Alan Milburn – 2001 Speech to the NHS Confederation Conference

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, on 6 July 2001.

The NHS is a graduate of the school of hard knocks. You only have to read a few of the daily newspapers to know that. The NHS was born in the face of fierce opposition. Today, still facing opposition from some quarters – some opposed to NHS principles, some opposed to NHS reforms.

Those of us who are wedded to those principles, who believe in those reforms, should draw confidence from them. For me, I have never been more confident about the NHS:

– the people working in it;

– the ethos they espouse.

And more confident about its ability to deliver far reaching improvements in the care it provides to patients.

My confidence stems from meeting people like those who received awards last night; ordinary people doing an extraordinary job, making reform happen in the work they do each and every day.

And when people had a choice at the General Election a few weeks ago, they backed public services and they backed the people who work in public services.

Today people know a fair society, where everyone in our communities- and not just some – get a fair chance, can only be built on strong public services alongside a strong economy. There can be no such thing as a fair society – or a strong economy – if the education system is geared to success for some but not for all. There is no such thing as a fair society if whole communities are laid waste by the ravages of drugs and crime. Above all else, we cannot have a fair society if health care denies people help when they need it where they need it.

In the five weeks of the election campaign I met staff and patients up and down the country. I visited good places and some less good places. I heard what NHS staff had to say. I saw what they were trying to do.

As a Health Visitor said to me on one visit, “it definitely feels better but it does feel like rolling a big boulder up hill.” There is an enormous effort going on throughout the NHS to bring about the improvements both staff and patients want to see.

As the election showed all too clearly people will no longer tolerate second class services. They will not put up with dirty wards or sluggish services. They quite rightly want health services which are responsive and which put their needs first. As we all know for too long the NHS has not been able to meet these tests. And people are impatient for improvement. The stakes are high for all of us who believe in the NHS.

Delivery – bringing about visible improvements in services – has to be the priority. A failure to deliver reform in the NHS will play directly into the hands of those who say that the NHS can never deliver.

The debate on the NHS has moved on. For years it was all about the need for more investment, since for decades the NHS had suffered under-investment. Today we are putting that right. With funding growing at twice the rate of the past the NHS is now the fastest growing health service of any major country in Europe. And because sustained investment will continue throughout this Parliament the debate on the NHS is now very different from what it was just a few years ago. It is now about whether even with this enhanced level of resources the way we organise and fund health care in this country can ever deliver a modern patient-focussed service. And you only have to read the comment sections of some of the daily newspapers to know that waiting in the wings are those who say that the fundamental principles of the NHS cannot work and must be abandoned.

I believe those newspapers are wrong. I believe those politicians on the Right who advocate their cause are wrong. I have a different set of beliefs. I believe in the NHS – in its principles and, above all, in the people working in it.

People do not work in the NHS to make a mint for themselves. They work in the NHS to make life better for others. It is the ethos of public service – its burning ambition to serve people regardless of their wealth or worth – that lies at the heart of public support for the NHS. It is the ethos of public service that can light the way to a fairer, more decent society in Britain today. But just as surely as it is that ethos of public service that makes the NHS, losing that ethos would break the NHS.

We risk the ethos of the NHS, its values and its principles, at our peril. That is why we say while we will forge a new relationship with the private sector, it is just that: a relationship, not a takeover. NHS values are not the same as private sector values. Health care relies on trust between patients and professionals. The fundamental reason the NHS is still trusted by patients today is because they know that decisions about their treatment are based on the scale of their needs not the size of their wallets. You only have to look across the Atlantic to see what happens when frontline health care is compromised by a clash of motives. Trust is lost. Competition replaces co-operation. Two tier care develops. In America, 40 million people have no health care cover whatsoever. A free market in health care does not work.

It is not the right way forward for health care in Britain. NHS values are British values – compassion, fairness, a belief in the strength of community, co-operation with others as the basis for individual progress. It would be folly to sacrifice these values and these principles. So while some subscribe to the philosophy that all things private are good, all things public are bad I say: that philosophy belongs not today but to yesterday.

