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Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, on 19 October 2001.

I want to set out today some of the improvements we have seen in the last year, some of the challenges we now face and the further progress we can now make.

There is today a shared agenda between local government and central government. A shared vision for social services and, I hope, for the wider public services. That is a vision of services designed around the needs of the user, rooted in the values of community.

In education: where pupils come first in highly performing local schools at the heart of their communities.

In health: where patients come first in hospitals and GP practices serving the needs of their communities.

And in social care: where the vulnerable adult or child come first in safe and sound community services.

In all of these areas local government is a valued and valuable partner. I strongly believe that should continue to be the case.

We have a shared agenda too, for improving quality in care. For services that offer fair access to all and which help promote opportunities for all.

I want to thank you for the contribution you make to the fairer society we want to create. People who work in social care – and those responsible for managing social care – do so under real pressure. You are on the front line of many of the major challenges which face our country today – addressing the problems of poverty and deprivation, a growing elderly population, and growing public expectations too.

And in this time of international tension, I want to place on record my gratitude for the work of local government – officers and members – in emergency planning and preparation. Your local contribution is vital to our national vigilance.

Meeting these challenges must sometimes seem like a Herculean task. Sometimes – often – there is scant thanks for what you do. And yet just a few months ago when people faced the choice in this country between short term tax cuts and long term investment in public services, the public of this country backed public services and they backed the people working in them. I think we should all take heart from that.

Today people know a fair society, where everyone in our communities and not just some get a fair chance, can only be built on the sure foundations of a strong economy and strong public services.

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, or if whole communities are laid waste by the ravages of drugs and crime. And we certainly cannot have a fair society if health and social services deny people help when they need it, where they need it.

We all know today we are a long way from having public services to match Britain’s position as the fourth largest economy in the world. We know too that the public are impatient for change. Some people say public services can never deliver, that private provision is the only answer for problems that are self evident.

I say that on grounds of efficiency and equity that view is wrong. But I say with equal firmness that failure to deliver reform in public services will prove the doubters right.

Delivering improvements in public services – in all aspects of our public services – is not an optional extra. In these next few years progress must be made – and be seen to be made – in all of our public services if we are to sustain progress towards the fairer society we seek.

There are good grounds for optimism. For a start the investment is going in. In health and education, with the NHS today the fastest growing health care system of any major European country.

In social services investment is growing too. I know there is real pressure on your budgets. I know that that’s true for children’s care and as well as elderly care. And that is why we responded just last week with a further £300 million of new funding for social care. It brings growth in social care budgets up to 3.7% in real terms next year compared to growth of 0.1% a year prior to this Government coming to office. I know we have not solved every funding problem. But we have made progress – and we will go on making progress.

I want to give you an example of one area of progress. Let me give you one example of progress. For years, politicians and newspapers blamed social workers for just about every ill our country faced. So, it is progress when I can come to this conference and say without equivocation: we need more social workers in this country not less.

That’s why today we are launching a three year social work recruitment campaign with a view to an extra 5000 social worker. I know that shortages of social care staff are biting hard in many parts of the country. But these shortages can be turned round. The nurse recruitment campaign we have run in the health service over the last few years has proved that. Last year at your conference I was able to provide extra cash to help students train for a career in social work. Now the recruitment campaign will set out the positive benefits of a social work career to help counteract the all too frequent negative coverage the profession receives in the media.

Expanding staff numbers and investing in frontline services then are the pre-conditions for improvements in social care. But investment alone will not deliver. The courage to invest must be matched with the courage to reform. And the courage to tell the truth about how things really are.

While I see real beacons of excellence in social services – just as there are real beacons of excellence elsewhere in public services – the best has not been available to the many: it has all too often only been available to the few. What is more, the needs of the service user have all too often come a poor second to the needs of the service provider.

In the modern world that will no longer do. To command public confidence our public services today have to offer choice as well as fairness to those who use them.

All the money in the world will not deliver these changes. Indeed, there is a danger that simply pouring more money in without linking it to reforms will ossify ways of working, embedding attitudes and structures that are long overdue for change.

Reform in social services then is as vital as reform in any other area of our public services. And just as in health or in education there are four main principles which underpin the reform programme:

First, high national standards and full accountability

Second, devolution to the front line to encourage diversity and local creativity

Third, flexibility around the needs of users in how staff are employed and how services are organised

And fourth, the promotion of alternative providers and greater choice.

So how should this programme apply to social services? Before I answer that, let me just say this: I know change is difficult – I know that there are real pressures out there – but it really must happen. Whether it is the exceptional high profile service failure or simply the day-to-day reality of unresponsive services, public confidence cries out for change.

We should be confident that we can meet the challenge of change. There is much to be proud of and much on which to build. The work we have done together in bringing in the Quality protects programme with its focus on the needs of the most vulnerable children, the General Social Care Council, the National Care Standards Commission testifies to our shared commitment to improvements in social care.

So let me begin with standards and accountability.

People have the right to know that they will get certain minimum standards wherever they live. And I am pleased to come to this conference today and report real progress. Today I am publishing the latest set of social services performance indicators. They cover performance over the last three years.

Compared to last year, 20 out of 23 indicators show either improvement or a continued high level performance.

More older people than ever before are being to helped to live in their own homes rather than in care homes.

The number of children adopted has risen again giving them the chance of a stable family life.

Compared to two years ago there are 850 more children who have found permanent adoptive families – well on the way to meeting our ambitions for a 40% increase by 2005.

I really do want to congratulate you for the progress being made. But as ever, there is much more to be done. It should concern us all that the target on delayed discharges was missed. That means people are being kept in hospital when they should be at home. There was a slight improvement this year it is true, but with the new money I announced last week for social services specifically to address the “bed blocking” issue, I expect to see significant improvements during the course of next year.

Similarly, more than 6 in 10 children are still going out into the world from care without a formal qualification. None of us would be happy with that for our own children. It is also unacceptable that only one quarter of councils reviewed all their child protection cases on time.

What is crystal clear from these tables is that there is excellence in our social services. But it is excellence spread too thinly. It is available only to some when surely our ambition as a nation must be to make it available to all.

Of course local services should be attuned to the needs of different local communities. That is why we have locally run social services. But right now, as these tables show, the variation in performance across social care is just too great.

Take London for example where there are particular problems with cash pressures and wide societal pressures. In one part of the City fewer than one in five children leaving care had a qualification. In another part almost 6 in 10 had. In one part of the North only 2% of looked-after children were adopted while in another part five times that number were. In both examples, alongside countless others, the councils concerned have similar locations, deal with similar problems of poverty and deprivation and have similar levels of funding.

These tables remove the excuses for unacceptable variations in performance. This is not primarily about money. It is about management and organisation. And that is the value of these tables. They expose those areas where performance needs to improve. I know there will always be arguments about the details in the tables and the methodology behind them but for me – and I hope for you too – there is a simple principle at stake here – the public who use our public services have a right to know how well those services are doing in comparison with others.

Public services don’t belong to me and they don’t belong you to either. They belong to the public. Accessible information for the users of public services is essential if we are to design services around the needs of users. That is what we are doing with schools and hospitals. And it is what we must now do for social services.

I know that current tables are far from perfect and are far too complicated. So I can announce today that we plan next year for a new approach which will provide more easily accessible information to the public about social services performance. From next year, we will bring together the existing performance data with information from inspections and in-year monitoring. The result will be a more rounded assessment of each council’s performance.

Just as we have recently done for hospitals this year, so from next year each council will receive a star rating for its overall social services performance. There will be separate ratings for adult and children’s services. We will work with the LGA and the ADSS on the details of the new system. I believe profoundly that it will help councils to improve their performance.

That brings me to the second part of the reform programme – devolving power and encouraging diversity.

Providing information to the public is just the first step. Being able to act on it is what counts. Action should follow assessment. Where there is good, bad and indifferent performance so different approaches are clearly needed.

Where there is good performance we should step back. Where there is poor performance we should be prepared to step in. We should offer more rewards for the best performers. And more help to turn around the poorer performers.

One of the greatest frustrations I hear expressed in the NHS and in social care too is that all too often rather than rewarding the good we simply bail out the bad. That is what we now must change if we are to provide the right incentives for improvement in all aspects of our social, and indeed all, services.

So beginning with this year’s best performers – including the top ten consistently high performing councils in Derby, South Tyneside, Sunderland, Derbyshire, Cornwall, Rotherham, York, Salford, Dudley and Leicestershire – in future all of them will get the greater local freedom they have earned.

We will invite the best performers to discuss with us how they could have greater control rather than less. We will explore with them a lighter touch inspection regime with non-children’s services being inspected, perhaps only every five years. We will consider removing the conditions attached to special grants so that top social services authorities are free to spend their money in ways they decide can best make the improvements in services for the communities they serve.

And we will give the best star rating performers their share of next year’s new £50 million performance fund to spend as they think fit. Some could go on staff bonuses. Some could go on developing new services. The point is that it will purely be a matter of local discretion.

The point is that good performance will earn the devolution of power. This new approach will not only reward success among the best it will encourage improvement among those who could be better.

The performance indicators show every council is doing well in some areas. Some authorities while not yet the best are improving and improving rapidly. Councils such as Cambridgeshire and Newcastle upon Tyne deserve special praise since they have only recently come out of special measures and they are making record improvement. We now need to make sure that every one of them do even better and that others can learn from what they have achieved. We will look to the Social Care Institute for Excellence as it develops its role, to disseminate and embed good practice.

I can announce today that we will consider using a part of the new Performance Fund to allow the fastest improvers to spread the benefits of their knowledge to others that are in most need of improvement.

For the few who are genuinely poor performers – including the bottom ten of the Isles of Scilly, Richmond on Thames, Buckinghamshire, West Berkshire, Windsor & Maidenhead, Kirklees, Torbay, Bracknell Forest, Warwickshire and Lambeth – I believe that different action is needed. We already have mechanisms to deal with poor performance including the powers to put Councils on special measures. There is evidence that performance does improve when the SSI is closely involved. But sometimes delivering improvements simply takes too long. So I can say today that I will act using Best Value and other intervention powers where the evidence suggests the pace of improvement is simply too slow.

I will also be discussing with the LGA, and with Stephen Byers at the DLTR, how we can use external expertise from the voluntary, statutory and private sector to turn round performance where local social services are persistently failing or falling behind.

We will want to explore in particular how to encourage the best performing local social services to take over responsibility for running the worst. I want to encourage in social care, as much as we are trying to do in health care, the development of a new public sector enterprise culture where we get the best people in public services to lead improvements across the rest of our public services.

So, today I am putting this year’s worst performers on notice:

First, they will be required to agree with the Chief Inspector an action programme for improvement.
Second, special measures will follow if services do not improve.
Third, by the time we award star ratings next summer, if performance and prospects for further improvement remain poor, I will consider using other intervention powers.
In some cases I know that social services management can struggle because there are problems at the corporate or even the political level. If I find evidence of corporate failures limiting social services delivery I will consider triggering corporate inspections so that we can find where the problems lie so then we can tackle them.

Where councils and the NHS are not working together effectively, I will consider asking the SSI and CHI jointly to investigate the reasons for partnership problems. If necessary I will use my powers to compel local health and social services to work more effectively together.

That brings me the third strand of the reform programme – building services that are flexible enough to meet the needs of their users. The painful truth about the way we organise care is that it is like a maze for too many of its users.

There is confusion and uncertainty about where the responsibilities of health and social care begin and end. Too often people who rely on these services – whether they are elderly or disabled or have a mental illness – find themselves faced with an endless procession of staff carrying out roughly the same assessments. And then of course there are turf wars over who funds what and who does not.

I know there is a monumental effort going into all parts of the country into improving partnership working both in health and in social services. I want to thank you again for the progress you have made. We saw the results of that last winter. I hope we can see it again this winter. Where partnership works it works brilliantly. Where it does not the needs of the user come a poor second to disputes between services.

