Alan Milburn – 2003 Speech to the National Association of Primary Care

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, to the National Association of Primary Care on 5 March 2003.

I want to begin by thanking the National Association of Primary Care for inviting me to speak but more importantly for being at the forefront of improvements in primary care and for speaking up for its interests.

Primary care is the frontline service of the National Health Service. Certainly, you are the people who make the health service work for millions of our fellow citizens every year. And from next month primary care organisations – PCTs – will be in charge of £46 billion a year – three-quarters of the total NHS budget.

So, today I believe we have an historic opportunity to put primary care where it should be: centre stage in a reformed National Health Service. In this speech I want to set out why it is necessary to achieve that renaissance in primary care and how we intend to make it happen.

The NHS today is the fastest growing health service of any major country in Europe. Six years ago resources were falling in real terms. Now they are set to double. In England, health spending has risen by 6.1% in real terms this year and will rise on average by 7.5% per year for the next five years.

The investment is going in to put the NHS on a sustainable footing for the long term. Quite simply if we want world class health care it has got to be paid for – if not through Pay As You Earn then through pay as you go. We have chosen on grounds of both equity and efficiency not to make people pay more for their own care when they are ill but instead to raise a little more in tax to get a whole lot more for the health service. A contribution from each of us to the health care of all of us. I believe that is the right decision for the country.

Some say resources never really produce results. In my view that is a counsel of despair and sometimes it is frankly motivated only by a desire to undermine the NHS and the people working in it.

Of course the NHS has problems. Decades of neglect and under investment are still felt in health centres and hospitals across the country. But steady progress is underway. Double the number of drugs are being prescribed to prevent heart attacks. 11% more prescriptions were issued last year and 13% more this year. One million more patients are getting a hospital operation every year. One and three quarter million more are getting seen in outpatients or in A and E every year. The number of patients waiting more than twelve months for an operation is down two-thirds. The maximum wait for a heart operation is being halved in just one year. Deaths from heart disease over the last few years are down 14%. Deaths from cancer down 6%. According to Professor Roger Boyle, the country has seen the largest fall in Europe in lung cancer amongst men and the largest decline in breast cancer amongst women.

In primary care there are particular challenges. In many parts of the country recruitment and retention remains difficult for example. But even here the “GP Golden Hello” scheme has contributed to the recruitment of over 2,200 new or returning GPs since it began in April 2001. The numbers of GPs in training has risen for 5 years in a row after previously falling for 5 years. New programmes, like the Flexible Careers Scheme and childcare support are helping more staff to achieve a balance between work and family life. For the first time since 1948 there is now a concerted programme to improve the quality of the working environment in primary care. Around 1,000 GP premises have already been modernised – well on the way to achieving the NHS Plan commitment to refurbish or replace up to 3,000 GP premises by the end of next year. There are extra resources being invested in the most under doctored areas. And alongside the investment, important reforms are already improving primary care for patients. The average waiting time to see a nurse in those practices involved in the Primary Care Collaborative is down by over 50%. The average time to see is a GP is down by more than 60%.

There is of course a huge amount of catching up to do and a long way to go. Notwithstanding some of the progress that is being made our primary care services face big problems. There are still too few GPs working in the NHS. Too many GPs and primary health care professionals have to work in poorly equipped premises. Too few GPs are able to spend enough time with their patients.

But the only way to address these problems – and to maintain the progress now being made – is to sustain the investment now going in. If people in the health service want to see progress then that requires money. That is why in my view it is right that the Government has taken the decision to add 1p to the tax bill so get the right level of resources and the right programme of reform into the health service.

I know there is a feeling in primary care that it does not get its fair share or that it always loses out. Sometimes in government we may have given the impression that it is always hospitals that come first, primary care services that must inevitably be second. I think that impression is wrong and today I want to tell you why that is and what we intend to do about it.

I know that over the years every secretary of state for healthSecretary of State for Health has said they want to shift the emphasis of where health care is provided from hospitals to primary care. I know too that primary care audiences generally respond with a few seconds of hope, a few minutes of scepticism and then years of disappointment. I believe however that this generation has the best opportunity there has ever been to put primary care centre stage in a reformed NHS.

I say that for a number of reasons.

Firstly, because patients are on the side of primary care. Primary care – despite the very real problems it faces – is the jewel in the crown of Britain’s NHS. It is where we lead the world. Other nations with supposedly superior health care systems look on our family doctor system with envy: admiring it for its better outcomes, lower costs and higher satisfaction levels.

Primary care makes a difference to one million patients every single working day. Nine out of every ten NHS patients are seen in primary care. And three quarters of patients are quite or very satisfied with the work their GP does for them.

And primary care is set to become even more important. It will play an even more pivotal role as we expand the choices available to NHS patients. For years the role of GPs has been described as a gateway into the health care system but as patients begin to exercise greater choice within the NHS, the role of family doctors, community nurses and other primary care staff will become increasingly important to help patients make informed choices about their care.