There is no saviour of the NHS other than the NHS itself. But we do need every bit of help we can get to renew the NHS. That’s why we will not close our minds to the NHS and the private sector co-operating where private sector expertise or finance can bring benefit to NHS patients. The point is to define the nature of the relationship – what it is and what it is not. It is not about creating a mixed economy of care. It is about maximising the care that is available to NHS patients, based on NHS principles.

Some have said our proposals are too opaque. I say we have taken a hard look at where the private sector can help. First, using spare capacity in the private sector, such as in private hospitals, to perform operations on NHS patients. Second, getting private sector management to run some of the new stand-alone surgery centres our Manifesto commits us to building and which will specialise in precisely those procedures where private hospitals have some expertise. Third, extending PFI beyond the hospital sector where it has already helped deliver the biggest hospital building programme the NHS has ever seen into new PPPs in primary care, social services and the provision of equipment. And fourth using private sector management expertise such as in the provision of IT systems.

It is around these four activities that we will forge a new relationship between the NHS and the private sector. This is not privatisation – the taking of services out of the NHS. It is bringing into the NHS private sector help in those areas where it has a track record and where there are benefits for patients. The private sector will help but the NHS is – and will remain – Britain’s dominant health care provider.

It is for this reason that reform in the NHS has to come from within the NHS. It has to be led by the managers, doctors, nurses, therapists, scientists and all the other staff who hold the knowledge and the skills to improve services for patients. The best in the NHS making sure the best is available to all who use the NHS.

Reform from within is not an easy option. It means grasping nettles that for too long the NHS has failed to grasp. It means big changes – in the way the NHS is organised and in the way NHS staff work. It means overcoming old boundaries between services and traditional demarcations between staff. It means changing the relationship between NHS services and NHS patients. In all these ways reform is already underway. It is being led by NHS staff. It strengthens my belief that there is nothing wrong in the NHS that can’t be put right but what is best in the NHS. The test for the NHS today is to prove it can make these changes from within, not just in some services and in some places but for every patient, everywhere.

The choice for all those who care about the ethos of the NHS is straightforward: to stand on the sidelines carping, as some do, or to join in the process of reform as thousands of NHS staff are already doing. We will work – I will work – with all of those who genuinely want to make reform happen. But I say to those who would stand in the way of reform: there must be, there can be, there will be no veto on reform any more than there can be a veto on the pace of reform. The best way of supporting the public service ethos is to support public service reform.

Reform is difficult. There may be a rocky ride. Reform is a risky business as well as a rewarding one. Sometimes we’ll get things wrong as we try to put things right. That’s what leadership is all about. You know that in the organisations you lead – there is no improvement without innovation, no innovation without risk.

But we have to take the risks, make the changes, earn the improvements now because the clock is already ticking. Now is the time – with the foundations laid from our first term and a clear mandate for delivery in our second – to up the pace of reform. Not because we can promise an overnight transformation but because we know that we need to deliver progress towards that transformation. Patients and the public alike will stand for nothing less.

The NHS Plan is unashamedly long term in its ambitions. Expansion in staff and improvement in services takes sustained time and sustained effort as well as sustained resources. And we should all be clear about one thing: public confidence demands real progress – not just over this whole Parliament but over these next few years.

That calls for an absolute focus on what matters most to patients. How long they wait. The standards of care they receive. The sense that theirs is the only vested interest that counts in today’s NHS.

We have made a start – and I want to thank you for what you have done. In managing change, in navigating last winter, in making expansion happen. But now we must go further and we must go faster.

There is a big agenda to implement. The NHS Plan is an ambitious plan for improvement. I know it can’t all be done at once. There are some things that are more important than others.

Today I can set out to you the five areas where progress should now be focussed. These five are what matter most to patients.

