Alan Milburn – 2001 Speech on Shifting the Balance of Power

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, on 25 April 2001.

Today we launch the NHS Modernisation Agency – part of new have been building over last four years. has a key role in helping organisations reform their services to offer patients better, faster care.

I am delighted David Fillingham is to be the Agency’s first Chief Executive. David is an NHS man. He comes with a track record of delivering impressive changes in those NHS organisations he has run. Now he has an even bigger job. One that sounds seductively simple in theory but is fiendishly difficult in practice. How, as Nye Bevan put it five decades ago, to universalise the best; to make best practice in one part of the health service the norm in all of its parts.

This is the challenge for the NHS today. A decade of improvement in the NHS is underway. The Agency is already supporting 30,000 clinicians and managers to make change happen: to raise standards of service and improve access to services. The Agency’s philosophy is simple: there is nothing wrong in the NHS that cannot be rectified by what is right. Realising the ambitions of the NHS Plan needs a modernisation movement which includes all one million NHS staff.

Over the next few years all parts of the NHS must be reformed, redesigned around the needs of patients. Earlier this year I set out in a speech how reform must fundamentally change the relationship between patients and the service. I said then that patients should have more information, more influence and more power over the services they receive. I called for the balance of power in the NHS to shift decisively in favour of the patient.

Today I want to argue this shift can only happen if the centre of gravity within the health service itself moves from Whitehall to the NHS frontline.

The NHS today stands at a crossroads. After decades of neglect the NHS is finally getting the investment it needs.

Between 1979 and 1997 NHS funding grew by an average of just 3% a year. In the last parliament it grew by even less. Funding for buildings and equipment was cut. Nurse training places and GP registrar numbers were both reduced too. In the final year of the last Parliament the overall NHS budget fell in real terms.

I know that some say we got it wrong in the first two years of this Parliament by putting prudence before investment. But the country has reaped a huge reward for it. Economic stability. Public finances under control. And now – precisely because of the choices we made – more investment, over more years, for more of our key public services.

Today the NHS is experiencing historic levels of growth. Double the rate of the past. As a result the NHS is now the fastest growing health service of any major European country. Expansion is underway. 17,000 more nurses; 6,700 more doctor; last year, for the first time in forty years, more beds in hospitals. The biggest hospital building programme the country has ever seen. 220 accident and emergency departments and 1,129 GP surgeries modernised. 500,000 more operations being done. Waiting lists for inpatients and outpatients both now falling.

There is a long way to go. I know that. Investment takes time to be felt at the frontline – but it is getting through and it will be sustained. The truth about the NHS today is that it is neither totally broken nor totally mended. There is real progress. But there are real problems. Staff are under real pressure. After two decades of almost continual chopping and changing it would be odd if there were not signs of change fatigue. There is weariness – and in some parts of the NHS there is wariness. Uncertainty about what reform will bring. Cynicism about whether it can be achieved.

And yet my message is simple: reform must happen. It was never meant to be easy. Reform is difficult. Much of it takes time. And it requires all of us to change. The NHS Plan will take ten years to fully implement but over the next few years reform must take hold. I say that for two reasons.

Firstly, because the NHS is under test. We have actually succeeded in changing one crucial aspect of the debate on the health service. Until recently virtually the only question about the NHS was whether it was getting enough investment. Now most people recognise that the growth in resources is about right. Today the public debate has moved on. It is about whether even with this record investment the health service can deliver the goods for patients.

Some say it can not. That the very way health care is funded and organised in this country makes it impossible to deliver the level or responsiveness of service modern patients expect. They say we have to move away from the core principle of care being provided according to need and not ability to pay. That more people should be charged for care with all of the manifest unfairness that would bring.

So make no mistake: the NHS has to continually earn not complacently assume the confidence of each new generation. Its opponents want it to fail. Reform is the pre-condition for sustaining public confidence in the health service. Reform to make the NHS more responsive to patients is the best answer to its critics.

