Alan Milburn – 2003 Speech to the Social Market Foundation

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, on 30 April 2003.

Domestic politics is back. This week there will be important elections in Scotland, Wales and England. Over these last few months, Iraq put bread and butter issues on hold. The Government’s decision on the Euro could have a similar effect. But whilst Iraq and the Euro are hugely important for the future of our country and the wider international community, it is not the five tests on the Euro that will determine this government’s fate. It is the three big domestic tests: delivering on jobs and the economy, crime and asylum, health and education.

Here there is a stark choice for the Government. To pursue the cautious incrementalism that sometimes characterised our first term, or to embark on a more fundamental transformation of our country. It is the latter course of action I believe we must choose if we are to successfully meet each of these three key domestic tests.

Reassurance was right for our first term. Radical reform is what is needed now. Not reform for reform’s sake but reform to open up new opportunities for people to deliver on our commitment to social justice.

So for public services that means using the considerable extra resources now going in to health and education to reinvent collective provision for today’s world.

Some find that an uneasy proposition. Reform in health or in education is often caricatured as being in conflict with the values of the Centre Left – as though reform can only ever come from the Right.

That is to confuse ends with means. The ends remain – of strong public services capable of providing opportunity and security in a globalised and increasingly uncertain world. It is the means of securing them must now change as society itself has changed.

We are in a century where deference is lower but expectations are higher than they were in the century that saw the creation of these great public services.

So, today I want to set out the case for public service reform. And I want to do so with particular reference to the changes we seek to make in the National Health Service including NHS Foundation Trusts.

My starting point is this: strong public services are the best provider of opportunity any society can have. A good education helps lift people up. A good police and criminal justice system keeps communities safe from harm. And a good health service secures the health of the nation.

All my adult life I have argued for policies and for values that are about widening opportunity in our society. That is why I believe the NHS is such a source of strength for our country. It expresses the values that I believe in. Solidarity, community, opportunity. With the NHS we all share in the security – Nye Bevan called it the serenity- of knowing that we all pay in when we can do so that we all can take out when we need to. The health of each of us depending on the contribution of all of us.

These were the ideals that inspired the generation of Bevan and Beveridge. They remain our inspiration today.

Indeed, I believe profoundly that the case for the NHS system of funding and values is stronger today than it has ever been. Now more than ever, we live in a world where health care can do more but costs more. Since none of us knows when we will fall ill, how long it will last or what it will cost, having an NHS that pools risk because it is funded through general taxation and is free at the point of use, based on need not ability to pay, is the right way forward for our country.

Conversely, the market-based approach favoured by others would be both inefficient and unjust. As the costs of treatment and drugs grow, the risks to family finances of pay-as-you-go and health vouchers would grow too.

I reject the vision of some privatised future where the health care you are guaranteed for your family is the health care you insure for privately or pay for, in part or in whole. Where poverty bars the entrance to the best treatments. I reject the dogma of those whose dislike of public services is such that they would prefer a private sector working inefficiently to a public sector working well.

It is because we recognise the unpredictability of health needs, the rising costs of heath technology and the equity and efficiency of the NHS tax funded system that for us the NHS will remain a National Health Service – a public service free at the point of use with decisions on health care always made by doctors and nurses on the basis of clinical need.

The Government’s decision to double health spending in real terms by 2008 from the position we inherited in 1997 is a declaration of that faith in the NHS. With the right level of funding we believe it can be the best health insurance policy in the world.

I believe we are right to raise tax to increase spending in the NHS and the increased spending we have been putting in is beginning to repay that declaration of faith. More doctors and nurses. More drugs being prescribed. More patients being seen. Shorter waits for treatment. As the Modernisation Board put it recently there is a long way to go but the NHS is now turning the corner.

But money alone, however, cannot deliver the modern responsive health services our nation needs. To get the best from the money the NHS needs to be properly organised. I have heard it said that since the extra investment is now paying dividends in the NHS further reforms are not needed. It is true that the resources are tackling the historic capacity problems the NHS has faced for decades. What is equally true however, is that the NHS has cultural barriers that must also be overcome if it is to reach its full potential. That cannot be achieved through investment. It can only be achieved through reform.

The NHS has great strengths in how it has been organised. For over fifty years it has provided good care and treatment for millions according to the right values. Its ethos and its staff express the values of the nation. Its unitary structure gives it great advantages both in overall levels of efficiency and its focus on public health. Its primary care services, led by Britain’s family doctors, are the envy of many other countries.

But the NHS has structural weaknesses too, not least its top down, centralised system that tends to inhibit local innovation and its monolithic structure that denies patient choice. NHS Foundation Trusts are a means of overcoming that faultline.

And for those of us on the Left the most depressing thing of all is that despite having the fairest health care system in the world, for fifty years the gap between the health of the wealthiest and the health of the poorest has widened not narrowed. A boy born today in Manchester will live on average a decade less than a boy born in Dorset.

For half a century, uniformity of provision has not guaranteed equality of outcome. Too often, even today, the poorest services are in the poorest communities. The hard fact is that for over fifty years it is poorer people and poorer communities who have lost out from poorly provided public services.

That is an affront to all that I believe in. For me, the only purpose of being in politics is to build a society where, regardless of race or gender or social class, there is opportunity for all not just for some.

Take choice, which the Left has mistakenly conceded to the Right. For too long choice in health care has only ever been available to those with the means to pay for it. Those with more money have been able to exercise more choice. That is the real two-tier health care in our country.

The trap we must avoid is that identified by Richard Titmuss four decades ago of so many people opting out of publicly provided health and education that public services become only for the poor and then end up themselves being poor services.

Then there’s the pensioner with modest savings. Worked hard, paid in all his life, finds he needs a heart operation and then is forced to choose between waiting for treatment or paying for treatment.

That is a dilemma I want to solve. The way to do it is to reduce the waiting times and make choice available on the NHS; choice for all not just for some so that for the first time NHS patients can choose hospitals rather than hospitals choosing patients.

The route to patient choice lies not through more healthcare charges but through big cultural changes. The cultural changes which redesign services around the needs of patients so that they are able to make choices about where and when and by whom they are treated. And so that NHS patients can make that choice free of charge, within the NHS.

So it is right to be bold on reform. But boldness is not an end. It is a means to an end. It should be about making health services more responsive so they can provide more opportunities for the communities they serve. That is the purpose of our reform programme in general and NHS Foundation Trusts in particular.

We must not allow our reform programme to be caricatured as a values-free zone. It is actually quite the reverse. It is about strengthening our public services as a means of securing the values that guide us – of social justice and stronger communities. It is boldness for a purpose.

So it is right to press ahead with fundamental reform in how the NHS works. For some – particularly on the Left – this is not an easy process because the NHS is in our blood. For many it is the touchstone of all that we stand for. And yet in our hearts we know that the NHS needs to be better – not because it has failed but because the world has changed.

Sixty years ago when the NHS was formed it was the era of the ration book. People expected little say and experienced precious little choice.

Today we live in a quite different world; a consumer age; the computer age; the informed and inquiring society. People demand services tailored to their individual needs. People want choice and expect quality.

We all do it and we all know it. These changes cannot be wished away. They are here to stay. And these changes challenge every one of our great public services.

To meet that challenge we’ve got to move on from the one-size-fits-all, take-it-or-leave-it, top down health service of the 1940s towards an NHS which embraces devolution, diversity and choice – precisely so that its services can be more responsive to the way the world is today.

Unless we do so, more and more of the public will simply walk away from public services eroding the national consensus that supports them. Reform is not about undermining tax-funded public services. It is about strengthening that consensus by making the NHS more responsive to those who use it.

In our first term we rightly sought to do that by putting in place a new national framework of standards. It is easy to forget how far we have come. There are new national standards for cancer, heart disease, mental health, elderly care and now for children’s services. There is greater transparency over local service performance so that we and more importantly, patients and staff, can spot if things are going wrong and put them right. There is a new legal duty of quality and a new system of clinical governance to enshrine improvements throughout the NHS.

There is the National Institute for Clinical Excellence to tackle postcode prescribing. For the first time the NHS has an independent inspectorate. With the NHS Modernisation Agency there are now new systems for when things go wrong and more help to learn from what goes right. There are clear targets to focus effort across the whole NHS not least to address the biggest public concern about the health service – how long patients wait for treatment. And for all the comment about targets no one should kid themselves that we would be making the progress we are now – with waiting times falling on virtually every indicator – without the targets we have set.

These measures have all served to strengthen equity in the NHS. And I believe they were all necessary to kickstart the process of improvement that was overdue. But the NHS cannot be run forever like a 1940s-style nationalised industry.

National targets and standards are important but ultimately improvement is delivered locally not nationally by frontline staff in frontline services. And that is where power needs to be located if those services are genuinely to be responsive to local communities.

Sustaining improvements in NHS performance can only happen when staff have more control and local communities have a greater say in how services are run. Disempowering frontline staff – whether it is doctors or nurses, social workers or police officers, teachers or managers – is never going to be the best way to run a public service. That’s why we have devolved power to Primary Care Trusts and why we want to establish NHS Foundation Trusts. It is right to set standards nationally but it is wrong to try to run the NHS nationally.

Just as there are limits to the role of free markets in health care, there have to be limits to the role of the centralised state.

Ours is a small country with big differences. It is not uniform. It is multi-faceted and multi-cultural. Different communities have different needs. We have local councils to run local services because we recognise that needs do differ between communities. What is true for social services is also true for health services. With the best will in the world, those needs cannot be met from a distant Whitehall. They can only be properly met locally not nationally.

That is why, with a national framework of standards and inspection now in place, the centre of gravity is shifting decisively to the NHS frontline. More devolution to primary care trusts, more diversity in provision, more choice for patients to open up the system so that it is more responsive to those who use it. NHS Foundation Trusts are part of that process.

We are now in transition from the old order to the new. As we set out in the NHS Plan the more performance improves the more control local health services will assume.

Rather than trying to drive improvements simply through top-down performance management, the transition is towards improvements driven through greater local autonomy in which PCT commissioning, new financial incentives and the choices patients make become the driving force for change, backed by national standards and independent inspection. That transition will take time but the direction of travel is now set – and it must not be reversed.

NHS Foundation Trusts are the next stage in that journey. In some quarters it is a controversial policy; for many in the NHS it is a welcome one.

Since I first outlined the policy more than a year ago, there have been a number of myths and misconceptions about what we intend to do and how we intend to do it. So let us nail some myths today.

NHS Foundation Trusts will be NHS hospitals. They will be fully part of the NHS but with greater freedom to run their own affairs.

Freeing NHS Foundation Trusts from day-to-day Whitehall control will improve care for patients by encouraging greater local innovation in service delivery. It will help unleash that spirit of public service enterprise that exists in so many parts of the NHS but for too long has been held back.

NHS Foundation Trusts will be owned and controlled by the public locally not nationally so as to strengthen the relationship between local hospital services and local communities.

In place of the centralised system of government appointments to hospital boards, for the first time there will be direct elections by local people and local staff of hospital governors.

Strengthening public ownership by making NHS Foundation Trusts more locally accountable will particularly help improve services in poorer areas. Indeed I very much welcome the fact that hospitals in some of the most deprived areas of the country, including Hackney, Liverpool, Bradford, Doncaster and Sunderland have all expressed an interest in being amongst the first NHS Foundation Trusts.

We are starting with existing three star NHS hospitals. In time the Foundation principle will be extended to mental health trusts and other parts of the NHS. To date 32 NHS Trusts have applied. I will be making decisions about those applications shortly. I hope to be able to approve the vast majority of them. But that is just the start. I will also be bringing forward plans – including extra financial support – to help each and every NHS hospital to become an NHS Foundation Trust over the course of the next four to five years. A policy, in other words, that is for all and not just for some.

This is part of an ‘equity guarantee’ that the Bill introducing NHS Foundation Trusts enshrines. That equity guarantee means that NHS Foundation Trusts will remain part of the NHS providing services to NHS patients according to NHS principles – care for free, based on need not ability to pay. It means they will be subject to NHS standards and systems of inspection. And it means they will be bound by a legal duty to work in co-operation with others to improve the quality of health care throughout the NHS in keeping with our values where the strong support the weak for the benefit of all.

So NHS Foundation Trusts will be built on the values and principles of community empowerment, of staff involvement, and of democratisation. Indeed the way they will work draws on some of this country’s best traditions of mutualism and co-operation. They draw too on international experience of greater independence improving performance in hospitals across Europe.

This is not the reinvention of an internal market. Far from it. NHS Foundation Trusts will get their income through local Primary Care Trusts, just like every other NHS hospital. They will all work within the flexibilities of the Agenda for Change pay system we have negotiated with the NHS trades unions.

There will be no competition based on hospitals offering the lowest price. In future all hospitals will be paid a nationally set price for the same procedure. Those who treat more NHS patients should of course get more NHS money. So there will be a payment by results system but NHS Foundation Trusts can not make a profit or pay a dividend. There will be a legal lock on their NHS assets ensuring their continued use for NHS patients and the proportion of their income from private patients will be capped at current levels.

So those who claim this is privatisation or a step in that direction – through the front door, through the back door or through the side door – are simply wrong.

By all means let us debate NHS Foundation Trusts but let us do so on the basis of what the policy is rather than what it is not. Greater local freedom, real local ownership, genuine staff involvement to give more responsive services and ensure community needs are better met.

NHS Foundation Trusts are part of a wider reform programme aimed at getting the right combination of national standards and local control. Both are needed if services are to improve and if the case for collective provision is to be won.

The Government has made public services the key political battleground in our country. We have staked our reputation on being able to deliver the improvements in public services that have escaped governments for decades. And we have embarked on a high risk but necessary strategy of raising taxes in order to raise resources for the health service and other key public services.

We have been right to do so. But we need to recognise that in so doing we have raised the stakes. Collective provision of public services – whether in health, education or local government – is challenged as never before.

The Right – in the media and in politics – believe the game is up for services that are collectively funded and provided. In today’s consumer world they argue that the only way to get services that are responsive to individual needs is through the market mechanism of patients paying for their treatment.

