Alan Milburn – 2002 Speech on Diversity and Choice within the NHS

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, to the NHS Confederation on 24 May 2002.

It’s a year since I last spoke to you. Those twelve months have been a time of great change and major challenge for the NHS and the people who work in it, lead it and manage it.

The old health authorities and regional offices have gone. The new primary care trusts are up and running and the new strategic health authorities are on their way. When these changes were first proposed some said they were too risky. It is certainly true that at a time when the NHS is focussed on delivering a major programme of improvement there were risks associated with making these changes.

But the transition has gone better than many feared. And that is thanks to you. Non-executive directors, managers, clinicians and chief executives. Without you these changes would not have been as well-managed as they have been. At a time when NHS management continues to face enormous criticism from some quarters – and even the occasional critical comment from me – I want to place on record my thanks for the job you have done. Good management is needed now more than ever in the NHS.

I also want to thank the NHS Confederation for the role you have played in taking the agenda of change forward in the NHS. First in Stephen Thornton and now in Gill Morgan you have strong advocates both for the NHS and for NHS reform. I am pleased that we are able to work so closely with you.

Last year I said at your conference that I wanted you to lead the negotiations for a new GPs contract. Those negotiations have gone well and thanks to the hard work both of yourselves and the BMA there is now the very real prospect of a new contract that is not only good for Britain’s family doctors but is good for NHS patients.

I hope we can build on what you have achieved in these negotiations. I want to move to a position where national negotiations over new contracts of employment are undertaken, not by the Department of Health, but by NHS employers acting collectively. Such a change would symbolise what I believe should be a new, more modern relationship between government and the health service – where devolution takes hold, where there is more power in the NHS and less in Whitehall. So that local health services can be more responsive to the needs and choices of patients.

I want to set out today the challenges facing the health service. And how I believe the NHS can rise to meet them. No-one should be in any doubt about the significance of the next few years for the NHS. It is make or break time. Either we prove that the NHS can change to become a service where the interests and choices of patients always come first or we reconcile ourselves to the fact that the NHS – great in principle – simply could not cut the mustard in practice in today’s world. I want to say unequivocally today that I have no doubt the NHS – with your help and leadership – will meet that challenge and can look to the future with confidence.

I say that in part because of the improvements already taking hold. I know too many of the stories in the newspapers are still focussed on what goes wrong rather than what is going right. Nobody in the NHS pretends there aren’t problems – there are – or that staff are not working under real pressure – they are. But the story the NHS should be telling in every community in the land is what it has been doing to put the problems right.

I want to pay tribute today to the staff of the NHS – not just the doctors and the nurses – but all the staff. The porters, the cooks, the cleaners, the scientists, the therapists, the secretaries, the managers and the administrators. They represent the very best of British public service and I believe that it is time we as a nation stood up and said that we are proud of the work you do.

There is good progress to report for which the NHS can justifiably be pleased. And the whole of the NHS can share in the achievements made.

In primary care, where waiting times are coming down. Where 10 million people can get out of hours care through a single phone call to NHS Direct. Where the prescribing of cholesterol-lowering drugs is up by one third. Tens of thousands of patients are receiving the latest drugs to combat cancer, heart disease, Alzheimer’s disease and arthritis. In the past year alone, death rates from cancer have fallen by 2 per cent., and from heart disease by 5 per cent.

In mental health services where in hundreds of communities new crisis and assertive outreach teams are in place providing services to thousands of vulnerable patients. In older people’s services where delayed discharges from hospitals are down, where more home based care is in place and where free nursing care is now the norm.

In ambulance services where today all but a handful are achieving the emergency response call time when just two years agor only a handful were achieving that.

In hospital services where a year ago people were having to wait up to 18 months for their hospital operation. Today the maximum wait at 15 months is moving towards the NHS Plan guarantee of a maximum 3 month wait. The number of people waiting more than 12 months for a hospital operation has fallen by one third in only one year. The number of people experiencing long waits for an out-patient appointment is the lowest on record. And for those with the most serious clinical conditions-cancer and heart disease-waiting times are lower still.