And reform is the best answer to the pressures facing NHS staff. I know some people working in the NHS believe it would be comforting if we could first expand the service and then make the reforms. Anything else they say is just too hard because staff are facing rising pressures and simply cannot find the time to reform as well.

I appreciate the strain staff face. They do a brilliant job. I know how difficult it can be to find the time to stand back from the service in order to assess how it needs to be changed.

Expansion in staff numbers will help. There are more qualified staff coming through. And more yet to come. But it is not just expansion that will make working lives easier. It is reform too. We have got to stop seeing reform as a new problem. And start seeing it as the solution.

For example, getting hospital test results and diagnosis on the same day make sense from the patient’s point of view. It makes sense from a staff point of view too: less paperwork; fewer missed appointments; and lower levels of frustration about a system which can seem intent on denying both staff and patients the rapid information they need.

The key to reform relies on making better use of staff skills, overcoming traditional demarcations between the professions. Training paramedics to give thrombolytic drugs to heart attack patients will cut call-to-needle times – and save lives. It will relieve the pressures on hospital doctors in accident and emergency. Getting nurses to triage casualty patients has the same impact – and delivers a faster service. In primary care the same is true. There telephone consultations and reorganised practice appointments are delivering shorter waiting times for patients – and making life easier for family doctors.

This is reform in practice. It is happening in many parts of the NHS. The reforms being pioneered in cancer services point the way for the rest of the NHS. The Cancer Collaborative programme has brought together clinicians and managers from across the whole spectrum of services used by cancer patients. Together they have worked to end some of the delays for patients who have been diagnosed with suspected cancer by examining, and then reforming, the patients’ journey through the system.

The results are impressive. On average, in the pilots, times from GP referral to first hospital appointment have been halved. What is more three quarters of the 51 projects in the programme have achieved or beaten the 8 week target from referral to treatment – 4 years ahead of schedule. Radiology waiting times have been reduced by 60%. In total it is estimated that the Cancer Services Collaborative has so far saved a combined total of more than 200 years of patient waiting time. No wonder patients are reporting higher levels of satisfaction with the services they are receiving.

Sure, we have made some extra investment to help it happen. Many of the big changes haven’t cost a penny. They have come from redesigning the way services are delivered. It is reforms like these which will deliver the NHS Plan. So, from this month every part of the country will benefit from this cancer services reform programme. And it is why we are extending the collaborative programme to services such as cardiac care and primary care.

The reform programme in cancer services has delivered because it puts staff in the driving seat of change. Doctors, nurses, scientists and others using their know-how, making their innovations, redesigning their services. Where staff have been in control they have come up with the goods.

The common thread which links the best reforms is the know-how and commitment of NHS staff being harnessed to improve care for patients. The task for the next few years is how to get that thread running through the whole National Health Service.

There is a harsh reality to be faced, not just for the NHS but for the wider public sector in education, local government and transport. Many people – particularly younger people – feel that public services have become ossified. That they are insufficiently responsive to the needs of parents or patients, residents or rail users. In some cases, those with savings or sufficient income have simply opted out of public services altogether. They have chosen private education for their children or private health care for themselves.

However comforting that choice might be for some people it does not provide a solution for most people. Indeed, there is a real risk that without middle class support public services will end up fulfilling Richard Titmuss’ prophecy – services for the poor which are poor services. Our ambition surely has to be to make the NHS – and our country’s other vital public services – a service of first choice, not last resort.

To realise this ambition there have to be radical changes to the way services are provided. There is here, a real conundrum. On the one hand, there are sometimes low levels of public confidence in the ability of services to deliver the standards and responsiveness people expect. And on the other, there remain relatively high levels of public trust in the doctors, nurses, teachers and others providing these services.

In part this reflects a public view that staff in public services have been simply doing their best inside a system that for too long has been under resourced. In the case of the NHS, people think staff are doing a good job despite the system not because of it. By and large people trust frontline public servants. Harnessing the motivation that these frontline staff have to improve public services is essential then for increasing public confidence in those services. In order to be the ambassadors for improved public services frontline staff also have to be the architects of public service reform.