First, on the conditions with the greatest clinical priority – cancer and heart disease and services for the elderly and those with mental illness. Rehabilitation services to build a bridge between the hospital and the home. Prevention and treatment services that improve outcomes and tackle inequalities. By 2005 we will be spending an extra £1 billion a year on cancer and cardiac services alone. Our ambition is to give our country levels of cancer and cardiac care that are no longer behind the rest but up with the best in Europe.

Second, primary care – the point of contact most patients have with the NHS. GPs and other staff are doing a good job under real pressure. That is why our priority has to be to increase the number of GPs as fast as we are able alongside expansion in nursing and other primary care professions too. And it has to be about getting extra investment directly to the frontline in primary care both to improve services for patients and to relieve pressures on staff. Together with the reform programme outlined in the NHS Plan – more specialist GPs, more personal medical services, a new GP contract – this investment will help give patients easier access to primary care services.

Third, emergency care – the point of contact patients most need to know is there for them when they require it. We will invest more in ambulance services, in accident and emergency departments and in expanding NHS Direct. We will also work to integrate these services so that better, faster care is there for patients. Far-reaching reforms and a better division of labour amongst clinical staff will, by 2004, have reduced average waiting times in accident and emergency departments to 75 minutes. Inappropriate trolley waits for admission and assessment will by then have been ended.

Fourth, cutting waiting times. The biggest concern about the NHS today is how long patients wait for treatment. It is frustrating for staff and distressing for patients. So building on what has been achieved to reduce waiting lists in our first term, our focus in this second term will now move on to reducing waiting times for treatment. In primary care. For ambulance services. In outpatients clinics, for inpatient treatment and in accident and emergency too. Today I am allocating £75 million to take forward reforms in orthopaedic, dermatology and ENT services so that patients do get better, faster treatment.

Fifth, getting the fundamentals of care right. Focussing on the patient experience to make sure that the wards are clean, the food is good, the care is there. That the buildings and equipment look good and feel good for both patients and for staff. That patients have more information and more influence over the services that they use.

Our priority then is simple: it is not an avalanche of new initiatives. It is delivery. To deliver progress on the NHS Plan. To deliver faster waiting times. Higher standards. To prove to public and staff alike that the NHS can be a service of first choice, not last resort.

I cannot make this happen. I don’t treat patients. I don’t provide GP services. I don’t manage NHS hospitals. You do. There are only one group of people who can transform the NHS. The people here today. The people in the service. The managers who lead change. The chairs and non-executives who can engage local communities in change. The frontline staff who are the key to change.

Delivery depends on more than a million people. Without them – without you – it simply will not happen. Right now NHS staff are working under real pressure. That is true in GPs surgeries, in community services and in hospitals too. Frontline staff – doctors especially – are feeling the strain. I know that. And I know we need to take action to address that.

Your top management priority is to engage with your staff – to support them so we can get more staff at the frontline and keep them at the frontline – to help them through the process of change so they can exercise power at the frontline.

First, then more staff and more support for staff. Here progress is coming through. What is more it is set to accelerate. The cuts in nurse and GP training places that took place in the 1990s have been reversed. Indeed, there has been a 40% increase in nurse and midwifery university places. There are also more scientists, more therapists, more doctors in training than ever before.

This year the NHS training budget is rising by 11%, the largest increase the NHS has ever seen. Investment in training will help sustain an unprecedented period of growth in NHS staff for a decade or more.

In the more immediate term, the NHS recruitment campaign is bearing fruit. Over 8,000 nurses and midwives – who left the NHS – have returned in the last eighteen months alone. And the campaign is now being targeted at groups like radiographers, midwives, clinical scientists.

Year by year to 2005 we can now be confident that the number of staff working on the NHS frontline will rise sharply. By then there will be 20,000 more nurses, 10,000 more doctors, 6,500 more therapists and scientists.

The corner is being turned on recruiting staff. We will maintain our efforts but our focus must now be on retaining them.