And let me just say candidly, I know the problem lies as much on the NHS side of the fence as on your side. The answer is to take down the fence. I believe we now have the means to do so.

From next year we will be putting in place a single process for assessing the needs of elderly people for health and social care. I hope that can be accompanied by fewer demarcations between staff to build on the pioneering work in places like Wiltshire where social workers and community nurses work as a single team.

Greater flexibility between staff needs to be matched by greater flexibility between organisations. Frankly, so far I have been disappointed by the take up of the legal powers, which are now available, for health and social care to pool their budgets and work more closely in partnership. I will be looking for faster take up of these powers in the year ahead, towards our aim of having them used in every part of the country.

What the bed-blocking problem in the NHS reveals is the simple truth that social services and health services sink or swim together. Each needs the other. The older person needs both. What we have to move to then, is one care system. Not by takeovers but through partnerships.

Today, I am pleased to be able to confirm that next year the first of up to fifteen Care Trusts will come on stream, bringing together in a single organisation health and social services for older people or for people with mental health needs. Eventually, I hope Care Trusts will be in place in all parts of the country because they break through bureaucratic boundaries in order to focus on the needs of service users.

That brings me to the final part of the reform programme – promoting greater choice and diversity in provision. In social care diversity of provision has already taken hold. Over 80% of residential care and over 50% of home based care is provided by the independent sector. Some of the best learning disability services are run by voluntary organisations.

Yet for too long, in my view, there has been a stand off in the relationship between the statutory, private and voluntary care sectors. There should be no ideological barriers getting in the way of the best care for vulnerable people.

Last week, I hope we saw the beginning of the end of that stand off with the publication of the ground breaking agreement between the Government and representatives of the NHS, local councils and independent sector providers in housing, health and social care. The document we published, “Building capacity and partnership in care”, marks a decisive break from the short termism of the past. It sets out principles and practices to underpin what I hope will become a more mature long term relationship between the public and private care sectors.

The recent losses of capacity in the care home sector call for such a relationship, with longer term contracts between councils and care homes. They call for the independent sector to have a seat at the table for planning future provision. They call for public and private sectors to work together not just to shore up existing provision in care homes but to develop new services in people’s own homes: intensive home care packages; new more active intermediate care where the emphasis is firmly on rehabilitation and independence. All of this is about providing more choice for users by promoting greater diversity in provision.

The £300 million we announced last week to deal with the problem of delayed discharge will translate the Agreement into action. This is a cash-for-change programme. We want to see real change to eat into the bed blocking problem. By the end of this winter, we want to see 1,000 fewer older people stuck in hospital at any time, that way we can release 1,000 extra beds for other NHS patients. Next year we will want to see further progress still towards our aim of ending widespread bed blocking by 2004.

Together, people working in health and social services are at can bring about these improvements. They can do it providing they seize the opportunities which now exist to reform these services.

For too long, social services have been undervalued in our country. Blamed when things go wrong. Ignored when things go right. Often expected to fail. Sometimes set up to fail.

So, let us make a fair assessment of social services in our country today.

Investment is now rising and performance is improving but there is much more that must be done to put the needs of the user at the centre of the service.

To do that, the best in social services must help reform the rest of social services. The old barriers, which divided health from social care, and separated public from private provision, must now be overcome.

The poor performers must receive direct support to do better.

The big improvers must spread the lessons of improvement.

The best performers must have new freedoms to be better still.

None of this is easy. Much of it will take time. All of it requires a huge amount of effort. This is a reform programme based on our belief in public services and our belief in social services. It is based also on our belief that these services can be better – and must become better than they are today. And most of all, we believe they can be better than they are. What we must now do is demonstrate we can deliver. We’ve made substantial steps forward – we need to build on that and we need to deliver. The public expect no less.

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.

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, in June 2001.

It’s good to be back. With a renewed mandate for investment and reform in the NHS and with a very clear instruction from the British people to deliver real improvements within the NHS.

At the General Election there was a clear choice on offer: between putting public services first or putting tax cuts first. The public chose public services.

As you all know Mrs Thatcher featured prominently in the campaign. Ironically, the result of that election campaign has laid to rest the dogma that public sector investment is somehow bad for Britain. That dogma left a legacy of under-investment in our key public services. In transport, in education, above all else in health. The result of the general election is the clearest signal that the country has moved on.

People today recognise that if we are to have a fair society where everyone in our communities- and not just some – get a fair chance to succeed then we must build strong public services to set 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 or a strong economy if whole communities are laid waste by the ravages of drugs and crime. Above all else, we cannot have a fair society or a strong economy if health care denies people help when they need it where they need it.

These are the public’s priorities. They are the Government’s priorities for this second term. And at the top of the public’s hopes for change – and top of their concerns too – is the National Health Service.

I have spent the last month, up and down the country, listening to what staff, patients and the public are saying about the NHS. I haven’t always visited the best places. I’ve seen the bad things as well as the good. Sometimes what I’ve seen and what I’ve heard has been encouraging. Sometimes it’s been more difficult. Wherever I’ve gone people have told it straight. And I’ve heard some home truths about what needs to change to realise our ambitions for the NHS.

Wherever I’ve been it’s clear people are impatient for improvement whether they’re NHS patients or NHS staff. So the stakes are high for all of us who believe in the NHS and in its fundamental first principles: care based on need, not ability to pay. A failure to deliver reform in the NHS will play directly into the hands of those who say that the NHS can never deliver.

It is important to recognise that 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 in the people working in it. And I know that NHS staff can deliver, that they want to deliver – and are already beginning to deliver – the changes needed to redesign the services of the NHS around the people who use them.

We have a long way to go but a start has been made. Today the NHS is in transition. The foundations for change are in place. New structures – ranging from primary care trusts to the Commission for Health Improvement – will help deliver higher standards of care. The extra resources the NHS has long cried out for are finally bringing about expansion in NHS services. 67 new hospitals to be built. 3,000 GP surgeries to be modernised. Thousands of trained staff already in place and thousands more to come. In the next five years alone there will be 10,000 more qualified doctors. And by 2005 we will have increased the number of medical students by 57% – the biggest rise on record and a guarantee of expansion in doctor numbers for a decade or more to come.

Now is the time – with these foundations laid and a clear mandate for deliver – 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.

I make no apologies for the fact that the NHS Plan is unashamedly long term in its ambitions. There are no quick fixes and no magic wands. We cannot conjure trained doctors and trained nurses out of thin air any more than we can conjure trained scientists or trained therapists out of thin air. Expansion in staff and improvement in services will take sustained time and sustained effort as well as sustained resources. As we manage change we also have to manage public expectations. We have to carefully reconcile the legitimate demands of the public for faster improvement in the NHS with the reality of staff working under real pressure and services straining every sinew to deliver better care for patients.

This is not complacency. We know what needs to be done. And we have the plans and resources for making it happen. We will not pretend that every problem in the NHS can be solved in one fell swoop but nor should anyone pretend that during these next few years we cannot make substantial progress towards our longer term ambitions for the NHS. Our priority for this Parliament is simple: it not an avalanche of new initiatives. It is delivery. To deliver the NHS Plan.

There are four key areas where progress will need to be focussed.

First, on the conditions with the greatest clinical priority – cancer and heart disease and services for the elderly and those with mental illness. These will be our top priorities for investment and reform. 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.

Today I can confirm that there will be no waiting list target but there will be a concerted drive to reduce waiting times. Priority will be given to those patients with the most serious conditions. Year by year the maximum waiting times for a hospital operation will fall from 18 months today to 15 months by Spring next year, then to 12 months and by 2005 it will be down to just 6 months. As staff expansion and service reform take hold average waiting times will fall lower still. And the same focus will get waiting times down for outpatient and for ambulance services too.

These are ambitious plans to improve the responsiveness of the NHS. Delivery here will rebuild public confidence in the NHS. It will also solve a real dilemma that confronts thousands of patients every year. Many people – particularly those who have a bit of savings – are currently forced to choose between waiting for treatment or paying for treatment. Many end up paying. However comforting that might be for some people it does not provide a solution for most people. Indeed there is a real risk that without support from middle income families public services will end up fulfilling Richard Titmuss prophecy: services for the poor which are themselves poor services. Our ambition as a country surely has to be to make the NHS a service of first choice not last resort.

We can have that ambition because of the expansion in staffing we are planning. 20,000 more nurses, 10,000 more doctors, 6,500 more therapists and scientists. We can have that ambition because we can deliver not just more staff at the NHS frontline but more support for staff at the frontline. More childcare support. More housing support. A new fairer pay system for staff.

Each year as the NHS grows so services will grow. But as NHS staff know better than anyone, our task is not to get the system to work harder but to get it to work smarter. To have an NHS judged not just by the quantity of services it offers but by the quality of care it provides.

This second term then is all about embedding far reaching reform in all parts of the health service and in social services too. Reform cannot be an optional extra. Investment alone cannot deliver the goods. It is reform that is the key to the improvements that we seek to unlock in the NHS.

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. And reform too which rejects ideological objections to the NHS working with the private sector – as well as rejecting ideological obsessions with the supposed superiority of the private sector – in favour of a modern relationship which best suits the interests of the NHS patient.

In this second term, reform in the NHS is not about abandoning the principles of the NHS. It is not about privatising NHS services. It is not about sidelining NHS staff. It is above all else about empowering frontline NHS services and liberating the talents of frontline NHS staff.

Our reform programme will 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.

I know that for some in the NHS, reform can feel like another burden to be confronted rather than a means of relieving the burden. There is real pressure on staff. It is hard to find the time to reform services. And yet when reform happens it is quickly seen as a help not a hindrance, to staff as well as to patients. GPs who have got waiting times for appointments down by changing how their surgeries are organised have found their working lives better not worse. In hospitals, doctors, nurses and therapists who have changed who delivers outpatient services have found greater job satisfaction not less. 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. And in time it is what the new University of the NHS will be all about. 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. I don’t treat patients. I don’t provide GP services. I don’t manage NHS hospitals. You do. The NHS can not 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 GPs through the fundholding scheme controlled just 15% of NHS resources. Today the GPs, the nurses, the patients and the local communities who run primary care groups and trusts control 50%. By 2004 they will control 75%. By then – if not before – two-thirds of existing health authorities will have been abolished. The NHS regional offices will have been abolished too. Power will have been devolved to frontline NHS services.

And I can announce today that in future resources will be devolved directly to frontline NHS services too. Within the next two years it is my intention to no longer allocate cash for local health services to health authorities. Instead it will be allocated directly to local primary care trusts so that they can decide how to commission services for the local communities they serve. I have heard from too many people too often in the NHS that resources have not been getting through to the frontline. Now I plan to give resources direct to those at the frontline.

This process of decentralisation that will now take hold in all parts of the NHS. I want to see a new culture of public sector enterprise in the NHS to rival the spirit of private sector enterprise which developed during the last few decades in our country. That requires more discretion over how local budgets are spent. It requires greater freedoms and more rewards for organisations which succeed. And it requires greater help and more support – rather than blame – for those which do not.

As standards and performance improve so greater autonomy will take hold. Good hospitals will get extra resources to help turn round persistently failing hospitals. And devolution to NHS organisations will be matched by devolution within NHS organisations. In hospitals ward sisters will have control over ward budgets. Matrons will have the power to fine cleaning contractors that fail to keep wards cleans. Hospital consultants and other senior clinicians will decide on how the new £100 million a year equipment budgets are spent.

The priority for reform will be to free the NHS frontline. Not a return to the anarchy of the 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.

That process will begin at once and it will provide an opportunity for every member of NHS staff to contribute to the programme of NHS reform. In every part of the country from this month through to the autumn health services will be conducting local modernisation reviews. Just as last summer there was a national programme to involve the NHS in drawing up the NHS Plan so this summer I want to see local programmes throughout the country to involve the NHS in implementing the NHS Plan.