It is easy to dismiss the Right’s policies as the last twitch of the Thatcherite corpse. But if we fail to match high and sustained investment with real and radical reform it will be the Centre-Left’s argument that public services can both be modern and fair, consumer-orientated and collectively provided that will face extinction.

We will win the argument for public service investment and reform if we accept that the era of one-size-fits-all public services is over and that the Centre-Left’s approach today should be based on decentralisation, diversity and choice.

Our objectives – social justice and opportunity for all – remain. It is our means of delivery that must now change. Our job in carrying through these reforms is to preserve values and yet still change structures.

Reform is difficult. It is often controversial. The pioneers who created the NHS found that. The job of re-creation and renewal will be no less difficult. But we will be failing the public if we did anything other than press ahead with reform. The Government’s foot needs to be firmly on the accelerator not on the brake. We have just entered the period of unprecedented expansion when it comes to investment. We must keep up the pace of reform.

Alan Milburn – 2003 Speech to the Association of the British Pharmaceutical Industry

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, on 3 April 2003.

Mr President, my Lords, ladies and gentlemen,

It’s a great pleasure to be here with you this evening and particularly to follow both John and Cliff.

It’s three years since I last had the pleasure of addressing you. I announced then the creation of the PICTF- an important symbol of the co-operation that I believe exists between industry and Government in our country. And I join with John in praising the leading role that colleagues from the ABPI and especially Phil Hunt played in taking that co-operation forward.

Tonight I want to suggest how we can build on that strengthened relationship.

The starting point is this simple insight: the health of the country and the health of your industry are intimately linked. The stronger our partnership the better it is for Britain.

Your industry as John rightly said is a major contributor to the wealth of our nation – and therefore ultimately to the funding of the great public services on which people in our nation rely. Indeed the Pharmaceutical Industry is a competitive and innovative, knowledge-based and high value-added industry. You are genuine world leaders – second only to the US in the discovery and development of the world’s leading medicines. Our job in government is to create the environment in which you can thrive.

A stable economy; a flexible and skilled labour market, a world-class university sector and science base – these are the keys to unlocking success in what is, as you know, a highly competitive global market place. On each of these fronts there is reasonable progress to report.

For example, we believe in investing in science. By 2005 the science budget will stand at nearly £3 billion – more than double what it was just a few years ago. Investment that will help grow your future workforce and sow the seeds for future scientific advance. The new R&D tax credits we introduced last year I hope will help that process. The green light that Parliament has given to stem cell research not only provides a further basis for new scientific endeavour but holds out the hope of new breakthroughs in the treatment and prevention of serious illness.

And for research to thrive it needs proportionate regulation and it also needs a safe environment – which is why John was right to highlight the threats posed by a small minority of animal rights extremists. I know that some of you here tonight will have been targeted by these people. Many more will have felt intimidated by them. All I want to say to you is that the Government unreservedly condemns their campaign of violence and intimidation. We are determined they will not succeed. That is why we have taken action to improve co-ordination between the police and other agencies. It is why we have strengthened the law. And I can say tonight we do not rule out further changes to the law to remove the threat that these extremists pose.

I believe that we must deal with those threats in order that we can realise the very real potential that now exists. Over these next few years a growing National Health Service and the prospect of further pharmaceutical advance provide new opportunities for both industrial prosperity and better health.

The NHS is in a period of unprecedented growth. By 2008 its budget will be double that of just a decade before. We have the fastest growing health care system of any major country in Europe. There is of course a huge amount of catching up to do. Nonetheless there aren’t many organisations in this country – perhaps not in the world – that know what their budgets will be in five years time. The NHS is in that enviable position.

The fruits of increased investment are already plain to see. Not just in the growth in nurses and doctors, more beds and new hospitals but in shorter waiting times for treatment and improved standards of care. In the last year alone there were around 30 million extra prescriptions for patients. The NHS drugs bill rose by £850 million. That represents a year-on-year increase of nearly 14 per cent, with a similar rate of growth likely this year.

I said three years ago that more spending on medicines is, in my view, a good thing, not a bad thing. Provided of course that the extra money is spent effectively and gets good value. Some feared, three years ago, that the advent of the National Institute for Clinical Excellence – and I pay tribute tonight to its work under the leadership of Sir Michael Rawlins – would act as a brake on drug spending in the NHS. Those who thought that obviously got the wrong pedal. NICE has not slowed down expenditure on new drugs. It has accelerated it. NICE decisions since it was set up three years ago have cost the NHS over £700 million. Amongst those benefiting have been an additional 31,000 cancer patients, 160,000 diabetes patients, 100,000 people suffering from alzheimers disease and 170,000 more who can benefit from atypical antipsychotic drugs. In the last year alone, as John said, prescribing of statins has risen by 30% benefiting over one million people and helping to save an estimated 6,000 lives.

Now as John commented – and I got the message – there is more that needs to be done. And just for the avoidance of doubt: I did not set up NICE so that its recommendations could sit gathering dust on the shelves of Primary Care Trusts. You want the guidance implemented, I want the guidance implemented and I will ensure that this is precisely what happens.

And over time I would expect to see the importance of medicines to the NHS continuing to grow. And in all likelihood drugs spending as a proportion of NHS spending will also continue to grow. Too much of the debate on health care today in my view is still focussed on the narrow terrain of hospital-based activity. Now what happens in hospitals is, of course, incredibly important. But it is not the be-all-and-end-all of what the health service does. Indeed changes in demography and the pattern of illness alongside scientific advance and technological breakthroughs are driving the NHS towards more health care being delivered in a non-hospital setting. As today’s World Cancer Report from the WHO argues, the focus increasingly needs to be on prevention, not just treatment. The work we have done together in government and the industry has given the NHS a world-leading smoking cessation service sets a course which we must now follow in the years to come.

Already in the last few years the number of premature deaths from major killers such as cancer and coronary heart disease have begun to fall dramatically in our country. New drugs and more effective prescribing have played their part in that. But there are new challenges too. The latest census for example showed that nearly 9 million people in England have a limiting long term illness. With the population of over-60s set to grow by one third in the next twenty years, that number will inevitably rise substantially.

At the other end of the age spectrum, rising levels of obesity, most worryingly amongst children, create future risks of diabetes, heart disease and of course renal failure. If current trends continue – and we need to see that they do not – up to a quarter of all adults in our country could be obese by the year 2010. And, of course, there are the threats posed to public health as a consequence of open borders, increased mobility and global travel.

New challenges then, demand new approaches. And here there are good reasons to be optimistic. Indeed, some commentators say we are likely to see in the next twenty years as much advance in healthcare as we have seen in the last two hundred. The pharmaceutical industry will undoubtedly be at the leading edge of these advances. Day by day the industry is helping us understand disease mechanisms better. And many believe this generation, our generation, stands on the threshold, fifty years after DNA was first decoded at Cambridge, of a genetics revolution that could transform health care across the world. Pharmocogenetics that tailor drug treatments to individual patient metabolisms. New drugs and therapies targeted at the cause of the disease rather than controlling its symptoms. Diagnostic methods that can help prevent disease before it develops. And gene therapies that hold out the prospect for entirely new treatments – and even cures – for cancer and other common diseases. I am delighted that Trevor Jones has agreed to chair the new Advisory Group for Genetics Research to provide the advice that we need to determine research priorities.

Because only if we make the decision to invest now will we harness this potential for the future. In a few weeks’ time I will publish a White Paper on genetics which will set out how we intend to work in partnership with the industry to put Britain at the forefront of this genetic revolution so that its advances can be made available to the people of our country.

And the benefits of scientific breakthrough and the great good that your industry brings need to be made available to poor nations just as well as to richer ones. No challenge can be greater than dealing with the threat to health posed by poverty and disease in the world’s poorest countries. John rightly mentioned the steps that pharmaceutical companies have already taken on this issue and I pay tribute to the work that you have done. It is true that governments and international organisations need to do much more too. But none of us can feel comfortable with a position where the industry develops medicines that can save lives, only for a minority of the people in the world who need them actually being able to benefit from them. It is precisely because of your achievement in creating new life-saving medicines that the world looks to you to do all in your power to make them available to the people who need them most. In Government we not only urge you to do that but we pledge to work in partnership with you to help make that happen.

In recent years we have built between us – industry and government – a strong partnership. It needs to be stronger still in the years to come if we are to meet the new challenges that confront us and realise the new opportunities that are open to us.

We are in an era of unparalleled growth in the NHS; a time of unequalled discovery in science and medicine; a period of profound potential in which both the UK’s health services and pharmaceutical industries can lay the foundations of better treatments for generations – in our own country and across the world.

To realise that potential however, we need to strengthen our partnership. We will then, I believe, truly unlock a rich seam of new science, new discoveries, new treatments and technologies which are genuinely capable of delivering better health and better lives in our own communities and communities across the globe.

This is the challenge for all of us. It is a challenge that I believe that by working together – Government, Industry and patients groups – we can meet that challenge.

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.

Alan Milburn – 2003 Speech on Localism

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, on 5 February 2003.

I would like to thank the New Local Government Network and the New Health Network for hosting today’s event. They are at the forefront of new thinking around public service reform and debates about what should rightly be done centrally and what locally. It is an important indication of where that debate is going that they have jointly hosted today’s discussion.

This speech is the first of two speeches I will be making over the next week on the theme of public service reform. My speech next week will focus on choice in public services. Today I want to cover the importance of local accountability and local control in public services.

The context is this. Any government succeeds or fails according to two simple tests. One whether it has a coherent vision for the country. Two, whether it can make progress towards realising that vision: whether the country is moving forwards or backwards.

We are now at a critical juncture for this Labour government. We have been in power for almost six years. Labour dominates the political landscape in a way quite unimaginable even a decade ago. The Conservatives are weak, divided, uncertain. And yet the decisions we take on reform now will determine the course of politics not just for the remainder of this Parliament but I believe for the remainder of this decade.

Of course the decisions we make in relation to Iraq and the Euro are hugely important. They will leave their mark for years to come. But it will be the bread and butter issues on the economy and public services that will shape public views.

Here we need to chart a clear course, both in setting our vision and in making progress towards it. On both counts we face a choice. In essence it comes down to this: to consolidate around what we have done to date, to pursue the cautious incrementalism that sometimes characterised our first term in office. Or to discover new momentum towards a more fundamental and radical transformation of our country. It is the latter course I believe we must choose.

Today I want to set out how we can transform public services in our country. And in so doing I want to make the case for what I will call ‘Real Localism’.

The Government has made public services the key political battleground in our country. We have staked our reputation on being able to deliver the improvements in public services that have escaped governments for decades. And we have embarked on a high risk but necessary strategy of putting up taxes in order to raise resources for the health service and other key public services.

We have been right to do so. But we need to recognise that we have massively raised the stakes. Collective provision of public services – whether in health, education or local government – is under threat as never before.

The Right – in the media and in politics – believe the game’s up for services that are collectively funded and provided. In today’s consumer world they argue that the only way to get services that are responsive to individual needs is through the market mechanism of patients paying for their treatment.

It is easy to dismiss the Right’s policies as the last twitch of the Thatcherite corpse. But if we fail to match high and sustained investment with real and radical reform it will be the Centre-Left’s argument that public services can both be modern and fair, consumer-orientated and collectively provided that will face extinction.

I believe that we can win the argument for public service investment and reform but to do so we have to accept that the era of one-size-fits-all public services is over and that the Centre-Left’s approach today should be based on decentralisation, diversity and choice.

We can win this argument for three reasons.

Firstly, in this era of globalisation public services are necessary to provide security, foster inclusion and promote prosperity. People today feel more insecure than ever. This can be a reflection of their own economic circumstances or a recognition that there are new and powerful forces at play – economic, social, cultural – which affect every developed country and impact on all our lives.

Greater economic uncertainty is inherent in globalisation. Crime, terrorism and international tensions have heightened this sense of personal and national insecurity.

Global insecurity makes the case for social and economic institutions which strengthen aspects of personal security. In this climate, strong values-based institutions which reinforce people’s sense of community become more rather than less important. The NHS is just such an institution.

And in any case, medical advance and technological change is making the NHS more, not less, relevant. When health care can do more but costs more, where no-one knows when or whether they may become ill, a National Health Service providing services for free, based on need not ability to pay, can provide a rock of stability in an otherwise uncertain world.

Secondly, we can win the argument because the NHS is now making progress. It has 40,000 more nurses and 10,000 more doctors. For the first time in four decades over two consecutive years the number of general and acute beds has risen. The number of patients waiting over 12 months for NHS treatment is down 59%. A year ago the maximum wait for a heart operation was 18 months. Today it is 12 months. By April it will be 9 months. Over 95% of patients with suspected cancer are now seen within two weeks by a specialist when many used to have to wait months.

In the last few years death rates for cancer have fallen by 6% and for heart disease by 14%. The latest reports show the survival rate for the most common forms of childhood cancer now rank amongst the best in the world.

There is still a long way to go. But the momentum is forwards not backwards. Of course, the Right’s strategy – having starved the NHS of resources for decades – is to deny that the NHS can ever translate extra resources into results for patients.

But the fact is the money is working. Since 1997, one million more patients are being admitted to hospital for an operation. A further one and three quarter million patients are being seen as outpatients or in A and E. The number of prescriptions by GPs rose by 11% last year and is up 13% this year. Prescribing of cholesterol-lowering drugs – which prevent heart attack- has doubled in the last few years. And for the record, whilst hospital bed numbers are rising management costs are falling.

The third reason for my optimism is that the investment is committed for the long term. The NHS is assured of high and sustained levels of resources up to 2008. And, after decades of stop-go and short-termism, we have a ten year NHS Plan of reform to match the high levels of resources.

The NHS will not make progress unless the two go together. Reform is too often characterised by its enemies as an attempt to undermine NHS values. But this confuses ends with means. Labour’s reform programme is all about preserving NHS values by changing NHS structures. The ends – care for free based on need not ability to pay – remain. The means – a one-size-fits-all nationalised industry monopoly approach – must change.

