Tag: 2002

  • Alan Milburn – 2002 Speech to the NHS Chief Executives’ Conference

    Below is the text of the speech made by Alan Milburn, the Secretary of State for Health, on 13 February 2002.

    Thank you for coming – and for all you do day in day out in the service of others.

    I have called this summit today to discuss with frontline nurses, health visitors and midwives together with your representatives how we can build on the progress that is taking place in building up the NHS after decades in which it was run down.

    Today for all the problems there are in the NHS – and which are very real – there are real signs of progress. The NHS Modernisation Board made this very point in its annual report just four weeks ago. Figures published at the end of last week showing fewer patients dying following surgery, more patients getting heart operations and more patients surviving cancer confirmed that progress is underway. Today the figures we are publishing on growth in staff numbers reinforce that the NHS is moving in the right direction.

    There is of course a long way to go. After decades of neglect it will take time and effort as well as sustained resources to bring about the sort of modern health service both patients and staff want to see. There will be ups and downs along the way but the NHS is on the road to recovery. The investment and reforms that are going in are starting to pay dividends.

    Nowhere is the impact of rising investment more important than on staff numbers. Shortages of staff are the biggest constraint that the NHS faces in expanding services for patients. NHS staff are the health service’s best asset. Every patient knows that. Every politician and every newspaper should know it too. At a time when the NHS – and those working in it – face an almost daily barrage of hostility from those who want to talk down it down in order to run it down, it is worth remembering a few simple truths.

    The NHS is staffed by people who give their all in their service of others. Overwhelmingly they provide high quality care to patients. In recent years NHS staff have been leading the way in reforming NHS services so that they are designed around the needs of patients.

    NHS staff then deserve our admiration and they require our support. You cannot be on the side of NHS patients unless you are on the side of NHS staff. And you certainly cannot be on the side of NHS patients unless you are on the side of rising investment in NHS staff.

    That is now underway. It is only five years ago when the number of nurses in training and the number of GPs in training were both falling. Now both are rising. And rising quickly.

    The number of qualified staff already working in the NHS is rising quickly too. The census figures being published today are good news for NHS patients. Between 2000 and 2001 there was a net increase in the number of nurses working in the NHS of over 14,400. This is the biggest increase on record. It means that the NHS Plan target of securing an extra 20,000 nurses in the NHS by 2004 has been met ahead of schedule. The NHS Plan is not only on target. It is ahead of target.

    The number of hospital consultants, health care assistants, qualified scientists, therapists and allied health professionals has also risen sharply. Although GP numbers have risen less quickly they too are up on the previous year’s increase and the number coming through training is at an all time high.

    But it is the rise in nurses, health visitors and midwives that is most dramatic. Many are people who have returned to nursing. People like Karen Gronhaug who is with us today. Karen is the 10,000th nurse to have come back to the NHS over the last few years.

    Together with the further big increases in nursing staff already in the pipeline it is now clear that the corner has been turned on nurse recruitment. Now however is not the time for complacency. There should be no resting on laurels. Instead I now want to build on the progress that has been made. The NHS still needs more nurses.

    We will continue our recruitment campaign – indeed we will launch the third year of it later this month – but I believe it is now time to switch the emphasis from nurse recruitment to nurse retention. We cannot have nurses coming into the NHS through the front door but find more leaving through the back door. Our objective then must be to improve the working lives of nurses to make nursing an even more attractive career.

    That is the reason for today’s summit. To give nurses and their representatives a proper say in the future of the profession. To provide a forum where we can work together to make nursing a career of choice for thousands more people.

    This is the first in a series of summits I will be holding with people working in the health service to hammer out ways of improving staff working lives. Over the next few months there will be similar events involving doctors, allied health professionals and support staff.

    There is much on which we can build. In recent years there has been a concerted drive to improve the working lives of NHS staff. Nurses pay has risen – but I know that there is more than we need to do. We have made a start in helping nurses with housing costs but there is more help needed still. The same is true for childcare and flexible employment where we need to build on the progress that has been made so far in allowing nurses to better balance their family and their working lives. The status of nursing has never been higher – but more nurses need help to break through the glass ceiling that still holds too many back. Better training and development could help many more nurses fulfil their potential. Many nurses are already taking on new roles and have got new powers but more would like to do so.

    Reforms like these hold the key to a better health service both for staff and for patients. Breaking down demarcations and liberating the talents of staff means faster better care for patients. Most people now recognise that what the NHS needs is not just more investment but far-reaching reform. My offer to people working in the NHS is this: we will continue to provide the sustained resources the NHS needs in exchange for the continued reforms it must have. We will work in partnership with those who are serious about reforming the NHS to make it a better place for patients to be treated and a better place for staff to work. There is a long way to go – but we can now build on the progress that is underway.

  • Alan Milburn – 2002 Speech on Genetics and Health

    Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, on 16 January 2002.

    PUTTING BRITAIN AT THE LEADING EDGE OF ADVANCES OF TECHNOLOGY

    I am delighted to see so many of you here today. We have representatives from the NHS, the professions, industry, academia, patient support groups and many others with a close involvement in genetics.

    I am no scientist and certainly no geneticist but I believe that advances in genetics have huge implications for us all. Few people now deny that genetics 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.

    Progress now in the science and scope of genetic technologies is moving at an incredible pace. Almost every week there seems to be some new breakthrough or potential application.

    Nine months ago, I spoke about 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.

    It is an ambition for the long term since no one can predict right now how long it will take before the full impact of these advances are felt. The genetics revolution is already underway. What is clear is that it is time we more actively prepared to embrace it. I want to use my speech today to outline some of the actions we are taking to do so.

    The implications of the advances in genetic knowledge have as great a potential to conquer disease as the discovery of antibiotics. 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.

    The potential is immense. Whilst genetics will never mean a disease-free existence, greater understanding of genetics is one of our best allies in the war against cancer for example. Advances in genetics will lead to a greater understanding of the occurrence of cancer and its treatment.

    Some rare cancers are caused by defects in a single gene and have clear patterns of inheritance from generation to generation. In these cases genetic testing could predict disease development in individuals with no symptoms.

    In other cases there is an interaction between genetic changes and environmental factors. The presence of the genetic changes can increase the risk of cancer. Careful monitoring, with the possibility of making some changes to patients lifestyle, aimed at lowering the risk of developing cancer, could make a real difference.

    And research into pharmacogenetics has identified genes affecting the impact of more than 20 drugs. In partnership with other cancer research funders we will determine how this knowledge can be used for anti-cancer drugs.

    So in the coming years, expanding knowledge of cancer genetics will have a major impact on the ability to predict an individual’s level of risk of developing cancer; the ability to detect and diagnose cancer early and the ability to select treatments most likely to be effective. Ultimately the genetic revolution may lead to ways of preventing cancer.

    Government’s job is to help prepare our country to harness the benefits of genetic advances and to avoid its dangers. That can only be done in partnership with science and industry, medicine and the National Health Service. It can only be achieved if breakthroughs by the scientific community are matched by public support and understanding in the wider community. It will only happen if we are all open and honest about the potential and the pitfalls which the genetics revolution presents.

    That is why later this year I will publish a Green Paper setting out the Government’s vision of how the genetics revolution could transform treatments and services available to NHS patients. It is intended to foster a more informed national debate about genetics. To try to move the debate beyond the horror stories and half-truths towards a realistic assessment of what the exploitation of genetic technology can and cannot offer society.

    Your input into the Green Paper will be vital. I am particularly pleased to be able to use this Conference to publicly thank Lord Turnberg, who chairs the Advisory Panel on the Genetics Green Paper, and the other members of the panel, for their assistance and support.

    It is unfortunate but true that BSE and other developments have inflicted real damage on the standing of science. It is fashionable in some quarters to be both anti-science and anti-medicine. To protect ourselves against that we need to move beyond simply providing more information. We have to provide positive safeguards to address the public’s concerns.

    We believe there are huge potential health gains in genetic advances; we respect the need for science and scientists to stretch the boundaries of human knowledge and understanding in the field of genetics in the interests of human health but we will draw those boundaries carefully in order to gain public consent to realise the full benefits of genetic science.

    We have to be careful not to suggest that public concern is based on irrationality or ignorance. It is not. Public concern about genetics is all too rational: it is based on a recognition that we are on the threshold of a science the full potential of which even the world’s leading scientists are not yet able to describe. Little wonder then, that sometimes science fiction takes the place of science fact. Our job – all our jobs – is to replace fiction with fact, to dispel doubt with understanding.

    The public had understandable concerns about the use to which genetic tests would be put by insurance companies. Fears about forced disclosure could have deterred some people from taking tests at all. The impact of those fears, reducing the potential pool of genetic information, would itself have limited the scope for further advances in genetic science. That’s why I said nine months ago that we would consider a moratorium on the use of genetic tests by insurers. In October, following fruitful and effective dialogue with the insurance industry, the moratorium was introduced and the terms are stronger even than the Human Genetics Commission recommended.

    It is though, the perceived threat that any advance in genetic science must necessarily herald a further step towards human reproductive cloning which is so corrosive of public support. That is why nine months ago I said human cloning should be banned by law, not just by licence through the HFEA. I gave a commitment then, that the Government would explicitly ban human reproductive cloning in the UK. In November – a little earlier than we had planned, as you may have guessed – we passed the Human Reproductive Cloning Act which put the legal position beyond doubt.

    With human reproductive cloning now banned, with protections for the public over misuse of genetic test materials in insurance now in place, the way is open to us to have a more rational debate about how best our country can be at the leading edge of advances in genetics technologies.

    Here in Britain we start with a huge advantage. 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 already the envy of Europe. To stay ahead, in the decade ahead, the capacity of our genetic services need to be enhanced so they are better able to capture advances in genetic medicine for many more NHS patients.

    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 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.

    There is growing investment from the public purse too. 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.

    On top of our comparative advantages in industry, science and research we have the strength of a single, national health service, funded by all and available to all.

    I believe there is no other health care system in the world better placed to harness the potential of genetic advances than the National Health Service. The values on which the NHS is based – providing care for all on the basis of need, not ability to pay – are uniquely suited to capturing the benefits of the genetics revolution. They provide a bulwark against the inequalities and inefficiencies of insurance-based health systems where the prospect of 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, is for many a very real threat.

    The values of Britain’s NHS mean 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 or become priced out of care or cover altogether. Already in the United States of America, where 40 million people have no medical cover, developments in genetics have stirred precisely these concerns.

    As our understanding of genetics advances, the case for private health insurance as an alternative to the NHS diminishes. Properly exploited, genetics strengthens the case for the values of the NHS. 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.

    To provide Britain with a real competitive advantage in the application and exploitation of potential genetic advances the NHS will need to change the services it offers: more gene therapy alongside invasive surgery; more genetic screening alongside more specialist genetic counselling; more drugs tailored to the personal genetic profile of the patient. Much of the health service’s work today is based on a model which aims to ‘diagnose and treat’ conditions. Developments in genetics should allow us to ‘predict and prevent’ the common diseases of later life.

    Last April I announced a £30 million package of new investment in NHS genetic services to enable us not only to make significant improvements in existing services but to lay the building blocks for the future. More consultants, more scientists, more genetic counsellors, and a single national network of genetic testing services which I can confirm today will be fully functional by the end of this year. This expansion is already coming through and will allow many more patients to be seen more quickly by our NHS specialist genetics services.

    In Trent, this funding will halve the reporting time for tests for hereditary cancers and the number of patients who can receive tests will more than double. In Southampton, 20% more families will be counselled and patients at risk of familial cancers will have to wait for less time to receive their test results. In Birmingham, more tests and quicker results will be available for genetic testing in leukaemias and bone marrow transplants, meaning that these patients can receive accurate treatment more quickly. In Cambridge, reporting times for new mutations will be cut from six months and more down to only 8 weeks. And in the South West, new clinical staff will allow substantial reduction in outpatient waiting times. And at Northwick Park this funding will allow 25% more patients to be seen.

    Today we can take another step forwards with the establishment and location of two new National Genetics Reference Laboratories. The national reference labs will help the NHS to keep abreast of scientific and technological discoveries in genetics and develop new and improved genetic testing. They will explore how better ways of working in laboratories such as automation or the more effective use of junior staff can reduce reporting times and increase cost effectiveness. And they will train NHS staff in the application of new genetic tests and technologies; and support the national NHS genetic testing network.

    I can tell the conference that the new National Genetics Reference Laboratories will be in Manchester at the North West regional genetics laboratory and in Salisbury at the Wessex regional genetics laboratory. Both have a well-deserved international reputation and have a track record in quality management.

    The Department of Health is continuing to work in partnership with the Wellcome Trust and the Medical Research Council to develop the UK Population Biomedical Collection, an initiative now known as BioBankUK. This is the country’s flagship project on molecular epidemiology for the new century. BioBank UK will provide a national resource for scientists wishing to study the interaction between genetic, environmental and lifestyle risk factors in the development of the common diseases of adult life, especially cardiovascular disease, metabolic disorders and cancer. The study will involve collection of personal data on health and lifestyle and there will be long term follow up via NHS medical records to accumulate data on health outcomes.