Yes, of course, there is a long way to go but the NHS is now beyond first base in delivering the NHS Plan. Each of these achievements has been hard won. There are many more challenges to come. Anyone who says there are no problems has clearly got it wrong. But those who say there has been no progress have got it totally wrong.

While they accuse the NHS of being a black hole which simply absorbs public money without return these critics should instead be pointing at dozens more hospitals, hundreds more beds, thousands more doctors, tens of thousands more nurses – and an NHS that is now on the up. They should go and see what I see in every hospital, health centre and surgery I visit. Not just the investment coming through but the reforms too – in how staff work and how services are organised.

The 10 year journey we mapped out in the NHS Plan is now firmly underway. And now we can move up a gear.

The Budget on April 17th marked a watershed for the NHS. And I don’t just mean the scale of the resources or the length of time for which they have been committed. Yes, against any historic benchmark they are generous. Five years of real terms growth averaging 7.5% will take health spending in our country beyond the EU average – an average which the cynics said we couldn’t even meet. It is worth remembering that just six years ago spending on the NHS was falling in real terms. By 2008 it will have doubled in real terms.

What is more, social services – for too long the poor relation – are to enjoy big rises in investment as well. Six years ago spending on social services was falling. Today it is rising by over 3% in real terms. We know that more is needed. We have listened to what local government, private sector care homes and local health services have all had to say. So now, spending on social services will double to 6% a year over and above inflation for the next three years.

I know there are many pressures and many demands. As we expand services after so many years of under-investment there will be growing pains along the way. But that is precisely what they are. The pains that come from growth. So no one should fall into the trap of saying that these unprecedented resources somehow bring problems when in fact they present the NHS with a huge opportunity.

The significance of what we have done should not be under-estimated by anyone in the NHS or outside. The Budget laid to rest a decades old fallacy – that we in Britain could have world class health care on the cheap. We can’t. The evidence is there for all to see. The run down buildings. The outdated equipment. The failure to invest in modern IT. The shortages of trained staff. The long waits that we inflict on patients.

We are bringing the decades of NHS neglect to an end. With the economy on a stable footing we can now put the NHS on a sustainable footing for the long term. We believe the time is now right to ask the British people to pay a bit more in tax to make the NHS a lot better for patients.

Make no mistake – when people are putting more in to the NHS they will expect to get more out. And rightly so. None of us can assume public confidence. Now more than ever we have got to earn it. As the reaction to the Budget has shown, there is overwhelming public support for the extra investment. But there is considerable public scepticism about the ability of the NHS to turn those resources into results for patients. A failure to deliver improvements will prompt only one response: not more money in the future for the NHS but less. Not collective provision of health care but more individual provision. Not the public sticking with the NHS but the public walking away.

You only have to read some of our newspapers to hear the voices of scepticism. Sometimes it is not just scepticism about the NHS. It is downright hostility. You can hear other voices too. Some in politics or in business who say the NHS precisely because it is run on public service principles can never actually deliver the goods for patients.

We have to prove those doubters wrong. And we have to do it together.

When we put taxes up to get more resources for the NHS – as people in the NHS urged us to do – we entered into a new contract with the people of our country. In exchange for extra resources we will deliver better results. Not just improvements in services for patients but services which are increasingly shaped by the informed choices of patients. Not the old style take it or leave it NHS of the last century but an NHS that is tune with the needs of this century – where services are responsive, where patients have choices, where quality always comes first. This is the challenge together we must now meet.

I believe that we are in a strong position to do so. NHS funding is secure. There is progress under way. There is a ten year NHS Plan, the cornerstone of all that we do. And there is a major programme of reform to match the programme of investment.

It is these reforms that are so crucial to the future of health care in our country. That are capable of making the NHS precisely the modern service that both patients and staff want to see.