There are four principal reasons for that.

First, the uncertainty engendered by globalisation is driving people to take refuge in what they know – in their families, their communities, their regions. People find shelter in the very local because the local can be influenced even if the global can not.

The way politics is structured needs to reflect that yearning for local control. In this country the advent of locally elected mayors, renewal of local government and, I hope and believe, the birth of regional government will give life to localism. Public services too, in the way they are structured need to reflect the growing public desire to control what they know.

Second, for all its great strengths – its staff, its public service ethos, the great advances it has brought in public health – the NHS has a profound weakness too. It took power away from local communities and vested it in the central State. Of course, this brought huge benefits but at a real cost. A gulf grew up between local communities and the running of local services. Today we must find a way to bridge that gulf.

Ours is a small country with big differences. It is not uniform. It is multi-faceted and multi-cultural. Different communities have different needs. With the best will in the world, those needs cannot be met from a distant Whitehall. They can only be properly met locally not nationally.

Third, health services are delivered locally not nationally by over one million expert staff whose principled motivation and ethos of service private sector organisations can only gaze at with envy. The NHS is a high trust organisation. It needs to be organised in such a way that trust can be enshrined at every level; trusting people to innovate and take initiative for themselves. In the end I don’t treat patients. 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. The simple truth is the NHS works best when it harnesses the commitment and know-how of staff to improve care for patients.

Fourth, ours is the informed and inquiring world. Universal education and now the internet are redistributing knowledge. In a consumer society more people are demanding public services that are responsive to their own needs and offer greater personal choice. This is a long way from the one-size-fits-all, take-it-or-leave-it public services that were the product of the 1940s. Then expectations were lower, deference was greater. Now it is the other way round. Sustaining public confidence in public services means they need to dance to the tune of the consumer.

Together, the push to the local and the pull of the consumer call for a new model of public services. One where patients and parents have greater choices over the services they use and where communities have greater control over how they are provided.

The new political battleground then, is around the politics of localism. The Right desperately want to claim this ground. In the process they will want to paint Labour as the Party of the centralised, out-of-touch State; the Party of Government-knows-best rather than consumer choice; the Party of old style, monolithic, unresponsive public services.

We pick up this mantle at our peril. And yet for reasons of history – both ancient and modern – Labour could easily have it laid upon us. At the end of the Second World War it was Labour that created big national institutions to tackle the country’s big national problems. Whilst across Europe other Socialist and Social Democratic Parties were championing community involvement and ownership – and indeed Left thinkers such as GDH Cole, RH Tawney and others from the mutualist tradition were advocating a similar approach here – in Britain we ended up with too a close an affinity between State ownership and public ownership.

Whilst the British post-War welfare settlement assured all our citizens of universal provision – particularly in health – it defined equality as uniformity in provision. It was easy to be convinced that by securing one we had inevitably secured the other. But just as communities are different, health needs are different too.

Uniformity of provision has not guaranteed equality of outcomes. Indeed health inequalities in the five decades since the NHS was founded have widened not narrowed. Too often even today the poorest services are still in the poorest communities.

The case for localism over uniformity is about shaping services more effectively to tackle health inequalities in our society every bit as much as it is about shaping them to be responsive to the concerns of the individual.

In our first term Labour’s approach was to try to do that from the top down through a plethora of service targets, inspection regimes and national standards. There is little doubt that many of these were needed to counter the effects of two decades where the Tories had fragmented services and, in the NHS, delivered a lottery in care.

And for all the concern about targets no-one should kid themselves that we would be making the progress we now are without the targets that we set then. Waiting times for treatment – which had been rising for decades – are now falling on virtually every indicator because targets focussed the health service on what is the principal cause of public concern about the NHS. Standards of reading and maths in primary schools are rising because teachers and parents now support the literacy and numeracy hours timetabled every day in every school.

Arguably it should not have needed Whitehall to focus our health and education services on these key objectives. But a monopoly public service can all too easily become ossified and immune, if not resistant, to public concerns. External pressure from above therefore, can be an important means of focussing efforts to address public concerns. So can the pressure brought by individual patients exercising choice and by enhanced forms of local accountability. In the next period the emphasis needs to move from top down pressure to these more direct forms of engagement between those providing public services and those using them.

Targets work best when they are properly focussed. Which is the reason, incidentally, why the Priorities and Planning Framework we issued late last year to local health and social services contained not 400 targets as some claim but just 60 or so for the next three years.

National standards are necessary to ensure equity. No-one who is serious about securing fairness wants to go back to the days when cancer treatments, for example, were available in one part of the country but not in another. So targets can work but targets can go too far as well.

Targets fail when there are too many of them and when they inhibit the ability of local staff to shape local services to meet local needs. Disempowering frontline staff – whether it is doctors or nurses, social workers or police officers, teachers or managers- is not the best way to run a public service. It is right to set standards nationally but it is wrong to try to run the NHS nationally.

Those of us who have had responsibility for frontline public services over the last six years realise that whatever we thought possible on the 1st May 1997 – however much we believed that taking control of the commanding heights of the central state was enough – we now know that finger-wagging from Whitehall can not deliver public service improvement any more than could the old laissez-faire mentality of the Tories’ NHS internal market.

A better balance is needed. Whereas, some suggest there is a choice to be made between national standards and local autonomy I believe that is a false dichotomy. 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.

As the Prime Minister’s four principles of public service reform rightly acknowledge, in any large organisation – public or private – there are some functions only the centre can perform: fair allocation of resources; setting of standards; monitoring of performance.

And it is precisely because we have a framework of national standards and inspection in place that the pendulum can now swing decisively towards local control and greater individual patient choice. I believe these must become the principal drivers of public service improvement in the next period.

We are now in transition from the old order to the new. As we set out in the NHS Plan the more performance improves the more control local health services will assume. Rather than trying to drive improvements simply 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 patients make become the driving force for change, backed by 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.

That transition has now begun across the public services. In local government the White Paper produced by Stephen Byers represented a turning point in the relationship between central government and local councils with the prospect of more freedoms, flexibilities and powers. The Deputy Prime Minister John Prescott is now taking this further. Similarly, in the health service from this April, three-quarters of the total NHS budget will be controlled by locally run PCTs with three year budgets. In turn PCTs will be able to devolve resources to their constituent practices. None of the 30% growth PCTS are on average receiving has been earmarked. They will be free to commission services from the public, private or voluntary sectors.

So we have been moving from a centralised command and control model to what has been called new localism. The issue is now whether we can make this localism real and permanent. Whether we can go beyond a relationship where localities receive a few crumbs of decentralisation from the top table of central government and are expected to be grateful. Or whether we can make localism irreversible through a shift in accountabilities, ownership and control out of the hands of the central state and into the hands of local communities. This is what I mean by real localism.

I believe we have the opportunity to transform governance in our country. To do so requires grasping some thorny nettles of reform.

It means placing limits on the role of Whitehall. We could do that through exhortations to good behaviour on the part of Ministers and civil servants. We could be much clearer about what the role of the centre of government is about; what the role of the individual government department is about; and what, together, is the best role for Whitehall to play. All of these, in my view, are needed. Some have already begun. But I do not believe they will be enough.

Central bureaucracies make work. They make demands. Politicians – for good reasons, not bad – want to get their hands dirty. We want to pull levers to make changes happen. And that places further pressure on local services. It is naive to believe that a self-denying ordinance in Whitehall will be sufficient.

If we want to place limits on the role of Whitehall we will need limits on the size of Whitehall. The time is right in my view for a fundamental re-assessment of what functions Whitehall needs to perform in an era where the premium is now not just on making policy but on securing delivery. Where there is an acceptance that securing improvements in public services requires a re-balancing between the power held by central government and the power held by local communities.

The nature of Britain’s unwritten constitution means all governments have experienced tensions between competing centres of power. It is not a new phenomenon. Throughout time, there has been a struggle for power within the British constitution: between barons and Monarchs; between the Church and the State; between the rights of Parliament and the Divine Right of Kings.

It can be seen in the continuing struggles over powers between the House of Commons and the House of Lords – where history seems determined to repeat itself, as Marx once said, “first as tragedy and then as farce”. And in the context of last night that is Karl Marx not Groucho.

And on the issue of Lords reform let me just say: surely the priority should be to address the imbalance between the centre, the region and the local rather than just concentrating on the balance between the Commons and Lords. Getting that balance right – through greater devolution – could then, in my view, be reflected in a reformed second chamber constituted from the different nations and regions of our country.

Today competing tensions exist in a more modern context but they exist nonetheless. Those tensions exist between Europe and the Nation State; between government from Westminster and Whitehall and devolved administrations in Scotland, Wales and Northern Ireland; between the decisions of Parliament and the interpretations of judges; between power best exercised from the centre and that best exercised by local communities themselves.

For all the reasons I have set out the days of Whitehall – or any one part of Whitehall – knowing best are over.

My argument is not that Government itself is bad – that is not true. Government has an important role determining policies and priorities, setting and monitoring standards, raising finance, ensuring value for money, assuring equality of access and opportunity. The alternative to government – or its proxy – doing these things is to leave them to the invisible hand of the free market, which as Gordon Brown was rightly saying only on Monday, is often an insufficiently effective mechanism for so doing.

My argument is that government at the centre has to be big enough to perform its function but limited enough to curtail its ambitions. All bureaucracies have a natural tendency to grow, to replicate themselves. With the Crown prerogative and an unwritten constitution, we have no basic law setting out the roles and responsibilities of governments at local, regional and national levels, no constitutional court, no real fetters on the power of central government to accrue powers to itself save those exercised through Parliament and Judicial Review.

In these circumstances, it is for those who believe in progressive reform of public services to ensure real power shifts from Whitehall to local communities. And power moves when ownership transfers.

This involves a fundamental change in governance. The centre will always be strengthened and the locality weakened so long as the one has the mandate of democratic accountability and the other does not. That is why I believe NHS Foundation Trusts are so important. They are not about relinquishing a little central control. They are about relocating ownership out of the hands of a State bureaucracy and into the hands of the local community.

In the process they relocate accountability – so that hospitals can look outwards to the communities they serve not upwards to Whitehall. That will help get local health services better focussed on meeting local needs and addressing local inequalities.

NHS Foundation Trusts will usher in a new era of public ownership. They will be owned and controlled locally not nationally. Modelled on co-operative societies and mutual organisations, these NHS Foundation Trusts will have as their members local people, local members of staff and those representing key organisations such as the PCTs. These members will be its legal owners and they will elect the hospital governors. In place of central state ownership there will be for the first time in the NHS genuine local public ownership.

It is not and it has never been my intention to retain these benefits solely for an elite few. The freedoms they offer provide a new incentive for all to improve. We do not advocate that any NHS hospital should be left to sink or swim. That is why we have put in place help and support for struggling services to get better. In time, all NHS hospitals could gain Foundation status.

I believe NHS Foundation hospitals will help bridge the gap between public services and the public who use them. With a clear public benefit purpose NHS Foundation Trusts can provide a model of local control and ownership that others could follow. They are localism made real. I believe they provide a model that could apply to other aspects of public services.

Community-owned NHS Foundation hospitals will allow us to tap the great reservoir of enterprise and knowledge which exists in local communities. Some say that allowing local people to be elected to hospital governing boards will always favour the sharp-elbowed middle classes. Yet in my constituency – just like any other – the people who make the biggest difference on local council estates are people from those council estates. What we need to do is open up public services in such a way that they can be properly representative of the communities they serve.

For example, where New Deal for Community boards have been set up to oversee regeneration in some of the poorest parts of our country turnout in the board elections has been much higher – in some cases double – the turnout for the local council elections.

Democracy is by no means perfect in practice but it is not a bad principle. Transferring ownership from the central state to local communities – giving local people a stake and a vote in the public services they use – is the best way of moving localism beyond a gift conferred by Whitehall – which can be taken away by Whitehall – into a permanent feature of our democratic landscape.

The implications of this approach are potentially far-reaching. In other countries with a stronger democratic input into local services, for example, local communities are able, through referenda or through local elections to agree to raise local funds to invest in the public service infrastructure. In the USA local bond issues are common. Some are issued by a local government authority which then lends the proceeds to the local hospital. Others are sanctioned by voters and issued by the hospital district direct. In this way, these health care systems can overcome the constraints either of central government capital rationing or the straitjacket of particular forms of procurement.

And in the context of our new approach to localism in this country there is already discussion of these issues here.

Alongside self-government in Scotland and Wales and the plans for regional government that John Prescott is leading in England, I believe that such devolution and democratisation of public services can point the way to a more pluralist and decentralised Britain.

The ramifications are profound. Where there is greater local control – as the Prime Minister, Chancellor and myself have all argued – there will inevitably be greater diversity. The one flows from the other. I think that is right. The NHS cannot survive as a monolithic top down centralised system. Without greater diversity the NHS cannot be more responsive. Without responsiveness there cannot be public confidence. Without public confidence the NHS will not be sustainable.

Despite fifty years of hard evidence that uniformity has not produced equality, the traditional fear on the Left has been that diversity must bring inequality. But it is worth recalling what R.H.Tawney wrote in his 1931 book Equality:

“equality of provision is not identity of provision. It is to be achieved not by treating different needs in the same way, but by devoting equal care to ensuring that they are met in the different ways most appropriate to them, as is done by a doctor who prescribes different regimens to different constitutions, or a teacher who develops different types of intelligence by different curricula. The more anxiously, indeed, a society endeavours to secure equality of consideration for all its members, the greater will be the differentiation of treatment which, once their common needs have been met, it accords to the special needs of different groups and individuals amongst them.”

Diversity, in other words, can bolster the pursuit of equality rather than undermine it.