    The linkage of genetic and health information and the potential for using the database for a wide variety of analyses aimed at determining susceptibility to disease raises important issues about confidentiality, security of data and informed consent. These concerns have been voiced as recently as Monday by GeneWatch, and they were the subject of a debate in the House of Lords yesterday. The Government takes these concerns seriously and will not allow the work to proceed until they have been satisfactorily addressed.

    I can also make a further announcement today. Last April I announced a £10 million Genetics Knowledge Challenge Fund to create four Genetics Knowledge Parks. I am pleased to say that with support from the Department for Trade and Industry the Challenge fund now stands at £15 million. Today I can announce six rather than four new Genetics Knowledge Parks.

    These new centres of excellence will work together to help ensure Britain remains at the cutting edge of the genetics revolution in order to gain the maximum health benefits for our citizens. The knowledge parks will bring together 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.

    The Genetics Knowledge Parks we are establishing will lead to increased availability of new drugs and treatments. They will extend the range of diagnostic tests for both single and multifactoral gene disorders with this, in turn, leading to the introduction of further screening procedures so that disease progression and treatment can be monitored more effectively. They will develop pharmacogenetic tests for the targeted treatment of patients, not only getting the right medicine to the right person but also reducing the incidence of unwanted side effects. And, perhaps most importantly, the Genetics Knowledge Park network will improve public engagement and education about medical genetics.

    So I can announce today that the Genetics Knowledge Parks will consist of consortia of institutions based in the following places, Newcastle, London, Oxford, Cambridge, the North West and Wales. I am particularly pleased that some of these new parks will be in parts of the country where research and development and new high tech industries need to gain a stronger footing. I hope the new Genetics Knowledge Parks will help those areas to do just that.

    These new Genetic Knowledge Parks will provide some important new opportunities across the country. I am determined that we take the necessary action now so that we can grasp the new opportunity genetic science can deliver to patients in all parts of the country.

    To do that we really do need your input into the preparation of the Genetics Green Paper.

    Our message to the public should be this:

    We need not fear the science of genetics if we put in place the proper public protections today.

    We need not miss the opportunities of genetics if we prepare future advances today.

    We should not think that the challenge of genetics is for some other country, some other industry, some other health care system, some other generation. It is for us – it is here today.

    By building on our strengths, making the necessary investment and careful preparation now, Britain can indeed be at the leading edge of advances in genetic medicine. If we do so I believe the Genetics Revolution will deliver real and lasting benefits for future generations of NHS patients.

  • Alan Milburn – 2002 Speech to the New Health Network

    Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, on 14 January 2002.

    Later this week we will publish our response to the Kennedy report into events at the Bristol Royal Infirmary. Those events were a turning point for the NHS and I believe a catalyst for change.

    The world has moved on since then of course but underlying the whole Bristol tragedy was a profound structural problem. An NHS that was more geared to its own needs than the needs of its patients. A health service where there was confused accountability between services, professionals and government.

    Today a new relationship is needed between patients and services and between the health service and the government. The NHS Plan we published eighteen months ago sets out our vision for the future of health care in our country. Where patients always come first. Where patients are in the driving seat able to make informed choices about their care. Where the NHS is decentralised with a plurality of providers operating within a framework of clear national standards regulated independently.

    I want to set out in this speech the nature of these new relationships and how I believe they can be forged. I want to describe how they will define a different sort of health service which genuinely puts patients first.

    Some say this vision of turning an old style monopoly nationalised industry into a patient-driven service can never be realised. That the NHS must be abandoned in favour of a market-based solution.

    The NHS today has never had more enemies. Over very recent years the NHS has faced an unprecedented ideological onslaught from the Right – sections of the media and politicians – determined to bring down what they now freely describe as a “Stalinist” creation.

    It is important for those of us who believe in the first principles of the NHS to recognise that underpinning much of the day to day hostility to the NHS is an ideological pursuit of a smaller state and an outdated Thatcherite obsession that public services must inevitably fail.

    It is collective provision of health and education and other public services that is now under attack. The NHS is on the frontline of that ideological battle. I believe it is time for those who believe in the concept of universal provision of health care, to which we all contribute via general taxation, to stand up for it. The NHS needs to speak up for itself. And it needs others – in professions, in the community, in politics, in voluntary and patient organisations – to forge a national alliance to speak up for it, too.

    Even today after decades of under-funding – which only a fool believes can be put right by a few years of extra investment – and at the start of the NHS Plan’s ten year reform programme the vast majority of NHS patients get good care. Yes, waiting times are too long but they are falling and 7 in 10 patients get their hospital operation within three months. The NHS needs to be reformed not rejected.

    Health care cannot be just another commodity to be bought and sold in a market. Our need for health care is, by its very nature, unpredictable. It can be extremely expensive. Rather than asking people to take the risk of providing for their own care it is surely right that we provide for it collectively and pool those risks across the population as a whole.

    The NHS gives each of us the security – “serenity” Nye Bevan called it – of knowing we will be cared for when we are ill. A system of health care that is used by all and financed by all makes for a stronger society for all. Now more than ever we should say unequivocally that an NHS providing comprehensive services, overwhelmingly free at the point of use, according to need not ability to pay is the right way forward for Britain.

    Expanding private health insurance would entail huge deadweight costs to subsidise those who already have it. It would end up costing the NHS more money than it saved. It would also mean a two tier health care system subsidised at taxpayers expense. The same is true of the option favoured by Iain Duncan-Smith of patients paying to see their GP. Aside from shunting patients into more expensive, already busy A&E departments. It would end up disenfranchising those – the elderly and the poor – who need health care most and can afford charges least.

    European insurance-based systems, cited so approvingly by some, are not without their problems either. Ironically, while some in Britain are looking to Europe for the answer, the experience in Europe over recent decades has actually been in the opposite direction – away from insurance towards tax-based systems driven by concerns about the scale of the funding burden placed on employers and employees. The real cost and complexity of a wholesale introduction of a new funding regime in Britain would be years of turbulence and instability. That would delay precisely the rapid improvements in services patients and staff want to see.

    What health care in these other European countries have had is not a superior system of funding but a superior level of funding. What the NHS in this country has lacked is investment and reform. It is that we are seeking to put right.

    On investment the NHS is today growing faster than ever before. It is the fastest growing health service of any major country in Europe.

    On reform the NHS is today implementing the biggest programme of change in its fifty year history.

    As the NHS Modernisation Board’s report quite rightly said last week after decades of neglect some very real problems remain. But there are signs of real progress too. Indeed one of the striking things I have found talking to NHS staff over recent months is that there is now a greater recognition of the money and changes coming through. I do not pretend for a moment that the problems are solved. They are not. We are just a year and a half into our ten year reform programme.

    But it is worth reminding ourselves that there are 10,000 more nurses than one year ago. Last year was the first year in thirty years where there were more beds not fewer in hospitals. The biggest hospital building programme in NHS history is now well underway. In the last year 800 GP surgeries have been modernised. The NHS now has the world’s best smoking cessation services. Prescribing of cholesterol lowering drugs has risen by one third in just a year. Waiting times for cancer and cardiac care are falling.

    So while sections of the media seem intent on describing every problem, and denying any progress, it really is time for a bit of balance in the coverage about the NHS. The NHS is not full of bad doctors. It is full of good ones. And good staff who are doing an amazing job for patients. The glass is half full not half empty. And it is being topped up.

    The investment and reform programme outlined in the NHS Plan is intended to bring the health service into the modern age. While its values are right its structures are wrong. Too much of it still has the feel of the 1940s – both for those working for it and those using it. Queuing is endemic. Staff are run off their feet. Capacity problems mean shortages of staff and equipment and services that are slow and unresponsive. Patients are disempowered with little if any choice. The system seems to work for its own convenience not the patient’s -a frustration that is shared between staff and patients alike. The whole thing is monolithic and bureaucratic. It is run like an old style nationalised industry controlled from Whitehall.

    The NHS today is a product of the era in which it was formed. In the post-War world of the mid-twentieth century big national problems were solved by creating big national institutions. Just as the National Coal Board took over a failing coal industry so Nye Bevan’s new National Health Service took over a failing health system. The NHS for the first time gave Britain a national system of health care

    The benefits were enormous, not least in driving through public health and immunisation programmes. But as the century wore on the NHS fell behind. Cost containment took precedence over quality of care. Top down control stifled local innovation. As a monopoly provider there was no plurality in organisation and no choice for the user.

    For fifty years, the structure of the NHS meant that governments – both Labour and Conservative – defended the interests of the NHS as a producer of services when they should have been focussed on the interests of patients as the consumers of services.

    In today’s world that will no longer do. People today expect services to respond to their needs. They want services they can trust and which offer faster, higher quality care. Increasingly they want to make informed choices about how to be treated, where to be treated and by whom.

    The Right says that this can only happen through market mechanisms. The overwhelming evidence however is that the public do not want a market in health care. More than three in four people agree with the proposition that the NHS is critical to British society and we must do everything to maintain it.

    What they want to see however, is a reformed service which genuinely serves patients.

    The NHS today lives too much in the shadow of its own history; as an organisation where government provided limited resources, doctors were left in charge of providing limited services and patients were expected to be grateful for the limits of what they received.

    The investment we are making is about breaking through those limits to expand the services available to patients. The reforms we are making are about designing those services in the interests of patients. Driving shorter waiting times and higher quality care. Getting the basics right – clean wards, good food, matrons in charge. Getting health and social care to work as one so that patients receive a seamless service. Providing services round-the-clock through NHS direct and walk in centres.

    There is no single ‘silver bullet’ that can deliver these changes. As in any complex organisation undergoing change, there needs to be a mix of levers. Recent research on high performing private sector organisations confirms that this is the case. Complementary sets of changes are needed. A relentless focus on the needs of the consumer alongside support for staff. Customisation wherever it can be made but standardisation where it is appropriate. Management through hierarchy alongside management through networks.

    These levers are now for the first time being consistently applied to the health service. Getting health and social care to work as one for the benefit of patients. New roles for nurses and therapists and new contracts for doctors to provide flexibility around the needs of patients. Inspection to highlight successes and to pinpoint problems. Targets to improve performance alongside devolution to those responsible for delivering them. Open assessment linked to rewards for those who are doing well and help, support, and where necessary, intervention for those who are not.

    All of these reforms involve government acting on behalf of patients in order to influence how the NHS relates to patients. They are all about getting the NHS to put the needs of its patients first. But a service designed around the needs of patients has to hand over more power directly to them. So there are reforms to give patients a greater role and a stronger say in the NHS – patients forums in every trust, patients electing patients onto trust boards, the results of patient surveys helping determine the ratings and the resources that trusts receive. And there are reforms too to introduce new procedures for informed consent.because while patients have a responsibility to keep healthy, treat professionals respectfully and use services wisely, they have a right to be involved in decisions about their own care.

    The balance of power has to shift decisively in favour of the patient. So now most fundamentally of all, our reforms will give patients greater choices over services. By the end of March 5 million patients will choose the date of their hospital operation rather than having it chosen for them. From April patients faced with a last minute cancellation of their operation can choose an alternative hospital for their treatment. From July heart patients who have waited six months for their surgery will choose between waiting longer locally or travelling further to be treated quickly in another public or private hospital. And then on the basis of the progress we make this year within the next four years patients throughout the NHS – helped by their referring GP – will be able to make informed choices about where they are treated, when they are treated and by whom they are treated.

    As capacity expands so choice will grow. Choice will fundamentally change the balance of power in the NHS. Hospitals will no longer choose patients. Patients will choose hospitals. And in primary care patients will have more information about the choices available there too.

    Most patients want a simple choice: the choice of a good local surgery and a good local hospital. And that is why – unlike the failed internal market experiment – we have put in place the levers needed to raise standards everywhere. But in this new choice-driven system hospitals will need to respond actively if they are to benefit most from patients, with their GPs, making informed choices.

    Of course the core costs in hospitals of providing emergency or long term care services will have to be met but patient choice over elective surgery will mean developing new ways of money flowing around the system to sharpen incentives to respond to patients. Hospitals, whether they are public or private, will get more money for being able to treat more patients more quickly and to higher standards.

    This is a fundamental change in accountabilities – where the patient is in the driving seat. Where the NHS looks outwards to patients and communities rather than upwards to government or inwards to its own providers. To make patient power happen there will need to be a changed relationship between the NHS and the Government.

    For fifty years the NHS has been subject to day-to-day running from Whitehall. The whole system is top down.. There is little freedom for local innovation or risk taking. The local health service has to get permission from somewhere else in the hierarchy to appoint a nurse consultant or even to spend the money it gets from sales of its own land.

    A million strong service cannot be run from Whitehall. Indeed it should not be run from Whitehall. For patient choice to thrive it needs a different environment. One in which there is greater diversity and plurality in local services which have the freedom to innovate and respond to patients needs.