Second, demographic change is on the side of primary care. The latest census showed that 18% of our population, nearly 9m people, have a limiting long-term illness such as chronic obstructive pulmonary disease, diabetes or arthritis. In some areas of the country this affects nearly one third of the population. The challenge of chronic disease is set to grow rather than diminish over the years to come.

Modern medicine is increasingly converting previously life threatening conditions into chronic conditions. Nearly three quarters of older people suffer from one or more long-standing illness. The number of people in the UK over 60 is projected to grow by one third by 2021; the number over 75 by more than one quarter.

At the other end of the age spectrum rising levels of obesity, most worryingly amongst children, create future risks of diabetes, heart disease and renal failure. According to research the Department of Health has undertaken into likely future trends in health care – and which I intend to publish before too long – if current trends continue up to one quarter of adults are likely to be obese by 2010.

Those with chronic conditions, especially the elderly and frail, need to receive care as close to home as possible. That calls for greater emphasis on expanding primary care services so that they can work more effectively in partnership with patients.

Third, medical advance and technological change are also on the side of primary care. Future technological change – near patient testing, digital imaging, telemedicine – together with new treatments and prevention strategies will all support an expanding role for primary care in taking a lead in the management of chronic disease.

For example, within the next decade it is likely that the miniaturisation of diagnostic and monitoring equipment will enable diagnostic kit to be available in primary care; intensive treatment will become available on standard hospital wards and even in the home; and there will be more widespread use of self-monitoring at home.

The trend in treatment is therefore towards it being delivered locally. Indeed in this era of globalisation that is what people increasingly want to see.

Public expectations. Changing patterns of health need. New treatments and technologies. The tide of history is flowing firmly on the side of primary care.

The government’s reform programme goes with this tide of change. As both the proposed new GP contract and the creation of Primary Care Trusts testify our reform programme too is on the side of primary care.

Let me take each in turn.

First the proposed new GMS contract. If it is accepted by the profession, I believe it could mark a turning point in the history of primary care.

I want to use this opportunity to say publicly what I have already said privately to the negotiators. Both the NHS Confederation and the BMA are to be congratulated on the agreement they have reached. The most ambitious quality based incentive scheme for primary care in the world. I hope very much that it is endorsed by the profession. Of course, I fully recognise that implementing this is going to be a major challenge for the NHS. But, difficult as it is, it is the right thing to do.

I say that because the contract will help GPs better manage workload, in particular the burden of out-of-hours care. It will support the desire I know many practices have to deliver a greater range of new and innovative services particularly at the primary to secondary care interface. And it recognises the independent practice unit as the cornerstone of primary care which should enjoy greater devolution of responsibility and greater freedom.

Where these developments help PMS doctors, we will look to incorporate them into the PMS arrangements. As I have said before, PMS is here to stay. We want to ensure that all patients have access to high quality services, whether their doctors are PMS doctors or GMS doctors, and we want to ensure that NHS resources are allocated equitably on the basis of the needs of patients and of practice populations.

The contract will bring an unprecedented 33% increase in new investment in primary care. That should allow those practices that want to, to achieve a step change in the range, quality and accessibility of primary care services.

Primary Care Trusts will help realise that objective too. From April, PCTs will be in charge of three-quarters of the NHS budget. PCTs exist for two main purposes: to hold the resources and the responsibilities to improve the health of the local population and to commission care which gives local patients the services that are right to meet their needs.

I have often heard it said this is all very well in theory but in practice the resources are already spoken for with hospitals that drain all the investment and primary care that inevitably loses out.

I want to take that argument on today – and to set out how, by working together, we can ensure that more not fewer services are provided in primary care and that PCTs are able to exercise real power.

To begin with, the resources we have allocated direct to local primary care trusts are for three years not one. The average increase is over 30%. This should allow PCTs to plan with certainty to increase capacity over the medium term. In the past short term funding hindered long term planning. Now PCTs are able to decide which local developments will take place when. And three year budgets should allow PCTs to decide longer term agreements with hospitals and with other providers.

We have also given PCTs the explicit freedom to purchase care from the most appropriate provider – whether public, private, voluntary or not for profit. Resources will follow the choices that patients and PCTs make so that hospitals which do more get more; those which do not, will not.

And we want to help PCTs develop this commissioning role. At present I know that when it comes to negotiating contracts it can feel like the hospitals hold all the cards. But remember this – PCTs hold all the money. And we want to create a more level playing field.

We are planning to build up PCTs’ capacity to commission first through the national PCT development programme, then through the new NHS University. I want the NAPC to be part of this process – so that every PCT in every part of the country has the information, the skills and the resources to get the best deal for patients. In some parts of the country PCTs are already drawing on the strengths of organisations such as Kaiser Permanente and United Healthcare from the USA to help them deliver improvements in commissioning of services. In the months to come we will want to find ways of more PCTs benefiting from such an approach. And I can tell this conference that we are already exploring how the concept of earned autonomy can be applied to PCTs so that those who are performing best get more freedoms and those that need more help get greater support. And the concept should not stop there. I will be looking at how Practices should benefit from earned autonomy as relationships with PCTs develop and the new GMS contract beds in.