The evidence from the specialist school programme shows that diversity and choice of provision delivers a real return not least in poorer communities. Specialist schools recruit on a broadly comparable basis to non-specialist schools in terms of deprivation and test results at age 11. Yet GCSE performance in specialist schools was six percentage points higher than in non-specialist schools – 55 per cent to 49 per cent, in terms of those gaining five or more good passes. Research also shows that the longer schools remain in the programme, the higher the rate of improvement. And on recent measures of value added performance – which allow comparisons to be made between schools with different intakes – specialist schools outperform non-specialist schools.

Diversity is not a stranger to other left-leaning countries. Whereas in the UK’s health care system there is uniformity of ownership, in many other European countries there are many not-for profit, voluntary, church or charity-run hospitals all providing care within the public health care system. There are private sector organisations doing the same. As other European nations testify there is no automatic correlation that tax-funded health care has to mean health care supply run purely by central government. That is why I believe tax funded health care in our own country can sit side by side with decentralisation, diversity and choice.

Labour’s objectives – social justice and opportunity for all – remain our mission. Our means of delivery however, must now change. We can preserve values and yet still change structures. We recognised this when we got rid of the old Clause 4 from our Party’s constitution. We did not change the values in which we believed but we renewed our Party’s appeal as a result. We now need to end the old Clause 4 approach to public service delivery. We must not abandon the values and ethos of public service but – through local control and ownership, diversity and choice – we must now reconnect public services directly to the public that they serve.

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

These are the building blocks of real localism. The challenge to government is not whether Ministers can use the rhetoric of locality but whether we are now all prepared to live – and govern – with the reality of localism. I believe we should.

Alan Milburn – 2002 Speech to Emergency Care Lead’s National Conference

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, on 27 November 2002.

I wanted to come along for a couple of reasons. First, there are many of you here from a variety of backgrounds and I want to thank you for what you are doing. I want you to thank the people who are working in emergency care when you return to your various hospitals, community centres and so on. Much of the discussion today inevitably centres on the problems that we have in the emergency care system. But I think it is quite important that we also recognise that most people get very high quality care most of the time. That is down to you, and the people that work with you and for you in the community.

I was recently travelling back from a conference with a television news presenter, who had recently taken his elderly relative to an A&E department in London. He compared it to his last visit two years before, and he was struck by how quickly his relative was seen and how there was very clear communication from the outset through each stage of the patient’s journey. He knew what was going to happen next and that was important for him. This was in marked contrast from his previous experience.

He did not know anything about Emergency Care Collaboratives or streaming, but he did feel their consequences. What he extrapolated from the experience was the state of the NHS. And this is why emergency care is so critical. Obviously, it is important in itself. But it is also an important barometer for the public for the whole of the NHS. The quality of the A&E experience has an impact on what people think of the whole healthcare system.

There are huge problems, and we all know that. But I think we have a real opportunity to change things for the better. There is more money going into the NHS. We are going to get five years of real-term increases in funding, worth around 7.5%. We have a unique opportunity to use that money to provide the quality of care that patients want to see. We need to get the money into the right places – into A&E – but that is not just hospitals. Primary care, community services and social services must work too.

If you are putting taxes up, which we are, people will want to see a return for the extra they are paying. The Emergency Care Strategy has set out a national framework for the way these improvements can happen. We have strong leadership in David Lammy and Sir George Alberti. There is a huge amount of change happening even though people are not always comfortable in managing and experiencing change.

When I see the fact that 20% of our A&E departments are now providing 90% of our patients with care within four hours that fills me with optimism. In the end, even though we can have as many national standards and targets as we like, there is a big difference between “us” on the platform and “you” out there. I do not treat anybody – you do. Nothing will happen without your involvement and your support. The real reason to be hopeful is that when you visit an A&E department, NHS Direct or anywhere, you are filled with a sense of amazement and privilege about what people are doing.

I have always believed in one simple thing: if you can put together the right level of investment, the right programme of change and reform, and you can harness the expertise, commitment and know-how of staff out there, then you can change things for the better.

There are a lot of problems in the NHS. But I believe one fundamental thing about it: we live in a world where healthcare can do more than it has ever done before, but it costs more than it has ever done before. In that world, I think NHS values and principles – care being free and based on a person’s need and not their wealth – is not a weakness for Britain, but an enormous source of strength for Britain.

So, I think we have a unique opportunity. We look to work with you, and to learn from you, to make these changes happen. I believe we have every reason indeed to be very optimistic about what the future holds for emergency care and our health system overall. Thank you very much for coming.

Alan Milburn – 2002 Speech to CBI Conference

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, to the CBI Conference in Manchester on 26 November 2002.

Thank you for the opportunity to take part in your conference.

As I have stressed in recent meetings with both Sir John Egan and Digby Jones the Government attaches particular importance to the relationship we have with the business community.

I am pleased to be able to put on record my thanks to the CBI for agreeing to work closely with the Department of Health on a number of specific projects. First of all on improving procurement so that public and private sectors alike are able to make the most from the record investment now going into renewing our key public services, especially the NHS. And secondly, encouraging mentoring, secondment and management support to the NHS from within the business community. By working together we plan to open up the NHS to new management talent from outside the health service to help meet some of the new management challenges we face – in areas like IT, procurement and programme management.

More generally we recognise as a government the pivotal role public private partnerships are playing in improving our vital public services. I very much welcome the statement launched today by the CBI on the role of PPPs. There is much in it with which we can agree. In essence the Government’s approach is about using the private sector where it can support the public sector to improve public services.

You can see that with the private finance initiative. PFI is a partnership that works. As an addition, not an alternative to public sector capital investment, PFI is helping deliver the biggest new hospital building programme the NHS has ever seen. It is allowing more new NHS buildings to be built more quickly. PFI is here – and it is here to stay.

In the face of sometimes fierce, often dogmatic opposition to PFI, both public and private sectors have a responsibility to explain that this is a partnership that is delivering results for patients and good value for money for taxpayers. We have a shared interest in doing so because we have a shared interest in making sure public services work. Public services are vital to business, the economy and the wider society we serve.

That is as true for health as it is for education or transport. At its simplest, the level of ill health in our country means a loss of productivity and a loss of potential skills that an increasingly knowledge-based economy simply cannot afford.

I believe that in a world where health care can do more but costs more an NHS free at the point of use based on need not ability to pay is a huge strength for Britain. So the values of the NHS are right. But for all its great strengths – its ethos, its staff, the great advances it has brought in public health – the NHS has profound weaknesses too. Too often the poorest services are in the poorest communities. Its centralised top down structure tends to inhibit local innovation. Staff too often feel disempowered. Local communities feel disengaged. And patients have little say and precious little choice.

The NHS needs two things. One, investment. Two, reform.

Improving the NHS requires us to address decades of under-investment. There is a simple truth here: if we want world class health care it has got to be paid for. The last Budget sought to do just that. Five years of real terms growth averaging 7.5% will take health spending in our country beyond the EU average. We have a lot of catching up to do but today we have the fastest growing health care system of any major country in Europe.

When we put taxes up to pay for more resources for the NHS we entered into a new contract with the people of our country. In exchange for extra resources we need to deliver better results. That means a tough new inspectorate to guarantee value for money for taxpayers and the highest clinical standards for patients. It means modernisation of how the NHS pays and employs staff. And it means, as we set out, in our 10 year NHS Plan far reaching reforms. Devolution of power. Diversity of provision. Choice for the consumer. Each is controversial, but all are needed if we are to get the best from the resources we are putting in.

Let’s start with devolution. The job of government is to set standards and objectives to ensure equity in healthcare provision. It is not to run the NHS. A million strong service cannot be run from Whitehall. It’s got to be run by the local staff and held to account by the local community.

As in any large organisation – public or private – getting the right balance between national and local holds the key to securing improvements in services. In the NHS today we are at the start of a transition where we move from a top down and centralised system to one where standards are national but control is local. So the performance of local health services is now being rated with those doing less well getting more help and those doing best getting more freedom. At one end of the spectrum new management teams will be brought in – from the public, private or voluntary sectors – to turn round persistently poor performance. At the other the best performers will become NHS Foundation Trusts freed from Whitehall direction and control, governed, indeed owned by the local community and with a bigger say for local staff. Reform means investing not just extra resources in front line services, but power and trust in those front line services.

From next April locally run primary care trusts will control three quarters of all NHS resources. They will have the freedom to purchase care from the most appropriate provider – public, private, voluntary or not for profit. This will bring greater plurality in local services with the freedom to innovate and respond to patient needs. So in addition to sustained growth in existing NHS provision and greater use of existing UK private sector hospitals to treat NHS patients, we will bring new private sector providers from overseas into this country to further expand NHS services. As other European nations show, a public health care system based on centre-left values does not need to be exclusively delivered by state-run line managed public sector organisations.

These reforms are about redefining what we mean by the NHS. Changing it from a monolithic centrally run monopoly provider to a system where different health care providers work to a common ethos, common standards and a common system of inspection. In this reformed 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.

A modern NHS is also one in which patients have power and choice. So if the local NHS hospital cannot offer a short enough waiting time but another hospital can patients can choose it.

Choice over hospitals has always been there of course but only as the exclusive preserve of those who can afford to pay. That is two tier health care. I believe health care and choice in health care should be based on need not ability to pay. So choice needs to be available on the NHS. Already hundreds of NHS heart patients have been able to choose faster treatment by choosing a different hospital. And as NHS capacity expands so choice will grow. By the end of 2005 we aim to have NHS patients needing a hospital operation in every part of the country having a choice over the hospital, the time and even the doctor that’s best for them. This reform marks 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. Resources will follow the choices patients make so that hospitals who do more get more; those who do not, will not.

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 the public sector as in the private sector.

Some say that a service, centred on individual patients offering real choice, can only happen in a private market by forcing patients out of NHS care into treatment they must pay for themselves. I say that with the right level of investment and the right programme of reform the NHS can deliver a modern responsive service to the people who use it and those who fund it. That is what we intend to do. We want to work with you to make it happen.

Alan Milburn – 2002 Speech to the Faculty of Public Health Medicine

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, on 20 November 2002.

It’s a privilege to be here today as guests of the Royal College of Obstetricians and Gynaecologists. For fifty years the Royal College has worked tirelessly to make pregnancy and childbirth safer for women and babies. Your work has made an immense contribution to reducing deaths during childbirth. And that contribution has been particularly important because it has been most measured amongst the poorest communities in our country where need is greatest.
I am also grateful to the organisers of today’s event – the Faculty of Public Health Medicine. For thirty years it has set the standard for public health not least by driving major improvements in training and personal development. I want to thank you for your leadership and your support.

Today I want to describe the national challenges we face in improving public health and tackling health inequalities. I also want to set out our national programme of action to address them.

My starting point is this: the health debate in our country has for too long been focussed on the state of the nation’s health service and not enough on the state of the nation’s health.

In my view the time has now come to put renewed emphasis on prevention as well as treatment so that we develop in our country health services and not just sickness services. It is time for a sea change in attitudes. A renewed determination to fulfil the ambition we should share as a nation: to improve the health of all and to improve the health of the poorest, fastest.

The key questions today should be about how best we can bring about that improvement in the public’s health. How best can we cut deaths from heart disease? How best can we improve cancer survival rates? How best can we add years to life and add life to years? And crucially, how best can we tackle the huge inequalities in health which scar our nation?

In the last five years we have made a start in answering these questions. And I want to thank the people working in public health from all the different health professions – alongside countless other dedicated staff working in the NHS – for the real difference you are making.

Together, we face formidable problems. Our rates of Coronary Heart Disease for example are amongst the highest in the world. Our cancer survival rates are too low.

Progress, however, is underway. Indeed, Britain now has the fastest improving heart and cancer services anywhere in Europe.

The latest data, covering the period from 1998 to 2000, shows that deaths from cancer have fallen by 6%, from heart disease by 14%. Just two weeks ago Professor Peter Boyle told us that the UK has had both the largest fall in lung cancer amongst men and the largest decline in breast cancer in the European Union.

There is a similar story on teenage pregnancy. We still have the highest rates in Europe but after years when teenage pregnancy rates rose they are now beginning to fall.

The introduction of the Meningitis C vaccine has reduced deaths by 90%. So new standards and new services are making their impact felt. But there is a long way to go. And I believe the time is now right to up our nation’s game on public health.

I say that for three principal reasons.

First, because for the first time in the history of the health service there is a long term commitment to extra NHS resources and to a ten year NHS plan for reform.

Improving public health – and tackling health inequalities – is a battle for the long term. It can’t be done when there is the uncertainty of spending being up one year but down the next. Today, after decades of neglect and underinvestment, we can look forward to the future with confidence. Five years of real terms growth averaging 7.5% a year will take health spending in our country beyond the EU average. Just six years ago spending on the NHS was falling in real terms. By 2008 it will have doubled in real terms.

Britain now has the fastest growing health care system of any major country in Europe.

To get the best from this level of investment – especially for our poorer communities – resources have to be accompanied by change and reform. The emphasis the NHS Plan places on improving health and reducing inequality has enjoyed insufficient attention since it was published two years ago.

The NHS Plan committed the Government to achieving the first ever national health inequalities targets; to increasing resources in deprived areas; to introducing new screening and preventative programmes. And in each of these areas there is already progress underway.

Second, however, renewed emphasis is needed on public health because there are new problems to deal with which make the challenge of health improvement both more difficult and more vital.

In an open, increasingly global economy disease recognises no boundaries. The rising incidence of TB across the under-developed world is now impacting on the developed world – including in this country.

Changes in lifestyle are having an impact too. Sexually transmitted infections are rising especially amongst young people. Over the last few years more people newly diagnosed with HIV were infected through sex between men and women rather than sex between men.

Obesity has trebled since 1980 – increasing the risk of heart disease, diabetes, stroke and some cancers. It is more common amongst lower socio-economic groups with unskilled women twice as likely to be obese as professional women.

There are similar trends in tobacco consumption. By the age of 15 around one quarter of girls are regular smokers. Not surprisingly while rates of lung cancer are falling among men they are still rising among women. Indeed lung cancer has now virtually caught up with breast cancer as the leading cause of cancer deaths among women. The problem is greatest amongst lower income women.