    Our reforms are about redefining what we mean by the National Health Service. Changing it from a monolithic, centrally-run, monopoly provider of services to a values-based system where different health care providers – in the public, private and voluntary sectors – provide comprehensive services to NHS patients within a common ethos: care free at the point of use, based on patient need and their informed choice and not their ability to pay. Who provides the service becomes less important than the service that is provided. Within a framework of clear national standards, subject to common independent inspection, power will be devolved to locally run services so they have the freedom to innovate and improve care for NHS patients.

    The implications of this re-definition are profound. It means that NHS healthcare does not need to be delivered exclusively by line-managed NHS organisations but by range of organisations working within the national framework of standards and inspection. The task of managing the NHS becomes one of overseeing a system not an organisation. Responsibility for day to day management can be devolved to local services. National accountability moves away from organising a particular institution around large numbers of targets towards overall systems performance and health outcomes. That in turn will allow a better concentration on tackling inequalities and improving health rather than just on improving health services.

    This direction of travel has already begun. I know there is concern about the pace of change and the extent of change to come. But these changes are rooted in the NHS Plan. They are needed at all levels in the NHS.

    For the Department of Health it means focussing on the things that only it can do. In any large organisation or complex system not everything can 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. The absurdity of describing the NHS as Stalinist is that until very recently there was little national control over quality or standards in local NHS organisations. When we came to office in 1997 there was an absence of national 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. As Kennedy identified it was this lack of clear standards and clear lines of accountability that underpinned the Bristol tragedy.

    font size=”2″ face=”Arial, Helvetica, sans-serif” 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. With the NHS Modernisation Agency there are now new systems for when things go wrong and more help to learn from what goes right. Today with that national framework in place, in our second term the centre of gravity is shifting decisively to the NHS frontline.

    That will leave the Department of Health with four essential functions. One, setting strategic direction by distributing resources and determining standards in particular to move policy towards a more explicit focus on improvements in public health. Two, ensuring the integrity of the whole system for example by securing integrated information systems, staff training and development support for improving services. Three, developing the values of the NHS through education, training and policy development. And four, securing accountability for funding and performance including ensuring reports to Parliament.

    The NHS should be able to speak more for itself as it is beginning to do for example by the NHS Confederation, rather than the department, leading negotiations on a new GP contract. Similarly, just as we have moved appointments to NHS bodies out of the hands of Ministers into the hands of an Independent Appointments Commission, so we intend to move responsibility for the regulation of the system to a strengthened Commission for Health Improvement.

    The CHI will take responsibility for the independent publication of information about clinical and organisational performance. It will have a greater inspectorial and reporting role over the health system’s performance. That will necessitate closer working, and over time, organisational integration between the CHI, the Social Services Inspectorate, the National Care Standards Commission and the Audit Commission so that health and social care services are subject to a common set of standards whether they are provided by public, private or voluntary sector organisations.

    There will be a transition towards politicians and civil servants focussing on strategic issues rather than on day to day management of the health system. Day to day management will devolve to the 28 new strategic health authorities in England. They will oversee the work of local NHS Trusts, PCTs and private providers. They will become the headquarters of the NHS locally. Their chief executives will account both nationally and locally for the performance of local health services. Franchises for running the STHAs will be let, based on performance against an annual delivery agreement with the Department of Health.

    The real power and resources in the NHS will move to the NHS frontline. The NHS is a high trust organisation. It works on the basis of trust between professionals and patients. In the way it is organised it needs to enshrine that trust. So from April this year locally-run primary care – involving professionals and patients – will be up and running in all parts of the country. Within a few years they will control 75% of the total NHS budget. They will be able to choose from which hospitals – public or private – care is commissioned. The best hospitals are likely to be those where they too, practice the philosophy of devolution and empowerment. Where the principled motivation and expertise of clinicians and managers alike can be harnessed to redesign services from the patient’s point of view.

    Both PCTs and Trusts will be subject to rigorous performance assessment. But the balance between top-down performance management and horizontal performance improvement will move sharply in favour of the latter as the NHS Modernisation Agency increases its role in spreading good practice throughout the system.

    Local services will operate within the context of clearly defined national standards. Intervention will be limited. It will be in inverse proportion to success. Where the CHI decides that an NHS organisation is in trouble it will recommend special measures are taken. That could include external help through the Modernisation Agency. In those local services where there are persistent problems – which are more often than not organisational and cultural – the management could be franchised. Within this new definition of the NHS, the franchise could go not just to another public sector health organisation but in time to a not-for-profit body such as a university or a charity or to some other external management team. As franchising progresses it is possible to imagine a number of local health organisations all being run by a single team of successful public service entrepreneurs. The assets, of course, of the franchised local hospital or PCT will remain within public ownership. It is the management that will be franchised. This is not privatisation in any way, shape or form.

    Each year CHI – rather than the Department – will rate local health services according to their performance. Those that are performing best will earn not just more rewards but greater freedom. As we said in the NHS Plan as performance improves this system of earned autonomy will see more and more power move to local frontline services in the NHS.

    The better the performance of the organisation the greater the freedom it will enjoy. The first wave of three star hospitals will be able to establish joint venture companies, get automatic access to capital resources and be subject to less monitoring and inspection.

    In order to encourage greater innovation and responsiveness in local services these existing freedoms will need to be extended.

    Last month I met with the chief executives of the three star Trusts. They had a list of further specific restrictions that they wanted to have removed from them and we are now considering how best to do so. But they also asked us to go further. If they were as good as we agreed they were why could they not become independent not-for-profit institutions with just an annual cash for performance contract and no further form of performance management from the centre? They all recognised the importance of external inspection and the national framework of standards. None were arguing to go private or to abandon the public service ethos. They wanted instead wanted greater freedom to improve services than they currently have within the existing state-run nationalised industry.

    There are precedents for this sort of structure in the public sector. Indeed NHS Trusts themselves already have potentially far-reaching powers of autonomy. In education schools are now encouraged to develop different forms of organisation within a national framework of standards. In further education, FE colleges used to be run by local authorities, but are now incorporated as autonomous not-for-profit trusts. As independent corporations they have the powers to borrow privately, engage in PFI -style investments, buy and sell assets and choose the mix of courses they offer subject to negotiation with the Learning and Skills Council

    This middle ground between state-run public and shareholder-led private structures is where there has been growing interest in recent years. Both the Right – through organisations like the Institute of Directors – and the Left – through the Co-operative Movement – have been examining the case for new forms of organisation such as mutuals or public interest companies within rather than outside the public services and particularly the NHS.

    Their proponents have argued that there could be potential advantages to such forms of organisation. They have a clear public service ethos and are not-for -profit. The assets remain within public ownership so there is no question of the NHS being privatised. They offer specific public benefits and cannot be transformed or taken over by another form of organisation which will not provide such benefits. They motivate staff and management alike through more active involvement and control. They offer freedom from top down management but are regulated in the interests of consumers. They give greater control to those who use them. They open up more options for greater community accountability.

    Our three star hospitals have now asked us to look at whether such models could be applicable to local health services to form Foundation Hospitals within the health service but run more independently than now. I think it is right that we should examine the case they have made. And we will consider the applicability of Foundations not just to the best hospitals but to the best primary care trusts too. Over the next few months we will be working with them to examine the legal, financial, governance and accountability issues. Amongst other matters we will be examining the case for specialist patient organisations to have a more direct role in the management of specialist hospitals or services.

    This will only ever be voluntary not mandatory for the health service’s best performers. Alongside national standards, new incentives, more devolution and greater choice, however, it will help make for a new sort of NHS.

    Some will see this as a very controversial step. I think it flows from the devolution agenda of the NHS Plan. And it is worth putting it into a slightly broader context. No other country in Europe, including those with a strong centre left tradition, would blink an eyelid at these plans. At the time the NHS was being formed as a nationalised industry in the UK elsewhere in Europe many socialist or social democrat governments forged institutions which favoured greater community ownership over state ownership. Even here there is a long and honourable tradition within the British labour movement of developing strong local community-led services. In the first part of the last century GDH Cole, Tawney and others were powerful intellectual advocates of such an approach. And in the first part of this century virtually every other public service has long since moved away from the pure nationalised industry model.

    The sole exception is the NHS. It is an exception both in this country and abroad. As far as publicly financed hospital services are concerned, for example, the UK stands out today in the degree of centralisation of service delivery and the uniformity of its ownership. In many other European countries there are many not-for profit voluntary or charity-run hospitals all providing care to the public health care system. There are private sector organisations doing the same.

    Similar steps are already starting here. We are in negotiations with BUPA about turning one of its hospitals over to the exclusive use of NHS patients. It will be run by BUPA but as part of the NHS. We will look to establish similar ventures in the future both from the domestic independent sector and from the sector in other parts of Europe that may wish to establish a presence in England. Like the use by the NHS of spare capacity in private hospitals this is all about expanding the volume of care available to NHS patients. There is no blank cheque. It is right that patients get the highest standards of care and taxpayers are assured of good value for money. But this is a relationship that is for the long term. It is not a one night stand.

    After all just because patients might be treated in a BUPA hospital today or a Foundation Hospital tomorrow that does not mean they cease to be NHS patients. Quite the reverse. Patients remain NHS patients treated on NHS principles with care that is free and available according to need. The NHS is not its bricks and mortar. It is not a set of structures. It is fundamentally a set of values. An ethos if you like. We should be resolute in our defence of the values of the NHS but not of its outdated structures.

    Getting there will not be easy. It will certainly not happen straight away. It will take sustained effort and time as well as sustained resources. It will mean sticking to the NHS Plan – developing it by all means but not departing from it. It will mean changing culture as well as changing structure.

    What we envisage is a fundamentally different sort of NHS. Not a state run structure but a values based system:

    where greater diversity and devolution are underpinned by common standards and a common public service ethos;

    Where treatment is free and provided according to need wherever it occurs;

    Where patients can make informed choices about their services and about their care;

    Where we liberate the talents of NHS staff to improve care for NHS patients.

    Where government no longer runs a nationalised industry but instead oversees a system of care;

    Where there is greater diversity of provision and more freedoms for local services to improve care for patients.

    Where there is a new common purpose shared across health sectors and a relentless focus on better health outcomes and less inequality;

    Where there is a single national health service – an NHS of all the talents. One that puts its patients first.

  • David Blunkett – 2002 Speech on Social Capital

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    Below is the text of the speech made by David Blunkett, the then Home Secretary, on 26 March 2002.

    Introduction

    I am very pleased to be here today. Throughout my experience of central and local government I have consistently seen the importance of social capital – those social networks and forms of trust which enable people to work together to achieve common objectives. Social capital is that which bonds us together and builds bridges between communities.

    I am an optimist about social capital. Over the years, civic responsibility and collective working has put down deep roots in our society. During the industrial revolution, working people in conditions of dire poverty, formed friendly societies, trade unions, co-operative clubs, institutes and libraries. In the early nineteenth century there were 900,000 members of friendly societies. A powerful ethos of mutual improvement was established in this era.

    Since that time, the ethos of mutualism has been reflected in the best of the trade and union and labour movement, co-operative societies, and a huge range of voluntary and community sector organisations. The same ethos has underpinned our traditions of adult learning. And mutual ownership still thrives in leading edge businesses, such as Swann Morton, in my own constituency.

    Active citizenship is built on these principles of mutuality. It is about engagement with the community that you are a part of, for the benefit of yourself, your family and those around you.

    Today, there are 350,000 school governors. There are 160,000 local neighbourhood watch schemes registered with the National Neighbourhood Watch Association. Social entrepreneurs are building on social networks to bring communities together to turn around neighbourhoods. I think of the way, for example, that residents of Balsall Heath took radical action against prostitution and crime in the early 1990s – forming a picket to deter curb crawlers – and have gone on to form the Balsall Heath Forum which is working to regenerate the area. They built the capacity and confidence of local people to create and sustain associations and services that make their neighbourhood strong. In 1990 there was one residents group. Today there are 21. In 1970 there were three voluntary organisations. Today there are 56. The Forum has calculated that 4,000 people out of Balsall Heath’s population of 12,000 regularly participate in a caring activity designed to improve the quality of life of the neighbourhood. The Forum’s ambitious target is to involve 60% of the population in local associations by 2004.

    But we all know that there have also been great challenges to this civic tradition over the last thirty years. The core institutions of post-war civil society – the churches, trade unions and local government – have all undergone decline as mass institutions.

    Unfettered individualism is, for many, no longer a taboo. At worst, it is celebrated. For that, I hold Rightwing ideologues partly to blame. But there are also those on the Centre-Left who suggest that individuals don’t have responsibilities for their action; that individual freedom transcends the very community foundations upon which it ultimately depends.

    But strengthening communities does not mean turning the clock back. We are discovering new, modern forms of community and social interaction in this era of globalisation. We do not have to give up the gains in personal freedom and social equality we have made in the post war period if we want to strengthen our communities. Indeed, it is precisely to enable individuals to lead decent and fulfilling lives that we must achieve civil renewal.

    So it is right that we consider the question of how to help build social capital. Trust, mutual association and civic institutions have, and can, make a real difference to people’s lives. But they are not inevitable features of British life. If we do not tend them, progress is impossible.

    The role of Government

    How can the Government make a difference? How can it help build social capital?