Our ambition has to be put primary care centre stage across the whole health service. For example, as w0e move over a four or five year period towards all hospitals having the opportunity to become NHS Foundation hospitals, PCTs throughout the country for the first time will be represented on hospital governance structures. That will put primary care even more in the driving seat.

And when we start to introduce from next month a common tariff system for hospital operations it will take out of the local negotiations between PCTs and hospitals the very areas where PCTs are weakest – on price negotiation – and leave those where they are strongest – on quality of service and outcomes of care. PCTs need their local hospitals – but not at any price. Hospitals need to deliver – and PCTs need to demand the right standards of services.

So I will stand up for PCTs. And PCTs need to stand up for themselves. I know that many feel honour bound to the local hospital. But the job of PCTs is to get the right services for patients. They need to flex their financial muscles and use their commissioning powers.

The truth is that delivering shorter waiting times in hospitals – whether in A&E or for a hospital operation – cannot simply be delivered by more activity in hospitals. It requires more intermediate care services, more social care services, more primary care. It needs more help so that people can avoid hospital by being treated in the community. That calls for more diagnostic and outpatient clinics in health centres. Better facilities to enable GPs who want to, to carry out more diagnostic services and more day surgery. It needs more locally based services so that those people who do need hospital treatment can return home when they are ready to do so. It needs a greater emphasis on prevention and not just treatment. A bigger role for self care. Better use of pharmacist skills. More walk in centres and community hospital services to build a bridge between the big acute hospital and the patient’s home.

Some PCTs are already grasping these opportunities. Many more can now do so. I believe that taken together, the potential of the proposed GP contract and power in the hands of PCTs, provide a once-in-a-lifetime opportunity to rebalance services in the NHS – between those provided in hospitals and those in the community. Of course hospitals will continue to be important – not least because long waits for treatment both corrode public confidence and frustrate GPs. But a better balance is required. Indeed the hospital won’t be able to do its work and we won’t be able to get hospital waiting times down unless the balance shifts towards primary and community services.

Take outpatients. Over these next few years we estimate that as many as one million outpatients could be treated in primary and community settings rather than in hospitals. That will ease the pressure on hospitals, provide care more conveniently for patients and enhance and expand the role of primary care.

That is dependent of course on expanding the capacity of primary care. The new GP contract and the new Agenda for Change pay system will be important means to that end.

It is also dependent on developing more GPs and nurses with a specialist interest capable of diagnosing and managing a range of conditions that currently require hospital referral. In Huntingdonshire GPs specialising in dermatology have helped reduce waits from 36 weeks to 4 weeks. In Bradford, GPs who are now running outreach clinics providing ENT services have reduced waiting times from 60 weeks to only a few weeks. Optometrists treating patients have reduced referrals to hospital ophthalmology services by almost two-thirds. If it can happen in some places we should try to extend to all.

And to help that process and to build on the Implementation Framework for GPs with a special interest we published last year, I can tell this conference that later this month we will publish ten further draft guidelines – we have developed with the Royal College of GPs and others – for accrediting GPs with a special interest in areas such as dermatology, diabetes, orthopaedics and neurology. At the same time we will also publish a similar Implementation Framework for Nurses in specialist roles to advise and encourage nurses and PCTs in establishing specialist roles.

We will also want to encourage more PCTs to follow the lead of those in places like Dudley, Milton Keynes, Salford and Southend-on-Sea which all employ consultants in specialities such as mental health and paediatrics. This is about securing greater integration in services. It is about overcoming the divide between primary and secondary based care. Most importantly of all it is about making services more locally accessible to patients. I hope that – consistent of course with appointments being properly regulated – PCTs will now consider how to extend these employment opportunities for consultants to surgical and other specialties.

In these next few years – with funding on a sustainable footing for the longer term – PCTs have a huge opportunity to reshape local services in the interests of local patients. If PCTs properly use the power and resources they now have, they will be central to bringing about a renaissance in primary care.

The future of the NHS lies in primary care. That is where patients want to be treated. It is where medical advance is moving treatment. And it is where both the profession and the government want to see prevention and treatment expand.

I believe we really do stand on the threshold of that renaissance in primary care. With the right level of investment, the right reforms, the good will of the profession and the support of the whole health community, we can secure a major change in the focus of health care in our country.

You are central to that.

For years primary care has dealt with most NHS patients.

From this year primary care will control most NHS resources.

From now on, primary care must drive investment and reform across the whole health service.

You have the power; you will have the resources; you now have the opportunity to change the system in the interests of the patients you serve.