In our first term our focus has been on setting tough new national standards first in health and education and then in local government and transport. Some say that process has gone too far. That creeping centralisation has crowded out local innovation. That staff have felt disempowered or worse disillusioned.

Getting the balance right is never easy. It is worth remembering that when we came to office, in the NHS there was an absence of national standards. No NHS-defined clinical standards and no means of implementing them. No means of spreading good practice or eliminating bad practice. No national evaluation of new treatments and no external inspection of local services. The anarchy of the NHS internal market had merely added to a long term spiral of decline.

It is easy to forget how far we have come in just four years. There are new national standards for services. For cancer, heart disease, mental health, elderly care. There is greater transparency over local service performance. 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 evaluating new treatments. For the first time the NHS has an independent inspectorate, the Commission for Health Improvement. There are new systems for when things go wrong and more help to learn from what goes right. The internal market has gone. Through new primary care groups and trusts family doctors and community nurses have a greater say over deciding the shape of local services.

For the first time in decades there is widespread agreement that these changes are right for the NHS. Indeed by and large not even our political opponents disagree with them. This has been a quiet revolution. But a revolution nonetheless. It is early days but the revolution is producing results. The national drive for improved standards is making a difference – whether that’s in cleaner wards or in better cancer care.

And yet what happens in the National Health Service happens in hundreds of hospitals, thousands of GP surgeries and is determined by almost one million staff. Healthcare is a people business – relying on personal interaction and professional judgement. The NHS cannot be run from Whitehall. But it is too simple to say that everything should be devolved from centre to local.

There is little public appetite for diverse standards between local services. People do worry about a lottery in care. When people hear about problems in one part of the NHS it tends to dent public confidence in the whole NHS. There is strong public identification with the NHS as a national service. That is a good thing. The universalism of the NHS helps to cement national cohesion and to shape national identity.

For all these reasons in our first term we have established a clear national framework within which local NHS services can operate. Now with that national framework in place, in our second term we intend to shift the centre of gravity to the NHS frontline.

The NHS is a high trust organisation. It works on the basis of trust between patient and professional. In the way it is organised the NHS needs to enshrine that trust. It needs to give more control to the frontline. Just as schools now have greater control over resources and how they are organised so local health services must now be given greater control.

We have laid the foundations for this approach. When we came to office GP fundholders controlled just 15% of the NHS budget. Today PCGs/PCTs control over 50%. By 2004 I want them to control 75%. The whole idea behind these new organisations was to give the frontline professionals who deal most with patients the power to reform local services. In some places Health Authorities and PCTs have put their relationship on the right footing. The local health authority provides the strategic leadership and the PCTs have the ability to shape local services to suit local community needs.

I want PCTs to be able to commission the services they decide are needed. In some places that is happening but in too many cases it is not. There, Health Authorities have retained control. They have held on to the pursestrings, sometimes even to the content of the purses. Too many family doctors and community nurses have felt disempowered rather than empowered. There are similar feelings in NHS Trusts. Many chief executives I speak to complain of too much day to day intrusion. From health authorities. From regional offices. From the department of health itself. Too much of the NHS today still feels like a centrally run bureaucracy to those at the frontline. This has to change.

The time has now come to free the NHS frontline. Not a return to the anarchy of the market. But a freedom to shape local services within a clear national framework of standards and accountability. That requires a number of major changes. I now want to set out to you how we will implement this approach for the second term.

There will be greater freedom for successful performance. The NHS Plan proposed that local NHS organisations would be graded according to an objective assessment of their performance. As standards and performance improves greater autonomy for local NHS services will be earned. The best performers will have more freedoms.

Today I can set out the forms some of these freedoms will take:

The best performers will have less frequent monitoring from the centre and fewer inspections by the Commission for Health Improvement.

They will be able to develop their own investment programmes without receiving prior approval and they will retain more of the proceeds of local land sales for re-investment in local services.

They will be used as the pilot sites for new initiatives such as team bonuses for staff.

They will receive extra cash for central programmes without having to bid for it.

