Alan Milburn – 2002 Speech to the HR in NHS Conference

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, on 2 July 2002.

It is a pleasure to be here today with you at your Conference. This event -now one of the largest HR conferences in Europe – has quite rightly become one of the major events in the NHS calendar. It’s especially heartening to see so many board members, managers and staff side representatives here today.

We meet during a week when we will celebrate the 54th anniversary of the founding of the NHS. When in all parts of the country the NHS celebrates its achievements by opening its doors to the people it serves. And I want to place on record today my thanks 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. All of the professions who, day-in, day-out, give their all in the service of others. 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.

For me – and for millions in our country – the NHS represents the best of Britain. Its values – of fairness, community, a belief that we really do achieve more together than we ever can alone – make the NHS more relevant than it has ever been. We live in an era where health care can do more – but costs more – than ever before. In this modern world, treatment that is free based on need not ability to pay, makes a tax-funded well-funded NHS the best way to deliver health care to all our people.

Today I want to set out how I believe we in this country can make the NHS the best insurance policy in the world. And I want to describe the challenges we now must meet if we are to realise that ambition.

It is true we face major problems in the NHS. Staff feel them and patients experience them. Old buildings, outdated equipment, staff shortages, long waits for treatment. But after decades of neglect today there is progress underway. Since the NHS Plan was published two years ago the NHS has chalked up achievements in which all parts of the service can share.

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. Where deaths from cancer and heart disease are down.

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 ago 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 experiencing long waits for an outpatient 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. The NHS Plan is unashamedly a programme for ten years not just for two. But the NHS today is now beyond first base in delivering it. Each of these achievements has been hard won. There are many more challenges to come. Anyone who says there are no problems is wrong. But those who say there has been no progress have got it totally wrong.

While those who are implacably opposed to the NHS – in principle as well as in practice – accuse it of being a black hole, which simply absorbs public money without return, those 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 in my view 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 get near. 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 too. Six years ago spending on social services was falling. Today it is rising by over 3% in real terms. From next April it will double to 6% a year over and above inflation for the next three years.

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.

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. 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. Some in politics and in business say the NHS, precisely because it is run on public service principles, can never actually deliver the goods for patients.

I know those doubters are wrong. Our job is to prove them wrong. And we can only do that by working together. Staff and managers, trades unions and employers. Our job is to use the extra investment to reform the NHS so that it can deliver faster treatment, higher standards and a better experience for patients.

You see 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 have to 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 in 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 we can only meet it by a combination of sustained investment and far-reaching reform.

In the first place, 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 x-rays, 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. And to help local health services focus on these priorities, we will not only cut the number of plans that have to be submitted to the centre but, for the first time later this year, give local services three year’s worth of funding so that there is financial certainty for the medium term rather than the short term.

Stability over resources will allow the NHS to 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 shift the balance of services so that more patients can be seen in primary, community and social services, not just in hospitals.

Each of the 28 new Strategic Health Authorities are now finishing their capacity plans. These plans will address how shortages – whether of buildings, equipment or staff – in each part of the country can be plugged. The biggest capacity constraint the NHS faces of course is the shortage of trained staff. That can place existing staff under huge strain. The new Workforce Development Confederations – working with the StHAs – have a key role to play in getting the extra staff the NHS needs into post.

And here too there are good foundations on which to build. The cuts in nurse and GP training places that took place in the 1990s have both been turned into growth. Training places for physiotherapists are up by almost two thirds. The number of applicants for nurse training has more than doubled since 1997. The fall in applicants for medical school places has been reversed. The largest ever increase in medical school places has already delivered 25% more medical students. The NHS Plan target to get an extra 20,000 nurses working in the NHS by 2004 has been hit two years ahead of schedule. Since 1997 the number of nurses working in the NHS has increased by over 30,000, the number of scientists and therapists by almost 14,000 and the number of doctors by 9,500. But there is more to do if we are to realise our latest plans for an extra 15,000 consultants and GPs, 35,000 more nurses, midwives and health visitors and 30,000 therapists and scientists on top of what has already been achieved.

Today I can report on two changes that will help NHS employers not just with recruitment but with retention too.

First, pay for staff. NHS staff deserve fair pay. There is no argument about that. But what I am not prepared to do is to see the large increases in funding for the NHS all go on extra pay. There has to be responsibility in public sector pay, including in the NHS. So I am prepared to invest more, but only in exchange for getting more. That is what lies at the heart of the new consultants contract we have agreed with the BMA. It is a something for something deal. Where consultants can earn more, but only if they do more for NHS patients. And it will be for NHS employers to make sure that is what the contract delivers.

A similar approach applies to the proposed new contract for GPs – the more they do the more they can get. Throughout the NHS better pay must be earned, through improved performance, greater productivity, more flexibility. That is the deal that is on offer through the Agenda for Change negotiations on a new pay system for staff other than doctors. These negotiations have been long and hard. I can confirm today, however, that we have started the final phase of the negotiations. I hope, after consultation, we can start implementing the new system – and a longer term pay deal alongside it – by the start of the next financial year.