The reviews will culminate in local three year action plans that set out the changes and the investment required to deliver the ambitions of the NHS Plan. These will be local plans for local communities. If they are to launch real change they will need be formulated by local NHS staff and local NHS patients. It will be for local managers to make that happen. But I will be writing to the royal colleges, the trade unions and patient groups urging them to ensure the involvement of their members on the ground.

This is a unique opportunity. For the first time in the history of the NHS staff and patients will be asked to help reshape and reform local health services in all parts of the country. It is a powerful symbol of our determination to put real power and real influence in the hands of those who use NHS frontline services and those who provide them.

Making reform happen will require not just a relocation of power to the NHS frontline but a change in the relationship between patients and frontline services. The culture of the NHS has to change. It has to be attuned to the times in which we all live. Services today have to operate for the benefit of the public, not the other way around. They have to operate on the basis of open information, not behave like a closed society. They have to enhance patient choice not deny it. These are big reforms. They form the basis of the NHS Plan.

In this second term of Government, our concentration will be on embedding the reform programme in the NHS Plan rather than an avalanche of new initiatives which sometimes follows the election of a new government.

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 for themselves.

Increasingly, the NHS has a cadre of “public sector entrepreneurs” – committed to the principles of the NHS, driving through local innovation themselves, eager to see reform take hold across the health service. Our task is to engage these “public sector entrepreneurs” against the coalition of “eternal pessimists” – on both Right and Left – who view reform of the NHS as either a threat to the system or as being doomed to failure because the system itself has already been deemed to fail.

These eternal pessimists see every change, in whatever direction as always bad; every extra pound of extra investment as either totally inadequate or pointlessly extravagant. They see every new PFI hospital as a threat of wholesale privatisation rather than as an opportunity for staff and patients to experience new and better NHS facilities.

As we decentralise and devolve more power to the frontline, we have to empower these public sector entrepreneurs to show by example that the NHS can be reformed, that change can be real and visible for patients, that the health service is growing and that it is changing to meet modern patient expectations. By doing so we will prove the eternal pessimists wrong.

There is now a mandate for investment. But there is also a mandate for reform. There can be no veto on either investment of 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 patient 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. With all those who know that it is not just sustained investment that the NHS needs by far-reaching reform.

This is the challenge ahead. It is a challenge we share. It is a challenge we can now meet. It will be most visible and most profound at the NHS frontline.

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.

Below is the text of the speech made by Alan Milburn in Newcastle-upon-Tyne on 19 April 2001.

It is a real pleasure to be with you today both to celebrate the achievements of the Northern Genetics Service and to welcome the new Institute of Human Genetics. You already provide services that are renowned nationally as well as regionally. Now thanks to all your efforts and the investments going in you will be able to provide world class genetic services for patients.

Hardly a week goes by without a new media story about genetics. Some of the advances we read about no doubt are more apparent than real. But one thing is for certain: genetics will, indeed already is changing the world in which we live – holding out the potential for new drugs and therapies, new means of preventing ill health and new ways of treating illness.

And yet, despite the profound potential inherent in the new technologies, it is a rare for any health secretary to speak about genetics. In part this reticence reflects uncertainty about the impact genetic advances will have on health care. In part it reflects unease about the ethical implications of some of these great steps forward. We have to get to grips with both.

In the process, we should not lose sight of what I am convinced are enormously exciting developments for human health. Late last year I convened a seminar on genetics in the Department of Health. Patient groups, doctors, leading scientists, the pharmaceutical industry and some of our country’s top geneticists attended. I learned a lot about both the potential and the problems associated with developments in genetics. What I heard convinced me that it is time for politicians and the public as well as scientists and clinicians to engage with the issue.

Any responsible government has a duty to assess the future challenges facing the country. Our horizon must be beyond the short term. We need now to be looking a decade or more ahead so we can ensure Britain is in the best position to benefit from the changes that will surely come.

Whether Britain prepares for it or not, advances in genetics will inevitably impact on health services and health prospects. The challenge for us is how best to ensure the impact is as positive as it will be profound; that it benefits all of our society, not just some of it.

I am no expert on genetics. I am a politician not a scientist. So what I want to say is less about the science of genetics – and more about the impact it can have.

I want to set out:

– what the Government believes could be the potential of genetics for improved health.

– the way we need now to be actively preparing the NHS so it can harness the benefits of these future advances for all the people of our country.

And a new ambition for Britain – to put us at the leading edge of advances in genetic technologies and to develop in our country modern genetic health services unrivalled anywhere in the world.
We have before us a huge potential. A gift that modern science has bequeathed medicine and society. The breakthroughs initiated by Francis Crick and Jim Watson five decades ago and taken forward by teams of scientists throughout the world in the human genome project have given us not only new knowledge about life itself but the potential power to improve life.

The human genome project has already crossed a new frontier in scientific knowledge – the question now is whether we can harness that knowledge to cross a new frontier in medicine.

The implications of the advances in genetic knowledge are enormous – equal potentially for the conquest of disease to the discovery of antibiotics. This is a revolution, with the potential in the first half of this century to dwarf the impact computer technology had on society in the second half of the last century.

In time we should be able to assess the risk an individual has of developing disease – not just for single gene disorders like cystic fibrosis but for our country’s biggest killers – cancer and coronary heart disease – as well as those like diabetes which limit people’s lives.

We will be able to better predict the likelihood of an individual responding to a particular course of drug treatment. And down the line, we will be able to develop new therapies which hold out the prospect not just of treating disease but of preventing it.

Of course it is a complex business turning new knowledge into new treatment. For one thing, the relationship between gene and environment is currently insufficiently understood. So no-one can predict right now the scale of the impact of genetics on health care, any more than we can predict its timing. There are no guarantees. It is worth remembering: people of my generation grew up being told that by now we would be certain there would be men on Mars – either because we’d gone there or they’d got here first.

What makes advances in genetic medicine different is they are already happening. Some genetic tests are currently available. Many more are within reach. There are promising signs from pioneering gene therapy treatments. Some new drugs are already being designed for specific groups in the population who can benefit most. Indeed, most experts agree the biggest advance we are likely to see in genetics in the near future lies in the discovery of hundreds of new, better targeted drug treatments.

There is no “Big Bang”. Instead, we are at the start of a “slow burn” which can only accelerate in the future. Our job is to prepare for change to harness the benefits of genetic advances and avoid its dangers. To do that we need to secure public approval for progress and to actively prepare our health care system for that progress. I now want to deal with each of these issues in turn.

First then, the views of the British public. Most of us in this room can already see the potential for healing which genetics may bring. Yet the subject evokes strong public scepticism, sometimes even hostility.

A MORI survey just last month showed that while 9 in 10 people agreed genetic developments could have positive health benefits, one third worried that research on human genetics amounts to tampering with nature. The creation of Dolly the sheep and false claims about the cloning of humans have understandably exacerbated these fears.

Little wonder then, that there remains some confusion in the public mind about where the science of genetics ends and the nightmare of eugenics begins. The pre-condition for dispelling some of the myths and ending much of the confusion is better engagement between the medical and scientific communities and society as a whole. Government and the media share a responsibility to help foster a well-informed, national debate about the promise and the problems genetic discoveries hold out for our country in the years to come.

Many of the advances we are likely to see in genetics over the next decade will probably come in areas which are the least likely to raise profound moral concerns – such as pharmaco-genetics.

But in a climate where the benefits of scientific advance are not always as automatically accepted as once they were, we need to move beyond simply stimulating a national debate about genetics. It is unfortunate but true that BSE and other developments have inflicted real damage on the standing of science. In some spheres there is the risk of an anti-science view taking hold. To protect against that prospect we need to move beyond simply providing more information or better education to the public about the potential of genetics. We have to provide positive safeguards to address the public’s concerns.

The terrible lesson of history is that science can be claimed for evil as well as for good. So whilst science must be able to discover the facts, Governments – on behalf of the public – must be able to make judgements about the use to which those discoveries can legitimately be put.

Advances in genetics raise difficult ethical questions. Most people, I guess, would accept as a good thing genetic testing for susceptibility to heart disease in order to be better able to prevent it. The same positive view would probably apply if we were able to tailor drugs to treat a particular individual for serious illness or if we could cure cancer by altering the make-up of a particular gene. Conversely, the prospect of genetically designing babies for their looks or for their intelligence is, for most people, repellent.

At present in this country, human reproductive cloning is banned because the Human Fertilisation and Embryology Authority will not licence it. The ban is welcome.

But I believe we need to go further to offer an unequivocal assurance to the public. Human cloning should be banned by law, not just by licence. I can confirm today then that the Government will legislate in the near future to explicitly ban human reproductive cloning in the UK.

There are huge potential health gains in genetic advances but until we address and allay public concerns we will not gain public consent to realise the full benefits of genetic science.

We have made a start with the Human Genetics Commission to provide independent advice on the social, ethical and legal implications. There are understandable public concerns that the advent of genetic testing will lead to new forms of discrimination – in employment or insurance for example. The extent to which the public accept, demand or avoid genetic screening services in the future will depend in part on who will have access to genetic information. There are important issues of confidentiality to be addressed. The Commission is currently exploring some of them, most notably in regard to insurance. We have also set up the Genetics and Insurance Committee to review the evidence about individual tests. The House of Commons Science and Technology Committee recently reported on the same issue. It called for a temporary moratorium on using genetic tests for insurance purposes to give time for the wider implications to be explored.

The question of whether insurance companies should have access to genetic information has provoked much public concern. There are powerful arguments for not treating genetic information the same as other kinds of information for insurance purposes. Right now the relevance of many genetic test results is still poorly understood. Many tests can only indicate an individual has a predisposition to develop a condition not a certainty that they will. Even so forced disclosure of test results could deter some people from taking tests at all, potentially putting their health at risk for fear of suffering discrimination by insurance companies or even by employers. In the longer term the danger we need to guard against is the creation of a ‘genetic underclass’, where high risk individuals are excluded altogether.

These are complex issues and it is for these reasons that the Government has asked the Human Genetics Commission to review the wider social and ethical aspects of the current policy on the use of genetic test results for insurance. We await their report and recommendations. Clearly the report is likely to give rise to a number of long term issues that will need careful consideration.

What I can say today is that the Government will look sympathetically at any proposals to prevent the inappropriate use of genetic information for insurance purposes, including legislation if necessary. If the Human Genetics Commission recommends a temporary moratorium on the use of genetic tests by the insurance industry then we will pursue it.

There will need to be safeguards to protect individuals from families affected by genetic conditions such as Huntingdon’s disease. I will therefore consult with genetic support groups and the insurance industry to examine what can be done to improve matters for those whose family history makes insurance difficult.

As the debate on insurance and genetics is revealing, genetic advances require new thought to be given to regulation nationally and internationally. In truth, scientific advance has outstripped the existing regulatory response. Without appropriate regulation, lack of public confidence will remain a significant barrier to fully harnessing the health benefits genetic developments represent.

Genetic advances can be a force for good. But that requires more than just public confidence. It requires active preparation. The genetics revolution has begun. It will only move forward faster in the future. It is time we as a nation started preparing today for the opportunities of tomorrow. Let me now set out then the preparations I believe the NHS must now make.

Whether it is genetic testing or pharmacogenetics or, in time, developments in gene therapy, the genetics revolution is going to make the NHS of the future look very different from the health service of today.

Developments in genetics should allow us to eradicate much of the trial and error common in medical practice. Much of the health service’s work today is based on a model which aims to ‘diagnose and treat’ conditions. Modern medicine has made great strides forward. But much of it still only comes into play relatively late in the history of an illness. Developments in genetics should allow us to test or screen for risk factors long before the symptoms of disease develop. The NHS of the future should increasingly allow us to ‘predict and prevent’ the common diseases of later life.

Genetics will never mean a disease-free existence; but understanding of genetics could eventually help to free society from some of today’s major diseases. The plans my department are currently discussing with the Wellcome Trust and the Medical Research Council for one of the world’s largest studies – involving 500,000 volunteers – into the interaction between genes and environment will give us further vital clues.