They will receive extra resources too for taking over and turning round persistently failing Trusts.

And where a successful local health service is receiving less than its fair share of cash through the resource distribution formula it will automatically receive an accelerated uplift to help close the gap.

In all these cases it will be for the local organisation to decide how best to use extra resources whether as bonuses for staff or as investment in services.

I want to make it more worthwhile for local health services to innovate in the way they deliver care to patients. I want to see a new culture of public sector enterprise in the NHS to rival the culture of private sector enterprise which has developed over recent decades. This requires more local discretion over how budgets are spent. It requires a greater emphasis on rewarding those who succeed and helping – rather than penalising – those who sometimes fail. And it requires organisational change to put the frontline first.

The NHS today feels too top heavy to many PCTs and NHS Trusts. In the end it is they who deliver care – and it is they who will deliver reform. The territory above them looks and feels pretty crowded. As well as the Department of Health itself and the NHS Executive centrally there are eight regional offices heavily focussed on performance management and 99 health authorities. Lines of accountability are confused. NHS Trusts running hospitals report to regional offices. PCTs report to health authorities.

Many in the NHS recognise that this intermediate tier of management must now be rationalised. As PCTs develop capacity and take on more powers the role of very local health authorities will be called increasingly into question. Some are already providing an answer. In various parts of the country health authorities are already preparing to merge.

With Nigel Crisp, the NHS Chief Executive, I have examined very carefully which management structures will be needed in the future. Today’s NHS needs an accountability structure to ensure delivery of a national framework of standards in a way that does not stifle local innovation. We have concluded that the current system cannot deliver.

Organisational change of course carries the risk of bringing instability and so could impede reform. But I have been convinced by people in the NHS that change is now needed to take reform forward and embed a new decentralised approach. Not a big bang tomorrow but a phased programme to put power and resources in the hands of the NHS frontline.

I can announce today then far-reaching changes to the way the NHS is organised.

By 2004 two thirds of existing health authorities will have disappeared as they merge. The 30 or so that remain will each cover an average population of 1.5 million, broadly corresponding to emerging clinical networks such as those for cancer services. Local consultation will shape their exact boundaries. Local services for patients will be unaffected by this change. Indeed there will be greater local control over local services as many of the old health authority functions are devolved to locally-run PCTs. They will be the primary point of contact with local government to develop more joint working. More of the planning to improve services and tackle health inequality will also take place at this local level.

In turn, as we prefigured in the NHS Plan, the new strategic health authorities will have responsibility devolved to them from NHS Regional Offices for performance managing the local health care system. Although both NHS Trusts and PCTs will be accountable to the new strategic health authorities both will have greater operational freedom. NHS trusts will be responsible for providing local hospital and other specialist services. PCTs will be responsible for commissioning them as well as providing primary and community services.

Where they wish to PCTs will be able to pool their sovereignty to realise the benefits of larger economies of scale but otherwise the new health authorities will not have hands-on commissioning responsibility. Similarly, health authorities will be able to come together at a regional level to discharge functions that make more sense at that level.

Following the establishment of the new health authorities, there will be a Regional Director for Health and Social Care with a small core group of staff – part of the Department of Health – there not to second guess local health services but with oversight of their development. The areas covered by these regional directors may be larger than at present. Otherwise the NHS Executive and, over time, the Regional Offices will disappear.

Their residual functions – for example over public health – will be overseen by the Regional Director, accountable to the Department of Health but co-located with Government Offices of the Regions, to encourage more joint working between health, transport, regeneration and the environment. In this way if new regional government structures emerge there will be a ready-made relationship with the NHS.

The new strategic health authorities will be the bridge between the Department of Health and local NHS services. They will have an absolutely crucial role to play in brokering solutions to local problems, holding local health services to account and encouraging greater autonomy for NHS Trusts and PCTs.

They will need to be well run, highly efficient organisations attracting some of the best management. So I can say today that I am examining proposals for ensuring this happens including inviting expressions of interest from the best performing management teams to run the strategic health authority “franchise”.