In each of these cases we have responded with new services and new approaches. But as the Chief Medical Officer’s report, Getting ahead of the curve, made clear new challenges mean that we must keep focussed on public health. Indeed that is why we are creating a new Health Protection Agency. And there is another pressing reason for upping the focus on public health – health problems, old and new, are all too often concentrated in the poorest communities.

Third, then, for over fifty years the health gap between the better off and the worst off has widened, not narrowed. For me, that offends against all this government stands for: a society based on fairness and justice, in which each citizen gets the opportunity to fulfil the potential of all their talents. Good health – like a good education – is the route by which each and every one of us can properly fulfil our true potential. It unlocks life chances and is a fundamental building block of wellbeing.

Too many people are denied this basic chance in life. That was principally the message of Sir Donald Acheson’s report. Poorer people get sick more often and die earlier. For us it is simply unacceptable that the opportunity for a long and healthy life today is still linked to social circumstances, childhood poverty, where you live, how much your parents earned, how much you earn yourself, your race and your gender.

In some areas of the country life expectancy is still the same as the national average in the 1950s. Two weeks ago the Office of National Statistics published new figures showing that even today a boy born in Manchester would live on average a decade less than a boy born in Dorset.

Social inequality breeds health inequality. Poverty literally cascades down the generations. Up to a quarter of all children are persistently in low income families. Babies born to fathers in social class five are more likely to be low birth weight. Low birth weight is a key factor in a child’s subsequent development and opportunity. Poor children are less likely to get qualifications and to stay on at school. Poor health then is linked to low educational attainment, which is not only bad for the individual but also bad for the nation.

Economic success today depends on harnessing the skills and potential of all of our people and not just some. Poor health blights too many communities and holds back too many people.

So, the time has come to recognise that health just like education is a route to economic fulfilment as well as personal fulfilment. Just as good education is a route out of social exclusion and into economic prosperity so too is good health. The vicious cycle of poverty, social exclusion, educational failure and ill health must now be broken.

It is this determination which drives the Government’s programme to reduce child poverty. Our aim is to reduce the number of children in low income households by at least one quarter by 2004 as a contribution towards our broader target of halving child poverty by 2010 and eradicating it by 2020.

Today on International Children’s Day it is worth reminding ourselves that compared with just five years ago, Britain has a quarter of a million fewer children growing up in homes where no-one has a job. 1.4 million fewer children live in absolute poverty today compared with five years ago. Almost 300,000 children in disadvantaged communities are already covered by Surestart, offering them the start in life others are able to take for granted.

Youth and long term unemployment are at the lowest level for 25 years. There are 1.5 million more people in work. The minimum wage and the working families tax credit have raised the living standards of millions of poorer families. There is more investment in childcare and in poorer communities. But there is an awfully long way to go.

By intervening in these sort of ways to break the cycle of poverty we can effect what Anthony Giddens once called the “redistribution of possibilities”.

Our task as a government is to ensure that the “redistribution of possibilities” becomes a reality for every section of society, every community in every part of our country.

Our vision is of a society where there are opportunities for all and not just for some. Where everyone does enjoy the chance to get on. The opportunity of a job. The opportunity of good education. To live in a community free from crime and the fear of crime. The opportunity to enjoy better health too.

So there is every reason in the world to take action to address health inequalities and improve public health. The necessary levels of investment are in place. We have a long term plan for reform. Without action the problems are likely to intensify. Above all – perhaps most simply of all – health inequalities offend against the values of social justice, the very values on which the NHS was founded.

And yet, for years there has been a sometimes paralysing debate about whether we could do anything to tackle health inequalities at all. Some argued that since they were the product of such deep-rooted social and economic factors they were beyond any realisable form of action from the NHS or indeed any other agency. Others argued – even when they were in government – that it was the individual rather than society that was to blame. Both analyses became a recipe for hopelessness and inaction.

Today we need a new outlook. An approach that accepts that there are wider determinants of ill health – and a wide-ranging programme of action is necessary and indeed is underway to deal with them. But an approach which also understands that the NHS can make a specific contribution to improving health prospects by working with the communities it serves: making the task of tackling health inequality something done with local people not just done to them. Indeed, such action is vital if the NHS is ever to deliver on its values of equity and social justice.

Today our insight surely must be that a healthier nation calls for a fairer society. The job of improving health then, is a job not just for one department of government but for the whole of government – and not just between government departments but between government, business, local communities and individuals to provide real and lasting opportunities for better health. And it calls for a renewed effort on the part of the NHS to focus on prevention so the “redistribution of possibilities” becomes a reality.

Today I am publishing the Government’s cross cutting review on health inequalities, part of this year’s Spending Review. The review commits – not just one government department but the whole of Government – to place tackling health inequalities at the very heart of public service delivery. So with the education department we will extend Surestart. With the transport department we will improve public transport in deprived communities. With local government we will improve the housing stock.

The Prime Minister will take a personal lead in addressing the inequality issues raised in the review. He will be chairing a meeting of cabinet colleagues to oversee the production of a detailed national programme of action on health inequality.

Within the Department of Health I am establishing a new Health Inequalities Unit. It will help lead our health-specific efforts on tackling these inequalities.

With resources biting alongside reforms, and with the focus on the long term not merely on the short term, we can now increase our emphasis on health prevention as well as treatment. This can not be the old-style health promotion policies of the past seeking to cajole people into adopting healthier lifestyles but a new approach that offers people the opportunity of better health. One that recognises that diets are often less healthy and smoking rates are higher in poorer communities. That acknowledges people have the right to make a choice about what they eat or whether they smoke but people should have the opportunity to have a healthier diet or to give up smoking if they so choose. Many are denied that opportunity because healthy food has not been available locally or until recently because help to give up smoking has not been available freely. It is on this basis that we can then ask people to take greater responsibility for their own health.

There are five specific steps we now plan to take.

Firstly, tackling inequalities in access to health services.

The most disadvantaged are not only more likely to get ill. They are less likely to get the best services when they are ill. You can see that in the way those parts of the country that have the worst levels of heart disease often have the worst heart services.

We have started to address this inverse care law – whereby those with the greatest need tend to get the least health care – that has dogged the NHS for fifty years. Equity demands national standards that level services up not down. The national framework of standards we have put in place – with national service frameworks and a national system of inspection – are a means to this end. So too, despite the controversy around them, are national targets to ensure equity in access to treatment.

The targeting of resources to areas where need is greatest is also important. In tertiary care for instance we are plugging historic gaps in heart surgery capacity by putting in place new services in Teesside, Blackpool, Wolverhampton, Bristol, Plymouth and elsewhere. In primary care GPs working under the personal medical services contract are delivering services in communities where none existed before like Sunderland, Salford, East London and Liverpool.

Two years ago I introduced the health inequalities adjustment into the NHS funding formula to ensure that extra resources were going to the areas of highest health need. Later this year I will introduce an entirely new formula for funding local health services so that we can achieve a better balance still between high cost areas and high need areas.

Secondly, then, we plan to put public health and addressing health inequality at the heart of the NHS. By devolving power in the health service we have begun to put public health centre stage. The truth is the fifty year old one-size-fits-all NHS hasn’t succeeded in reducing health inequalities. Uniformity in provision has not guaranteed equality of outcome. That is why we are moving towards an NHS where standards are national but control is local. Since different communities have such very different needs it must be right to put resources and responsibilities in the hands of frontline services.

Today Directors of Public Health are based within local Primary Care Trusts, directly serving more than 300 local communities. There is a huge opportunity here for public health to take a hands-on community-orientated role; to use the PCT structures to forge local alliances – between public, private, voluntary and community organisations – which are necessary to tackle specific local health problems. And there is now a clear mandate to do so.

The two national inequalities targets we have set are now firmly embedded in the NHS Priorities and Planning Framework for the next three years. They are now core business for the whole National Health Service.

I can also say today that the next set of performance indicators on which all local health services will be rated and rewarded will have at their core securing improvements in public health and better health outcomes. We are considering indicators on infant mortality and mortality from circulatory diseases and cancer, alongside success rates for smoking cessation services, screening and immunisation.

Thirdly, we need to focus relentlessly on defeating our country’s biggest killers – cancer and coronary heart disease. Between them they kill over 200,000 people a year. Many of these deaths are preventable. Unskilled men are three times more likely to die from heart disease than professional men. Survival rates from cancer are worse in lower income areas than in higher income ones. Since both diseases have such a strong social class gradient a concerted effort here will make the biggest contribution to narrowing the health gap.

In the last three years since the publication of the national service framework on heart disease in 1999 and the Cancer Plan the year after, much progress has been made.

The number of cardiologists has risen by over 40% since 1997. The number of heart surgeons is up by more than 30%. There are 500 more cancer consultants today than there were in 1999. There are 500 more to come.

182 Rapid Access Chest Pain clinics are now open. The number of new linear accelerators has increased by 20%, CT scanners by 50% and MRI scanners by 100%. Again there are many more to come.

The best drugs are becoming available across the NHS too. Prescribing of statins to control cholesterol, while putting pressures on PCT budgets, is up by one-third. A few years ago taxanes to treat cancer were available – not according to clinical need – but according to the local chance of whether a GP or a health authority had decided to make them available to patients. Today they are available to all who need them, not just some. Thanks to the work of the National Institute for Clinical Excellence, over 30,000 patients can already benefit from new cancer drugs. Many more will do so in the years to come.

And, step by step, the NHS is making progress in tackling waiting times for treatment. Today 95% of patients urgently referred with suspected cancer are seen within a fortnight when they used to have to wait for months. The maximum wait for heart surgery is down from 18 months to 12 months. By spring next year it will fall to 9 months and will be lower still in future years particularly as more patients are able to make more choices about where they are treated.

In the next three years the NHS will be able to make further progress still by focussing not just on further advances in treatment – through faster waiting times and new drugs – but also on prevention.

Fourthly, we need to secure a better balance between prevention and treatment. Sir Richard Peto said earlier this year that halving the rate of premature death worldwide is within the capability of current medical expertise. We simply can no longer regard prevention as playing second fiddle to treatment. That is why we are extending our NHS screening programmes. Breast screening has been extended to 65-70 year old women. So far 130,000 women have been invited. By 2004, 400,000 women will be benefiting each year. Nationally, we will now move to extend other screening programmes such as for prostate cancer when there is the means to do so and for colorectal cancer as soon as we are able to do so.

Locally, more and more GP surgeries are already establishing registers of patients at risk of disease so that they can intervene sooner rather than later. Also, in this session of Parliament we are proposing to legislate for far-reaching reform of NHS dental services. PCTs, with the support of dental public health colleagues, will need to assess local oral health needs, including health inequalities, to meet their new responsibilities for dental services. Moreover, for the first time since the foundation of the NHS, primary care dentists will be given what is essentially a public health role, with the opportunity to focus on prevention and promotion, as well as treatment.

I hope that local PCTs will use their three year budgets to commission services in such a way that we get a better balance between services in the community and those in hospitals, between prevention and treatment. So that we can open up new opportunities for people to choose a healthier lifestyle.

We know for example that healthy eating could reduce by one-fifth deaths from cancer, stroke and heart disease. Fruit and vegetable consumption in our country is among the lowest in Europe – and still less in lower income groups than high income ones. Research I am publishing today on local five-a-day initiatives shows that those trends can be reversed. Those eating least before the schemes began ended up increasing their intake of fruit and vegetables once they had the opportunity to do so. Teachers have reported similar enormous benefits since we have introduced free fruit in schools. Today around 400,000 children are benefiting. By the start of the next school year it will reach 1 million children.

And the changes we are proposing to the welfare food scheme will open up choices for low income families to buy healthy food – including milk – for their young children. Together with the work the NHS is doing to encourage greater exercise – alongside partners like the New Opportunities Fund and Sport England – these opportunities to improve diet will not only help tackle the rising incidence of obesity but in the process help improve health and tackle health inequalities.

Fifthly, however the biggest contribution of all will be made by tackling smoking. As our 1998 White Paper starkly put it: smoking kills. It kills about 120,000 people each year in Britain. One in five of all deaths. It is the main avoidable cause of death. It is the principal cause of the inequalities in death rates between rich and poor. It costs the NHS £1.7 billion a year. Smoking is a public health disaster.

And yet we know that 7 in 10 smokers say they want to quit. Our job is to help them do so. That is why we have set challenging objectives to get smoking rates down not just among adults but amongst children. To target special help on lower income groups so that we can make most impact where the incidence of smoking is greatest. To help pregnant women to quit because smoking is the key preventable cause of low birth weight babies, one of the main determinants of future health.

We have made a start in delivering reductions in smoking. Smoking rates have fallen and the fall has been greatest amongst those in manual occupations. Now I want to set out how we will accelerate the drive to combat smoking.

To begin, with after years of obstruction in the courts and in Europe, the Tobacco Advertising and Promotion Bill received Royal Assent on 7 November. We made the commencement order giving start dates for implementation of the ban in Parliament yesterday. It comes into force today. By next Spring advertising on billboards and in the press will disappear. By next Summer tobacco companies will no longer be able to target their product at children because at long last tobacco advertising will be illegal.

What is more by this time next year, all cigarette packs will carry stark health warnings on the front of each packet. There will be new health messages including warnings about smoking causing impotence and clogged arteries. Misleading double-speak on cigarette packets such as “mild” and “light” will disappear.

Next year will also see, for the first time, tobacco companies having to provide information on the additives they put in cigarettes. We know already they include chemical compounds more usually associated with sweeteners and chocolate, solvents and turpentine. Each year we will publish the list of additives by brand and their known health effects.

With our European partners we will work to develop new graphic warning pictures on packets of cigarettes and other tobacco products. And we are working with the World Health Organisation to introduce a comprehensive Framework Convention on Tobacco Control to restrict tobacco advertising globally and improve tobacco control worldwide.