These reforms began in our first term with the introduction of a new national framework of standards. As the Kennedy Report into the tragedy at Bristol confirmed, it was really the absence of national standards that was such a structural weakness in the NHS. Hence the NSF programme, the National Institute of Clinical Excellence, the system of clinical governance, the Modernisation Agency, the Commission for Health Improvement. All of this, designed to prevent bad practice and to spread good practice, so that patients everywhere get the care and treatment they need. Whatever doubts there might be about finer points of detail there is broad consensus that this new national architecture is right for the NHS and most importantly for NHS patients.

With this national framework in place, in this second term our core objective is to shift the centre of gravity in the NHS. As both the NHS Plan and our recent follow up command paper Delivering the NHS Plan make clear, it is right that standards are set nationally but it is wrong to try to run the NHS nationally. It is only frontline clinicians and managers in day to day contact with patients who can transform local services. This is something which the new strategic health authorities in their relationships with Primary Care Trusts will need to fully understand: the PCTs need to be helped and enabled not commanded or controlled. In turn, they need to devolve resources to their constituent practices from the growing proportion of the NHS budget the PCTs will control.

As the NHS Plan indicated a million strong service cannot be run from Whitehall. For patient choice to thrive it needs a different environment. One in which there is greater plurality in local services with the freedom to innovate and respond to patient needs.

It is an explicit objective of our reforms therefore to encourage greater diversity in provision and more choice for patients particularly for elective surgery. Hence primary care trusts having the explicit freedom to purchase care from the most appropriate provider – whether public, private or voluntary. From next April we will begin to move to a system of payment by results for NHS hospitals. Resources will follow the choices patients make so that hospitals who do more get more; those who do not, will not. Over the next four years an increasing proportion of each hospital’s income will come to it as a result of the choices patients make. For the first time in the NHS patients will be able to choose hospitals rather than hospitals choosing patients. That process will start this summer when patients waiting more than 6 months for a heart operation will be able to choose a faster waiting time in another hospital which has the capacity to treat them – whether it is public or private, on the doorstep or further afield, in this country or abroad.

Later this year we will also test in different parts of the country how patients with other conditions can exercise greater choice over where they are treated. We will want to work with the NHS in developing these policies – just as we have done in developing our thinking on NHS Foundation Trusts – so that by 2005 patients will be able to choose not just the location of their treatment but when to be treated and by whom.

This is the most fundamental change the NHS will have ever faced. It will mark an irreversible shift from the 1940s take it or leave it, top down service. Patients will be in the driving seat – and not before time. Of course different approaches will be needed to bring about improvements say, in emergency care or mental health services.

And more choice for patients, of course, requires more capacity in services. Patients can only choose to have an operation if a hospital is able to provide it. Consistent growth in staff numbers and in capital infrastructure will be needed if local NHS services are to expand patient choices and gain from the new system of financial incentives.

The biggest constraint the NHS faces is shortages of capacity. So I can tell this conference today that in addition to sustained growth in existing NHS provision, we will bring new providers from overseas into this country in order to further expand elective services for NHS patients.

A few have already started work in the NHS but as you know it is very early days. I can tell the Conference that we are now in discussions with a number of major overseas providers to bring clinical teams – in particular extra surgeons and other doctors – to this country. I can tell the Conference today, I will be meeting personally with prospective providers from both Europe and America over the course of the next few months with view to encouraging them to invest in England. They will concentrate on elective surgery in hard pressed specialties in those parts of the country where capacity constraints are greatest. I expect to see a growing number of these new providers in place beginning later this year. Like NHS use of existing private sector providers, this is not a temporary measure. These new providers will become a permanent feature of the new NHS landscape. They will provide NHS services to NHS patients according to NHS principles. And in the process they will open up more choices for patients and more diversity in provision.

These reforms are about redefining what we mean by the National Health Service. Changing it from a monolithic centrally run monopoly provider to a system where different health care providers – public, private, voluntary and not for profit – work to a common ethos, common standards and a common system of inspection. In such a system wherever patients are treated they remain NHS patients because they get care according to NHS principles – treatment that is free and available according to need not ability to pay. This is the modern definition of the NHS.