    Those interested in social capital have sometimes been wary of the role of Government. It is true that the State has too often ignored the importance of informal community association. Too many post war regeneration schemes excluded communities and disrupted rather than supported local societies. Initiatives such as Development Corporations focused too much on building physical infrastructure, and failed to make long term improvements because they ignored the community.

    But most evidence shows that the best way to build social capital is to make it a joint endeavour between State and specific communities or individuals. Schools and GP surgeries, for example, can be real hubs of the community. Take West Walker primary school in the East End of Newcastle. As well as driving up exam results over the last few years, they have taken an increasing role in supporting the development of social capital. The school brings together residents through a thriving adult education centre, a lively café and projects such as building a nature garden. Some parents have now gone on to form a housing association. West Walker is, in turn, already repeating the benefits of local social renewal. Groups of parents are now helping the school, such as with a joint ICT learning initiative.

    Three specific roles for Government stand out:

    – Promoting social order and security;

    – Investing in individuals and communities, so that they can help themselves; and,

    – Working in partnership with people to change their own communities.

    Social Order & Security

    Social order is the first responsibility of government. Progressive Governments have rarely given sufficient weight to social order, with disastrous consequences for communities and democracy itself. If progressives cannot maintain order, far more reactionary groups will step in, as the histories of the Weimar and Spanish Second Republics show. And when we do not maintain security, it is those who can afford it least who tend to suffer. The chance of being burgled is typically three times as high for people living on council estates than those living in affluent suburban areas.

    Security and order are also the first building blocks of social capital. Order generates trust. In turn, those who trust others are more likely to participate in community organisations. Without a sense of security, people find it harder to work with others. They are scared to go out on the streets. They are fearful of talking to others.

    And without basic social order, communities don’t stand a chance of renewal and regeneration. That is why supporting the police is vital. A more effective police force, which cuts crime, does not simply reduce the direct problems caused by crime. It also provides the basis for renewed societies. That is why I am ensuring we have more police and more police on the streets, and that all police forces reach minimum standards. It is also why I have announced the first five police priority areas – communities that need significant intervention and support to tackle the endemic problems of crime and disorder they suffer.

    We are also developing new ways to improve security in collaboration with communities themselves. Street wardens are one example of that. They are employed for local communities, to help them maintain order. I am determined that they, other wardens and community safety officers, will have the powers to do this job effectively. As an aside, we always hear some concerns about how new wardens will work with the police and use their powers. Exactly the same debates accompanied the introduction of traffic wardens. In fact, wardens are an important new resource for creating secure and orderly neighbourhoods, not a substitute for or alternative to the police.

    And I am putting particular emphasis on tackling anti-social behaviour and drug misuse – both of which destroy communities. For example, we are proposing to stream line Anti-Social Behaviour Orders by establishing interim orders on application, by giving powers to housing associations and other registered social landlords to apply for orders and ensuring that, when necessary, orders will travel with people when they move house. And we are building a new approach to tackling anti-social behaviour with Crime and Disorder Partnerships, working closely with local communities, drawing down funds like the Community Champions Fund so as to build a preventive approach to tackling anti-social behaviour.

    To emphasise, these are civil renewal measures, not just crime cutting measures.

    On your side: investing in individuals and communities

    Millions of people across the country want to work together to make a difference to their communities. But the truth is that without resources, their achievements will be limited. Many give up. Mutual working withers. Social capital can collapse.

    The lack of resources is most acute in deprived areas, where those in poverty, those with disabilities and those struggling to bring up children on their own are concentrated. Compared to the rest of the country, deprived areas have twice as many people dependent on means tested benefits, three times more children in poverty and 30% higher mortality rates.

    We have been determined to ensure that, in these areas in particular, people have the resources they need to help themselves. I am now working closely with Steve Byers to ensure that we have a fully joined up approach to regeneration and neighbourhood renewal. Crime reduction is at the heart of our policies for civil renewal in these areas.

    And mobilising people for progress is crucial. As I said earlier, the example of Balshall Heath shows what can be done. People took control of the situation for themselves – tackling drug addiction, picketing on the streets to get rid of the pimps and the prostitution that flooded the area, and dealing with thuggery and intimidation. Over time, stronger partnerships with government have been built up. This shows what can be achieved when government supports people, so that they can make a difference to their lives and communities. Not simply providing for people, nor abandoning them to global forces outside their control.

    This investment approach has characterised our support for individuals – enabling more people to have a better education and giving more children a better start in life. The proposed new Child Trust Funds extend the investment approach to financial assets.

    The same philosophy – of helping people build up the assets needed to help themselves – applies to communities. It is when communities have the resources to help themselves that they can work together to create real change. In this process, social capital is built. Take the North End and North Lynn Community Trust in King’s Lynn. The Trust was set up with just £55,000 in 1992. From that, it has built a range of services, including childcare schemes and a healthy living centre. And as their assets have grown, more and more people have got involved. Social capital has developed, laying the foundations for further mutual working.

    Sure Start is one example of how we are already making a significant investment in the assets of communities – by providing new buildings, skills and organisational capacity and the long-term future of our children.

    But we need to do more. Where appropriate, central and local Government needs to transfer assets and control to communities. Parks, community centres and leisure centres are sometimes better controlled by community groups. With the right support, they can manage them more effectively and become local community institutions.

    Risky? Undoubtedly. But if we don’t take risks we will never give communities the control over their own futures which stimulates social action. So I welcome the intention of the Department for Transport, Local Government and the Regions to remove the need for ministerial consent before local authorities can transfer land at less than market price under the Local Government Act 1972 and believe that we need to do more to encourage and support appropriate asset transfers.

    We also need to invest in community institutions, like North End and North Lynn Community Trust – hubs of local communities. Through the Active Community Unit we are already providing grants to umbrella organisations, such as the Community Action Network, which support community groups. We should now consider how the Government and others can better directly invest in community organisations, so that they can make a real difference.

    We particularly need to invest in those community institutions which bring together people with different cultural backgrounds. The disturbances in Bradford, Oldham and Burnley last summer demonstrate the important of investing in social networks and organisations building community cohesion.

    Cheaper finance for community groups is part of the solution – the Phoenix Fund and other social investment initiatives are helping achieve that. There may also be scope for carefully managed grants which give organisations the flexible working capital needed to lever in loans and get projects started.

    Working in partnership to help people change their communities

    Thirdly, we need to recognise that people and communities need to work directly in partnership with the Government to build social capital and change their communities. By this, I do not mean lots of talking shops. I mean real collaboration. Getting things done.
    I mentioned West Walker primary school earlier. A good example of how local government services can be important parts of the fabric of local societies. Likewise, the police have worked closely with Balsall Heath Forum.

    The Government is learning much about working in partnership with small community groups. At the Home Office we are simplifying grant regimes, encouraging joint working between the police and local communities, and looking at new ways to involve communities and families in tackling drug misuse.

    But some local authorities are reducing their support for community groups. I hear of too many important community institutions, such as Volunteer Bureaux and Councils for Voluntary Service, at severe risk of collapse because their local funding is being withdrawn. I am pleased to announce today that we have set up a £500,000 emergency fund to support some of these groups over the next year. But these will be one off contributions. Local authorities should be supporting the community sector too, and Stephen Byers and I will be writing to relevant local authorities to emphasise this to them. We are determined to work together to support civil renewal in this area, as others.

    We also need to consider better ways for central and local government to work in partnership with community leaders – the people who make social networks work for the common good, by bringing people together to tackle crime, improve education and develop public spaces. Paid or voluntary, community leaders can galvanise local people around a vision of change and practical action. So we need to build on, and develop initiatives like the Community Champions Fund, and the new Neighbourhood Managers under the Neighbourhood Renewal Programme, investing in and trusting local leaders.

    Conclusion: Social Capital and Citizenship

    The roles I have outlined for Government – creating a safe and secure environment, investing in communities and working in partnership with people – are all areas where we are making progress. I would like to end by touching on the other side of partnership – the responsibility of individuals. Government has important roles, but individuals must play a role in renewing communities. People must make the effort to work together, to reach out across communities, to make a difference. There has to be a civil spark.

    That is why I believe that we must think about building social capital in the wider context of citizenship. The two weave together. Those who volunteer in their communities tend to be more likely to vote. Conversely, those who have a sense of citizenship tend to work with others to improve their communities.

    A final part of our approach must, therefore be to reinforce citizenship at a national level. That is why, as Secretary of State for Education, I introduced citizenship classes into the school week, including ensuring that young people learnt by doing – going out into their communities and helping others.

    It is also why our immigration, nationality and asylum policies are designed to reinforce citizenship, through new ways of welcoming people and ensuring that people can fully participate in British society by speaking English. Ultimately, these are policies for building social capital.

    So to end on a personal note, the opportunities to help build social capital and drive civil renewal are one of the reasons why I have so much pride in being Home Secretary. As I noted at the start, I am an optimist about social capital, but know that it has to be tended. The Home Office brings together security, investment in communities, partnership working with communities and citizenship. As we take action on all these fronts, I believe that we are seeing social capital, our neighbourhoods and democracy renewed.

  • Gordon Brown – 2002 Speech at UNISON Conference

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    Below is the text of the speech made by Gordon Brown, the then Chancellor of the Exchequer, to UNISON Conference on 20 February 2002.

    I am delighted to be here today at this discussion of the future of public services – not just because this meeting allows me to set out some of the considerations that led to the Government’s Budget decisions and some of the conditions including reform that will lead to our decisions in the Spending Review to come, but as important because this forum allows me to set out the beliefs which have shaped the Government’s decisions.

    First, in Britain a well established ethos of public service – so important to the delivery of our public services – rightly runs deep in our history, determines the character of our country, defines Britain’s uniqueness to the world, and in our Budget decisions we aim to sustain and renew that ethos of public service.

    Second, I will suggest that the case for a health care system free to all at the point of need is stronger today – when the costs of new technology in health are far greater than ever – than in 1948 when the National Health Service was first created, and we should aim to make the NHS the best insurance policy in the world.

    Third, our approach to public services will always be built upon a foundation of delivering economic stability, a discipline from which we will not depart.

    And, fourth we will not hesitate to press ahead with modernisation so that at all times resources are matched to reform to ensure the best delivery and results.

    All of us can tell our own story about the importance to us and to Britain of the ethos and traditions of public service in our country.

    We think of our own teachers and the extraordinary power of teachers to make a difference to our lives.

    We know nurses, doctors and health service staff who everyday can make the difference between life and death.

    Social workers and care staff, who can transform hopelessness into hope.

    Home helps and care assistants who for the frailest and the weakest make public service the mark of civility.

    Street orderlies and ancillaries who show by their commitment why public service is about improving the quality of life.

    And if you’ve ever been involved in an emergency you remember the calm unflappable skill, the professionalism, and self-sacrifice of all our public services.

    Each time good is done it sends out a message that duty, obligation and service are at the heart of our country’s sense of itself. And it is from these acts of selfless dedication inspired by higher ideals that the ethos of public service is continuously renewed and the very character of our country as a community with its shared needs and linked destinies is shaped.

    And many will look back like me and recall that so many of the opportunities we have had – the best schooling, the best of health care when ill, for many of us the best chances at university – so many of the opportunities we have enjoyed – owe their origin to the decisions of past Governments to create a welfare state that takes the shame out of need, to fund a National Health Service free to all, to build decent public services worthy of a civilised society.

    That is why through public investment built on a platform of stability we have new more ambitious objectives in our generation.

    Not just to build the best modern transport, health, education and housing our country can afford, but through tackling child and pensioner poverty to ensure every child has the best start in life and every pensioner dignity in retirement.

    And through raising standards in education to ensure that for the first time not a minority but a majority of young people can attend university and so education, once the preserve of the minority, can become the hope and aspiration of the majority of our citizens.

    For me the National Health Service is a clear, enduring and practical expression of these shared values which shape our country: the NHS built upon the conviction that the health of each of us depended upon a contribution by all of us and that it was the mark of a modern caring society, compassion in action, that we moved from the patchwork of uneven voluntary, charitable, private and municipal pre-war provision, and ensure universal access to health care, regardless of ability to pay: health care as a fundamental human right, not a consumer commodity.

    And the question for Britain is whether the consensus that endured on a tax funded health care system for the last fifty years should be renewed for the next fifty. And it was right for us to examine other systems. The Government has examined the case for funding healthcare by private insurance where, in the case of the US, family premiums average around £100 a week and are set to rise next year on average by £13 a week, and because of its costs insures only some of the people for some of their care.

    We have examined the case for funding by social insurance whose narrower base for contributions means – in France for example – the typical employer paying £60 a week per employee and where the direct relationship between insurer and insuree usually means less investment in public health preventive health and community health services.

    And the Government has examined the case for charging for clinical services which also means patients paying rising bills for individual operations and treatments – costs ranging from £6,000 for a hip replacement to £10,000 for a heart by-pass on the BUPA price list – basing our healthcare system on medical charges would mean, in effect, the sick pay more for being sick.

    There is another consideration as we look to the long-term.

    In 1948 when the NHS was founded, much of what could be offered was a standard, and in practice rather modest, service. At that time, the scientific and technological limitations of medicine were such that high cost interventions were rare or very rare.