Our approach is not just about getting people to quit smoking but to make sure that people – especially young people- never start. The £59 million we have invested over the last four years in anti-smoking advertising is making a difference. These adverts have a higher recall rate than those of McDonalds. Elsewhere in the world where smoking prevalence has been dramatically reduced – places like Massachusetts, California and Australia – a major factor has been hard hitting media campaigns which have set out the reality of the damage caused by cigarettes. The impact, especially of TV advertising, has been just as high among low income smokers as amongst more affluent smokers. Research on the national tobacco campaign in Australia estimated a reduction in adult smoking prevalence of 1.8% over the initial 18 month period of the campaign. The costs of implementing it were more than offset by projected savings to the health care system.

Over the last few months my department has been discussing with some of our key health charities how we could learn those lessons from abroad and apply them here at home. I am pleased to be able to announce today that we will be providing an extra £15 million over the next three years to allow those charities – beginning with the British Heart Foundation and Cancer Research UK – to run similar hard-hitting campaigns here.

Let me just say at this point that I am grateful not just for the work of these two charities but for the work of countless others in tackling the scourge of smoking including the British Lung Foundation, the Royal College of Physicians, the BMA, ASH and QUIT.

And finally we will give more support to help more of the 7 in 10 smokers who say they want to give up smoking to do just that. Today the NHS is providing a genuinely world leading smoking cessation service. Zyban and Nicotine Replacement Therapy are already available on prescription. We began these services in the poorest communities and they are now available nationwide. Nearly 220,000 smokers have been helped to kick the habit, many for good. And now over the next three years we plan to help a further 800,000 smokers to quit.

We will do so by building up local services and developing our partnership with the pharmaceutical industry. Over the last few months we have been in discussion with GlaxoSmithKline, Glaxo Consumer Healthcare Novartis and Pharmacia about working more closely together to deliver even more smoking cessation services in local communities.

I am pleased to be able to tell this conference today that from the start of the next financial year we intend to have in place a rebate or a “cash-back” system between the Department of Health and these companies whereby the NHS receives a payment back for every extra smoking cessation product it buys over and above an agreed level.

We will in turn pass this cash back to local PCTs directly linked to how much they have invested in smoking cessation. The more they spend up front the more they will earn back. For the first time there will be a positive financial incentive to invest in public health. And we will want to explore how this principle could be extended further still.

We are engaged in a major national effort to tackle health inequality and improve public health. We need to mobilise individuals and communities. Above all else we need to mobilise you as public health professionals – without whom none of this would be possible – to lead it.

I have no doubt some people will dismiss this renewed commitment to public health and our campaign against health inequality as a road merely paved with good intentions.

But our actions are as determined as our ambitions are bold: to do what no government has ever done – to improve the health of the country as a whole and to improve the health of the worst off at a faster rate still.

Our determination springs not just from a recognition that health inequalities are in themselves an injustice but from a realisation that they hold our whole country back.

Our drive to tackle inequality comes not just from our view that a damage done to one is a damage done to all but our belief that to ignore health inequality is to tolerate even to condone it.

We do not condone health inequality. We must not tolerate it. It is time to tackle it. I hope that together we can do just that.

Alan Milburn – 2002 Speech on Cancer

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, on 5 November 2002.

Introduction

May I first of all thank Ian Gibson and my colleagues in the All-Party Parliamentary Group on Cancer for sponsoring this important Conference today and inviting me to speak this morning.

I would also like to thank Professor Boyle for his interesting and encouraging presentation.

Too often Britain is portrayed as the poor relation in European cancer care. It is encouraging to see that overall we are heading in the right direction.

When I became Secretary of State for Health three years ago I said then that reducing the number of deaths from cancer and improving the care and treatment cancer patients receive was a personal priority for me.

Over the last 3 or 4 year, the priority we have placed on winning the fight against cancer is beginning to deliver some results. Of course, that’s with the enormous caveat that there is still a long way to go. The people who deliver cancer services – doctors, nurses, radiographers, pharmacists, scientists, therapists and so many others – are still working under huge pressure in the NHS. Overall, patients get good quality care but sometimes patients still do not get the services they deserve.

Putting right years, and in some cases, frankly, decades even, of under-investment takes time and effort as well as sustained resources. That is why we have a ten year Cancer Plan. And today it is paying dividends in improved services and better outcomes. Today in our country we have the fastest improving cancer services of any major country in Europe. We are catching up – and catching up fast. Death rates are falling faster here than in other countries. Britain is starting to win the fight against cancer although there’s a long way to go.

I want to put on record today my thanks to those who are making this progress possible: the thousands of NHS staff across the country who are working together across organisations to modernise cancer services and whose commitment to excellence is, in my view, quite unrivalled in any other country in the world; the cancer charities, research bodies and voluntary sector and patient organisations who are now working together as never before to improve services for cancer patients. And of course, to Mike Richards – a lot of things only happen because of good leaderhip – Mike is leading this process of change – and is the best possible champion for cancer care any country could have.

The Cancer Plan is unashamedly a ten year programme. We are just two years in to it. Everybody – including me – wants to go more quickly. But – we have to be honest – we would simply be kidding ourselves, and misleading the British public, if we said turning round decades of neglect could be sorted with a quick fix. It can’t.

We should have the courage to acknowledge – to the press and to the public – that getting world class cancer care is a battle for the long term not the short term. It is a journey best completed step-by-step – recruiting staff, renewing equipment, changing attitudes, reforming services.

And, as we are honest about the scale of the challenge, we should also be determined to celebrate every single successful step along that journey. There is considerable progress to report. Investment in cancer care is rising and, in line with the Cancer Plan, by next year NHS spending on cancer will be £570 million more than it was just two years ago. I know – in this audience and elsewhere – sometimes there have been concerns about whether this extra funding is all getting through to frontline cancer teams. I take those concerns extremely seriously. We are putting in place work to better track that the investment is going in to where it is most needed but there is already growing evidence that extra resources are beginning to produce results for patients.

To begin with, the capacity problems faced by NHS cancer services are at last starting to be addressed. There are 500 more cancer consultants today than there were in 1999 – an increase of 15%. There are nearly 500 more to come.

There are still skill shortages of course – I think most acute in the all important area of diagnostic services. Again however progress is underway. The number of radiographers in training, for example, has risen by 28% in the last five years after it had fallen in the years before that. So we are making progress towards a long term solution.

The same is true for the other main capacity problem we face today in securing better cancer treatment services – shortages of the most up to date technology. Here the progress has been even more rapid. Since 1997 the number of new linear accelerators has increased by 20%, CT scanners by 50% and MRI scanners by 100%. Almost half the CT scanners currently working in the NHS are new since January 2000

There will be a further 100 additional scanners and 45 linacs for the NHS over the course of the next couple of years. We are currently working with local health services to decide where best the scanners should be located in order to plug the gaps in capacity that otherwise produce a lottery in cancer services. I will be making announcements about their location within the next few weeks so that the first of them can be delivered and imaging patients before next summer. This investment is essential to tackle the health inequalities which scar our nation and which are so evident in cancer care.

The lottery in funding for cancer drugs is already coming to an end. It is worth recalling that just a few years ago taxanes, for example, were available – not according to clinical need – but according to the local chance of whether a GP or a health authority had decided to make them available to patients. Today they are available to all who need them, not just some. Indeed, thanks to the work of the National Institute for Clinical Excellence, the NHS today is making available new cancer drugs for the treatment of ovarian, lung, brain, pancreatic, breast and bowel cancers as well as leukaemia and follicular lymphoma. Over 30,000 patients are already benefiting from these drugs. Many more will do so in the years to come. I can also tell the conference today that NICE are already appraising the next generation of new cancer drugs and will continue to make cancer a core priority of its work programme. And through the extra effort going into cancer research – particularly the establishment of the National Cancer Research Network – we can now aim to double the number of patients entering clinical trials of the latest drugs.

And, step by step, the NHS is making progress in tackling waiting times for treatment especially the time taken to see a cancer specialist Today 95% of urgent referrals are seen within a fortnight.

The extension of breast screening for 65-70 year olds is on schedule. So far 130,000 women have been invited. By 2004, 400,000 women will be benefitting each year.

And it is in this area of screening and prevention that we should now look to make further progress. So many of the 125,000 premature cancer deaths in the UK each year are preventable. Early intervention can make all the difference. Cutting down on tobacco consumption and improving diet could help to save up to 75,000 lives. In a few weeks time I will be outlining our proposals to place greater emphasis on prevention, alongside treatment, in the fight against cancer, when I speak to the Faculty of Public Health Medicine.

Today I want to suggest one way in which we can take this approach forward and use it to build on the progress that is already underway in improving cancer services.

Colorectal cancer, as Peter Boyle quite rightly said, is the second biggest cancer killer in our country. Each year it kills over 14,000 a year in England. Here – more than in any other area – earlier intervention can save lives. Patients with colorectal symptoms need to be diagnosed and treated without delay and research has shown that screening people who are asymptomatic can reduce the death rate from this cancer. In the Coventry and Warwickshire area good progress is being made with a bowel screening pilot and we are awaiting the results of the MRC funded Cancer Research UK flexible sigmoidoscopy trial with interest.

Today I can confirm to this conference my commitment to introduce a national bowel cancer screening programme. It will take several years to get there. It will not happen overnight. It will take time, but in preparation for this I am asking Professor Mike Richards to start work now with all the relevant experts to determine the best way forward. This work will consider specifically the workforce and training needs both for symptomatic services and for a screening programme.

Our overall aim is to cut deaths from cancer by one-fifth by 2010. Already, over a three year period the death rate from cancer has fallen by 6%. If we can maintain this rate of progress the ambitious target we have set for 2010 for our country should not just be hit, it could be exceeded. I believe we have a unique opportunity to do so.

No one questions how far we still have to go and I do not pretend meeting the challenge of creating world class cancer services in our country will be easy. But I believe we have every reason today to be optimistic about the future. I say that for five principal reasons.

Firstly, because the foundations have already been laid and I’ve said a word or two about that already.

Secondly, because the resources are available now and for the foreseeable future. This year’s Budget marked, in my view, a watershed for the NHS. Five years of real terms growth averaging 7.5% will take health spending in our country beyond the EU average – an average which, it’s worth remembering, 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, because of these extra resources, it will have doubled in real terms. Britain now has the fastest growing health care system of any major country in Europe. The Budget laid to rest a decades old fallacy that we’ve had in this country – that we in Britain could have world class health care on the cheap. We can’t and nowhere is that fallacy more starkly demonstrated than in cancer services. If you want world class health care the resources must go in.

When we put taxes up to get more resources for the NHS we entered into a new contract with the people of our country. In exchange for extra resources we have to deliver better results. I believe that by delivering the NHS Cancer Plan – health services, charities, voluntary sector, universities, Government and patients organisations together – we can demonstrate the value for cancer patients of every pound of extra investment. That is why improving cancer care is and will remain a top priority for the NHS. It is also why reforms in these services are as important as the resources.

Thirdly, because of the commitment of cancer professionals to the reform of cancer services. Cancer services are already leading the way in reforming how the NHS works. The Cancer Services Collaborative is one of the most innovative means of reforming services I have ever seen. It has not only a national, but also an international reputation. By bringing together clinicians, managers and crucially patients to re-assess and redesign the way care is provided it is cutting waiting times for treatment and improving standards of care. It is all about empowering local clinicians so that they have the scope to bring about improvement for patients.

In the South East London Cancer Network the waiting time for radiology ultrasound services is down from 12 weeks to 11 days. And in the Queens Medical Centre in Nottingham the waiting time for patients with prostate cancer is down from 81 days to just 7 days.

Across the whole of the National Health Service the Collaborative has brought some 1,500 changes in around 500 individual projects. By the end of March next year we estimate that 30 per cent of diagnosed cancer patients will benefit from redesign work in breast, colorectal, lung, gynaecology and urology care. The Collaborative approach however is so successful that, in my view, it should not just benefit some cancer patients. It should benefit all. So I can confirm today that the NHS Modernisation Agency is now planning to spread this approach into the heart of mainstream service delivery for all cancers.

The Collaborative is just one example of how cancer services are leading the way in working across boundaries and devolving power to the frontline. Cancer networks have been successfully drawing together primary, secondary, tertiary and voluntary service providers and are showing just what can be achieved when staff across organisations work together to deliver frontline services.

Fourthly then, because the commitment to reform in the NHS is reflected in the Government’s commitment to put more power and resources in the hands of frontline professionals. As the Collaborative proves, the NHS works best when it harnesses the commitment of staff in order to improve care for patients. We are now at the start of a transition where more and more decisions about health care in our country are taken locally rather than nationally. Where standards are national but control is local. And it is precisely because we have put in place such a rigorous framework of national standards that the centre of gravity can now move to the NHS frontline.

The more overall performance improves – as I am confident it will as the reforms and the resources bite – the more autonomy will be earned across the whole NHS. That is what I want to see. Where we move from a 1940s NHS – top down and centralised – to a more modern system where standards are national but control is local. Where those who are doing less well get more help and those that are doing best get more freedom.

That process will now gather pace. From next April Primary Care Trusts will be in charge of three-quarters of the NHS budget, able to commission services as they see fit.

What is important about financial allocations to PCTs later this year will be not just for one year but for three. This will allow PCTs to plan with certainty increases in capacity not just for the short, but over the medium and longer term. Short term funding has hindered long term planning, not least in the provision of cancer services. Now the local health service will be able to decide which local developments will take place, when. Three year budgets will allow PCTs to decide longer term agreements not only with hospitals but with other providers too.

PCTs now have the explicit freedom to purchase care from the most appropriate provider – whether public, private, voluntary or not for profit.

That brings me to the fifth reason why I believe we should be optimistic about the future of cancer care in our country. Because of the development of new forms of partnership to improve care for cancer patients.

The principal partnership in health care is between the clinician and the patient. A modern NHS must do more to fully engage patients as partners in their health care. I am grateful to the 65,000 patients who’ve helped us do that by responding to the NHS Cancer Patient Survey. I am grateful too, for the time and commitment of people up and down the country involved in user groups and other partnership initiatives. I want to see these partnerships go from strength to strength and flourish in every part of the country.