It is also a fundamental change. Not in how the NHS is funded or the values on which it is founded, but in how it is organised. NHS healthcare no longer always needs to always be delivered exclusively by line managed NHS organisations. The task of managing the NHS becomes one of overseeing a system not running an organisation. Responsibility for day to day management can be devolved to local services. None of this means the abandonment of national standards. Far from it. It is precisely because over these last five years we have put in place such a rigorous framework of standards nationally that the centre of gravity can now shift to how improvements can be delivered locally.

So while some advocate a false choice between national standards and local autonomy, the experience from elsewhere in Europe in the health sector, and from across the developed world in other economic sectors, is that securing improvements in performance requires both.

There is a simple deal on offer here. The better you do the more you get. It is a discipline that needs to work just as much in public services as in the private sector. I have lost count of the number of times I have been told by NHS managers and NHS clinicians alike that the NHS has got to stop bailing out the poorest performers and instead reward the better performers in the NHS in order to provide the right incentives for innovation and improvement to take hold across the whole of the NHS. And that is precisely what we must do if we are to translate the extra resources into real results for patients.

That is the reason for star rating the performance of local health services so that those who are doing less well get more help, those that are doing best get more freedom and those that are persistently failing feel the consequences. Where there are persistent problems we will step in. Where there is progress we will step back. At one end of the spectrum new management teams – whether from the public, voluntary or private sectors – will be brought in through the franchising process to turn round NHS organisations that are in trouble. At the other the best performers will become NHS Foundation Trusts legally free from Whitehall direction and control. Three star trusts will have less monitoring and greater freedom.

The more overall performance improves – as I am confident it will – the more autonomy will be earned across the NHS. That is what I want to see happen. We are at the start of a transition where more and more decisions about the NHS are taken locally rather than centrally.

It is time to unleash the spirit of public service enterprise that I know exists in so many parts of the NHS.

As in any large organisation some functions will need to be undertaken centrally but they should be strictly limited. The Department of Health will focus on setting strategic objectives, determining standards, distributing and accounting for resources and securing the integrity of the overall system through for example workforce planning and better IT. Overall the Department will be slimmed down as power and resources are devolved out of Whitehall. Some functions will move from the Department to the new Commission for Healthcare Audit and Inspection as the existing Commission for Health Improvement, National Care Standards Commission and the value for money work of the Audit Commission are brought together. The new CHAI will benefit from the comments that the Confederation and others in the NHS have made about avoiding bureaucracy and fragmentation but it will have the teeth to ensure that money is being spent wisely and that standards are improving.

Rather than trying to drive improvements through top down performance management the transition will be towards improvements being driven through greater local autonomy in which PCT commissioning, new financial incentives and the choices that patients make become the driving force for change with scrutiny through independent inspection. That transition will take time. It will require careful management and a new, more mature understanding about the relationship between government and the health service where the government does less and the NHS does more.

To help smooth that transition there are three areas where I hope government can help the NHS.

First, by focussing on the priorities for patients. If the NHS is to deliver for patients it has to remain focussed on what counts for patients. And the extra resources must be properly focussed too. The NHS does many things. There will be many pressures from many quarters for many good causes. But none of us will be forgiven if having raised the resources we fail to use them to get the results that both staff and patients want to see. Shorter waiting times. Higher clinical standards. Better health outcomes.

The public’s priorities have to be the health service’s priorities. Getting waiting times down in every aspect of NHS care from ambulances to diagnostics, from primary care to secondary care. Providing quick high quality emergency services not least in A&E. Making sure that the fundamentals are right – clean wards and safe care. Improving cancer, cardiac, mental health and elderly services.

These are the priorities. In time it is true we will develop further NSFs but only at a pace the NHS can properly absorb. I know the complaint in the service is that there are too many priorities and too many plans. I sometimes hear people say they cannot see the wood for the trees. It is true that sometimes in the rush to make change happen we have opted for the short cut of a dictat from Whitehall when what was needed was a longer discussion with the service. But in a public service like the NHS there has to be accountability to ensure that public money delivers the results that patients want to see whether that is matrons in charge of wards or shorter waiting times for treatment.