    There was no chemotherapy for cancer, cardiac surgery was in its infancy, intensive care barely existed, hip and knee replacement was almost unknown.

    Now, the standard of technology and treatment is such that unlike 1948 some illnesses or injuries could cost £20,000, £50,000 or even £100,000 to treat and cure.

    Because the costs of treatment and drugs are higher than ever, the risks to family finances are greater than ever, and therefore the need for comprehensive insurance cover of health care stronger than ever.

    Insurance policies that, by definition, rely for their viability on ifs, buts and small print can cover only some of the people some of the time.

    Because none of us ever know in advance whether it is you or your family that will need that expensive care – for acute or chronic illness – the most comprehensive insurance cover is the best policy to cope with unpredictability.

    And this is true for the most comfortably off members of our society as it is for the poorest.

    Why? Because charges for any one of these treatments could impoverish individuals, households, and families far up the income scale, it is now not just in the interests of a lower income family but those on middle or higher incomes to be insured in the NHS’ comprehensive way.

    Some present the current NHS system of funding as an ideological hand-me-down from the immediate post war era to be supported only out of sentiment rather than hard headed calculation.

    Others dismiss the NHS funding system as an impossible dream – “fine in principle, a failed experiment in practice”.

    But far from being a hangover from a distant age or an unrealisable vision, the NHS system of funding – comprehensive and inclusive insurance with treatment free at the point of need – is demonstrably the modern rational choice. Not just for poor or low-income families in Britain, but for the vast majority of families in Britain. Not just for today but for tomorrow too.

    And far from it being valid for the needs of the 1940s but not for now, a tax funded system offering the most comprehensive insurance is Britain’s better way forward for coping with the three challenges facing health care: the rising costs of new technology, the increase of 3 million by 2020 in the elderly population, and the ever rising expectations for higher standards of personal care.

    So it is our view that the NHS system of funding with comprehensive cover available for all is not just the most equitable but that a reformed NHS, by offering the most comprehensive insurance policy to meet the rising costs from medical advances – the best insurance policy in the world – can give the British people the greater security they need.

    Yet the Budget debates have revealed an astonishing and dramatic break with a fifty year long all party consensus on the NHS system of funding – that the NHS would be free to all at the point of need.

    Where health care is universal it would not, for them, be free and where it was free it would not be universal – with severe consequences for all: a huge growth in means testing of low income families on American Medicaid lines; the bills literally sent to middle Britain which would have to pay charges or insurance premia for its health care; and because forcing people to pay would be the biggest assault on the family finances of middle England, those advocating this must now explain what would be the cost of a hospital stay, a GP visit, or an operation under their policies.

    This Government rejects those visions of some privatised future where the healthcare you’re guaranteed for your children and your family is the healthcare you insure privately or pay for and where poverty bars the entrance to the best hospital, and we reject the dogma of those whose dislike of public services is such that they would prefer a private sector working inefficiently to a public service working well.

    It is because we recognise the unpredictability of health needs, the rising costs of health technology, and the equity and efficiency of the NHS tax funded system that, for us, the NHS will remain a National Health Service – a public service free at the point of use with decisions on care always made by doctors and nurses on the basis of clinical need.

    The foundation for improved public services is an economic stability that can sustain increases in public investment in health, and let me say something about the background to our public spending decisions.

    When I became Chancellor in 1997 I said that without stability first, without stability as the precondition of growth – and without, therefore, the first tough two years – we could not build the foundation for sustainable rises in public investment.

    So since 1997, we have taken tough decisions to deliver economic stability, starting with Bank of England independence and cutting borrowing to bring the public finances under control.

    Having in six budgets since 1997 entrenched economic stability and fiscal discipline; cut unemployment and debt, releasing new resources to invest in the NHS and vital public services; and, insisted that strings are attached to match new resources to better results, we have managed to set in place a modern and more long-term framework for better public services.

    When we reformed public spending in 1997 we moved on from the Plowden principles that had dominated public spending decisions since the 1960s.

    The Plowden approach was annual, input driven, ad hoc and incremental, departmentalist, consumption dominated and remote from the private sector.

    In its place our approach to public spending is long term, with a three year not one year cycle.

    It is results driven with targets for outputs.

    Spending decisions are based on in depth policy review, not simply on last year’s figures.

    Spending decisions are based not on the old departmentalism but on interdepartmental reviews as to whether across Government there is sufficient co-ordination so that overall objectives are being achieved.

    Investment has been restored to its proper place so that we can tackle major long-term infrastructure problems, and a backlog of under-investment.

    And we have ended the sterile war for territory between public and private sectors and see public and private now working together for public interest objectives.

    So we have a new spending regime which has now allowed us the largest sustained rises in public investment the country has seen.

    Just as we have taken tough decisions to reform our monetary and fiscal regime to secure stability for the economy, we must now take equally tough decisions to ensure investment in public services delivers results.

    For just as schools exist for school children, and the NHS exists for patients; public services exist not for the public servant but for the public who are served.

    And our aim must be that every classroom has the best teacher, every school the best staff, every operating theatre the best doctors and staff, every police station the best police men and women – that every public service has the best public servants.

    And those of us who believe passionately in public services have a special responsibility to ensure their effectiveness, understand that there can be no blank cheques, that the days of something for nothing are over in our public services. And know also that we can only deliver world class public services if strings are attached and we change, update and modernise, to ensure that public services can best serve the public.

    Just as we cannot serve the public if investment is low, staffing poor and conditions unacceptable, we cannot serve them either if service is poor, if performance is faulty, if there is resistance to necessary change.

    And behind the modernisation of delivery are a set of principles that will dominate decisions not just on NHS spending but in our public Spending Review.

    First, an emphasis on national standards with proper audit and accountability to ensure standards are met;

    Second, “front line first”, with local devolution and delivery;

    Third, greater flexibility to achieve greater results; and

    Fourth, extended choice.

    First, we are setting national standards with proper accountability – working with hospitals, schools, police forces and local government to agree tough targets, and to see performance independently monitored so people can see how their local services compare.

    The Spending Reviews and the Public Service Agreements that we have introduced reflect a much needed culture change in focusing Government on results. In the coming Spending Review, there will be even more of a focus on standards based on evidence of customer satisfaction – delivering through a system of clear accountability the improvements that make the most difference to citizens’ actual experience of their services.

    Performance targets have an important role to play in measuring how far these standards are being met. School and NHS trust performance tables, local authority and police performance indicators, all offer the public the chance to see how well their local school, hospital, council or police force compares with others in the country.

    There were, for example, no national standards of treatment of coronary heart disease in 1997 even though it is the biggest cause of premature death in the UK.

    To tackle this problem, we published the National Service Framework for Coronary Heart Disease in March 2000 to ensure national standards in prevention, treatment and care. Heart operations are now up by around a quarter and the use of cholesterol-lowering drugs is up by over a third.

    The National Service Framework for Coronary Heart Disease has been followed up with similar frameworks for tackling cancer, providing services for the elderly, and delivering mental health services.

    So we can meet our objective of genuine opportunity for all, a national strategy to assist secondary schools in driving up standards of achievement for 11–14 year olds is being rolled out, to complement the literacy and numeracy targets succeeding in primary schools.

    So a majority of young people can enjoy university education, challenging targets have also been set to increase higher education student numbers, and the newly-established adult learning inspectorate is helping raise standards of teaching and learning.

    A new Police Standards Unit has been established, to measure performance, enable clear and fair comparisons to be made and, in partnership with Her Majesty’s Inspectorate of Constabulary, help every police force aspire to the standards of the best.

    And so that our local government service can rival the best, the Local Government White Paper sets out how the “Best Value” framework is being streamlined and strengthened, to enable councils to use it as an opportunity for radical challenge, and to engage citizens and staff in improving services.

    And for the first time for modern public services we have insisted on a separation of responsibility for standards and of the responsibility for audit, inspection, scrutiny of users’ complaints and reporting to the public.

    So the public will now have the right to know what is happening, how money is being spent, whether standards are being achieved, how targets are being met, what people’s complaints are and the link between the money they invest and the results achieved.

    The second modernisation is the policy of front-line first: local devolution so the money gets down to the local level. Moving far beyond the old days of ‘the man in Whitehall knows best’. Central Government has had to learn to let go and give successful front-line professionals the freedom to deliver.

    Learning from the success of devolution to date, in the context of well-defined accountability, the Government is determined to devolve and delegate further. Local government will be released from unnecessary restrictions and controls and in the police service, basic command units should have the freedoms they need wherever possible to meet the demands of the public on the ground.

    Demanding standards and devolution need to go together. The best way in which a national standard can be met is by recognising local and often individual differences, and giving service providers the flexibility to shape services around the needs and aspirations of customers and communities.

    Our best NHS hospitals have asked the Government to explore new models of service delivery which would see them fully part of the public sector NHS with new freedoms and flexibilities the idea of ‘foundation hospitals’ is to move from a top down management system to a system based on a few key rules within which organisations have much greater flexibility over managing their resources and designing services. This innovation is part of our move to devolve responsibility to the frontline and improve accountability to patients and the public.

    And so that our local services can be the best, the Local Government White Paper proposes that high-performing councils should be given a wide range of freedoms and flexibilities, including the right to trade and raise forms of income.

    The third modernisation is flexibility to achieve results – removing the artificial barriers that prevent staff delivering service improvements.

    A key part of devolving power and responsibility will be the removal of needless rules that are a hangover from the era of centralisation. And if local managers are to be freer to innovate, they need greater freedom of movement.

    There must be responsibility in pay agreements. Just as sustained economic growth demands responsibility in setting private sector pay, so a sustained commitment to better public services demands responsibility in setting public sector pay. Discipline will be our watchword.

    Central to better results is an end to the sterile dispute between public and private sectors. We want to see public and private working together for the public interest. In transport, for example, we will maintain our £180 billion ten-year plan to modernise our transport infrastructure – a doubling of transport investment. And we will continue our programme of public private partnerships.

    Let me give the example of the Underground.

    Prior to 1997, the average public investment in London Underground was just £395 million a year. In the next 15 years the public investment in trains, track and stations will total £16 billion – investing at three times the old rate – the biggest single investment in the Underground in its history. More investment by the public sector in the next 15 years than we saw in the last hundred years.

    And when billions of your money are being invested you would want us to ensure not only best value for money but the best possible public service.

    So to construct the new infrastructure that will increase the Underground’s capacity by 20 per cent to 1.3 billion travellers each year, the construction and engineering companies will simply continue to do the work as they always have in digging the tunnels, building the infrastructure and replacing the track. But now for the first time they will have to take responsibility for what they deliver. So they will have to pay for the overruns, the delays, the faults in the construction and the mistakes that lead to extra maintenance.

    So that we do not have another Jubilee Line fiasco – two years late, massive overruns – which if repeated in the new Underground investment programme would cost us two billion pounds.

    And while the private sector directs its skills and expertise in risk and project management towards maintaining and improving the infrastructure, the public sector in the Underground – and public sector staff – will operate the track, run and provide signalling, run trains and stations on every line, set service levels, set the standards and ensure safety, and be in charge of an integrated tube network from 5.00am to 1.00am.

    At all times safety paramount with the London Underground and the safety inspector the final decision-maker on what needs to be done for a safe transport system.

    And we will work with the approval of the Health and Safety Executive on the highest of safety standards.

    Our choice is clear. Not a return to the old ways, not the short-termism of the past, but an approach that makes sure that the billions we invest provide the best service for the public.

    The fourth modernisation is extending choice. In designing services around citizens, it is important to be clear about their requirements. In some cases, we all want pretty much the same service – the bin to be emptied regularly, the street to be swept clear of litter. But in others, citizens increasingly want to be able to choose the service which best fits their requirements. They might want to choose the GP surgery that is most convenient for them to get to. They might want to be able to choose the hospital with the shortest waiting times or the most experienced specialists.

    It is the Government’s task to ensure that everyone can make appropriate choices, regardless of income. This means that customers need better quality information on their public services and, in particular, how these services match up against the standards that matter most to them. And where standards are not being met, citizens should be able to seek effective redress.

    A key area where these reforms are being put into practice is the NHS. And let me tell you what has been happening with the budget.

    I said at the time of last November’s Pre-Budget Report that the precondition of new resources was reform, and the Secretary of State for Health, Alan Milburn, has announced vital new reforms to ensure extra money secures results:

    – new financial incentives for hospital performance;

    – greater freedoms for high performing hospitals and trusts;

    – powers and resources devolved to front-line staff in Primary Care Trusts;

    – reform of social services care for the elderly; and

    – a series of measures increasing choice for patients.

    In order to make sure that money invested yields the best results, for the first time in the history of the NHS, we will enshrine in statute, independent audit, independent inspection, and independent scrutiny of patient complaints – with a duty to account and report to the public on money spent and standards achieved.

    It is right however to show where money is spent and the results achieved and in future an annual report to Parliament prepared by the new independent auditor, will account for the money allocated to the NHS, where it has been spent and what the results of the expenditure have been. This will be accompanied by local reports stating, for each local community, the link between money spent and results achieved.

