Alan Milburn – 2003 Speech to NHS Executives

Below is the text of the speech made by the then Health Secretary, Alan Milburn, to NHS Executives on 11th February 2003.

I would like to begin by thanking you for the leadership you show in the NHS. It has never been more vital.

In the months to come that leadership will be more important still. We are a critical juncture for the NHS. It is over two years since the NHS Plan was published. Investment in the NHS is rising fast. This April taxes will go up to pay for the extra resources.

As a result, capacity is growing. From the late 1970s to the mid 1990s only ten major new hospital developments were completed. Since 1997 13 have been built, seven more are under construction and a further 34 are in the pipeline. In each of the five years before 1997 the number of GPs in training fell. In each of the last five years they have risen. There are 10,000 more doctors, 40,000 more nurses, and 11,000 more therapists and scientists working in the NHS now than then. In primary care prescribing of cholesterol lowering drugs has doubled in 3 years. For decades acute and general beds in hospitals were cut back. For the last two years they have grown.

The local plans PCTs and NHS Trusts are concluding for the next three years will need to increase capacity further: in primary and community services, not just hospital services; in staffing, especially in doctor numbers; in new ways of working, not just the old ways of doing things.

Extra capacity is needed because the NHS is still working under very real pressure. It is tough out there. It is easy to lose sight of the fact that the journey we have begun is well underway. Of course, there is a long way to go but the momentum is now forwards.

Take waiting times. Thanks to your efforts waiting times – which had risen for decades – are falling – and doing so on virtually every indicator. In heart surgery, for example, the maximum waiting time which was eighteen months at this time last year will have been halved to nine months by April this year. So, in what remains of this financial year, it will be important to deliver the continued progress we have promised towards an NHS where waiting times are lower and quality is higher.

For patients, progress will be judged not just on whether waiting times are shorter but on whether their own experience of the service is better. There is no doubt that waiting – whether it is to see the family doctor or the hospital specialist – is the single biggest public concern about the NHS. But unless we can improve the quality of the patient experience we could end up hitting every target and ticking every box – and finding that the public believe the NHS is no better.

That is why the resources have got to lever in reforms. The investment cannot be used to ossify the system. It must be used to change it.

Last week I argued for devolving power and resources from Whitehall to the NHS frontline. The move to a more diverse, more devolved NHS will help make local services more responsive to the needs of the local communities they serve. Today I want to set out another crucial element of our reforms: greater choice for patients. I want to describe why I believe choice is important and how we plan to make it happen.

The starting point is this: when the NHS was created expectations were lower; deference was greater. Today it is the other way around. Some argue that in today’s consumer world the only way to get services that are responsive to individual needs is through the market mechanism of patients paying for their own treatment. I believe that is wrong and would fail. In a world where health care can do more but costs more than ever before, such an approach would make the best health care an exclusive club for only the very wealthy. The new possibilities brought by medical advance and – in our generation, the genetics revolution – make the case for an NHS where care is free and based on the scale of people’s needs, not the size of their wallets.

So public service values are right. But winning the argument for investment and reform means accepting that the era of one-size-fits-all public services is over. At the heart of public concerns about the NHS is the sense that its services are simply too indifferent to the needs of its patients. Staff and patients alike are up against a system that feels too much like the ration book days of the 1940s. Public confidence demands not just a change in structure but a change in culture too.

In our first term we tried to make services more responsive from the top down through service targets, inspection regimes and national standards. This national framework of standards is important to guarantee equity but in the period we are now in the transition is towards improvement being driven from below. Hence these three crucial elements of our reform programme:

Devolution – with Primary Care Trusts having the power to commission local services to meet the needs of local communities.

Democratisation – with NHS Foundation Trusts transferring ownership from a centralised state bureaucracy into the hands of local people.

Diversity – with different providers – public, private and voluntary – providing NHS services to NHS patients according to a common ethos, common standards and a common system of inspection.

These reforms make possible greater choices for patients. There are of course limits to choice in the health service, just as there are in any other service. For one thing, health care is often an emergency service. The last thing the patient in the back of the ambulance wants is to be asked to name their A&E of choice. They want the nearest, fastest service. And for another, patients do not just have a relationship with the NHS as consumers. They are also citizens who recognise that in A&E it is necessary for the less serious injuries to give priority to the more serious ones. In other words patients have both rights and responsibilities. Indeed I believe that as we strengthen rights and choices so we can demand more responsibility from patients – to use services appropriately and to treat staff respectfully.

But the NHS is a lot more than an emergency service. In fact, only one in three NHS hospital admissions are for emergency cases. Half are for routine, planned surgery where patient choice could play a role. A further one in seven are for maternity services where many mums and dads already exercise choice: between this hospital and that, between a midwife-delivered service and a doctor-delivered one, between a birth at home and one in hospital.

Indeed, it is precisely because women have been able to exercise choice for themselves that those services have become more sensitive to their needs. When we publish the new national service framework on children’s services later this year it will include proposals on how we can extend choice further in maternity care.