So national standards are necessary. Nobody wants to see a lottery in care where cancer patients are denied treatments in one part of the country which they are entitled to in another.

And targets are necessary – without them history shows that GP and hospital waiting times would not now be falling so consistently. But national standards and targets work best when they are focussed on key priorities.

Today I can announce some changes that will do just that. To begin with we will reduce the number of plans that local health services have to submit to the Department of Health.

At present the NHS is asked to produce scores of plans every year. We will be working with the NHS to review the number of these plans with a view to cutting their numbers by at least two thirds. If we can go further we will. In future planning will focus around delivering the core priorities. The same will be true of monitoring. The concentration will increasingly be on outcomes and outputs. That will allow the volume of overall guidance and monitoring to be reduced. We have already cut the number of circulars issued to the NHS each year and shortened the planning guidance. But senior staff still complain they receive too much clutter that does not help them focus on the core priorities.

So I can announce today that we will establish a panel of senior managers and clinicians from the NHS to act as a firebreak, to vet communications between the Department and local health services so they are limited to those that are absolutely necessary.

Secondly, I want to give the NHS the stability it needs to deliver the NHS Plan. The five year financial settlement that the health service has now got allows us to plan for the longer term particularly to meet the waiting time reductions planned for 2005. I can confirm to this Conference today that when we make financial allocations to PCTs this autumn they will receive funding not for a single year but for three years. Annual planning and annual target setting can become a thing of the past. Local health services will be able to concentrate on what needs to be done to bring about improvements over the medium rather than the short term.

Thirdly, stability will help local health services implement a sustained programme of expansion. It is time to go for growth. To use the large scale increases in both revenue and capital funding to expand capacity. To get the staff, the buildings, and the equipment the NHS needs. To shift the balance of services so that more patients can be seen in primary, community and social services, not just in hospitals.

To help this programme of expansion take hold locally there will be help nationally. As far as IT is concerned we urgently need to reverse almost two decades of failed attempts to modernise the NHS core infrastructure. So I can tell this conference today that later this summer we will bring forward a nationally run IT programme which will be backed by large scale investment.

Alongside the programme to bring overseas clinical teams to England we will be helping to establish the first generation of Diagnostic and Treatment Centres to separate elective from emergency work. Some will be run purely by the NHS, some by the private sector, some through partnerships between public and private.

To help the NHS focus on this longer term capacity building the next three years there will be a minimum amount of earmarking by the centre of local NHS resources. PCTs will have greater discretion over how growing NHS resources are spent.

These changes are all about helping the NHS to deliver. The national standards are in place. The resources are there. The NHS Plan is underway. There is a clear focus on what counts for patients.

We are in transition but the direction of travel is one way. Our supply side reforms – payment by results, freedom of commissioning, power to PCTs, NHS Foundation Trusts, plurality of provision – all lead towards a more devolved and more diverse health service where patients have greater choice.

You know transition takes time. I know that. So does bringing about improvement. Public expectations are high. But they also need to be reasonable. People need to understand that a 10 year plan is exactly what it says. It will take time to be delivered in full. But the NHS has to prove – not in five years time or in ten – but over this coming year that progress is underway in every part of the service.

The Budget this year represents an enormous vote of confidence in all of you, in the whole of the health service.

The ethos of the NHS and its staff express the values of our nation. Some have said that the Budget is a gamble. In some people’s minds it may be. But not in mine. I wouldn’t have fought so hard for the resources we’ve now got if I thought there was a better way of providing health care for our country. For me there is no better way than a tax funded, well funded NHS.

It is a genuine One Nation policy that puts need before ability to pay. Quite simply in a world where health care can do more – but costs more- than ever before the NHS should be supported with our heads as well as our hearts.

With the investment now secured, with the reforms now taking place, with the brilliance of our staff, I can tell this conference without a moments hesitation: I believe the best days of the NHS are ahead of us not behind us. I believe that investment plus reform does equal results.

And above all, I believe that you can do it.