This new flatter NHS structure will help liberate local services so they can get on with the business of reform. It will also free over

£100 million from bureaucracy for investment in frontline services.

That brings me then to the final major change I wish to make to give frontline services more freedom. Devolution to frontline NHS organisations must be matched by devolution within frontline NHS organisations. As the Cancer Service Collaborative programme has already proved successful reform depends on giving clinicians as well as managers the power to reshape services. That means stopping clinicians – nurses as well as doctors – feeling that reform is a process that is done to them rather a process that they control. I know the whole ethos of the Modernisation Agency will be about change being done with people rather than to them.

At a national level we have worked hard to involve clinicians in the work of the department, in the formulation of new standards and in drawing up the NHS Plan. The same process of engagement must now happen in every local NHS organisation. During the summer I will be asking every local health service to carry out a local modernisation review of what needs to be done to deliver the NHS Plan. Managers will need to work with clinicians across the primary, secondary, social services divide to identify the local obstacles standing in the way of progress and how best these can be overcome.

That process may give rise to new structures. In cancer care, for example, the country’s best cancer networks are already applying to take direct control of local budgets for services. In time I believe we can put the country’s top cancer specialists in charge of new funding for all cancer patients. Other local innovations to put frontline staff in charge of services will be encouraged too.

Health authorities as they divest themselves of direct management responsibility for services should pass cash down to local primary care groups and trusts. Hospitals should consider how to give clinical teams greater control over budgets. We have made a start here by giving each ward sister control of a

£5,000 ward budget and by bringing back matrons to exercise control over cleaning and other basic services. Within the next fortnight I will set out how I intend to take this process further by giving hospital clinicians control over extra resources for new equipment budgets.

In the meantime, we will provide further help for staff to reform services. Staff who work day-in, day-out under great pressure often know there could be better ways of delivering treatment and care. Lack of staff time can be the biggest barrier to reform.

We will include a total of £60 million in local NHS budgets over the next 3 years to allow frontline staff some protected time to look at how they can improve the quality of patient care. The first 20 pilot sites are already up and running.

I want these staff modernisation sessions to become common practice throughout the NHS – just as INSET days have in education. Together with the work of the new Leadership Centre, headed by Barbara Harris, these sessions will give clinicians, working alongside managers, the tools to reform local patient services.

Frankly it should never have needed Ministers to tell hospitals that informed consent, clean wards and good food are basic requirements in a modern NHS. It is a salutory lesson for those who complain about too much central intervention that it was only this process which focussed attention on getting some of the fundamentals of care right for patients.

Change needs to come from the bottom up not just the top down. I am confident that the reforms now taking hold throughout the NHS are putting a new focus on designing services around the needs of patients. This will leave the centre to do the job it should properly do. Provide the resources. Set the standards. Hold the system to account.

Nigel has launched a review of the department to better focus on its core tasks. The review has involved consultation with the NHS and external stakeholders. Just like the rest of Whitehall, the Department faces a fundamental challenge: how to overhaul its apparatus to be better focussed on seeing change through, not just devising policies for change.

Over the next few years the job of the department has to be a single-minded focus on implementing the NHS Plan and the related reform programme for social care and public health. Amongst other changes, this is likely to require more frontline staff being recruited to work in the Department to build on the success of the “tsars”. In this way, the Department of Health can become a model for the modern service-delivery Whitehall department.

There will be democratic accountability – as there should be in a National Health Service – but operational control will be devolved outwards and downwards to the NHS frontline.

To save the NHS we had to a get a grip: to put national standards in place where they were absent; to put resources in place where they had been denied; to develop a programme of sustained reform alongside a programme of sustained investment.

With this national framework in place, the time has come to liberate the NHS frontline.

To expand staff numbers and to value staff more.

To encourage their innovation which will reform the health service.

To foster their initiative on which better patient care can be built.

To realise the immense potential of our million, brilliant staff.

And above all else, now to shift the balance of power from Whitehall to the NHS frontline.

This approach is a huge vote of confidence in the doctors, nurses, managers who run frontline services.