In other parts of the NHS patients also exercise choice. In primary care for example, most patients are able to choose their own family doctor. Between July and September last year almost quarter of a million patients, through their GPs, booked the time of their hospital appointment at their own convenience rather than the hospital’s.

No health care system, whether it is public or private, however, can provide unlimited choice. Most private health insurance schemes, for example, exclude maternity care and primary care as well as psychiatric and other long-term treatments.

But I believe we can open up more choices to NHS patients. The issue is firstly, whether we should and secondly, how we could.

Let me deal with the first of these issues. It is often argued that capacity constraints mean that choice on the NHS is not possible. It is certainly true that choice can only grow as capacity grows. What is not true is that some capacity is not already available or that more cannot be grown.

In London, for example, today the average waiting time for elective surgery in different hospitals varies between 10 weeks and 25 weeks. With the right incentives some hospitals would take on more work. When UCLH bought the London Heart Hospital from the private sector last year that doubled local heart surgery rates. In that area today only 40 patients are waiting more than one month for a heart operation, many for personal reasons. That hospital could easily take on more patients. There will be others elsewhere in the country which could do the same. Many more will be able to do so as extra resources produce extra capacity. So the capacity argument against more choice does not work.

The main argument against more choice has been that it will bring less equity. I want to argue the reverse: that greater choice can mean greater equity.

We do not start from a position where uniformity of provision in the NHS – with precious little choice for patients – has guaranteed equality of outcomes. In fifty years health inequalities have widened not narrowed. Too often even today the poorest services are in the poorest communities. Choice has only ever been available to those with the ability to pay. Those with the money have been able to exercise more choice – and buy faster, if not better, services as a result.

This institutionalised two-tier health care is anathema to those of us who believe care should be based on need and not ability to pay. The real inequity is to force the pensioner with modest savings who has worked hard all their lives and then needs a heart operation to choose between paying for treatment or waiting for treatment. That is a dilemma I want to solve.

We can do so by making choice more widely available on the NHS so that it is extended to the many not just the few. Some say poorer people do not want to exercise choice or are not able to do so. I disagree profoundly. That is patronising nonsense.

When I grew up on a County Durham council estate it didn’t much impress me that it was the council, not my family, who chose the colour of my front door. Perhaps unsurprisingly hundreds of thousands of council tenants opted out of council ownership when they had the chance to do so. The old-style, often paternalistic take-it-or-leave-it, like-it-or-lump-it relationship between council housing services and council tenants weakened public attachment to public services. Expanding choice can strengthen it.

And by linking the choices patients make to the resources hospitals receive – alongside the systems of standards, inspection and intervention we have put in place – we can provide real incentives to address under-performance in local NHS services. As we know poorer performance is often concentrated in poorer areas. Giving people the power to choose between services will drive standards up. In this way, greater choice can enhance equity, not diminish it.

The world has moved on from the days when Henry Ford said you could have any colour car as long as it was black. The Ford Motor Company is 100 years old this year. Today, Ford produce cars so that you can have any colour – including five different shades of black!

Of course, choice in public services is more complicated than choosing the colour of a new car but unless the NHS offers some choice to patients, more of them – at a time when personal disposable income continues to rise – will simply take their custom elsewhere. More will abandon collectively funded public services for privately paid-for services. In the mid-1950s only half a million people had private cover for health care. Today it is almost 7 million. Ironically, those who rail against choice in public services on the grounds that it is a market-based reform risk ending up strengthening private markets not weakening them.

The trap we must avoid, is that identified by Richard Titmuss four decades ago, of middle class people opting out so that public services become only for the poor and then end up being poor services. By strengthening the appeal of NHS provision across social classes, greater choice can enhance social cohesion not diminish it.

The question in my mind is not whether NHS patients should have more choice but how to make choices more widely available.

We have made a start. And again I want to thank you for the role you have played. Since July last year heart patients waiting more than 6 months for surgery have been offered the choice of early treatment at an alternative hospital – public or private – which has the capacity available to treat them. Over 1,700 out of 3,800 patients – almost half – decided to make that choice.

They are not the only patients to benefit. Since October last year patients in London waiting for a cataract operation have been able to go to another hospital for treatment if they have waited 6 months. Over two thirds have chosen to do so.

I now want to explain how we intend to build on these first pilot schemes. We want to extend choice to other geographical locations and other clinical specialities. In the next year around 100,000 extra patients will be able to choose in which hospital they are treated. The sites we have chosen include those where waiting times are longest and where electronic booking of hospital appointments is being tested.

First, from this summer all patients in London waiting more than 6 months for any form of elective surgery will be offered the choice of an alternative hospital.

Second, from July patients in West Yorkshire needing eye operations will be offered choice when they are referred to a hospital specialist by their GP. In Greater Manchester those needing orthopaedic, ENT and general surgery will also be offered choice if they have been waiting longer than 6 months.