Today my department is writing to all NHS Trusts seeking expressions of interest in joining this initial implementation phase. Agenda for Change holds out the prospect of better pay for NHS workers, in exchange for an end to old-fashioned working practices. It will mean an NHS where staff are paid according to the work they do not the job title they hold. So that the senior nurse who takes on more responsibility gets more pay. So that the clerical officer who provides support for a large clinical team gets paid more than the administrator who is in charge of more routine work. We need a system which makes sure people are paid for what they do and encourages them to progress. So that there is a positive incentive to encourage the ambulance technician to become a full paramedic and, in turn, for the paramedic to gain advanced skills so that they can deliver more frontline clinical care to patients.

Agenda for Change is all about transforming and modernising working practices in the NHS. If we can get it right, it will help bring to an end the remaining outdated professional demarcations that stand in the way of patients getting the faster, high quality care they need.

Pay reform alone, however, will not deliver the extra staff the NHS needs. Improvements in care for patients can only happen if there are improvements in the care we give to staff. I have never agreed with those who say that we have to choose between investing in staff or investing in services. In the NHS they are one and the same.

The HR in the NHS Plan, which Andrew Foster launched yesterday at this conference, makes the case for the health service becoming a model employer. The NHS won’t get better treatment for patients unless it offers better treatment for staff. The NHS is already Britain’s largest employer. Our aim should be to make it the best.

In a world where patients rightly want flexibility – over when they are treated – and where staff need flexibility – to balance their family and their working lives – NHS employers need to respond. That is why we put in place the Improving Working Lives programme, so that every part of the NHS offers staff flexi-time, annual hours, flexible retirement or career breaks. Some employers are already doing precisely that – and reaping the benefits through more staff and better staff morale. By next Spring I will be looking to every NHS employer to deliver these changes.

Help with childcare is crucial too. Our manifesto commits us to invest an extra £100 million – from the savings made by abolishing the old health authorities and NHS regional offices – in improved childcare for staff. A start has been made. By this time next year the NHS will have funded double the number the number of workplace nurseries than it did just last year. Staff I have met – whether at the Freeman Hospital in Newcastle or at the Lewisham Hospital in London – have all stressed how important these nurseries are for them in what are inevitably busy lives.

On-site nurseries, while good for some staff, however, are not right for all. I can announce today then a further £6 million to make other forms of childcare – such as after school clubs and holiday playschemes – available to NHS staff. All staff – including our country’s family doctors and their staff – will be eligible for help.

These changes – a new pay system and more support for staff – will help deliver the increases in professionals the NHS needs. By necessity this is a programme for the medium term. It takes 3 years to train a radiographer, and many more to train a consultant. The last few years have seen more staff of course – and there are more to come – but there are still staff shortages. This is particularly the case with doctors in certain key specialities. That is why, over recent months, we have embarked on a major drive to recruit trained medical staff to the NHS from abroad.

Today I can report on progress. Since the global recruitment campaign began we have identified around 500 doctors who are suitable for employment in the NHS. To date around 100 have been matched with NHS Trusts who are interested in employing them. In addition, Sir Magdi Yacoub is heading our efforts to bring highly qualified doctors to this country through a specially devised NHS International Fellowship Scheme. Doctors who come to this country will work in the NHS on Fellowships for up to 2 years. We are initially concentrating on recruiting them to four key shortage specialities – cardiothoracic surgery, histopathology, radiology and psychiatry.

We had expected to recruit 50 fellows in the first phase. In fact, thanks to the help of the medical royal colleges and others, I expect double this number to be short-listed. And I expect the majority of short-listed International Fellows to be in place by the end of 2002.

Last week, I also met with private health care providers from France, Germany and Sweden who are interested in bringing into this country their own clinical teams in order to further expand elective services for NHS patients. We are now in active discussions with several of them. A key stipulation for us is that they bring their own suitably qualified medical staff with them, rather than seeking to take existing NHS doctors out of NHS hospitals.

Some, both from within the NHS and from existing private sector providers, have expressed concern about this plan. Similarly, some have pointed to concerns and even resistance to our proposal to recruit individual overseas doctors into NHS hospitals. I find this surprising. Everyone knows the NHS need more doctors. It is doctors, above all others in this country, who have quite reasonably argued that case. Of course standards – including language skills – have to be right. But what we cannot have – and what I will not accept – is anyone having a right of veto on NHS patients getting the extra doctors they need. There can be no question of restrictive practices, wherever they are found, standing in the way of an expansion in services for NHS patients. I will be looking to NHS employers to always put the needs of NHS patients ahead of any other consideration.