To realise the potential genetic advances could have, however, the NHS will need to change the services it offers. Hospitals might do less invasive surgery but more gene therapy treatment. Overall the NHS will need to gear itself increasingly to prevention and not just treatment. In primary care where the majority of patients will be seen, the pattern of care will alter, as new services take the place of existing ones: more genetic screening alongside more specialist genetic counselling; more regular check-ups; more help for people to give up smoking not just advice that they should; more exercise on prescription alongside drugs on prescription, tailored to the individual’s personal genetic profile.

Patients, of course, must be able to choose how best they as individuals can benefit from these genetic advances. People have a right to know and a right not to know information about their own health. For genetic tests, the rate of take-up will inevitably depend on factors such as family health history and the possibility of treatment. There will be huge dilemmas for the individual patient – as women who are at high risk from breast cancer have already found after deciding whether or not to have a genetic test. But overall, I believe genetic developments should give patients more control and more choice over their own health.

The role of health professionals will be to help patients choose what is right for them. There will be a greater emphasis on providing clear information to patients so they can make informed choices. Informed consent should be the governing principle here, with a greater sense of partnership between professional and patient.

Genetic services will spread out of specialist centres into GP surgeries, health centres and local hospitals as I know you are now doing here in the North East. A new generation of specialist primary care professionals are likely to develop to work alongside family doctors – and help relieve the burden on them – by specialising in genetic testing, advice and counselling. Mainstreaming genetic services in the NHS will also require big changes in how we educate and train health professionals.

There is then a lot of preparation to do. Day-by-day we are seeing advances which could offer more patients the benefits of genetic services. Today for example, I am able to announce agreement between my department and the Cancer Research Campaign for the use of their world class research to support testing for the presence of breast cancer genes. The CRC has held a patent on the detection of one of the breast cancer genes for some time. Such a patent could have made it prohibitively expensive for the NHS to test women for this gene if the CRC had used their patent powers to impose a charge. The agreement we have reached with the CRC ensures that women will not face this problem – so incidentally giving the lie to the claim that some have made that genetic patenting inevitably will land the NHS with unaffordable costs. I can also say today that discussions are underway with a leading United States-based biotechnology company, Myriad Genetics Inc, to enable NHS patients to benefit from the company’s extensive research and development on a related breast cancer gene. I hope these discussions will be a model for future collaborations with our health service.

These advances, however, inevitably place great strain on NHS genetic services. I want to pay tribute not only to the work that John and his team do here in Newcastle but to the work of our regional genetic services up and down the country. You already provide vital – sometimes life-saving services for thousands of people with single gene disorders. You are at the sharp end of the genetics revolution – a revolution with the potential to transform health care in our country but which must not be allowed to overwhelm it.

Here in Britain we start with a great advantage. Despite the very real pressures our genetic services are under, they are the envy of Europe. A recent study in the European Journal of Genetics concludes that the UK and the Netherlands provide our continent’s most comprehensive genetic services.

According to the Nuffield Trust no other country in the World provides a service which offers combined strengths in clinical, laboratory and research activities. When it comes to genetic services it is no exaggeration to say the NHS is a world leader. Now it is time to enhance the capacity of our genetic services so they are better able to capture advances in genetic medicine for many more NHS patients.

Today I can announce a £30 million package of new investment in NHS genetic services.

Firstly, the government will increase the number of consultants specialising in genetics. The NHS is in the midst of major expansion, after decades of neglect and under-investment. Already there are than 17,000 nurses and 6,500 more doctors than when we came to office. The next few years will see further expansion still. Genetic services will be a major beneficiary. Consultants numbers will double from 77 today to over 140 by 2006.

Secondly, we will also double the number of scientific and technical staff working in genetics over the next five years to provide the specialist laboratory skills needed to maximise benefits to patients. Staff numbers will rise by 300.

Thirdly, we will more than double the number of genetic counsellors working in the NHS not only in specialist units but in primary care as well. There will be at least an extra 150 posts and we will work closely with Macmillan Cancer Relief to develop more specialist genetic cancer counsellors.

Fourthly, we will create two new national reference laboratories for genetics specialising in rare genetic disorders and identifying new tests and treatments that can bring benefits to patients.

Fifthly, we will address the lottery in care in genetics services. As the Bobrow report recommended, we will now, for the first time, form our regional genetics services into a single national network capable of providing specialist services to groups of patients regardless of where they happen to live. The creation of a Genetics Commissioning Advisory Group involving patient representatives under the chairmanship of Sir John Pattison will also ensure greater national co-ordination of genetic services.

More consultants, more scientists, more counsellors, new laboratories and a new national network of specialist genetics centres – a five point plan for expansion in genetic services – will allow the NHS to offer greatly enhanced treatment and care for patients.

The number of NHS patients being seen by specialist genetics services will increase by 80% to 120,000 a year over the course of the next few years. More NHS patients with common conditions like cancer as well as those with single gene disorders will be offered tests. Regional centres will be able to routinely see the family members of patients so they also have the information and the tests necessary to make decisions about their own future treatment needs.

Waiting times to see a genetics specialist will fall from as long as twelve months at present to just three months in future. Laboratory test times too will fall and test numbers will double by 2005.

This is the first tranche of investment we will be making to ensure the NHS is able to offer patients the benefits of the latest genetics advances. Further investment will be needed in education and training for staff and in IT systems as well as in new equipment. I know that in this region funding for genetic services will expand by one quarter over the next three years alone. The investment we are making is not just a signal of our belief that these advances hold out real health care benefits, it is confirmation of our belief that the NHS is uniquely placed to maximise those benefits for all.

Some argue that the costs of absorbing these advances will swamp the NHS. That is not my view. Of course there will be up front costs if the NHS is to spread the benefits of genetic developments. But, down the line, there could be significant financial gains to put alongside major health gains. For example, using genetic profiling to more accurately prescribe drugs will reduce side-effects, improve treatment outcomes and save the NHS a small fortune. Advances in pharmacogenetics could reduce the estimated 1 in 20 of hospital admissions which result from adverse drug reactions and currently cost the NHS anywhere between £1billion and £2.5 billion a year. Similarly, once we are able to identify say, the 10% of people most at risk from heart disease we will be able to provide them with extra preventive services. One estimate puts the costs of doing so at around £60 million with the savings at around £200 million.

There is no other health care system better placed to harness the potential of the great advances now within reach than the National Health Service. The way the NHS is organised – providing care for all on the basis of need, not ability to pay – uniquely suits it to capturing the benefits of genetics for the good of all.

Our nation’s health service is our best defence against the nightmare vision of a ‘Brave New World’ of two tier health care: a “genetic superclass” of the well and insurable; and a “genetic underclass” of the unwell and uninsurable, unable to pay the premiums for medical care.

Britain’s system of socialised health care means citizens can choose to take genetic tests free from the fear that should they test positive they face an enormous bill for insurance or treatment. Worse still that they are priced out of care or cover altogether. Already in America developments in genetics have stirred precisely these concerns.

Genetic advances lay bare the fallacy that private health insurance is the way forward for our country. Genetics strengthens, rather than weakens the case for Britain’s NHS.

We in this country have good reason to be confident of being able to harness the benefits of genetic advance for all our citizens, rather than just a privileged few: the NHS, funded by all and there for all; genetic services, already among the best in the world, and now to be enhanced; and on top of this international strengths in science, education and industry.

We have in this country some of the best scientists, academics and universities anywhere in the world. The Government’s Medical Research Council and the Wellcome Trust were responsible for a major funding contribution to the human genome project. Over half of all European gene therapy clinical research now takes place in Britain. The UK is home to world beating pharmaceutical companies. Our biotechnology industries have more drugs in late stage clinical trials than the rest of Europe put together. And – with the sole exception of the USA – growth in investment in pharmaceutical research and development outstrips the rest of the World.

The Government wants to see British science leading the World so there is growing investment from the public purse too. Tax reforms – including new incentives for research and development – will help entrench further investment still. Already the science budget is receiving unprecedented increases. The Research Councils are now spending £600 million a year on biotechnology and medical R&D. Spending on genomics is set to rise by at least £60 million a year.

These are huge advantages for our country. If properly harnessed we can reap a double benefit: prosperity for our country’s economy and progress for our country’s health. We can now go on to pool these advantages to realise the economic and health gains genetic developments could bring.

The NHS Plan we published last summer set out our intention to establish a number of genetic knowledge parks. Today I want to tell you what they will look like and how they will work.

The knowledge parks will bring together on a single site clinicians, scientists, academics and industrial researchers. They will be centres of clinical and scientific excellence seeking to improve the diagnosis, treatment and counselling of patients. Research will help create successful spin out companies specialising in genetic technologies. Developing research and industrial clusters of this sort has already produced enormous gains in the IT sector both in this country and abroad. Where we have seen the development of a silicon valley in the past we can now develop a genetics valley in the future. Indeed with the UK’s academic, industrial and clinical strength we should aim to have more than one of them. Nor should these knowledge parks be a cold scientific or clinical environment. As here at the Centre for Life, I want them to have an open educational ethos engaging in information and debate with the public about both the science and ethics of genetics.

In the last few months we have had preliminary discussions with a number of potential partners to develop the first genetics knowledge parks. The Economic and Social Research Council is interested in a joint venture on the personal, social and ethical issues. We are discussing a joint investment with the Medical Research Council on bioinformatics. One of the UK’s major pharmaceutical companies has agreed in principle to collaborate on a genetics park. A number of universities are keen to participate too.

Stephen Byers, the Secretary of State for Trade & Industry, is working with me to ensure the new parks contribute to the government’s regional economic policy agenda. I want some of the genetic knowledge parks to strengthen the economies of regions which traditionally have had lower levels of research and development, lower indigenous company formation and fewer industries of the future.

There is enormous potential here. We need to act quickly if the UK is to maximise the comparative advantage we currently enjoy against growing global competition. I can therefore announce today, in addition to the £30 million for the NHS, a new £10 million fund – the Genetics Knowledge Challenge Fund – to establish up to four knowledge parks in England over the next few years.

Some of the new Genetics Knowledge Parks may be based in existing centres. Others will be new centres altogether. In the near future I will be inviting bids from universities, regional development agencies, NHS Trusts and private sector firms who have formed collaborative ventures to develop proposals for genetics knowledge parks. I expect to give the go-ahead to the first tranche of genetics knowledge parks before the end of the year.

What I believe is now needed is a major national effort to put Britain at the leading edge of new genetics services and new genetic technologies. We should be cashing in on the dominance we as a country currently enjoy. But that can only happen if we prepare for change and if we ensure that the public have confidence in those changes.

I have tried today to set out how I think we can take the genetics agenda forward in terms of public safeguards, service enhancements, economic developments.

As with any new science we are in uncharted territory. The response of some is to turn their back on genetic advances. To say that the implications are too big or too difficult to contemplate. To leave it to chance, to others, or to the whim of the market. I believe that would be a profound mistake for Britain.

The developments we are seeing have the capacity to bring so much good to so many people. But I recognise there is much to do if that latent potential is to be realised. I have touched on some of the crucial issues today. I do not pretend to have covered all the questions, let alone given all the answers. More work and more consideration, more public information and debate is necessary.

So I can announce today that next year, we will publish a Government Green Paper on genetics – the first of its kind. It will examine in depth the ethical, clinical, scientific and economic issues. It will build on the work undertaken by government, parliamentary committees, the Human Genetics Commission, research councils, charities and others.

There are many points of view on genetics. I want the Green Paper to be a focus for them – and to be informed by a spectrum of views and interests including patient groups, the wider community, the NHS, science and the pharmaceutical industries. I am therefore establishing an advisory panel made up of representatives from these interests to look at some of the issues the Green Paper will need to cover. The panel will be led by Lord Turnberg, the former President of the Royal College of Physicians, who has, I am delighted to say, agreed to chair it.