Third, also from July, choice will be extended to patients, mainly older people, needing cataract operations in the south of England where waiting times are currently longest. Patients will be able to choose, initially from two and then normally from four hospitals, where to have their cataract operation. The aim is to cut waiting times to 6 months by 2004 and to 3 months by 2005. For cataract patients in the south, this means that the NHS Plan target will be achieved three years ahead of schedule.

Fourth, the lessons learned from these areas will inform the extension of choice across the whole of England’s health service. From summer 2004, as the Prime Minister announced recently, all patients waiting six months for any form of elective surgery will be able to choose at least one alternative hospital and normally four – public or private – for treatment.

Fifth, from December 2005, by when extra capacity will have come on stream, choice will be extended from those patients waiting longest for hospital treatment to all patients. They will be offered choice at the point the GP refers them to hospital. Patients needing elective surgery will be able to select from at least 4 or 5 different hospitals, again including both NHS and private sector providers. Millions of patients a year will benefit.

Sixth, as capacity grows further in the NHS so choice will grow. Beyond 2005 patients needing surgery will be able to choose more hospitals in which they can be treated.

And choice needs to be embedded across other parts of the NHS where it is appropriate to do so. In primary care, for example, pharmacists will help more patients manage their medicines. More drugs will be sold over the counter rather than needing a doctor’s prescription. NHS Direct will provide more advice and information to more patients. And more NHS Walk-in Centres will allow more patients the choice of where to be treated.

There need to be other changes too. In a busy mobile society patients should be able to register with a GP practice near where they work if that is more convenient for them. The published Framework Agreement for a new GPs contract also opens up the prospect of greater choice. Patients who have traditionally been referred to hospital for minor surgery or for outpatient consultations could be seen instead in their local health centre by a specialist GP.

These reforms are about embedding choice across the NHS – from primary care to hospital services. They will require changes in the way the NHS works.

Patients will need help to make informed choices. Knowledge is power. To make choice work, the NHS will need to provide reliable and relevant information to patients in a way people can understand.

In primary care, for example, PCTs will need to use the annual patient prospectus, they issue to all the households in their areas, to highlight where women patients are able to see a woman GP. I can also announce today that later this year we will publish local guides to maternity services so that mums and dads-to-be are better informed about the choices available to them.

More generally we intend to make available easily accessible information on hospital performance, quality and waiting times so that as capacity grows in the NHS patients are able to exercise greater choices. The job of GPs, nurses and other members of the primary care team will increasingly focus on helping navigate patients through the care system so that they can make the choice that best suits them.

To make choice work there has to be better IT across the whole of the NHS. The huge investment we are making in IT will support this extension of choice. Electronic booking of hospital appointments from the GP surgery will be a reality in all parts of the NHS by December 2005. There will be more information to compare hospitals not just on the internet but through NHS Direct and touchscreens in GP surgeries, pharmacies and other locations. We are also exploring experience from other countries. In Bologna for example, patients themselves, after they have been seen by their GP, can book their hospital appointment, not just through their family doctor or pharmacist, but through a specialist call centre. The system gives patients more direct control and relieves burdens on GPs.

Choice requires diversity in capacity. A new generation of DTCs will be providing care to 250,000 patients a year by 2005. Insulated from emergency work these will be able to concentrate on elective surgery and shorter waiting times. Some will be run by NHS providers. Others by private sector providers. In making their commissioning decisions PCTs will need to consider how best to use both existing and new private sector provision for the benefit of NHS patients. They will also need to consider how best to use voluntary sector providers. I can tell this conference that, following discussions with key voluntary health care providers, I am planning to draw up a concordat to extend the relationship between the NHS and the voluntary sector.

And choice will only work if there are the right incentives in the system. From this April we will begin to move to a new system of payment by results for NHS hospitals. Resources will follow the choices patients make so the hospitals which do more get more; those which do not, will not. We will put in more help for hospitals that are struggling to improve. And, alongside this external assistance, these new incentives will act as a spur to improvement. Over the next four years an increasing proportion of each hospital’s income will come as a result of the choices patients make. Choice in other words is not just about making patients feel good about the NHS. It is about giving the patient more power within the NHS.

All these changes will take time of course. Giving patients greater choice in the NHS requires a fundamental culture change in how the health service works. It will put patients in the driving seat – at the heart of the health service – and not before time. Patients will be able to choose hospitals rather than hospitals choosing patients. There will be more choice in primary care and in maternity care too. This is a world away from the 1940s take-it-or-leave-it top down service.

For too long, for too many, the choice has been to pay or wait. Mrs Thatcher talked about getting treatment at the hospital of her choosing, at the time of her choosing. Her choice though was to opt-out of the NHS altogether. Our choice is for the NHS but a reformed NHS.

An NHS where more can have that choice of time and place of treatment; where more can share in choices previously only enjoyed by the few who could afford to pay; where people choose to stay with the NHS not opt-out. An NHS which genuinely puts need before ability to pay. That is what our reforms are about. That is what we intend to deliver.