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.