I believe the Green Paper will help stimulate a real national debate on the future benefits of genetics for our country. But the new frontier of genetic science and medicine recognises no boundaries between regions or nations: the clinical and ethical issues which genetic discoveries raise will be global. Britain has to maintain and enhance its position as a leading world player in the development and application of genetic technologies.

And so, as part of the preparation of the Genetics Green Paper, Britain is to host an International Conference on Genetic Medicine bringing together the world’s leading experts, to provide a global perspective on these issues.

Genetics presents a new frontier for the future of medicine and health care. The NHS should face that future with confidence. I believe Britain’s health service is in a stronger position to secure the benefits of the genetics revolution for our people than any private alternative. Better able to establish the trust of its people. Better equipped to translate scientific discovery into clinical success. Better positioned to exploit the potential of genetic testing for all our population rather than see genetic testing leading to exploitation of some in our population.

If the NHS prepares for it – as we are determined it shall – the genetics revolution will make the case for a health service based on clinical need and not ability to pay. The values of the NHS will be invaluable as the full scope of this new science reveals itself. That is why I say today, properly prepared, the development of genetic medicine will make, not break the NHS.

Our task is to prepare the NHS properly. To set boundaries beyond which science will not go but, as we have with stem cell research, to break down barriers to get the best for patients. To involve the public and invest the public finances in new technologies and new treatments which can help to improve the National Health Service and our nation’s health prospects. Above all, our task now is to determine how best we can harness the potential of genetics for the benefit of all our people and for all parts of our country.

This is the challenge of genetics. It provides an enormous opportunity for our country.

Hardly a week goes by without a new media story about genetics. Some of the advances we read about no doubt are more apparent than real. But one thing is for certain: genetics will, indeed already is changing the world in which we live – holding out the potential for new drugs and therapies, new means of preventing ill health and new ways of treating illness.

And yet, despite the profound potential inherent in the new technologies, it is a rare for any health secretary to speak about genetics. In part this reticence reflects uncertainty about the impact genetic advances will have on health care. In part it reflects unease about the ethical implications of some of these great steps forward. We have to get to grips with both.

In the process, we should not lose sight of what I am convinced are enormously exciting developments for human health. Late last year I convened a seminar on genetics in the Department of Health. Patient groups, doctors, leading scientists, the pharmaceutical industry and some of our country’s top geneticists attended. I learned a lot about both the potential and the problems associated with developments in genetics. What I heard convinced me that it is time for politicians and the public as well as scientists and clinicians to engage with the issue.

Any responsible government has a duty to assess the future challenges facing the country. Our horizon must be beyond the short term. We need now to be looking a decade or more ahead so we can ensure Britain is in the best position to benefit from the changes that will surely come.

Whether Britain prepares for it or not, advances in genetics will inevitably impact on health services and health prospects. The challenge for us is how best to ensure the impact is as positive as it will be profound; that it benefits all of our society, not just some of it.

I am no expert on genetics. I am a politician not a scientist. So what I want to say is less about the science of genetics – and more about the impact it can have.

I want to set out:

– what the Government believes could be the potential of genetics for improved health.

– the way we need now to be actively preparing the NHS so it can harness the benefits of these future advances for all the people of our country.

And a new ambition for Britain – to put us at the leading edge of advances in genetic technologies and to develop in our country modern genetic health services unrivalled anywhere in the world.
We have before us a huge potential. A gift that modern science has bequeathed medicine and society. The breakthroughs initiated by Francis Crick and Jim Watson five decades ago and taken forward by teams of scientists throughout the world in the human genome project have given us not only new knowledge about life itself but the potential power to improve life.

The human genome project has already crossed a new frontier in scientific knowledge – the question now is whether we can harness that knowledge to cross a new frontier in medicine.

The implications of the advances in genetic knowledge are enormous – equal potentially for the conquest of disease to the discovery of antibiotics. This is a revolution, with the potential in the first half of this century to dwarf the impact computer technology had on society in the second half of the last century.

In time we should be able to assess the risk an individual has of developing disease – not just for single gene disorders like cystic fibrosis but for our country’s biggest killers – cancer and coronary heart disease – as well as those like diabetes which limit people’s lives.

We will be able to better predict the likelihood of an individual responding to a particular course of drug treatment. And down the line, we will be able to develop new therapies which hold out the prospect not just of treating disease but of preventing it.

Of course it is a complex business turning new knowledge into new treatment. For one thing, the relationship between gene and environment is currently insufficiently understood. So no-one can predict right now the scale of the impact of genetics on health care, any more than we can predict its timing. There are no guarantees. It is worth remembering: people of my generation grew up being told that by now we would be certain there would be men on Mars – either because we’d gone there or they’d got here first.

What makes advances in genetic medicine different is they are already happening. Some genetic tests are currently available. Many more are within reach. There are promising signs from pioneering gene therapy treatments. Some new drugs are already being designed for specific groups in the population who can benefit most. Indeed, most experts agree the biggest advance we are likely to see in genetics in the near future lies in the discovery of hundreds of new, better targeted drug treatments.

There is no “Big Bang”. Instead, we are at the start of a “slow burn” which can only accelerate in the future. Our job is to prepare for change to harness the benefits of genetic advances and avoid its dangers. To do that we need to secure public approval for progress and to actively prepare our health care system for that progress. I now want to deal with each of these issues in turn.

First then, the views of the British public. Most of us in this room can already see the potential for healing which genetics may bring. Yet the subject evokes strong public scepticism, sometimes even hostility.

A MORI survey just last month showed that while 9 in 10 people agreed genetic developments could have positive health benefits, one third worried that research on human genetics amounts to tampering with nature. The creation of Dolly the sheep and false claims about the cloning of humans have understandably exacerbated these fears.

Little wonder then, that there remains some confusion in the public mind about where the science of genetics ends and the nightmare of eugenics begins. The pre-condition for dispelling some of the myths and ending much of the confusion is better engagement between the medical and scientific communities and society as a whole. Government and the media share a responsibility to help foster a well-informed, national debate about the promise and the problems genetic discoveries hold out for our country in the years to come.

Many of the advances we are likely to see in genetics over the next decade will probably come in areas which are the least likely to raise profound moral concerns – such as pharmaco-genetics.

But in a climate where the benefits of scientific advance are not always as automatically accepted as once they were, we need to move beyond simply stimulating a national debate about genetics. It is unfortunate but true that BSE and other developments have inflicted real damage on the standing of science. In some spheres there is the risk of an anti-science view taking hold. To protect against that prospect we need to move beyond simply providing more information or better education to the public about the potential of genetics. We have to provide positive safeguards to address the public’s concerns.

The terrible lesson of history is that science can be claimed for evil as well as for good. So whilst science must be able to discover the facts, Governments – on behalf of the public – must be able to make judgements about the use to which those discoveries can legitimately be put.

Advances in genetics raise difficult ethical questions. Most people, I guess, would accept as a good thing genetic testing for susceptibility to heart disease in order to be better able to prevent it. The same positive view would probably apply if we were able to tailor drugs to treat a particular individual for serious illness or if we could cure cancer by altering the make-up of a particular gene. Conversely, the prospect of genetically designing babies for their looks or for their intelligence is, for most people, repellent.

At present in this country, human reproductive cloning is banned because the Human Fertilisation and Embryology Authority will not licence it. The ban is welcome.

But I believe we need to go further to offer an unequivocal assurance to the public. Human cloning should be banned by law, not just by licence. I can confirm today then that the Government will legislate in the near future to explicitly ban human reproductive cloning in the UK.

There are huge potential health gains in genetic advances but until we address and allay public concerns we will not gain public consent to realise the full benefits of genetic science.

We have made a start with the Human Genetics Commission to provide independent advice on the social, ethical and legal implications. There are understandable public concerns that the advent of genetic testing will lead to new forms of discrimination – in employment or insurance for example. The extent to which the public accept, demand or avoid genetic screening services in the future will depend in part on who will have access to genetic information. There are important issues of confidentiality to be addressed. The Commission is currently exploring some of them, most notably in regard to insurance. We have also set up the Genetics and Insurance Committee to review the evidence about individual tests. The House of Commons Science and Technology Committee recently reported on the same issue. It called for a temporary moratorium on using genetic tests for insurance purposes to give time for the wider implications to be explored.

The question of whether insurance companies should have access to genetic information has provoked much public concern. There are powerful arguments for not treating genetic information the same as other kinds of information for insurance purposes. Right now the relevance of many genetic test results is still poorly understood. Many tests can only indicate an individual has a predisposition to develop a condition not a certainty that they will. Even so forced disclosure of test results could deter some people from taking tests at all, potentially putting their health at risk for fear of suffering discrimination by insurance companies or even by employers. In the longer term the danger we need to guard against is the creation of a ‘genetic underclass’, where high risk individuals are excluded altogether.

These are complex issues and it is for these reasons that the Government has asked the Human Genetics Commission to review the wider social and ethical aspects of the current policy on the use of genetic test results for insurance. We await their report and recommendations. Clearly the report is likely to give rise to a number of long term issues that will need careful consideration.

What I can say today is that the Government will look sympathetically at any proposals to prevent the inappropriate use of genetic information for insurance purposes, including legislation if necessary. If the Human Genetics Commission recommends a temporary moratorium on the use of genetic tests by the insurance industry then we will pursue it.

There will need to be safeguards to protect individuals from families affected by genetic conditions such as Huntingdon’s disease. I will therefore consult with genetic support groups and the insurance industry to examine what can be done to improve matters for those whose family history makes insurance difficult.

As the debate on insurance and genetics is revealing, genetic advances require new thought to be given to regulation nationally and internationally. In truth, scientific advance has outstripped the existing regulatory response. Without appropriate regulation, lack of public confidence will remain a significant barrier to fully harnessing the health benefits genetic developments represent.

Genetic advances can be a force for good. But that requires more than just public confidence. It requires active preparation. The genetics revolution has begun. It will only move forward faster in the future. It is time we as a nation started preparing today for the opportunities of tomorrow. Let me now set out then the preparations I believe the NHS must now make.

Whether it is genetic testing or pharmacogenetics or, in time, developments in gene therapy, the genetics revolution is going to make the NHS of the future look very different from the health service of today.

Developments in genetics should allow us to eradicate much of the trial and error common in medical practice. Much of the health service’s work today is based on a model which aims to ‘diagnose and treat’ conditions. Modern medicine has made great strides forward. But much of it still only comes into play relatively late in the history of an illness. Developments in genetics should allow us to test or screen for risk factors long before the symptoms of disease develop. The NHS of the future should increasingly allow us to ‘predict and prevent’ the common diseases of later life.

Genetics will never mean a disease-free existence; but understanding of genetics could eventually help to free society from some of today’s major diseases. The plans my department are currently discussing with the Wellcome Trust and the Medical Research Council for one of the world’s largest studies – involving 500,000 volunteers – into the interaction between genes and environment will give us further vital clues.

To realise the potential genetic advances could have, however, the NHS will need to change the services it offers. Hospitals might do less invasive surgery but more gene therapy treatment. Overall the NHS will need to gear itself increasingly to prevention and not just treatment. In primary care where the majority of patients will be seen, the pattern of care will alter, as new services take the place of existing ones: more genetic screening alongside more specialist genetic counselling; more regular check-ups; more help for people to give up smoking not just advice that they should; more exercise on prescription alongside drugs on prescription, tailored to the individual’s personal genetic profile.

Patients, of course, must be able to choose how best they as individuals can benefit from these genetic advances. People have a right to know and a right not to know information about their own health. For genetic tests, the rate of take-up will inevitably depend on factors such as family health history and the possibility of treatment. There will be huge dilemmas for the individual patient – as women who are at high risk from breast cancer have already found after deciding whether or not to have a genetic test. But overall, I believe genetic developments should give patients more control and more choice over their own health.

The role of health professionals will be to help patients choose what is right for them. There will be a greater emphasis on providing clear information to patients so they can make informed choices. Informed consent should be the governing principle here, with a greater sense of partnership between professional and patient.