The biggest asset we have in the NHS is the one million people we employ. I know the newspapers are often full of stories about bad doctors. But we know that the NHS is full of good doctors. And good nurses, midwives, health visitors, scientists, therapists, cooks, porters, cleaners – and all the other staff who make the NHS tick. Our job is to get the best from all of them. Improvements in the way we treat patients can only happen if there are improvements in the way we treat staff. Our focus should be on removing the barriers that stand in the way of staff achieving their full potential.

We can’t get the best from staff if the NHS continues as an old-fashioned and rigid employer. Nowadays there is growing demand for more flexible employment from staff. Part time employment is becoming more popular. Some NHS employers have responded well to these changes. Others have not. Within two years every NHS employer will need to offer staff flexi-time, annual hours, flexible retirement or career breaks. The NHS has to be a more flexible employer if it is to become a model employer.

We won’t get the best from NHS staff if they are not helped to balance their family and their working lives. We know that 25,000 nurses alone say that help with childcare would encourage them to return to the NHS. That is why our manifesto commits us to extra investment in childcare. On top of the £30 million a year we are already pledged to invest by 2004 we will be investing an extra £100 million in improved childcare for staff.

As an organisation – in every part of the organisation – the NHS must now focus on removing those barriers that stand in the way of NHS staff being able to do their best for patients. Staff deserve to be valued – and to feel valued. That way we will get more staff at the NHS frontline. We will keep them working at the NHS frontline. And we will liberate their talents for the benefit of patients at the NHS frontline.

Our reform programme for the NHS must have as its core purpose an absolute determination to harness the commitment and know-how of staff to improve care for patients. Where staff have been given their heads they have delivered far-reaching change. You can see that in the cancer collaborative programme where joint working between clinicians, managers and patients has already reduced outpatient waiting times by 50% and radiology waiting times by 60%. The collaborative principle and the collaborative process now need to be spread to all parts of the NHS.

This second term is all about embedding far reaching reform in all parts of the health service and in social services too. Reform to reorganise services from the patient’s point of view – to make same day tests and diagnosis for example the norm and not the exception. Reform to overcome traditional demarcations between staff – to release the talents of nurses and therapists and relieve the pressures on doctors. Reform to break down barriers between services – to get health and social care working as one part of one organisation rather than competing organisations.

What we need now to do is to support more staff through the reform process. That is what giving staff protected time to improve their services is all about. It is what the Modernisation Agency and the Leadership Centre are all about. It is what Individual Learning Accounts for unqualified staff are all about. In time it is what the new University of the NHS will be all about too.

All of this is about one thing: to unleash the tide of innovation that exists among staff in every surgery and in every hospital.

With a clear framework of national standards and policies in place from our first term this second term will be all about shifting the centre of gravity to staff at 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 now needs to enshrine that trust. It needs to give more control to the NHS frontline. The NHS cannot be run from Whitehall. Just as schools now have greater control so local health services must now be given greater control too.

Four years ago through the fundholding scheme GPs controlled just 15% of NHS resources. Today through the primary care groups and trusts they control 50%. Our manifesto commitment is to give the PCTs control of 75% of the NHS Budget. Working at the NHS frontline, the PCTs can harness all that is best about the NHS – good managers, strong clinical leaders, clear community involvement. The PCTs need to be the engine of change in the NHS, driving new partnerships with NHS Trusts, with social services, local agencies and the communities they all serve.

So I can confirm today that within two years PCTs will receive direct allocations of cash rather than cash being directed through health authorities. And I can announce today that in future resources for block capital, as well as for revenue, will be directed not just straight to PCTs but straight to NHS Trusts too.

For the first time in the history of the NHS the majority of NHS resources will go directly to the local services which provide and commission frontline care. By 2004 PCTs and NHS Trusts will be receiving at least £44 billion of capital and revenue direct at the frontline.

