have seen, at home and abroad, the fundamental choice patients want to see is the choice of access to a good local hospital. Unlike the Tories’ botched internal market this is Labour’s primary objective. Over the last four years we have developed an array of means to deliver that – including cash that is tied to outputs and now a ratings system that gives greater freedom to the best performing hospitals and that franchises the management of the poorest performing hospital.

These levers are producing change. But the problem is they all top down. entail hospital responding to centre when what hospitals need be able do respond patients. So alongside these we should give patients greater choice over location of their treatment as another more direct means getting directly in other words not just about making patient feel good NHS. It giving power

From April next year patients will have more power. Any patient who finds their operation is cancelled at the last minute and are not then re-admitted within 28 days be able to choose an alternative hospital for treatment. They can public or private NHS pay there. This act as a powerful incentive hospitals improve performance on operations which causes misery frustration staff.

As capacity grows in the NHS we can now consider how to extend this choice principle to other aspects of hospital care. By March next year 5 million patients will have already chosen dates for hospital appointments convenient to themselves. By 2004 two thirds of all in patients and outpatients will be booked at the convenience of the patient not the system. By 2005 all patients will be in that position. And by then of course waiting times should be much lower.

Even then some patients will find themselves stuck with a longer waiting time at their local hospital than is available in other hospitals. London today for example the average all inpatient specialities varies between 7 weeks and 23 weeks. If we could extend choice of particularly to those who wait longest it would give patient greater control over own times treatment. Provide another incentive hospitals improve performance.

At present it is difficult for patients to choose opt a shorter waiting time. The way hospital funding rules work, deter rather than enhance patient choice. Many cannot exercise choice because they travel far afield. And there limited information available – or their GPs on times in different specialities hospitals. We are examining how these blocks can be removed I will bringing forward proposals near future.

Some within the NHS will see it as a threat. I can understand that. It is certainly a big change. But I believe it is the right thing to do. Today the patient has to be in the driving seat of change.

This brings me to the third point I want make: an NHS that is open choices by local patients must be better able respond needs of communities. way was set up took ownership away from It invested instead in State. course brought huge benefits. But there a cost. gulf grew between communities and running services. Today we find bridge it. all know strength feeling retain for their health You can see when walk into any hospital are met team volunteers drawn community. formal structures need embrace community support rather than keep at arms length.

I believe a key task for this second term is to reconnect public services with the communities they serve.

The wider social determinants of ill health – from poverty to poor housing call for the NHS be actively involved with others in local community improve and tackle inequalities. By devolving power frontline services most notably primary care trusts there is now an opportunity public re-engage communities they serve.

Devolution will help re-engage NHS staff too. The NHS is a high trust organisation. It works on the basis of trust between patient and professional. In the way it is organised it needs to enshrine that trust by giving more control to frontline services where patients and professionals interact. The simple truth is the NHS cannot be run from Whitehall. It employs over one million people. Improving services relies on them having a greater say over those services.

That is why we are slimming down tiers of management above the NHS frontline. It’s devolving resources to locally run Primary Care Trusts. Within three years they will control quarters budget. want unleash a spirit public sector enterprise that can rival any private enterprise. framework new national standards have established, use commitment and know-how staff improve for patients. give local freedoms innovate, develop services.

Patients should be at the heart of this process. present structures for giving patients a voice in NHS – most notably through Community Health Councils lack teeth and are out date. Just as reform is needed elsewhere here too. Alongside our plans forums to strengthen say local communities have over services we also need consider how can build on flowering experiments with citizen juries panels that has taken place recent years. I now asked Nigel Crisp, Chief Executive, work managers best Trusts advise me concept earned autonomy could relationship between they serve.

There is an analogy here with developments in urban planning the 1960s and 1970s which were supposed to usher a golden age of housing. That too was era expansion extra investment. Huge sums invested tower blocks council estates. intentions good. But outcomes – as we all know not. Estates became rundown almost quickly they put up, destroyed communities when intention create communities. Investment failed to deliver a new dawn social. It because people who be its residents never involved creation.

That’s why the relationship between citizens and public services in this 21st Century should be based on principles of decentralisation and empowerment. In health, in education, in housing, in local government and elsewhere we need to decentralise and empower staff and citizens alike. We must decentralise from the nation to the region. We must decentralise from local councils to local schools and to local housing estates. And in the NHS we must give communities more voice as well as giving patients more choice.

Our agenda for government must be about empowering citizens as well providing first class public services. It have at its heart a commitment to involvement much investment; reforming the way we engage deliver services; decentralisation key part of delivery.

For this generation of Labour Ministers our commitment to the values NHS must mean creating a more direct relationship between public and their services than was possible – or even conceivable in Bevan’s generation. That will require some big reforms. We need look at how can forge new settlement patients, professionals service. To open up choices for patients and recast structures so control means something simply state control.

Nye Bevan would not have been afraid of any these changes. For Nye winning elections was about gaining power over society. It using to change Indeed his whole philosophy summed up in that one phrase: “the purpose getting is be able give away.”

In conclusion then, I believe that just as the weakness of free markets are now clear, the shortcomings of monolithic, paternalistic public services are self-evident. Our answer is not just a stream of extra investment but a strategy of fundamental reform. To reshape public services, safeguarding equity of access whilst empowering the individual; to decentralise from Whitehall, ensuring greater local accountability within a framework of national standards. To deliver consistent quality and patient choice within an NHS which itself has more plurality of providers. This is an ambitious agenda for public service reform. It is an essential programme for this second term.