Partnership with the voluntary sector is vital too. The role of the voluntary and charity sector in the development of health care in our country – whether in research, patient representation, health promotion or direct provision – is essential as we move into a more diverse, less centralised, more patient-centred NHS.

In cancer services that partnership is already well developed. The most visible arena for this partnership has been in palliative care where the NHS, in my view, has a great deal to learn from the voluntary sector. I am not one of those who support the “nationalisation” of the hospice movement through a wholesale takeover through government funding but we do need to address the long-standing difficulties in securing appropriate levels of NHS investment in specialist palliative care. That’s why I have asked Mike Richards – working with the National Council for Hospices, Help the Hospices, Macmillan and Marie Curie – to take forward this work in time for the 2003 planning round.

But involving the voluntary has to extend beyond to palliative care. We have to go further to mainstream voluntary sector involvement across the whole health service – especially in cancer care.

That is why I am particularly grateful to Breakthrough Breast Cancer and Macmillan Cancer Relief for their involvement with the taskforce which oversees implementation of the NHS Cancer Plan. CancerBACUP and Macmillan are key members of the National Coalition for Cancer Information.

And, of course, the major cancer research charities – serving alongside the Government and Medical Research Council – now play a central role in the National Cancer Research Institute (NCRI) which co-ordinates Britain’s research effort in the fight against cancer.

This partnership approach has to be the basis for making further progress in Britain’s fight against cancer.

That fight – as Professor Boyle has rightly indicated this morning – is now beginning to be won. Don’t get me wrong: we do have a long, long way to go but we are now putting in place all the elements necessary to achieve that victory.

We have a health service in our country that is absolutely right in its fundamentals – based on the right principles – care that is free, according to need not ability to pay.

We have a Cancer Plan in place and the long-term investment necessary to deliver it.

We have a shared commitment across the professions, amongst patients, charities and the government and a radical reform programme to get the best from all, the best for patients.

And we have some sure signs of progress with new equipment, ground-breaking research, shorter waiting times, and falling cancer death rates.

So my message today to this Conference, is that we can deliver world class cancer services in our country. We can, and now – with the right level of investment, the right programme of reform and a firm commitment to partnership – in time we will.

Alan Milburn – 2002 Speech to the Commonwealth Fund International Symposium on Health Policy

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, on 23 October 2002.

It is an honour to be here with my friend and colleague Secretary Thompson. And it is a privilege to join friends and colleagues from around the world. We are all deeply grateful to you Secretary Thompson for hosting this evening and for allowing us to share once again the splendid surroundings of Blair House.

I am grateful to the Commonwealth Fund for once again bringing us together to share common problems and search for common solutions. Co-operation between the US and the UK on health policy, supported through the Commonwealth Fund, is already well developed with work proceeding on patient safety, performance incentives and clinical quality. We are learning much from one another.

There are big problems out there in the world of health care – and I’m sure I speak for every health minister here when I say that we need all the help we can get. There is no one better than the Commonwealth Fund – under Karen Davies’ leadership – in helping us learn from one another by learning together

Tonight is the first opportunity I have had to speak to you since John Eisenberg’s death. I know that the loss of John is still keenly felt here in the United States. I can tell you that in Britian we share that feeling of loss – John was truly a great American but he was also a great friend and support to all of us. He wasn’t just a leader. He was an inspiration. And he will be sadly missed.

I am proud today to be in Washington at a time when the US and the UK have never been closer. When Prime Minister Blair met President Bush in Crawford earlier this year the President spoke for people on both sides of the Atlantic when he said “our nations share more than just a common language and a common history. We also share a common interest in a common perspective on the important challenges of our times.”

September 11th changed the world. It also challenged the world. To stand together for values that are universal, that transcend any one country or any one continent, any one religion or any one language. Freedom and tolerance, the rule of law and respect for human life. These are universal values. Human values. September 11th challenged us to defend them. It challenged the world to defeat an enemy that is not just waging war on America but waging war on us all. The events in Bali challenge us once again not to weaken our coalition behind these values but to renew it and deepen it.

Last year at this conference my good friend Julio Frenck gave a compelling account of the problems confronting health systems in developing countries. Tonight I want to talk about some of those and particularly the challenges facing those of us leading health reform in the developed world.

Today’s world – more prosperous but more insecure than ever – calls for more co-operation than ever. It calls for new coalitions – not least in health care – to express our common interest.

In health care today new technology and knowledge transcend the old borders and boundaries. Demographic change and medical advance bring new possibilities but cause new problems. Expectations always seem to rise but costs never fall.

These waves of change are redefining health care – not just in any one developed country but in all. They present us with common challenges. So far the evidence suggests we have some way to go to meet them. Everywhere the media talk is of health care in crisis. This is not peculiar to one country. It is common to all. Last year’s Commonwealth Fund international health policy survey found that in all five of the countries surveyed a majority of people believed their health system was in need of fundamental change. The specific problems may have varied from nation to nation – waiting times for treatment in the UK and Canada, problems in paying for treatment in the USA, a mix of both these concerns in Australia and New Zealand – but the underlying problem remains the same. How to respond to a world where health care can do more but costs more than ever before.

The good news is this. In the developed world, people are living longer. Our lives are healthier. Deaths claimed by the big killers – cancer and coronary heart disease – are falling. To be sure, new challenges like obesity and diabetes continue to test our ingenuity. But there is no doubt that, taken overall health is improving. And health care spending is growing. The richer we become, the more health care we want to consume. That is as true for countries as for individuals. In the UK after decades when investment in health care fell behind today we have the fastest growing health service of any major country in Europe. Six years ago health care spending was falling in real terms. By 2008 it will have doubled in real terms.

So far so good. And it helps to be an optimist if you are a health minister. However, as Aaron Wildavsky, the eminent policy analyst, once put it: we are ‘doing better but feeling worse’. The danger is that feeling becomes the norm in health care. The weight of public expectation today is enormous. The advent of the consumer society sometimes looks as though it will overwhelm health care systems regardless of how they are structured or funded.

I do not believe that is inevitable. But it requires the courage to change health systems that have got out of tune with the age in which we now live. I believe it requires the forging of a new relationship between services and patients. Where patients are no longer on the outside – purely passive recipients of care – but are on the inside with the power to make decisions and choices about health care.

Reform has never been more needed – or more pressing. In every one of the countries represented here tonight health care reform is at or near the top of the political agenda. This year’s Commonwealth Fund symposium gives us a unique opportunity to understand how lessons learned in one country could be applied in another.

Let me describe how we are approaching reform of the NHS in England.

The National Health Service is pretty unique. It is tax funded and has given Britain a single health care system where services are free at the point of use, based on the needs of patients not their ability to pay. For many, the NHS is part of what it means to be British. It expresses values that are ingrained in the British character

– fairness and decency, compassion and a belief in the power of community. Social justice as a legitimate objective for the nation. And yet for all its great strengths

– its one million staff, its ethos of public service, the great advances it has brought in public health

– the NHS has profound weaknesses. In the fifty years since it was formed the health gap between rich and poor has widened. Too often the poorest services are in the poorest communities. Its centralised top down structure too often stifles local innovation. Staff too often feel disempowered. Local communities feel disengaged. Patients have little say and precious little choice.

Our reform programme seeks to remedy these weaknesses in order to build on the NHS great strengths. At the time the NHS was being formed as a nationalised industry in the UK elsewhere governments – many on the centre left – were creating institutions which favoured greater community ownership over state ownership. As those other nations testify there is no automatic correlation that tax funded health care has to mean health care supply run purely by cental government. In today’s world, tax funded health care can only be sustainable if it sits side by side with diversity in provision and choice for patients.

The NHS scores well on fairness but is weak on choice. Crucially patients wait far too long for treatment. Our reforms seek to preserve equity but improve access. Getting this balance right is what every health care system is struggling to achieve.

In Britain we started five years ago by putting new national standards and a new system of independent inspection in place to tackle what had become a local lottery in services. Priority setting – for decades avoided – has become more open. The National Institute for Clinical Excellence now assesses which treatments are clinically cost effective and should be available to NHS patients. There is no health care system of course that is able to avoid making these decisions. The issue is about how best to do so not about whether it has to be done. And as the accumulated experience of Oregon, New Zealand and elsewhere has shown no system is perfect. In the end, however, in a public service the public have a right to be involved. NICE in appraising health technologies and issuing guidelines already involves patients and the public as well as drawing on expert advice. By the end of this year NICE will have established a Citizens Council to give the public a direct say on the decisions it makes. This is about putting the public on the inside of health care rather than keeping them outside. Dealing with dilemmas – that is what clinicians and policy-makers have to do every day in any health care system. The relentless march of medical advance and public expectations demands that we enlarge the decision-making tent so that more share its rights – and its responsibilities.

Government alone cannot solve health care problems. New relationships are needed both with those with using health services and those providing them. There is a clear role for government of course in setting standards and objectives that ensure equity in provision. In holding the system into account. In stepping in when there is failure in order to uphold standards. But increasingly stepping back to ensure success. In Britain we have learned that a million strong NHS cannot be run from Whitehall. It has got to be run by the local staff and held to account by the local community. We are now at the start of a transition where more and more decisions are taken locally rather than centrally. Where the old style monolithic structures are broken up so that we do not just invest extra resources in frontline services but place power and trust in those frontline services. The simple truth is that health care works best – as Kaiser Permanente have shown here in the US – when it harnesses the commitment and knowledge of clinicians to improve care for patients. The collaborative programmes – pioneered by Don Berwick and others here and now taken up in the UK – are delivering staggering results in reducing waiting times for patients precisely because they shift control to where it counts – on the frontline.

They are helping move health care in Britain from a 1940s model – top down and centralised – to a twenty first century model where standards are national but control is local. Securing improvements in services does not require one – it needs both.

From next April three quarters of the total NHS budget will by controlled by 300 locally run primary care trusts able to purchase care from public, private, voluntary or not-for-profit health care providers. The three year budgets that these primary care trusts will hold will allow them to reshape local services in the interest of local patients. So that there is a greater emphasis on prevention and not just treatment. More intermediate care alongside hospital care. More local services so that people can avoid hospital by being treated in the community. Over these next few years we estimate that as many as one million outpatients appointments could be taken out of hospitals and delivered by primary and community services. That will mean less pressure on hospitals and more convenient care for patients.

I want us to go further still. I have been particularly impressed by evidence here in the US from United Healthcare’s “Evercare” model for older people which, by expanding services in the community and intensively monitoring patients’ conditions to catch illness early, is reducing hospitalisation rates and improving health outcomes. We are in the final stages of agreeing to pilot this approach in Britain in partnership with United Healthcare Group.

An explicit objective of our reforms is to encourage greater plurality in the range of services available to patients. And greater diversity in the range of providers. With more NHS patients treated in private sector hospitals. Greater use of the skills of voluntary and community organisations. New private sector providers becoming a permanent feature of the NHS landscape.

This is about redefining what we mean by the national health service. Changing it from a 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 paid for by the NHS according to NHS principles. This is the modern definition of the NHS.

The implications of this redefinition are profound. It means that NHS healthcare does not need to be delivered exclusively be line managed NHS organisations but by a range of organisations working within a national standards framework. The task of managing the NHS becomes one of overseeing a system not an organisation. Accountability becomes more local not national. The shift is from running a large organisation around particular targets towards overall systems performance and health outcomes. In turn that will allow a better concentration on tackling inequalities and improving health rather than just on improving health services.

These changes redefine the role of government too – no longer running but enabling. One of my greatest predecessors as secretary of state for health Nye Bevan – the man who brought the NHS into being – once said: the purpose of getting power is to be able to give it away.

And today there are more pressing reasons than ever for doing so. Not least to re-invest trust in clinicians who for decades have felt that ever more rigorous systems of accountability have undermined their authority. Today it must be a priority to re-engage them. And I believe we can only do so if governments are prepared to transfer control not just to clinicians and managers providing frontline services but to the communities who use them.

In health care the crucial relationships are local ones. Between the doctor and the patient. The community and the hospital. Ownership today needs to be local not national. That’s why we plan to give local communities – alongside local staff – control over the best performing local NHS hospitals. A new generation of NHS Foundation Hospitals will be run by local people not national politicians.

This too is about putting the public on the inside. Some will say that the risks are too great. That health care has to be determined by politicians and professionals. I think the risk is quite the reverse. If we keep people out they will demand more not less from a system that will not be able to cope. Health care today needs to embrace the public as partners not as passive recipients. The spread of universal education has made for a more inquisitive and demanding public that is less willing to accept that politicians or professionals always know best. The internet is redistributing knowledge. Information that used to be the preserve of the doctor can now be accessed by the patient. None of this is going to go away. It is here to stay. It is here for good. And I believe that, despite the pressures it brings, in the end it is a force for good.

The evidence suggests that the informed patient is a better patient. In arthritis care for example educating patients and increasing their role in self-management has been shown to produce better outcomes. Patients with chronic conditions – a growing proportion of the cared for population – have to live with their condition every hour of every day. They need to have a greater role and a bigger say in their own care.

The emergence of more informed and expert patients has profound implications for relationships between patients and health care professionals. It means professionals taking patients into their confidence. Communicating better. Acknowledging risks as well as benefits. Actively seeking consent. Owning up to mistakes not covering them up. Earning trust, not just assuming it.

Public services do not belong to professionals, still less to politicians – they belong to the public who use them and who fund them. Services – whether they are private or public – succeed or fail according to their ability to respond to modern expectations. In today’s consumer age hey have to be tailor made to the needs of the user, not mass produced to the convenience of the producer. That is why for the first time the views of patients themselves now influence the performance ratings – and therefore the resources and freedoms – each NHS organisation receives.

A modern health service is one in which patients can exercise more power. And that means more choice. In Britain we are moving to a system where, for the first time, within the NHS, patients will be able to choose the hospital, the time of treatment and even the doctor that is best for them. And because resources will follow the choices patients make it will provide real incentives for improvements in performance. Those hospitals that perform best will get more, those that do not, will not. 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 the public services as in the private sector. It will take time to get there of course. But when we do it will put patients in the driving seat – at the heart of the health service – and not before time.