I want to give the local leaders of change the cash and the clout to get on with the job. That means slimming down tiers of management above the NHS frontline. It means by April next year abolishing the existing 95 health authorities. It means introducing a reduced number – of around 30 – more strategic health authorities with responsibilities, not for hands-on commissioning of services, but for oversight of local services. It means the existing NHS Regional Offices must go by April 2003.

I know this will be difficult to handle. I know it is not risk free. But we have got to get power and resources devolved to the NHS frontline.

What I want to foster is a new culture of public sector enterprise in the NHS to rival the spirit of private sector enterprise. That requires more discretion over how local budgets are spent. It requires fewer directives from the centre. It requires a clearer focus on what is a priority and what is not. And it requires devolution to NHS organisations to be matched by devolution within NHS organisations. Ward sisters to control ward budgets. Matrons to have the power to fine cleaning contractors who fail to keep wards clean. Hospital consultants and other senior clinicians to decide on how new equipment budgets are spent. It requires greater freedoms and more rewards for NHS organisations which succeed. And it requires greater help and more support for those which do not.

Very often the poorest services are in the poorest communities. That cannot be right. So while we will celebrate success, we will encourage innovation, we will incentivise improvement, we cannot stand idly by where there is persistent failure.

Public service reform will be led by public service entrepreneurs. The NHS has bred its own entrepreneurs – people with a track record of transforming local services. I want to give them a bigger stage to apply their talents. That’s why Nigel Crisp was right when he talked yesterday about the best people from inside the NHS having a bigger role in the NHS – not just to turn around the handful of consistently failing organisations but earning greater freedom to make their own organisations even better.

I want to get the best people in the NHS to get the best out of the NHS. Let’s have a bit more confidence in ourselves. We’ve got the best people in the NHS. Reform is already being led from within the NHS. The NHS has the means to improve the NHS. As the awards ceremony put it last night: Together we can.

The people at this conference today are leading change. Now we have to drive it forward: engage with all the staff, work with them, motivate them. Get staff and patients involved in the local modernisation reviews, change how staff work so we can change how the health service works.

Your priority for reform – our priority for reform – is to free the NHS frontline. Not a return to the anarchy of the internal market but a freedom to shape local services in this second term within the clear national framework of standards and accountability we established in our first term. With a reformed Department of Health doing only what it can properly do in an accountable public service. Providing the resources. Setting the standards. Holding the system to account.

I know the Department needs to devolve and decentralise. That is why we have set up an appointments commission so that trust boards are appointed independently and not by ministers. It’s why I have set up an independent reconfiguration panel so that expert managers, clinicians and patients can provide advice to ministers on contested local service changes.

And there is one further aspect to this process of devolution I can announce today. The BMA, the NHS and the Government all want to see a new contract for GPs. Negotiating a new employment contract will not be easy. Negotiations never are. I have come to the view that the process of negotiation will be helped if the NHS rather than a government department or government ministers speak for the employers side of the table. In the end GPs – whether they are independent contractors or salaried employees – work for the NHS. It must be right for the NHS to speak for itself as these negotiations begin. I have therefore asked the NHS Confederation if it would lead the negotiations. The involvement of the NHS Confederation will help ensure that any new contract is both good for GPs and meets the needs of local NHS services and most importantly the needs of local NHS patients. Clearly we need to finalise the details of these arrangements and the NHS Confederation will need to consult on this proposal. But I believe it is the right thing to do and I hope we can get on with it.

Government alone can not change the NHS: real and visible improvement to patient care only happens – is only happening – because NHS staff make it happen. In this second term, NHS staff will be given the power, resources and responsibility to reform the NHS.

There is now a mandate for investment. And there is a mandate for reform. Of course there will always be differences over detail and negotiations over contracts. But I believe there is a natural alliance between NHS staff striving to improve care for patients and the Labour Government striving for sustained investment, far reaching reform and devolution of power to the NHS frontline.

Our commitment – my commitment – is to work with all those who want to see the NHS succeed. It can not be done without you. It can only be done with you.