Genetic services will spread out of specialist centres into GP surgeries, health centres and local hospitals as I know you are now doing here in the North East. A new generation of specialist primary care professionals are likely to develop to work alongside family doctors – and help relieve the burden on them – by specialising in genetic testing, advice and counselling. Mainstreaming genetic services in the NHS will also require big changes in how we educate and train health professionals.

There is then a lot of preparation to do. Day-by-day we are seeing advances which could offer more patients the benefits of genetic services. Today for example, I am able to announce agreement between my department and the Cancer Research Campaign for the use of their world class research to support testing for the presence of breast cancer genes. The CRC has held a patent on the detection of one of the breast cancer genes for some time. Such a patent could have made it prohibitively expensive for the NHS to test women for this gene if the CRC had used their patent powers to impose a charge. The agreement we have reached with the CRC ensures that women will not face this problem – so incidentally giving the lie to the claim that some have made that genetic patenting inevitably will land the NHS with unaffordable costs. I can also say today that discussions are underway with a leading United States-based biotechnology company, Myriad Genetics Inc, to enable NHS patients to benefit from the company’s extensive research and development on a related breast cancer gene. I hope these discussions will be a model for future collaborations with our health service.

These advances, however, inevitably place great strain on NHS genetic services. I want to pay tribute not only to the work that John and his team do here in Newcastle but to the work of our regional genetic services up and down the country. You already provide vital – sometimes life-saving services for thousands of people with single gene disorders. You are at the sharp end of the genetics revolution – a revolution with the potential to transform health care in our country but which must not be allowed to overwhelm it.

Here in Britain we start with a great advantage. Despite the very real pressures our genetic services are under, they are the envy of Europe. A recent study in the European Journal of Genetics concludes that the UK and the Netherlands provide our continent’s most comprehensive genetic services.

According to the Nuffield Trust no other country in the World provides a service which offers combined strengths in clinical, laboratory and research activities. When it comes to genetic services it is no exaggeration to say the NHS is a world leader. Now it is time to enhance the capacity of our genetic services so they are better able to capture advances in genetic medicine for many more NHS patients.

Today I can announce a £30 million package of new investment in NHS genetic services.

Firstly, the government will increase the number of consultants specialising in genetics. The NHS is in the midst of major expansion, after decades of neglect and under-investment. Already there are than 17,000 nurses and 6,500 more doctors than when we came to office. The next few years will see further expansion still. Genetic services will be a major beneficiary. Consultants numbers will double from 77 today to over 140 by 2006.

Secondly, we will also double the number of scientific and technical staff working in genetics over the next five years to provide the specialist laboratory skills needed to maximise benefits to patients. Staff numbers will rise by 300.

Thirdly, we will more than double the number of genetic counsellors working in the NHS not only in specialist units but in primary care as well. There will be at least an extra 150 posts and we will work closely with Macmillan Cancer Relief to develop more specialist genetic cancer counsellors.

Fourthly, we will create two new national reference laboratories for genetics specialising in rare genetic disorders and identifying new tests and treatments that can bring benefits to patients.

Fifthly, we will address the lottery in care in genetics services. As the Bobrow report recommended, we will now, for the first time, form our regional genetics services into a single national network capable of providing specialist services to groups of patients regardless of where they happen to live. The creation of a Genetics Commissioning Advisory Group involving patient representatives under the chairmanship of Sir John Pattison will also ensure greater national co-ordination of genetic services.

More consultants, more scientists, more counsellors, new laboratories and a new national network of specialist genetics centres – a five point plan for expansion in genetic services – will allow the NHS to offer greatly enhanced treatment and care for patients.

The number of NHS patients being seen by specialist genetics services will increase by 80% to 120,000 a year over the course of the next few years. More NHS patients with common conditions like cancer as well as those with single gene disorders will be offered tests. Regional centres will be able to routinely see the family members of patients so they also have the information and the tests necessary to make decisions about their own future treatment needs.

Waiting times to see a genetics specialist will fall from as long as twelve months at present to just three months in future. Laboratory test times too will fall and test numbers will double by 2005.

This is the first tranche of investment we will be making to ensure the NHS is able to offer patients the benefits of the latest genetics advances. Further investment will be needed in education and training for staff and in IT systems as well as in new equipment. I know that in this region funding for genetic services will expand by one quarter over the next three years alone. The investment we are making is not just a signal of our belief that these advances hold out real health care benefits, it is confirmation of our belief that the NHS is uniquely placed to maximise those benefits for all.

Some argue that the costs of absorbing these advances will swamp the NHS. That is not my view. Of course there will be up front costs if the NHS is to spread the benefits of genetic developments. But, down the line, there could be significant financial gains to put alongside major health gains. For example, using genetic profiling to more accurately prescribe drugs will reduce side-effects, improve treatment outcomes and save the NHS a small fortune. Advances in pharmacogenetics could reduce the estimated 1 in 20 of hospital admissions which result from adverse drug reactions and currently cost the NHS anywhere between £1billion and £2.5 billion a year. Similarly, once we are able to identify say, the 10% of people most at risk from heart disease we will be able to provide them with extra preventive services. One estimate puts the costs of doing so at around £60 million with the savings at around £200 million.

There is no other health care system better placed to harness the potential of the great advances now within reach than the National Health Service. The way the NHS is organised – providing care for all on the basis of need, not ability to pay – uniquely suits it to capturing the benefits of genetics for the good of all.

Our nation’s health service is our best defence against the nightmare vision of a ‘Brave New World’ of two tier health care: a “genetic superclass” of the well and insurable; and a “genetic underclass” of the unwell and uninsurable, unable to pay the premiums for medical care.

Britain’s system of socialised health care means citizens can choose to take genetic tests free from the fear that should they test positive they face an enormous bill for insurance or treatment. Worse still that they are priced out of care or cover altogether. Already in America developments in genetics have stirred precisely these concerns.

Genetic advances lay bare the fallacy that private health insurance is the way forward for our country. Genetics strengthens, rather than weakens the case for Britain’s NHS.

We in this country have good reason to be confident of being able to harness the benefits of genetic advance for all our citizens, rather than just a privileged few: the NHS, funded by all and there for all; genetic services, already among the best in the world, and now to be enhanced; and on top of this international strengths in science, education and industry.

We have in this country some of the best scientists, academics and universities anywhere in the world. The Government’s Medical Research Council and the Wellcome Trust were responsible for a major funding contribution to the human genome project. Over half of all European gene therapy clinical research now takes place in Britain. The UK is home to world beating pharmaceutical companies. Our biotechnology industries have more drugs in late stage clinical trials than the rest of Europe put together. And – with the sole exception of the USA – growth in investment in pharmaceutical research and development outstrips the rest of the World.

The Government wants to see British science leading the World so there is growing investment from the public purse too. Tax reforms – including new incentives for research and development – will help entrench further investment still. Already the science budget is receiving unprecedented increases. The Research Councils are now spending £600 million a year on biotechnology and medical R&D. Spending on genomics is set to rise by at least £60 million a year.

These are huge advantages for our country. If properly harnessed we can reap a double benefit: prosperity for our country’s economy and progress for our country’s health. We can now go on to pool these advantages to realise the economic and health gains genetic developments could bring.

The NHS Plan we published last summer set out our intention to establish a number of genetic knowledge parks. Today I want to tell you what they will look like and how they will work.

The knowledge parks will bring together on a single site clinicians, scientists, academics and industrial researchers. They will be centres of clinical and scientific excellence seeking to improve the diagnosis, treatment and counselling of patients. Research will help create successful spin out companies specialising in genetic technologies. Developing research and industrial clusters of this sort has already produced enormous gains in the IT sector both in this country and abroad. Where we have seen the development of a silicon valley in the past we can now develop a genetics valley in the future. Indeed with the UK’s academic, industrial and clinical strength we should aim to have more than one of them. Nor should these knowledge parks be a cold scientific or clinical environment. As here at the Centre for Life, I want them to have an open educational ethos engaging in information and debate with the public about both the science and ethics of genetics.

In the last few months we have had preliminary discussions with a number of potential partners to develop the first genetics knowledge parks. The Economic and Social Research Council is interested in a joint venture on the personal, social and ethical issues. We are discussing a joint investment with the Medical Research Council on bioinformatics. One of the UK’s major pharmaceutical companies has agreed in principle to collaborate on a genetics park. A number of universities are keen to participate too.

Stephen Byers, the Secretary of State for Trade & Industry, is working with me to ensure the new parks contribute to the government’s regional economic policy agenda. I want some of the genetic knowledge parks to strengthen the economies of regions which traditionally have had lower levels of research and development, lower indigenous company formation and fewer industries of the future.

There is enormous potential here. We need to act quickly if the UK is to maximise the comparative advantage we currently enjoy against growing global competition. I can therefore announce today, in addition to the £30 million for the NHS, a new £10 million fund – the Genetics Knowledge Challenge Fund – to establish up to four knowledge parks in England over the next few years.

Some of the new Genetics Knowledge Parks may be based in existing centres. Others will be new centres altogether. In the near future I will be inviting bids from universities, regional development agencies, NHS Trusts and private sector firms who have formed collaborative ventures to develop proposals for genetics knowledge parks. I expect to give the go-ahead to the first tranche of genetics knowledge parks before the end of the year.

What I believe is now needed is a major national effort to put Britain at the leading edge of new genetics services and new genetic technologies. We should be cashing in on the dominance we as a country currently enjoy. But that can only happen if we prepare for change and if we ensure that the public have confidence in those changes.

I have tried today to set out how I think we can take the genetics agenda forward in terms of public safeguards, service enhancements, economic developments.

As with any new science we are in uncharted territory. The response of some is to turn their back on genetic advances. To say that the implications are too big or too difficult to contemplate. To leave it to chance, to others, or to the whim of the market. I believe that would be a profound mistake for Britain.

The developments we are seeing have the capacity to bring so much good to so many people. But I recognise there is much to do if that latent potential is to be realised. I have touched on some of the crucial issues today. I do not pretend to have covered all the questions, let alone given all the answers. More work and more consideration, more public information and debate is necessary.

So I can announce today that next year, we will publish a Government Green Paper on genetics – the first of its kind. It will examine in depth the ethical, clinical, scientific and economic issues. It will build on the work undertaken by government, parliamentary committees, the Human Genetics Commission, research councils, charities and others.

There are many points of view on genetics. I want the Green Paper to be a focus for them – and to be informed by a spectrum of views and interests including patient groups, the wider community, the NHS, science and the pharmaceutical industries. I am therefore establishing an advisory panel made up of representatives from these interests to look at some of the issues the Green Paper will need to cover. The panel will be led by Lord Turnberg, the former President of the Royal College of Physicians, who has, I am delighted to say, agreed to chair it.

I believe the Green Paper will help stimulate a real national debate on the future benefits of genetics for our country. But the new frontier of genetic science and medicine recognises no boundaries between regions or nations: the clinical and ethical issues which genetic discoveries raise will be global. Britain has to maintain and enhance its position as a leading world player in the development and application of genetic technologies.

And so, as part of the preparation of the Genetics Green Paper, Britain is to host an International Conference on Genetic Medicine bringing together the world’s leading experts, to provide a global perspective on these issues.

Genetics presents a new frontier for the future of medicine and health care. The NHS should face that future with confidence. I believe Britain’s health service is in a stronger position to secure the benefits of the genetics revolution for our people than any private alternative. Better able to establish the trust of its people. Better equipped to translate scientific discovery into clinical success. Better positioned to exploit the potential of genetic testing for all our population rather than see genetic testing leading to exploitation of some in our population.

If the NHS prepares for it – as we are determined it shall – the genetics revolution will make the case for a health service based on clinical need and not ability to pay. The values of the NHS will be invaluable as the full scope of this new science reveals itself. That is why I say today, properly prepared, the development of genetic medicine will make, not break the NHS.