    New incentives for individual members of staff will be matched with a new system of financial incentives on NHS organisations. The hospitals that can treat more patients will earn more money. Traditional incentives work in the opposite direction. Indeed it is often the poorest performers who get the most financial help.

    We will therefore introduce a new system for money to flow around the health service, ending perverse incentives, paying hospitals by results. The incentive will be to treat more NHS patients more quickly to higher standards.

    And patient choice will drive this system. Starting with those with the most serious clinical conditions, patients will have a greater choice over when they are treated and where they are treated.

    From this summer patients who have been waiting six months for a heart operation will be able to choose a hospital – whether it is public or private – which has capacity to offer quicker treatment.

    Reductions in waiting times to get into hospital must be matched by cuts in waiting times to get out. Older people are the generation who built the NHS and who have supported it all their lives. This generation owes to that generation a guarantee of dignity and security in old age. Bed blocking denies both.

    In recent months the extra resources we have made available has reduced the numbers of elderly patients whose discharge from hospital has been delayed. But the long-term solution is not just investment. It must be matched by reform.

    So in order to bridge the gap between health and social care we intend, as they have done in Sweden and elsewhere, to legislate to give local councils responsibility from their 6 per cent extra real terms resources for the costs of beds needlessly blocked in hospitals.

    Councils will need to use these resources to ensure that older people are able to leave hospital when their treatment is completed.

    If councils reduce the current level of bed-blocking so that older people are able to leave hospital safely when they well, they will have freedom to use these resources to invest in extra services. If bed blocking goes up councils will incur the costs of keeping older people in hospital unnecessarily. There will be similar incentives to prevent hospitals seeking to discharge patients prematurely. In this way we will provide local councils with the investment and the incentives to improve care for older people.

    So on the basis of reform and modernisation I set aside money for public spending in last week’s Budget. I propose to raise current public spending from £390 billion this year to £420 billion next year, to £444 billion in 2004-5 and £471 billion in 2005-6.

    And I propose to raise our historically low levels of net public investment that were at 0.6 per cent in 1997 to 2 per cent by 2005-6. Taken together, the largest sustained investment for better services in our history.

    And in last week’s Budget, I announced plans to raise UK NHS spending on average by 7.4 per cent in real terms each year – an annual cash rise of 10 per cent – not just for three years but for five years.

    With year on year rises, UK health spending will grow from this year £65.4 billion to £72.1 billion to £79.3 billion to £87.2 to £95.9 billion and then to £105.6 billion in 2007-8: even after inflation a 43 per cent rise over five years. Since 1997, a real terms doubling in health service investment.

    UK health spending will rise from 6.7 per cent of national income in 1997 and 7.7 per cent of national income this year to 8.7 per cent by 2005-6 and to 9.4 per cent by 2007-8 – rises year on year well into the next Parliament.

    Last year we invested £2,370 for the average household on the NHS.

    By 2007-8 we will be investing £4,060 pounds per household: after inflation, a 48 per cent real terms increase.

    And let me spell out exactly what this new investment will deliver:

    35,000 more nurses

    15,000 more doctors

    40 new hospitals

    500 primary care centres.

    Upholding and improving the NHS not just because it is an institution that is part of our history and our shared values but because, reformed and renewed, it can be the most efficient and equitable guarantee of health care for millions, provide the better choices and service they need and become, for the British people, the best insurance policy in the world: the best for each of us and the best for all of us.

    Let us be clear about the choice in this Parliament on our great public services.

    This is a battle for nothing less than the future of the National Health Service, and our public services.

    It is a battle to demonstrate that in the 21st century we can build strong public services, there when people need them.

    I started by saying that at their best our public services represent the best ideals of Britain.

    Indeed our public service ethos – the emphasis on service, duty, obligation and not profit at the heart of health care provision – marks Britain out from the rest of the world.

    With the new investment in public services to tackle underlying long-term problems in our country, that public service ethos can bring out the best of Britain to root out the worst of Britain.

    It is because we all benefit from reformed, modernised public services that let us join together in this crusade for renewing the National Health Service and our public services.

  • Gordon Brown – 2002 Speech at Commonwealth Parliamentary Association’s Conference

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    Below is the text of the speech made by Gordon Brown, the then Chancellor of the Exchequer, to the Commonwealth Parliamentary Association’s Conference at Lancaster House, in London, on 12 March 2002.

    Your Majesty, Your Royal Highness, fellow parliamentarians, ladies and gentlemen.

    This meeting – of parliamentarians from every part of the commonwealth – is a very special one:

    It celebrates Your Majesty’s fifty years as Head of the Commonwealth;

    And it launches – in honour of that – a new ‘Commonwealth Education Fund’.

    From the Pacific Islands to the British Isles, from the Caribbean to Central Africa, the Commonwealth is a community which spans the reach of global geography and the entire breadth of the economic spectrum – a community united in its vast diversity by a common heritage and shared values of democracy and human rights.

    Today we take an historic step to advance those values.

    This Tuesday morning, when almost every child in Britain is in school, there are in the Commonwealth 75 million children who are not because they have no schools to go to.

    Children who will never enjoy even the most basic primary education;

    Children thus destined to fail almost before their life’s journey has begun.

    With the new Commonwealth Education Fund – and other funds – we aim to ensure that, by 2015, no child is left out and that every child in the Commonwealth will receive primary education.

    And, Your Majesty, we believe that it is an altogether fitting tribute to your fifty years of service to plant, across the Commonwealth, seeds that will still bear fruit in another half century.

    I think of the five year olds who, as a result of this new Education Fund, will be given opportunities they would never otherwise have both in learning and in life – a chance that will transform their own lives immediately … and lift the life of their nations for the next half century and beyond.

    Since 1997, the International Development Secretary has committed £650 million to support progressive governments determined to achieve, high-quality primary education, mainly in sub-Saharan Africa and South Asia. And she will significantly raise our commitment to overseas development over coming years and its share of national income.

    The new Commonwealth Education Fund which will build on these British efforts will be a proud and permanent legacy of this Jubilee year.

    The UK government will provide an initial £10 million.

    And we will match pound for pound contributions from businesses and members of the public – in particular through this year’s Comic Relief campaign – “Sports Relief”.

    Most of this money will be channeled through charities and NGOs to help the Commonwealth’s poorest countries open the doors of learning to all their children – most of all the most vulnerable and disadvantaged street children, child soldiers and aids orphans.

    And I hope that this lasting legacy of the Jubilee Year will also be felt here in the UK.

    At the moment around 870 schools from the Commonwealth are ‘twinned’ with British schools. I visited one of those schools this morning and saw myself how it is helping British children to gain a better understanding of other cultures.

    The Commonwealth Education Fund will widen and deepen such ties, raise the awareness of international poverty and development in our schools and build new bridges between young people in Britain and across the Commonwealth.

    In so doing, I hope that our children will grow up with a new consciousness of their responsibilities as global citizens – and a real sense that deprivation and despair anywhere diminish all of us everywhere.

    There are threats we must face and defeat – from terrorism to exploitation to the easy temptations of indifference. But before us there is also an unprecedented possibility of progress.

    We have in our hands the power and obligation, never given to any other generation at any other time in human history, to banish ignorance and poverty from the earth.

    Every time we lift one child out of the slums and the destitution and squalor of living above open sewers…

    Every time we cure one child afflicted by disease, and give her the chance of learning…

    Every time we rescue one child soldier impressed into combat…

    We are making a difference.

    But if, through education, we can lift not just one child, but 75 million children out of poverty and hopelessness, we will have achieved a momentous victory for the values of the Commonwealth and the cause of our common humanity.

    2002 is a momentous year for Your Majesty. And for your honour and ours, let it also be a momentous year for the Commonwealth

    I can think of no tribute and no legacy that would better mark Your Majesty’s Jubilee Year than a promise, a commitment, that every child will at least have a decent start in life.

    By opening the doors of learning to all of them, we can secure a stronger, fairer, more prosperous future, not just for them but for all our nations and peoples.

  • Gordon Brown – 2002 Speech at Social Market Foundation

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    Below is the text of the speech made by Gordon Brown, the then Chancellor of the Exchequer, to the Social Market Foundation in London on 20 March 2002.

    The challenge of next month’s Budget is not just to build a stronger more enterprising economy but to put the National Health Service on a solid foundation for the long term.

    Our five Budgets since 1997 have pursued a consistent course: to entrench economic stability and fiscal discipline; to cut unemployment and debt, releasing new resources to invest in the NHS and vital public services; and, by insisting strings are attached that match new resources to better results, to set a proper framework for better public services.

    The Secretary of State for Health has already shown – and will continue to show in the coming months – how, to put patients first, there will be new national standards and improved accountability, devolution to front-line services and greater choice and flexibility.

    My role as Chancellor is to ensure not just that our public services are properly funded, but that funds are raised in a fair and efficient way which ensures value for money.

    We have not come this far to put our hard-won economic stability and fiscal discipline at risk – and with low inflation and low unemployment again today – we will not compromise on our economic stability.

    The something for nothing days are over in our public services and there can be no blank cheques.

    Our ambition for the Budget and Spending Review is to put the NHS on a sound long-term financial footing. And this must be based on tough choices between and within Departments, matching resources with reform.

    In the coming Budget and Spending Round, before committing the Treasury to additional expenditure, we will need to know of Health and all Departments whether extra spending is a priority, whether there is a clear strategy of reform to deliver value-for-money, and the track record of increased resources leading to improved results.

    Today – in the run-up to the budget and spending review – I want to advance the debate on how we finance healthcare. It is a debate crucial to the wider debate on the future shape of our public services. Indeed it is a debate about what kind of country we are, because it is a debate not just about the technicalities of finance but about the national values we – the people of Britain – hold to be important.

    It was because of our concern about the demographic, technological and other pressures on health care services in Britain that in 2000 the Treasury announced a major review on long term health finance needs and appointed Mr Derek Wanless to conduct it.

    Having received his interim report at the time of the Pre-Budget Report, the Government urged that a national debate should take place.

    In the same way there was a national consensus after 1948 on the funding of the NHS, a new national consensus should be sought for the future funding of health care, one that matches greater reform and modernisation of the NHS with greater resources.

    I said at the time of the Wanless Review that for me the NHS is a clear, enduring and practical expression of our shared values as a country – that all our citizens should have decent health care and that an NHS with quality service for all, based on need irrespective of income, should represent the realisation of this ideal.

    Indeed I was brought up to believe that the NHS reflected what Professor Richard Titmuss called the “gift relationship”, giving practical effect to people’s altruistic as well as self interested impulses – a unique British institution that has marked Britain out in the world.

    My own experiences have confirmed that instinct and that belief: that the uniqueness, indeed the greatness, of the NHS as a British institution is that – with its dedicated and expert staff – it is designed to be there when you need it, open to all, no matter what your circumstances.

    And there is evidence that this view of the NHS is shared by the majority of British people too.

    But at a time when its values, its affordability and even its right to existence are being questioned, it is proper – indeed essential – for us to examine all our assumptions about the future of health care and its funding here in Britain.

    At the time of the Pre-Budget Report, I asked those who advocate a different way to pay for health care in Britain to come forward with their specific proposals.

    Today, having examined the main alternatives – user charges, private insurance and social insurance – I want to set out the Government’s own analysis.

    And I want to set out our views not just by reference to the past and the present. For what we need is not just a funding system able to meet the health care needs of today but one that meets the challenges of the long term future – particularly the increasing cost of technology, demographic change and rising expectations.

    Let me explain.

    There was an assumption after 1948 that once healthcare was free at the point of delivery demand would fall as the backlog was cleared.

    But for a whole range of reasons, that did not happen.

    In 1948 the NHS offered 400,000 operations in NHS hospitals and one million outpatients were seen.

    Today there are 6.5 million operations each year, with over 40 million outpatient appointments.

    The first reason for this is the growth in availability of new treatments and drugs as a result of technological advance.

    It has been suggested that this huge expansion in technology and in its costs calls into question the entire nature of the health service.

    Over the last half-century technology has opened up vast new areas of diagnosis and treatment. We know more, we can do more, so we can deal with many more illnesses and save many more lives.

    And as a result of the progress of the last fifty years, many illnesses and injuries that were not then survivable can now be treated with confidence and a new certainty of success.

    So the medical miracles of a generation ago are commonplace occurrences today.

    And of course the rate of accumulation of new knowledge – and new abilities to intervene – continues to increase. We are in the midst of a pharmaceutical and biomedical revolution with – looking to the future – new techniques from genetics to stem cell therapy and new drugs to prevent, alleviate or cure conditions like Alzheimer’s and HIV/Aids.

    But costs are increasing too. For while a maturing technology often brings rising cost effectiveness, each emerging technology that is proved effective brings new demands for its use.

    Many new technologies, like minimally invasive surgical procedures, are cheaper than the old technologies which they replaced – largely because they are less traumatic and hospital stay has fallen accordingly – but their convenience has substantially increased referral and uptake leading to greater costs too.