Let me just make this general point: reform is not an optional extra in the NHS. It is as vital as the investment. It is central to the renewal of the health service. To be clear : when it comes to NHS reform our foot will be on the accelerator not, as some argue, on the brake.

So I am planning for the first of a growing number of these new overseas providers to be in place later this year. They will concentrate on elective surgery in hard-pressed specialties in those parts of the country where capacity constraints are greatest. 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.

All of this is about expanding the services that are available to NHS patients so they can get faster treatment and higher standards. These reforms are also 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 NHS patients are treated they remain NHS patients because they get care according to NHS principles – treatment that is free, based on need, not ability to pay. This is the modern definition of the NHS.

This new diversity in NHS provision, coupled with sustained expansion in capacity, provides the basis for patients to exercise more choices about their care. As capacity expands so choice can grow. From next April we will begin to move to a system of payment by results for NHS hospitals. For elective services resources will follow the choices patients make so that hospitals that 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 so marking an irreversible shift from the 1940s take it or leave it, top down service.

That process started this week with patients waiting more than 6 months for a heart operation being offered a choice of 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. This week sees the first small but significant step towards our 2005 ambition of a service where all patients needing a hospital operation can choose not just the location of their treatment but when to be treated and by whom.

Of course, different approaches will be needed to bring about improvements say, in emergency care or mental health services. But overall this is the most fundamental change the NHS will have ever faced. Not in how it is funded or the values on which it is founded, but in how it is organised. Patients will be in the driving seat – and not before time.

NHS healthcare no longer always needs to 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 truth is that securing improvements in performance requires both.

Later this month local health services will receive a star rating for their performance. Those who are doing less well will get more help. Those that are doing best will get more freedom. 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 be able to 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.

The reason for this is simple enough. In the end I don’t treat patients. You do. Whitehall doesn’t provide care. That is what hospitals, health centres and surgeries do. And that is where power needs to be located. On the frontline. Our core objective is to shift the centre of gravity in the NHS. It is right that standards are set nationally, but it is wrong to try to run the NHS nationally. 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. From 2004, three-quarters of the NHS budget will be controlled by PCTs.

It is time to unleash the spirit of public service enterprise that I know exists in so many parts of the NHS. The simple truth is the NHS works best when it harnesses the commitment and know-how of staff to improve care for patients. That’s why we are putting ward sisters in charge of ward budgets and giving health visitors a greater say over community health budgets. It’s why matrons are being given the power to get the fundamentals of care – like clean wards and good food – right for patients. It’s why nurses are being given new powers to prescribe drugs and discharge patients.

And crucially doctors – with all their skills and knowledge – need to be empowered too. Too many doctors for too long have felt disempowered. Through PCTs there is now a major opportunity for doctors in primary care to shape local services to suit local circumstances. Devolution of budgets to practices will aid that process of clinical engagement. In secondary care there is more to do. Here a new effort to engage doctors in the process of change is needed. Just as PCTs need to devolve responsibility to their front-line staff, so do Trusts. Resources and responsibility need to be placed on the front line. That will become an absolute imperative as patients get greater choice and their choices are backed by resources. Clinical teams need to have the resources and authority to make their services more responsive to patients. And as staff at the James Cook University Hospital on Teesside were arguing with me yesterday, when clinical teams do well, staff need to be rewarded too.

The people at this conference today are the key to delivering these changes. Senior managers in the NHS – working with the NHS trade unions – have a real responsibility to ensure that staff at all levels are involved in the process of change and, crucially, that clinical teams are engaged and empowered.

When they are – as in the collaborative programmes already begun in cancer, coronary and primary care – the results are staggering. More than 90% of practices involved in the primary care collaborative for example are able to guarantee patients an appointment to see a GP within 48 hours. But staff involvement should not have to be left to special programmes in some parts of the NHS. It should be the norm in every part of the health service. Whether it is the doctor or the porter, the engineer or the cleaner, every member of staff in the NHS should be involved in helping make change happen.

In a world where knowledge is king, other industries have long since learned that the successful organisation is one that consistently develops its staff and harnesses their potential. It is a lesson that the NHS has been too slow to learn. But through the NHS University, NHS Learning Accounts, the NHS Modernisation Agency and the Leadership Centre we can now put that right.

Last year, for example, almost 20,000 NHS staff who are currently without a qualification were able to access either an NHS Learning Account or NVQ training or assessment. This year the £60m that has been allocated direct to Workforce Development Confederations will allow a further 90,000 staff to benefit. And when staff benefit, patients benefit too – through people delivering services who are better trained and better able to fulfil their potential.

There is no more important management function in today’s NHS than getting the best from all its staff.

In the end, the NHS is the people who work for it. I want to see an NHS that is true to its principles but reformed in its practices. Where patient choice drives change. And where front-line staff are empowered to make those changes happen.

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

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 through the NHS.

And with your help, I know that the best days of the NHS lie in the future, not in the past.