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.