    And as drug efficacy and acceptability improves, more patients will be treated over the longer-term to prevent harm and disease: for example with statins to lower cholesterol – where the numbers using them are expected to rise dramatically from one million to over six million by 2010 – or anti-hypertensives to reduce the likelihood of strokes.

    Overall, the average annual increase in the cost of medicines, dressings and appliances dispensed in the community rose by nearly 10 per cent per year during the 1990s. Some drugs – such as those used to treat metabolic disorders – can now cost up to 8,000 pounds per prescription.

    We should never lose sight of the overwhelming trend: the good – even great – news that many more lives can be saved, many more diseases cured, many more serious and complex injuries survived.

    But what challenges us is that the same new treatments, surgical procedures and curative and preventive drugs carry costs from which – in other countries – individuals and families are not protected: costs that can overwhelm family budgets, bringing poverty and bankruptcy simply from paying for health care.

    After more than fifty years of the NHS, it is easy for us in Britain to forget that for an individual or a family unprotected by a system such as ours the cost of catastrophic illness or an acute condition can be – and often is – literally catastrophic. And many would suggest that the last thing people who have the anxiety and fear of being sick need is the added anxiety and fear of whether they can pay for treatment.

    The second challenge to healthcare systems is changing demography, and with long term care increasingly an issue of concern there is a case for looking at health and social services together.

    The British population is not only larger than in 1948, rising from 50 million to nearly 60 million, but older. And these trends are set to continue.

    The population is forecast to grow by one fifteenth to 64 million over the next 20 years with the number of the people over 65 increasing by nearly a third over the same period to 12.5 million.

    We know that because much of ill-health is age-related, health care costs rise with age and that the average annual cost to the NHS of a person aged over 85 is approximately six times the cost for those aged between 16 and 44.

    But because such systematic evidence as is available suggests that, as life expectancy rises, people will be less severely ill for longer at the end of their lives, Derek Wanless suggested in his interim report that, overall, demographic pressures will only add around 1 per cent a year to Britain’s total health care bill.

    The third challenge is the increase in expectations about standards of care in hospitals and healthcare generally – and an increasing demand for patient choice.

    We know of health gaps between Britain and our main European comparators in life expectancy, infant mortality, premature mortality and survival rates from cancer and heart disease.

    And recent surveys show what we all know: that as well as safe, high-quality treatments, taxpayers rightly expect improvements in the quality of service the NHS offers. They want improved use of new technology, shorter waiting times, more time with their GP, a more joined up service, and better accommodation and facilities. In fact, to move towards meeting these needs, one third of beds in new hospitals will be in single rooms.

    All this reflects the fact that people want greater choice with services designed around their individual needs – the end of a one size fits all approach.

    Changing technology, demography and expectations provide the context within which we are considering the twenty year funding needs of the health service.

    It is within this context that I want to test each possible system of healthcare funding – user charging, private insurance and social insurance – on their capacity not just to meet today’s needs but future needs.

    And I will suggest that those who use rising expectations and new demographic and technological demands to make the case for user charges or private insurance are conveniently misusing new challenges to pursue ancient prejudices.

    Of course, most countries rely on a mix of different funding streams for healthcare but most are based predominately on one financing system. And I will examine in detail the case of those who contend that a different system would be better for Britain.

    There are those who argue that the NHS, while valid for the more basic needs of the 1940s, is out of date for the more sophisticated needs of today. But I will argue that the future impact of new technology makes the case for a revenue-funded National Health Service even more valid today than it was in 1948.

    User Charging

    The first alternative to examine is user charging – requiring patients to pay directly for all or part of the cost of a particular treatment or service.

    In Britain we already have user charges for dentistry and prescriptions but in other countries this phenomenon is much more extensive.

    At the heart of the theoretical case for widespread charging in health is the assumption that health care is a commodity to be purchased like any other – individuals paying the full price for what they consume, each household freely choosing their pattern of consumption, with the supply of health care permanently and rapidly adjusting to the pattern of preferences: a pure free market position.

    But many influences impact upon demand in healthcare in a way that is different from an ordinary market.

    Health consumption is, of course, unpredictable and can never be planned by the consumer in the way that – for example – weekly food consumption can. It does not reflect free choice in the way that consumer demand does for other commodities: we demand healthcare not principally because we want it but because we need it.

    And, unlike a conventional market, the consumer will normally have less information and less expert knowledge to seek out the best product at the lowest price than in an ordinary buyer and sellers arrangement. Patients are not doctors and they generally have less knowledge than in other markets to make informed judgments about what care they need, where to obtain that care, or easily compare the price and quality of the services on offer.

    At the most extreme, there could be an added danger where the professional whose expertise the patient relies on for medical judgment also has the power to set the price of their service.

    Moreover, there is clearly a public interest question that means healthcare cannot be treated like a normal market.

    “tackling contagious diseases cannot be left to the ordinary operation of supply and demand”, Anuerin Bevan said in 1948, “the maintenance of public health requires a collective commitment”.

    And whether it is in preventing contagious diseases and other risks to public health or, more generally, in advancing the economic benefits of a healthy workforce, governments have an interest in ensuring that individuals receive treatment which may have a small personal benefit but a large social gain.

    There is strong evidence that not only would charges discourage people from using preventive care – and divert demand to other areas of the health system where charges aren’t levied – but that they would discourage some people, particularly the least well off and the elderly, from seeking treatment altogether.

    According to a recent survey in New Zealand – where there is a system of charges for GP visits – 20 per cent of respondents said they had a medical problem but did not visit a doctor due to cost, compared to 3 per cent in the UK. 14 per cent didn’t get a test, treatment or follow-up care due to cost, compared to 2 per cent in the UK.

    About 80 per cent of patients in France – where GPs charge around £20 per visit and hospitals £6.50 a day – take out supplementary insurance to pay for the charges. Until 2000, the other 20 per cent who couldn’t afford private insurance were left to pay the charges themselves and one in four people surveyed said that they were put off seeking care for financial reasons. In response to this inequity, the French Government now provides free supplementary insurance for those on low incomes.

    If people are discouraged from seeing the doctor, they may simply end up back in the system at a later time with more severe health problems that require more intensive and costly treatments – a result which is potentially more painful for the individual and less cost effective for national health care.

    So exemptions would have to be introduced to ensure those with a clinical need are not discouraged or prevented from receiving treatment.

    But these exemptions would inevitably make a charging system even more complicated and less efficient, with higher administration and collection costs.

    In New Zealand hospital charges were introduced but eventually dropped because the large number of exemptions and high administration costs meant that the scheme raised less than 0.5 per cent of total health service costs in extra revenue.

    In his interim report, Derek Wanless concluded that there could be cases where the use of charges did not result in such significant equity or efficiency problems but did give greater choice. He suggested that this might be the case with charges for non-clinical services, such as access to computer facilities or digital TV in hospital rooms.

    But we in Britain reject user charges for GP and hospital care because of the effects they would have on the poorest and most vulnerable in our society. Put starkly, user charges would mean the sick pay for being sick.

    So making health care reliant on charges is not a road we will take.

    Let me turn now to the three other alternative funding systems – private insurance, social insurance and general taxation.

    The fact is that none of us know when we will be in a position to need healthcare. We don’t know in advance what all our health care needs will be, or when we are going to be sick. It is to deal with precisely these risks that individuals, families, and entire societies seek to insure themselves against the eventuality of being ill. And why most systems of financing healthcare – either public or private – are based primarily around the insurance principle.

    The essential idea of insurance is always the same – the pooling of risks – but the reach of the insurance and the method of finance determine whether health care is treated as a commodity or as a right.

    Before discussing public insurance models, I want to examine the advantages and disadvantages of the second funding system – private insurance.

    Private Insurance

    To move to a British health care system reliant on private insurance would mark a dramatic shift for our country.

    Like most of Europe, Britain has never had a strong tradition of private insurance in health. Even today only 3 per cent of adults buy their own insurance and with company schemes only 11 per cent have it.

    And the advisability of making such a change would have to be tested against considerations of equity – the large number of citizens who, in other countries, cannot afford such schemes – and efficiency, including the higher administrative costs of private schemes.

    As with charges, the paradox of healthcare systems based on private insurance is that the people who need healthcare the most are the least likely to be able to afford it.

    We know that the poorer and older someone is, the more likely they are to fall ill. And in the United States – as with private insurance more generally – the less healthy pay the highest insurance premiums, with premium costs climbing sharply with age. According to the American Consumers’ Union, the sickest 10 per cent of the American population spends six to seven times what the average person does on healthcare.

    As a result, over 26 per cent of families in the US report that they have foregone necessary medical treatment over the last year because of prohibitive medical costs and about 250,000 people each year give up insurance for cost reasons.

    In total, 18 per cent of adults of working age and 12 per cent of children do not have any insurance in the US – over 40 million people in all. 80 per cent of these are in working families, many of them in small businesses or self-employed. The elderly and very poor are covered through public insurance schemes – Medicare and Medicaid.

    So adopting private insurance as the UK health care system would clearly fail to help those with the greatest needs, but paradoxically it is also likely to fail to deliver for those on higher incomes.

    Even comfortably off families in the United States can be faced with huge additional bills because insurance packages tend to exclude high cost chronic care altogether and have co-payments of 20 per cent or more. Someone with a private insurance policy covering 80 per cent of charges can face additional costs of nearly 2000 dollars for hospitalisation for childbirth and up to 5000 dollars for a heart bypass operation.

    In Germany where people on higher incomes have a choice between the public insurance offered by sickness funds and private insurance, two thirds choose the public option because it is considered to be cheaper and less risky.

    No private scheme covers every treatment an individual might need for life at a price they could afford. Private insurance policies currently on offer in the UK usually exclude primary care and emergency care – which currently accounts for over 90 per cent of patient contact – including GP visits, outpatient drugs and dressings, and hospitalisation for childbirth, as well as treatment for HIV/Aids or other pre-existing or chronic conditions. Indeed the UK website for Medi-Broker states:

    “in general, private medical insurance plans do not cover chronic or critical illness which cannot be cured. For example, multiple sclerosis, asthma or diabetes.”

    Rising knowledge of genetics also seems likely to further exacerbate the problems already present in private insurance systems.

    People with a predisposition for a particular disease will be open to discrimination and may face excessive premiums, reductions in coverage or find it impossible to obtain private insurance altogether.

    In fact, advances in genetics makes the case for the widest possible pooling of risk. The more accurately you can predict risks the greater the case for risk pooling.

    But does private insurance meet the test of efficiency?

    Because of poor cost control, fragmentation of service and high management and administration costs, private insurance systems in other countries are consistently more expensive for both consumers and taxpayers than publicly funded health systems.

    In the United States, the cost of private insurance premiums are high and rising. In April 2001, it was estimated that annual premiums for employer-sponsored plans were over 2,500 dollars for single coverage and over 7,000 dollars for family coverage with employees paying between 50 and 70 per cent of these costs. During 2001, premiums rose in price by 11 per cent, compared with general inflation of only 3 per cent, and are forecast to rise by a further 13 per cent in 2002.

    Administrative costs in the US are twice as high as in Canada – a system based predominately on general taxation – largely due to the cost of insurance companies selling and handling policies, processing claims and pre-approving procedures, in some cases overruling doctors and denying needed care.

    Of course there are models of best practice in the private sector from which we can learn – such as Kaiser Permenante in California. But the evidence suggests that Kaiser offers a better service not because it is funded through private insurance but because of its innovative use of resources including IT, the wider range of treatment offered in primary care settings and the co-ordination of health and social care. These are lessons which can be applied in the public as well as the private sector.

    And simply moving towards a private insurance system is not guaranteed to reduce the amount of money spent by the state on publicly funded healthcare. Despite a large private insurance sector, the public sector cost of healthcare in the US is still significant.

    Medicare and Medicaid cost 400 billion dollars a year, and with tax relief for private insurance, US public expenditure on health is 500 billion dollars a year, about 7 per cent of national income.

    The irony is that the United States spends nearly as high a share of national income covering some of the health needs of some of its people as the United Kingdom spends on covering all the health care needs of all its people.

    At the end of the day, 90 per cent of private insurance policies in the united states are taken out by employers for their employees – costing employers nearly 100 billion dollars a year.

    And there is evidence that workers themselves are reluctant to change jobs for fear of losing cover. This leads to a less flexible and less mobile workforce, with subsequent knock-ons to the economy as a whole. In different US surveys at least 10 per cent and up to 30 per cent reported that they or a family member remained in a job at some time because they did not want to lose health insurance coverage.

    So private insurance fails the equity test. It does not pass the efficiency test, what of choice?

    Although the United States probably has the most market driven system of healthcare – which in theory should give consumers greater choice – in practice the position is less clear cut.

    To ensure that the cost to the employer is minimised, many companies enroll their employees in health maintenance organisations, or managed care plans. These narrow the choices patients have about the doctors and hospitals at which they can be treated.

    So far from the issue being – as some imply – the statist NHS denying choice versus the pro choice private systems, the private insurance systems are essentially managed systems which restrict consumer choice.