Our task is to prepare the NHS properly. To set boundaries beyond which science will not go but, as we have with stem cell research, to break down barriers to get the best for patients. To involve the public and invest the public finances in new technologies and new treatments which can help to improve the National Health Service and our nation’s health prospects. Above all, our task now is to determine how best we can harness the potential of genetics for the benefit of all our people and for all parts of our country.

This is the challenge of genetics. It provides an enormous opportunity for our country.

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, to the LSE Annual Health Lecture on 8 March 2000.

It is a great honour to be here this evening to give the sixth annual LSE Health Lecture. Health secretaries don’t often speak at the London School of Economics. But there are powerful reasons – as I will set out in a moment or two – for seeing a new and closer relationship between the state of our country’s economy and the state of our country’s health.

As a Cabinet Minister who has served in both the Treasury and the Department of Health people sometimes paint me as a gamekeeper turned poacher. This might make clever newspaper copy. But it assumes a dichotomy that I consider to be false. Treasury parsimony versus Health profligacy. It demonstrates a profound misunderstanding of the role of health and health care in the modern economy.

Health care as social investment

The conventional orthodoxy is that health spending is a debit, not a credit – a drain on the economy and a burden on the taxpayer. I want to demonstrate today that in the new global knowledge-based economy it is time to turn that thought on its head. I will argue that health is not only a good in its own right but that good healthcare is an imperative for improved productivity and national economic success. Put a different way, I am arguing that healthcare spending is not just a question of resource distribution, but is also linked to the physical and social organisation of economic production. In other words health care should be regarded not just as current consumption but as social investment. An investment that builds Britain’s economic infrastructure.

But it can only rightly be so if two conditions are fulfilled. One, that it is organised efficiently to deliver the maximum health gain without generating undue economic burdens. And two, that it is organised so that it delivers preventative services and not just sickness services, intervening upstream as well as downstream.

My contention is that the UK’s health service – modernised and reformed – will be better placed than most other systems of health care world wide to fulfil these conditions. In other words, the Government’s modernisation programme for the NHS has positive economic benefits for UK plc.

That is not the traditional view. Indeed, over the past decade or so health care reform in the developed world has been driven by cost containment. In the USA, for example, new managed care systems have begun to make significant inroads into the spiralling costs of the American medical-industrial complex. Yet, despite this, in January this year, President Clinton had to go to Congress for $110 billion funding so that just 5 million uninsured Americans could get health care cover.

Similarly, in Western European countries changes to rigid and, sometimes, bloated welfare systems have been fuelled by intense concern about national competitiveness in a period of rapid globalisation. This is perhaps not surprising given the structural inefficiencies intrinsic, for example, to the French and German social insurance health care financing systems.

In the light of recent noises “stage right” in our country about moving away from a tax-based system, it is worth making the point that the funding system that we have in the UK is, from the perspective of enterprise and competition, arguably, the most efficient way of financing health services. Tax based funding relies on the whole tax base, so it reduces distortions in the economy. By contrast, social insurance tends to fall heavily on the employed and employers. That is why French employers are walking away from it. The Institute of Directors in the UK may wish to take note. Social insurance turns healthcare into a tax on jobs. It has distributive and incentive effects that are hard to offset. It can also make job switching more difficult, reducing labour flexibility.

It’s worth noting too that a tax-based NHS as a model has competitive advantage over its Western European comparators for at least three other reasons. By virtue of its global budgeting, which controls healthcare inflation. By virtue of its low transaction costs, which means resources reach the frontline. And by virtue of its clinically managed care, which is provided by the GP gatekeeper role. Ironically, at the very time that some would urge us to abandon our model in favour of the continental health care model France and Germany are looking to import the very best features of the UK’s health care system.

The truth is that the NHS, in the words of the OECD, is “a remarkably cost effective institution.” That is not to say that there is not variation in performance which needs to be tackled. There is more that we can get out for what we put in – but overall as the Prime Minister has rightly said, we need to invest more of our national income in the NHS.

That is right, because as countries grow more prosperous they choose to invest more in health care. This is a perfectly rational thing to do, aggregating as it does the individual preferences of citizens in advanced industrial economies.

It is of course also right that we only spend what we can afford. Any other route leads to economic ruin. Careful management of the public finances is one of the keys to economic stability. As previous governments have found to their cost, without it we will simply not get the growth, prosperity and employment that the country needs. That is why this Government has constructed a new macroeconomic framework to provide the stable foundations for economic growth. It is also why we seek to reshape public spending, as far as possible, so that it invests in future success rather than mopping up the costs of past failure.

I want to argue today that health expenditure is such an investment for success. Health is, of course, an important goal in its own right – an intrinsic good. Its value is one of the truths that we as a society hold to be self-evident. As Halfdan Mahler, a former Director of the World Health Organisation has said, health isn’t everything – but without it you have got nothing. Good health is the route by which each and every one of us can properly fulfil our true potential. It unlocks life chances, and is a fundamental building block of wellbeing

The link between health and economic success

But such health investment is also of instrumental importance in improving national economic performance. As economic historians such as Fogel and others have concluded, perhaps one third of the per capita growth rate in Britain between 1780 and 1979 was as a result of improved health and nutritional status. And the World Health Organisation has reported that this figure is within the range of estimates produced by similar cross country studies for the last three or four decades.

Just last month, a report in the Journal “Science” by Bloom and Canning noted the striking finding that real income per capita will grow at a third to half (0.3%-0.5%) a year faster in a country where life expectancy is five years longer than in another country which is comparable in all other respects. This is significant, at a time when growth rates over the past few decades have averaged only 2-3%, and when there is every prospect of life expectancy increasing by a further 5 years over future decades. The mechanisms underlying this relationship include the direct impact of health on labour productivity; the incentive that people living longer have to invest in developing their skills; the fact that longer lives and greater savings for retirement can lead to increased investment; and the existence of a healthy and educated workforce as a “magnet” for foreign investment.

Another study by the Pan-American Health Organisation of an emerging economy found that for every one year’s increase in life expectancy there will be an additional 1% increase in GDP 15 years later. And as the importance of human capital grows in advanced economies, health status may have a greater and not a lesser impact on economic output.

This is because, in today’s world it is no longer simply access to financial resources or to physical resources that make or break a country – any more than they make or break a company. In today’s world the raw materials of any country are the skills of its people. Now in the new knowledge-based economy labour is king. Today as never before our key asset is our human resources. Human skills are a precious commodity. They have to be nurtured and maintained.

The contribution of healthcare

In the knowledge economy, there really is a premium on good health. And on good health services. Even the Institute of Directors acknowledged just last month that:

“The efficient provision of healthcare services is of vital importance for business. Sickness is a major cost for business, and, if an employee goes long term sick, this can be very disruptive, especially for small businesses.”

Sickness is a hidden social tax on business, undermining competitiveness and reducing productivity. 47,000 working years for men alone are lost every year due to coronary heart disease, and the total lost to all disease is almost a quarter of a million years each year. That’s not just a health concern – it is an economic concern too. If you changed that sentence to “quarter of a million working years lost to industrial action last year” then business would be banging on Government’s door and demanding urgent action.

The CBI estimates that temporary sickness absence costs business over £10 billion each year. As the IOD noted, these disease-driven inefficiencies in the economy can have particularly acute effects on small and medium sized enterprises. Here smaller pools of employees mean that the temporary loss of indispensible skills can spell disaster.

And not just for the individual firm. There are wider implications for the economy as a whole. Ill health involves a major loss of productivity potential. It imposes costs on taxpayers and it has significant opportunity costs too. Ill health is a significant cause of unemployment and its attendant costs to the benefits bill. 15% of jobless people cite back pain alone as a reason for not working. It accounts for 119 million days of certified incapacity. It also consumes 12 million GP consultations and 800,000 in-patient days of hospital care. It costs the state almost £1/2 billion each year. These figures point to a clear relationship between ill health and labour market exclusion.

Figures released just last week by the Office for National Statistics suggest that 29% of adults in workless households said their health was not good, compared with eight per cent in homes where someone worked. The number of people who are long term sick and disabled wanting a job but not presently looking has doubled in just a decade to almost 750,000.

This level of ill-health causes a loss of productivity and a loss of potential skills that a human resource-led labour market can ill-afford. As we move towards the potential of full employment, that threat to growth becomes more real – there are already labour shortages in specific areas. This threat to growth and low inflation can be at least partly offset by growing the active labour supply. The feasibility of doing this is demonstrated by the fact that when this Government came to office, four and a half million adults lived in households where no-one was working, twice the rate of France and four times the rate of Germany.

Worse still, worklessness is now the principal cause of poverty in Britain today. And the well-versed argument that poverty – principally through peoples’ exclusion from the labour market – is a significant cause of ill health is only one part of the equation. It is true that poorer people are ill more often and die sooner. The other part of the equation, however, is that poor health contributes to poverty, not least because it excludes people from the labour market. Studies of the effect of chronic mental health problems have shown this relationship, and it exists for other conditions too. The route between poverty and ill health then, is not a one way street. It is a two way street.

Poverty finds expression in social division and in social exclusion. It is not just their victims who end up paying the price. We all do. The decent hard-working families who live in fear of crime. The loss we all feel from a declining sense of shared community. The taxpayers who pay the bills of social failure. This is one way that the cycle of ill-health and poverty imposes economic burdens.

There are other ways too. Poverty cascades down the generations. Up to a quarter of all children are persistently in low income families. Babies born to fathers in social class five are more likely to be low birth weight. Low birth weight is a key fact in a child’s subsequent development and opportunity. Poor children are less likely to get qualifications and to stay on at school. Poor health then is linked to low educational attainment, distorting our future competitiveness in the knowledge economy.

The vicious cycle of poverty, social exclusion, educational failure and ill health is mutually reinforcing. It needs to be broken. It can be broken. We know that good education is a route out of social exclusion and into prosperity. The time has come to recognise that health just like education is a route to economic fulfilment and personal fulfilment Just as good education is a route out of social exclusion and into economic prosperity so too is good health. By intervening in the poverty cycle, health services can effect what Giddens calls the “redistribution of possibilities”.

Modernised NHS for a modern economy

What, then, should be the response of the healthcare system? A modernised NHS can rise to these economic challenges by providing new interventions that actively help break the cycle of poverty and ill health, that are preventative as well as curative, and which are fast and convenient.

First then an NHS that works with others to help break the cycle of poverty and ill health as a contribution to expanding the productivity potential of the wider economy. In the first three years of the last decade if all men of working age had had the same death rates as those in the top two social classes there would have been 17,000 fewer deaths each year. Action here is long overdue. The White Paper Our Healthier Nation sets out an ambitious programme not only to improve the health of the nation but to close the health gap between the worst off and the better off. SureStart is one of the key delivery mechanisms – putting extra resources into health and education services in deprived communities, targeted at the first three years of a child’s life. Similar action involving local authorities, voluntary organisations and others to tackle teenage pregnancy, or drug misuse, are other examples of the approach.

But we also need to reverse the inverse care law that has dogged the NHS for fifty years – whereby those with the greatest health need get the least health care. You can see that in the way that those parts of the country that have the worst levels of heart disease often have the worst heart services. Two days ago I said I would break that cycle by targeting new cardiac services into those areas where they were most needed. Health Action Zones are another means to the same end.

Second an NHS that is preventative as well as curative. That means intervening earlier rather than later. Our modernisation programme will help transform the NHS into a springboard for better health, not just a fix-and-mend service when people fall ill. So, for example, this winter the NHS became the first country in the world to introduce the Meningitis C vaccine.

In our new blueprint for saving 20,000 heart disease lives a year we set out how improvements in heart surgery can make a real difference to survival rates. But the new smoking cessation services that we are providing for the first time on the NHS signal how it can stop just acting as a sickness service and start fully working as a health service. We are also expanding access to the most cost-effective treatments such as aspirin, beta-blockers and statins to help prevent the need for heart surgery in the first place.