And giving patients more rights makes it easier to demand more responsibilities. To use services appropriately. To treat health care professionals respectfully. To contribute to their own health and wellbeing. To help others through blood donation or organ donation. To acknowledge that there are limits to what any health care system can provide. To give as well as to take.

That is what co-operation and partnership are all about – giving as well as taking. When President Bush met Prime Minister Blair in April, the President made the following commitment on behalf of our two nations “even as we work to make the world a safer place we must also work to make the world better.”

Earlier this month Tony Blair echoed this commitment. He said:
we need coalitions not just to deal with evil by force if necessary, but coalitions for peace, coalitions to tackle poverty, ignorance and disease.

Today half the world’s people live on less than $2 a day. Hunger remains endemic. 10 million children die each year from preventable childhood illnesses. Millions more die from AIDS, TB and malaria. And yet the gap between where we are and where we could be is not so great. There are effective and relatively inexpensive ways of tackling HIV/AIDS, malaria, TB, and childhood infectious diseases. Support is needed – in cash of course – but also in kind. Developed nations could do so much more to help the developing world build the skills and the capacity that are needed to deliver effective health services. Our nations have an abundance of skills in health. It is time we shared them with others. And perhaps the Commonwealth Fund could consider how best we do so.

A world of open borders and easy travel, mass migration and rapid information means that a problem somewhere can quickly become a problem everywhere. In this interdependent world common problems do indeed call for common solutions. The events of the last year have brought home to all of us that our countries cannot enjoy the fruits of growth and development oblivious to the challenges faced by the rest of the world. Terrorism thrives only when one set of moral values look to others immoral. If one part of the world stands aside from the problems of another. If prosperity seems indifferent to poverty. If resources and skills are used for the benefit of some but not for all.

Defeating terrorism calls for a war on all fronts. In the end we will defeat terrorism because it is the enemy of all nations and all faiths. The enemy of humanity itself. We will defeat it of course by intelligence, by police and even military action. By the vigilance and the support of our peoples. But we will defeat it also in the triumph of the values that terrorism abhors – tolerance, freedom, the rule of law, the respect for human life.

These are the values which unite the nations of the Commonwealth Fund. They are the values which inspire us to share perspectives on common problems in health care and encourage us to co-operate in pursuit of solutions to them. I want to thank our friends and hosts here in the USA and wish us all a positive and productive few days at this Symposium. I believe the strength of our common endeavours this week demonstrates that health is no longer just a matter of domestic policy. Health policy today is truly international: shared challenges across boundaries; shared solutions between countries and a shared understanding that the interests of the developed world are linked inextricably to those of the developing world.

Alan Milburn – 2002 Speech to the NHS Alliance

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, on 17 October 2002.

In just four years the NHS Alliance has become a force to be reckoned with. In Mike Dixon and his colleagues you have leaders who not only champion change but who argue the cause of primary care.

And today I want to set out to you how I believe primary care can lead the reform and reshaping of health care in the whole of our country. Whatever the problems there are in primary care – and I know they are real – there has never been a better opportunity for primary care – than we have today.

Our country’s family doctors are the backbone of the NHS – and the service they provide is not just valued by patients in this country it is envied in other countries across the world. So when some newspapers imply that the NHS is full of bad doctors let us just so this: it is full of good doctors doing their best for patients. And good nurses, therapists, administrators and professionals helping provide care for one million patients every day. I believe it is time that we as country said that we are proud of the work that you do. As a nation we owe you an enormous debt of gratitude.

People in primary care are working under real pressure but you are delivering real progress. In recent years you have helped chalked up significant achievements in which all parts of the service can share.

In primary care itself where waiting times are coming down. Where 3 in 4 patients can now see a GP within 2 working days. Where the growth in prescribing of cholesterol-lowering drugs is contributing directly to reduced deaths from heart disease.

In hospital services too, there is progress. A year ago people could wait up to 18 months for their hospital operation. Today, the maximum wait is at 15 months and coming down, moving towards the NHS Plan guarantee of a maximum 3-month wait. For cancer and heart disease, waiting times are coming down faster still – and most importantly of all mortality rates are falling too.

Of course huge problems remain. The pressures are real. Staff shortages are still there. Waiting times are still too long. But after decades in which the NHS was at best standing still and at worst going backwards the momentum is now forwards. There is a long way to go but I firmly believe the NHS has turned the corner. The NHS Plan is on course to be delivered. And we should now be confident that we can move up a gear.

This progress is all the more remarkable because it has been accomplished against a background of significant organisational change. Health authorities and Regional Offices have gone. Primary Care Trusts and Strategic Health Authorities are up and running. The transition has gone better than many feared. And that is thanks to you. Managers, clinicians, non-executive directors.

The NHS – with your leadership – can look to the future with confidence. No-one should doubt the significance of the next few years. It really is “make or break” time. Either we prove that the NHS can 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. Bold steps to radically reform the health service are now needed if we are to secure the improvements in health and health care that our country needs.

We should be confident first of all because the values of the NHS are right and indeed are more relevant than they have ever been. In a world where health care can do more – but costs more than ever – before, an NHS that is free at the point of use based on need not ability to pay – is the right way forward for Britain. With the NHS the health of each of us depends on the contribution of all of us. It gives the people of our country health care, not as a commodity to be bought and sold in a market but health care as a right we all enjoy as equal citizens in a fair society.

Frankly it offends against that principle when some propose as they do that the taxpayer should subsidise private health insurance so that those that can afford to pay in a voucher scheme get a fast-track to treatment ahead of those with a greater need but a smaller purse. The sick paying to be sick and the worse off paying for the better off could only create a two tier health care system that would be both expensive and divisive.

Such a proposal can only succeed if the NHS fails. So the stakes are high for all of us who believe in the values of the NHS. And here, although this is difficult we have to be honest with one another. For all its great strengths – its staff, its ethos of public service, the great advances it has brought in public health – the NHS has profound weaknesses too. Health inequalities have widened not narrowed. Too often the poorest services are in the poorest communities. Its centralised top down structure too often stifles local innovation. Staff too often feel disempowered. Local communities feel disengaged. And patients have little say and precious little choice.

Our job together is to remedy these weaknesses so that we can build on the NHS great strengths.

How do we do that? We do so in the first place by addressing the legacy of decades of under-investment not just in the health service but in our social services too. The Budget on April 17th marked a watershed for both. Social services will get twice as much next year as they are getting this year. And for the NHS it is worth remembering that while just six years ago funding was falling in real terms, by 2008 it will have doubled in real terms.

But when people are asked to pay more in tax to get more into the health service they will quite rightly want to see extra resources delivering real results. Not just improvements in services for patients but services that 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. Progress is underway. There is a ten year NHS Plan with a major programme of reform to match the programme of investment.

It is these reforms that hold the key to delivery.

As both the NHS Plan and our more recent follow up command paper Delivering the NHS Plan made clear, it is right that standards are set nationally but wrong to run the NHS nationally. The job of government is to set standards and objectives that ensure equity in the provision of health care. Our job is not to run the NHS. Indeed a million strong service cannot be run from Whitehall. It’s got to be run by the local staff and held to account by the local community. That is something which the new strategic health authorities in their relationships with PCTs need to fully understand: PCTs need to be helped and enabled not commanded or controlled.

The more overall performance improves – as I am confident it will as the reforms and the resources bite – the more autonomy will be earned across the whole NHS. That is what I want to see. We are now at the start of a transition where more and more decisions will be taken locally rather than centrally. Where we move from a 1940s NHS – top down and centralised – to a more modern system where standards are national but control is local. Where those who are doing less well get more help and those that are doing best get more freedom. Reform cannot be achieved by holding on to the monolithic, centralised structures of the 1940s. We cannot reform by looking backwards. We need to look forwards. Reform means investing not just extra resources in front line services, but power and trust in those front line services.

I believe that process will now gather pace. From next April Primary Care Trusts will be in charge of three-quarters of the NHS budget, able to commission services as they see fit. The reason for this is simple enough. I don’t treat a single NHS patient. NHS staff do. Whitehall doesn’t provide care. That is what local hospitals, health centres and surgeries do. And that is where power needs to be located. On the frontline. It is time to unleash the spirit of public service enterprise that I know exists in so many parts of the NHS.

PCTs need to lead that process. And I want to help you do so. PCTs exist for two main purposes. One so that there is a local organisation holding the resources and the responsibilities to improve the health of the local population. And two, to commission care that gives local patients the services that are right to meet their needs.

I have often heard it said – even at this conference – this is all very well in theory but in practice the resources are already spoken for with too many national priorities, 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 less services are provided in primary care and that PCTs are able to exercise real power.

So, while over the next few years there will be more money in PCT budgets there will be less ringfencing by central government of those local budgets. And in place of the current maze of annual agreements and duplicated plans, local health services will be able, as I’m sure Nigel set out this morning, to put together a single delivery plan for the medium term rather than the short term. These plans can focus on delivering improvements in the areas that count most for patients – waiting times (including in primary care), emergency care, cancer, cardiac, mental health, elderly and children’s services.

I can confirm today that when we allocate resources direct to local primary care trusts later this year they will get budgets not just for one year but for three. This will allow you to now plan with certainty to increase capacity over the longer term. Short term funding has hindered long term planning. Now you will be able to decide which local developments will take place when. And three year budgets will allow PCTs to decide longer term agreements with hospitals and with other providers.

Let us just be clear on this point: PCTs now have the explicit freedom to purchase care from the most appropriate provider – whether public, private, voluntary or not for profit. This is 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 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.

And a modern NHS is one in which patients have power. And that means they have got to have choice. So that if their local NHS hospital cannot offer them a short enough waiting time but another hospital can they can decide to choose with the help of their GP. We have made a start by offering choice to heart patients. By the end of 2005 we aim to have all patients needing a hospital operation in every part of the country have a choice over the hospital, the time and even the consultant that’s best for them. And it will be family doctors and community nurses who can ensure that patients are able to make informed choices.

As NHS capacity expands so choice will grow. Resources will follow the choices that patients and PCTs make so that hospitals who do more get more; those who do not, will not. Making choice available for the first time on the NHS will strengthen PCT power to commission services that are in the best interests of patients.

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 – you 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 NHS Alliance 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. And when we start to introduce a common tariff system for hospital operations over these next few years it will take out of the local negotiations between PCTs and hospitals the very areas where you are weakest – on prices – and leave those where you 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

It is time PCTs stood 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 an 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. It needs more services in the community 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 through NHS Direct. 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. It is time to shift the centre of gravity in the NHS. 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. Of course patients need more hospital services which is why there is the biggest programme of building new hospitals the NHS has ever seen. It is why after decades when hospital bed numbers were cut back they are finally being built up. New diagnostic and treatment centres are going up. New equipment is going in. Hospitals have more staff – and there are more to come.

Hospitals have a secure future. But health care is not just hospital care. And with hospitals under real pressure they have to be freed up to concentrate on providing the specialist services in which they excel. So as every PCT knows with the right level of investment and the courage to make these reforms many more patients could be treated in the community.

Some are already doing that. In Hampshire the local PCT and the local Trust are now using a new primary care diagnostic centre to provide vascular services in the community rather than in the hospital. In many areas – including my own – patients needing minor surgery such as a vasectomy or the removal of a skin lesion now have their operation in the local surgery rather than in the local hospital. We need more not less of this. The presumption surely must be that only those procedures that need to be done in hospitals – for safety reasons and clinical reasons – are actually done in hospitals.

Take outpatients. Over these next few years we estimate that as many as one million outpatients could be taken out of hospitals and delivered by primary and community services. That will be mean less pressure for hospitals. More convenient care for patients. And a bigger role for primary care services.

This is happening already – but only on a small scale and in some areas. I would like it to become the norm in all areas.

It will mean 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 reducing 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 these places it can happen in all.

But it will require PCTs to have the confidence and the courage to put their money where their mouths are. Into building up primary care not as an alternative to hospital care but as an addition. It will require significant investment in facilities, equipment and above all staff.

Patients being treated in primary care can only grow so long as capacity in primary care grows. And here too we want to help.

For the very first time in the history of the NHS we have set out a clear investment programme to improve the primary care estate. The NHS Plan set out our proposals to refurbish or replace up to 3,000 GP premises and to develop 500 one-stop primary health care centres. Over 1,000 premises have already been modernised. There are many more to come.

And we need many more GPs too. Progress here has been slow and we need to up the pace. But crucially after years when GP registrar numbers fell back they are now at their highest ever level. The trick is to persuade them to become fully-fledged GPs. Proper rewards and a new contract will, no doubt, help. Better childcare and more flexibility in how people are employed will help too.

But in the end I believe the biggest difference will be made by giving GPs better control over their working lives and greater ownership over the process of change. And this is where PCTs have such a crucial role to play. Just as we are devolving power and resources from Whitehall to local PCTs so local PCTs need to devolve to local practices. The PCTs need to get practices and clinicians – nurses as well as doctors – involved in reshaping local services. Every time I visit a practice and speak to a GP or a practice nurse what strikes me most is their absolute determination to raise standards in order to provide the highest quality services to their patients. Our job – together – is to harness that commitment. If we do it will not be “meltdown” for primary care. It will be the making of primary care.

The challenge for PCTs in the NHS is the challenge for all of us who care about its future – to take the opportunity of the new resources and use them to transform services for patients.

– To diversify a service which has been too monolithic for too long.

– To decentralise a service which has been centralised for too long.

– To build capacity in the service which has been neglected for too long.

– To bring choice to a service where none has existed before.

– PCTs are there for a purpose – to develop local services that genuinely meet local needs.

I do not underestimate the challenge nor the difficulties ahead. But neither do I underestimate the innovation, initiative, expertise and skills that exist in PCTs.

Only PCTs can lead these changes. You exist not to maintain the status quo – but to change it.

You have the powers and the resources to do so – now is the time to use them.