But all of these preventive activities have to be grounded in knowledge of what works and what does not. That is not always the case at the moment. We cannot afford well intentioned but ineffective programmes. That is why I have tasked the NHS R&D programme to provide a better evidence base for health promotion. Public health activity needs to demonstrate cost-effectiveness just as do other forms of health intervention.

Even more fundamentally, the time has come to take public health out of the ghetto. For too long the overarching label ‘public health’ has served to bundle together functions and occupations in a way that actually marginalises them from the NHS and other health partners. Let me explain what I mean. ‘Public health’ understood as the epidemiological analysis of the patterns and causes of population health and ill-health gets confused with ‘public health’ understood as population-level health promotion, which in turn gets confused with ‘public health’ understood as public health professionals trained in medicine. So by a series of definitional sleights of hand the argument runs that the health of the population should be mainly improved by population-level health promotion and prevention, which in turn is best delivered – or at least overseen and managed – by medical consultants in public health.

The time has come to abandon this lazy thinking and occupational protectionism. To do that we need to distinguish these three meanings of public health. The National Service Frameworks provide a way to do so. Take the Coronary Heart Disease NSF published this week as the model. It starts with an evidence-based analysis of the patterns and causes of heart disease. It then attempts a dispassionate look using the available evidence at the relative contribution to tackling heart disease that can be made by primary prevention, secondary prevention, hospital treatment and care. It seeks to identify the optimal cost-effective mix between them, rather than privileging one level of intervention for its own sake. And then it allocates responsibilities between agencies and professions on an entirely pragmatic basis, not on the basis of historical demarcations.

In short, rather than define the NHS as healthcare delivery, and then assert that the NHS has very little do with health improvement, the time has come to reframe what we mean by the NHS and how it acts. The NHS has to encompass the full spectrum of intervention, and it has to get in to new ‘markets’ too – as a provider of information and lifestyle advice not just a provider of treatment and care.

Which is not to understate the importance of health care treatment. Because the third method by which NHS modernisation can contribute to improved health and economic success is by providing treatment services that are fast and convenient. I believe that the principles of the NHS are right but that its practices have to fundamentally change. People wait too long for treatment. Faster waits for cancer treatment, new fast track chest pain clinics and services that are recast to design delays out of the system are all important. And they are on the way. Last year the NHS treated about 5 million working age adults as in-patients. Around three quarters of these patients waited under six months, but a fifth waited for between six and twelve months; and about one-in-twenty waited more than a year. We need to do further work to model the proportion of conditions that kept people off work or out of the labour market, and the proportion of treatment that succeeded in getting people back to work. But it is clear that faster and more effective treatment services will get people back to work more quickly.

In these three ways – tackling health inequality, plus better prevention, plus faster intervention – the NHS is changing the way it works and what it does. In the process it is becoming better placed not only to meet the needs of individual patients but to meet the needs of the economy too. It is performing an economic function as well as a health function. It is good for patients and it is good for business.

The health of workers

Indeed I think that we need to look to see what more the NHS can do here. An obvious area of potential is the sphere known as occupational health. The growth of the knowledge-based economy and the premium on retaining skilled labour means that employers – whether in the public or private sector – will face higher opportunity costs from sickness absence. They will also have to find new ways of retaining and rewarding their staff. Pay of course will be a key determinant. But people’s career decisions are not simply crude financial calculations. Flexible working patterns will be important too, particularly for parents with young children. And so too will be facilities to maintain good health at work. As it is employees and their representatives are increasingly litigious about health and the workplace – so it is enlightened self-interest for employers to make sure that their own house is in order.

In the past “occupational health” has tended to have a heavy health and safety bent to it. The Health and Safety Commission will shortly publish proposals to modernise occupational health so that it is better suited to the needs of small and medium sized businesses.

The NHS has to make sure that its own house is in order on this issue. Healthcare is one of the biggest knowledge-based sectors of the economy, and we cannot afford to lose highly skilled staff. Quite the reverse. I want to expand the services that the NHS provides to make them faster and better for patients – and that relies on having more doctors, nurses and other health care professionals. Improving quality of working life in the health service is one of the factors that will help us expand staff so that we can expand services That is why I am examining how we can improve occupational health care services for our own employees whether in the primary, community or secondary care sectors.

There are some real beacons of good practice in the NHS. The Walsall Hospitals NHS Trust’s Occupational Health Department for example looks after 6,000 staff at the trust as well as its neighbouring NHS organisations. Managers get pre-employment checks and staff get health checks, advice on health and safety, health information, risk assessment, environmental health advice and stress management. But what is unusual here is that Walsall is also successfully marketing its services to both the public and private sectors, selling its occupational health services to the local university and to 12 small factories. It gets back enough money to break even. The Royal Berkshire and Battle Hospital NHS Trust generates £100,000 a year looking after employees in a number of small businesses and public sector bodies.

These two NHS organisations are making a tangible contribution to business. I am interested in exploring whether there is scope for the NHS more generally to provide similar occupational health services to employers. ‘NHSPlus’ if you like. A service of this sort might be particularly valuable for small and medium-sized firms which lack the size to organise in-house services but where ill health amongst key employees can have devastating consequences.

Back pain and stress management services will be of particular relevance, as shown by the 19 ‘Back in Work’ pilots that are now operating. Sandwell Healthcare NHS Trust, for example, is now working with small and medium sized businesses to provide early assessment and intervention for workplace back pain. Salisbury Healthcare NHS Trust is working with 300 local businesses in partnership with the local Chamber of Commerce.

And let’s be clear about two things. First – providing these new services will potentially be good for the NHS, not a burden. Intervening to prevent and avoid injuries and sickness will have downstream benefits for the NHS in avoided GP appointments, outpatient attendances and hospital treatment. And second – these new services hold out the prospect of net savings to employers, not extra costs. What’s more, as NHS waiting times come down for elective surgery, private employers will increasingly be able to free up the £1 billion-plus they currently spend on employee private health insurance, instead targeting that resource on more effective workforce health interventions of the sort that NHS Plus might provide.

There is then an intimate connection between good health, properly targeted health services and economic performance. So far my argument has focussed on three groups in the population. One – potential workers currently outside the labour market as a result of mutually reinforcing processes of social exclusion. Two – future workers, namely our children, for whom health and educational attainment are the routes to prosperity. And three, existing workers – and their employers – affected by sickness absence.

The health of older people

But there is a fourth group – retired people – that is ex-workers – whose health status also has an impact on economic performance. If we look at the country’s demographic profile there are significant implications for the economy in the next few decades. The number of older people has doubled since 1931. The overall upwards trend is set to continue to about 2030, when the population will stop growing as a result of past falls in birthrates. Increasing numbers of people will survive well beyond the age of 85.

We have to make the investment choices now about what those extra years of life are going to be like. If they are years of ill-health, disability and dependency that has clear economic consequences. It will mean not only that older people cannot contribute economically in their “third age”, but it means high costs for formal care, however it is financed. For those outside formal care, potentially productive labour will be taken out of the economy for informal care of dependent older people.

So investment now to prevent ill-health and to promote fast and effective treatment and rehabilitation may be as important economically as it is socially. There is evidence to suggest that increasing years of life can be relatively healthy, or of only mild-to-moderate disability. But the extent to which that is the case will depend on, amongst other things, on the availability of good health services including active rehabilitation.

The new aim of our care services here is to foster independence for elderly people just as it is to foster independence for working age people. We should no longer accept the so-called ‘dependency ratio’ (that is, the ratio of working age adults to others) as the principal prism through which we view these matters. Perhaps we need a new measure – perhaps we should call it the ‘independency ratio’ – to track the proportion of the post 65 population capable of active life and self care. Developing services to improve this measure is precisely what the Government intends to do. We are committed to a new set of intermediate care services specifically designed around the rehabilitation and recovery needs of elderly people. And for the reasons I have outlined, they will be beneficial both in human and in economic terms.

Conclusion

So to conclude – good health, good healthcare and good economic performance should no longer be seen as parallel universe. They are mutually reinforcing. You can’t have one without the other. It is time to look at the NHS in a new way.

No longer just as a consumer of resource. But instead as a generator of wealth. No longer just as a provider of treatment services. But instead as a promotor of good health. No longer working in isolation. But instead working alongside others to foster independence and create opportunity.

In short the NHS can make a major contribution to improving productivity and expanding the economy.

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, in Geneva, Switzerland on 19 May 2003.

The UK Government endorses the statement made by the Presidency of the European Union.

I want in particular to record our thanks to Dr Brundtland for the successful role she has played over the last 5 years as Director-General. She has successfully led the World Health Organisation through a time of change and challenge for all health systems – in the developed world every bit as much as the developing world. I believe the World Health Organisation has been immensely strengthened by her period as Director-General.

As events of recent weeks show, the world needs a strengthened World Health Organisation. The emergence of SARS in developing and developed countries, in the Northern and Southern hemispheres, has confronted all nations with a new public health challenge.

Sadly, this is not the first time nor will it be the last that the global community has had to respond to new and emerging diseases. In the last 30 years we have been faced with the emergence of an average of one new infectious disease a year. As the new threat of bioterrorism signifies, infectious diseases are now a challenge to stability and security as much as to health and prosperity to this generation of children as well as future generations..

If the WHO did not exist we would now surely have to invent it.

The WHO has been at the forefront of combating the spread of SARS, using its global surveillance networks. The United Kingdom believes we not only need to maintain a strong WHO, but we need to strengthen those surveillance systems, to cope with old threats and new.

Global trade and travel, environmental, land use and other changes, make inevitable the emergence of new infectious disease. Infectious disease recognises no international boundaries.

Our best response is no more a fortress world, than it is a fortress Europe or a fortress United Kingdom. If the international community is to successfully resist calls for a world of closed borders and isolationist economies – with all the loss that would mean for developing and developed nations alike – then a new global resolve is now needed.

First, the emergence of SARS demonstrates, were there any doubt, of the need to maintain and strengthen international vigilance. Our watchword must be to “expect the unexpected”. Where infectious disease in one part of the world can become within days, if not hours, a problem for another; each and every nation owes an obligation, one to another. To put in place the surveillance, the capacity and the planning to combat these new threats. And I hope the WHO will lead this new global resolve by preparing a nation by nation audit of our state of international preparedness. Nor, if necessary, should we shrink from strengthening obligations under international law.

This is the agenda we wish to support the WHO in developing. Not only to defeat the major diseases that effect child and adult alike – TB, malaria, HIV/AIDS. Not only to successfully prevent disease like cancer and heart disease through measures such as the Framework on Tobacco Control which the UK supports and looks forward to seeing successfully concluded. But a renewed focus on strengthening our ability to combat new diseases as they emerge. We strongly welcome Secretary Thompson’s announcement of new resources to allow us to do just that. Just as in the UK we are continuously reviewing and strengthening our surveillance systems and contingency plans, I hope the WHO will help every country to do the same.

For second, if we are to successfully combat infectious disease, we can only do so with public support. Resilient public health systems are the bedrock of public confidence. Without them public concern can all too easily overwhelm scientific sense. SARS shows the importance of developing such resilience. It also demonstrates the need to maintain a sense of perspective and proportion about risk. We need to examine better ways of informing and educating our publics about the nature of risk and relative risk in health. Not just to change behaviour in order to reduce risk but to be clear that panic and over-reaction can be as harmful to public confidence as complacency and inadequate preparedness. All the actions we take and the advice we give must be firmly rooted in the best scientific and clinical evidence.

While we should never pretend that medicine is anything other than a human science – not an exact one – we cannot allow fear to dictate our response to the new threats we all face. I welcome the accent the WHO has put on patient safety. I hope together we can now consider how better to communicate risk to the people we all serve.

The WHO is in a stronger position to pursue such an agenda because of the leadership of Dr Brundtland. There is much for which we have to thank her. We shall remember her many achievements with gratitude. We wish her well for the future.

And we look forward to working closely with her successor as together, we work for a more healthy and more secure world.