    Currently, private insurance does play a part in providing some supplementary cover for a small minority in Britain so even if there is not a case for a wholesale shift to compulsory private insurance, is there a case for extending tax relief for those who wish to take up private insurance – either generally or for elective surgery – on a voluntary basis?

    A study was conducted by the Treasury and the first and significant cost is a deadweight cost – at least £500 million – of providing tax relief for those who would take out private insurance policies anyway.

    Even when tax relief was available in the UK during the early 1990s it wasn’t particularly successful in encouraging people to subscribe to voluntary health insurance. It cost one billion pounds in subsidies but the number of people with private insurance rose by only 50,000 in seven years – an increase of 1.6 per cent.

    As the then chancellor Nigel Lawson said at the time the tax relief was introduced, “if we simply boost demand…by tax concessions to the private sector without improving supply, the result would not be so much a growth in private healthcare but higher prices…. increasing demand in the private sector pushes up prices and therefore pay. That would inevitably spread across all staff costs in the NHS and we would end up getting less value for money”.

    Social Insurance

    The third alternative funding system is social insurance – the model in France, Germany and the Netherlands.

    There, healthcare is predominately financed by compulsory contributions from employers and employees, calculated as a proportion of earned income, paid into and managed by independent, not for profit, sickness funds.

    Fifty years ago, Bevan rejected a system funded in this way. He said that a contributory system which would have denied some a full range of benefits; endless anomalies, he said, resulted; and such restrictions or exclusions were out of place for a national scheme. He said it would create a two-tier NHS.

    Some countries still have a two-tier social insurance system which restricts equity of access. In Belgium, 88 per cent of people are included in a scheme which provides comprehensive benefits and 12 per cent in the alternative scheme for the self-employed where the benefits package cover major risks only.

    And in France reforms were introduced in 2000 as a response to fears that the previous structure was harming access to care amongst low income groups. The Universal Health Coverage Act entitles everyone legally resident in France to public health insurance, regardless of their contribution status. The Act also provides free supplementary insurance for those on low incomes.

    So even insurance based systems, which nominally link benefits to contributions, have had to find ways – financed through general taxation – of tackling the two-tier system and including the uninsured.

    Those in favour of social insurance argue that it encourages people to pay more for their healthcare because the sickness funds are independent from government, giving a greater sense of ownership and therefore greater support for the system as a whole.

    But in fact, it is often employers who end up footing much of the bill. In France employers contribute 12.8 per cent of their earnings – on average, around 60 pounds per week per employee. And in Germany, they contribute around 7 per cent, with average weekly payments per employee of around 30 pounds.

    Of course, it is right for employers to contribute on the grounds that ill health could have significant effects of the productivity of their business. But it should be noted that one advantage of the National Health Service is that employers are not expected to pay all or most of their own employees health care costs.

    Furthermore, introducing local insurance funds could not easily be done in the UK where our national service represents a very different tradition of healthcare from Germany, the Netherlands and France whose insurance has been regionally and locally based. It was to move from a patchwork of local provision that in 1948 a unified national service was created.

    Indeed while some theorists argue that Britain should move from a tax funded system towards social insurance, in practice countries such as France are moving from social insurance towards greater use of general taxation, in part because of concerns about people being excluded but also to widen the revenue base of the funds.

    In these circumstances, it would be perverse to go through the administrative upheaval of totally reorganising along continental social insurance lines.

    As the French funding system moves towards Britain, it would seem strange for the British funding system to move towards the French.

    Finally, some argue that social insurance systems give people greater choice – first, because they can choose between social insurance or opt out and, second, because they can choose between funds within the social insurance system.

    In fact, apart from in Germany, very few people have the choice of opting out of the state system – and in some cases, such as the Netherlands, higher income groups are simply compulsorily excluded.

    And the choice provided between different funds within the social insurance system can, in practice, be constrained. In Germany, for example, there are over 400 different insurance funds but what they cover is strictly defined in law leaving little room for choice.

    In addition to our findings on social insurance, we have so far found that charging fails both the equity and efficiency tests.

    And we have discovered that because of the exemptions, restrictions and its partial coverage, private insurance fails the equity test without being either more administratively efficient or, in practice, as conducive as might appear in principle to choice.

    So let me now turn to the NHS.

    The National Health Service

    The question is whether in a reformed NHS the system of NHS funding is, in principle, sound for today’s and tomorrow’s world.

    In the original document sent to every citizen in 1948 the promise was unequivocal: the new health service will “provide you with all medical and nursing care” it said. “everyone – rich or poor, man, woman or child – can use it or any part of it. There are no charges, except for a few special items. There are no insurance qualifications. But it is not a “charity”. You are all paying for it, mainly as taxpayers, and it will relieve your money worries in time of illness”.

    There could be no clearer statement of the principle of equity: the NHS was built around the cornerstone of universal access to health services, regardless of ability to pay. And at its core is the recognition of health care as a fundamental human right, not a consumer commodity.

    But in the intervening years between 1948 and now Britain did not invest as other countries invested in health care. Indeed, Derek Wanless pointed out in his interim report that between 1972 and 1998 a cumulative £220 billion less was invested in UK healthcare compared to the European Union average.

    But while the idea has been underfunded, is the NHS idea of funding universal access and universal provision itself still valid? Do we still support a health service free at the point of use, available to all, based on ability to pay not just out of sentiment but as the rational choice for Britain’s future?

    While other models of insurance involve different levels of coverage for different individuals, the unique value of the NHS idea is that, no matter your circumstances or needs, risks are universally pooled and everyone is included.

    There is no doubt that the NHS is a good deal over the life cycle. Healthcare costs are most expensive in the last years of an individual’s life – at precisely the time when people generally have less money than during their working lives. Unlike private insurance, where premiums rise with age, the way the NHS is financed means that elderly people actually contribute significantly less for healthcare than those of working age.

    While private insurance – as we have seen – involves exclusions, access and provision by the NHS is designed to be more comprehensive than any other covering GP visits, GP house calls, nurses, health visitors, the whole primary care team, elective surgery, accident and emergency cover and the medical costs of catastrophic illness.

    While private insurance covers some of the people some of the time, the evidence is that what people want is a health care system that covers all of the people all of the time.

    So people want the NHS at its best to combine the universality of access with universality of provision – and thus offer the best insurance policy in the world, without the ifs and buts and small print of private insurance policies but with, as far as possible, everything and everyone covered.

    And just as the principles of access to the NHS are fair and equitable, so is the system of funding it.

    80 per cent of the NHS is funded from general taxation, which means the charge for the NHS is broadly-based not falling on one particular group.

    Unlike systems of charging, it does not charge people for the misfortune of being sick.

    Unlike systems of private insurance, the NHS does not impose higher costs on those who are predisposed to illness, or who fall sick.

    And unlike social insurance systems, while the NHS does rightly ask employers to make an additional contribution in recognition of the benefit they receive from a healthy workforce, it does not demand that employers bear the majority burden of health costs.

    In France, the amount contributed by employers to healthcare is around £60 a week for an employee on average earnings; in Germany it is around £30 a week.

    The amount contributed by UK employers to healthcare through national insurance is around £5 a week for an employee on average earnings. Even taking into account the contribution made by employers through general taxation, this would be no more than £10 a week per employee.

    So the NHS scores well on equity, what of efficiency?

    Some people say that the cost of equity is inefficiency, indeed abuse. Because, for example, GP visits are free of charge, the system is abused.

    Even with a free GP system, the number of GP visits per person tend to be lower in the UK than in America, France or Germany. With the GP system an essential gatekeeper for access to the rest of the NHS – doing so by coordinating a wide provision of primary care with its hospital based services – the NHS avoids much of the inefficiency of systems based much more on open access to hospital specialty care.

    Moreover, while those who advocate charging argue that they would make financing healthcare more efficient because they would encourage the more responsible use of resources the truth is that, most of the costs of healthcare are initiated by the doctor, not the patient.

    As we have also seen, the fragmented nature of other systems of funding, particularly private insurance, is a source of additional administrative costs.

    Of course, the NHS can be more efficient and productive. As Derek Wanless has already pointed out in his interim report, NHS productivity could be far higher than it is. For example, with the right investment in IT and the reforms Alan Milburn is making, including improved triage schemes, better use of nurses and booked admissions, designed to make greater efficiency and productivity possible.

    But the key point is that there is no reason to think that the funding system for the NHS itself makes for a less efficient service.

    Finally, choice.

    As we have seen, all systems in fact restrict choice – even private insurance systems.

    I would argue that greater choice will increasingly become possible in the NHS as we improve its capacity, and that is what the Alan Milburn’s reforms are designed to achieve.

    That is why we are committed to increasing not just the number of GPs but improving their premises and facilities as well.

    Patients will not simply be empowered with greater information, but also be given more choice than in the past.

    As we made clear in our election manifesto, by the end of 2005, every hospital appointment will be booked for the convenience of the patient, making it easier for patients and their GP to choose the hospital and consultant that best suits their needs.

    And finally, there is already some degree of choice about non-clinical services – people can pay for a single room for maternity services, for example. So I believe the evidence suggests that the NHS can accommodate greater choice and expectations in the future.

    But some say that the NHS will be overwhelmed in the future, in particular by the costs of new, high-tech treatments.

    However, I believe that these rising costs actually make the NHS system of funding more valid today than at its creation.

    In 1948 the argument for common funding and pooled risk centred on the unpredictability of health needs and the expense of health care.

    At that time, much of what could be offered was a standard, and in practice, rather modest service.

    At that time, the scientific and technological limitations of medicine were such that really high cost interventions were rare or very rare.

    There was no chemotherapy for cancer. Cardiac surgery was in its infancy, intensive care barely existed. Hip and knee replacement was almost unknown. A whole range of diagnostic and treatment techniques that today we take for granted were simply not available.

    Now – because the more effective treatments that can be offered today are far more expensive and because, of course, we still do not know when we or members of our family will need health care – the argument for common funding and pooled risk is in my view stronger than ever. And immeasurably stronger than it was in 1948.

    Look at what is possible medically – and what, in the absence of the NHS, would too often be impossible financially for almost every family. Treatments ranging from serious heart abnormalities in a new born baby to the cost of care for longer-term problems, such as behavioural disorders, diabetes and HIV/Aids.

    Many of these illnesses and injuries come unexpectedly.

    No one budgets for them, and very few could.

    The standard of technology and treatment is now such that unlike 1948 some illnesses or injuries could cost £20,000, £50,000 or even £100,000 pounds to cure.

    Because the costs of treatment and drugs are higher than ever, the risks to family finances are greater than ever, and therefore the need for comprehensive insurance cover of health care needs stronger than ever.

    Because none of us ever know in advance whether it is you or your family that will need that expensive care – for acute or chronic illness – the most comprehensive insurance cover is the best policy to cope with unpredictability.

    Insurance policies that, by definition, rely for their viability on ifs, buts and small print can cover only some of the people some of the time.

    In a world of expensive treatments and even more expensive drugs, charging is simply making the sick pay more for being sick.

    So more than ever families need a system of funding that insures everyone as comprehensively as possible against the risks of huge medical bills.

    And this is true for the most comfortably off members of our society as it is for the poorest.

    Why? Because charges for any one of these treatments could impoverish individuals, households, and families far up the income scale, it is now not just in the interests of a lower income family but those on middle or higher incomes to be insured in the NHS’ comprehensive way.

    Some present the current NHS system of funding as an ideological hand-me-down from the immediate post war era to be supported only out of sentiment rather than hard headed calculation.

    Others dismiss the NHS funding system as an impossible dream – “fine in principle, a failed experiment in practice”

    But far from being a hangover from a distant age or an unrealisable vision, the NHS system of funding is demonstrably the modern rational choice. Not just for poor or low income families in Britain, but for the vast majority of families in Britain. Not just for today but for tomorrow too.

    And far from it being valid for the needs of the 1940s but not for now, a tax funded system is Britain’s better way forward for coping with the three challenges facing health care: the rising costs of new technology, the increase of 3 million by 2020 in the elderly population, and the ever rising expectations for higher standards of personal care.

    If we can match reform and results to resources, our Budget and Spending Round offer an historic opportunity to put NHS funding on a sustainable footing – not just for a year or two but for the long term. Upholding and improving the NHS not just because it is an institution that is part of our history and our shared values but because, reformed and renewed, it can be the most efficient and equitable guarantee of health care for millions, provide the better choices and service they need and become, for the British people, the best insurance policy in the world: the best for each of us and the best for all of us.

    This is the time for people to join the debate.

    I believe that, following this debate, we can build a national consensus around making the NHS the best insurance policy in the world.

  • Gordon Brown – 2002 Speech to the British American Business

    gordonbrown

    Below is the text of the speech made by Gordon Brown, the then Chancellor of the Exchequer, in New York, United States, on 19 April 2002.

    I am delighted to be here in this great city – speaking to this great new transatlantic organisation – to inaugurate this lecture series in honour of a truly great man, Winston Churchill.

    And let me start by paying tribute to you – the British American Business Inc – the work you do, the service you give, and the contribution you make – not just promoting British-American trade but strengthening the historic links between our two nations.

    Being back here in New York and seeing its recovery at first hand moves me.

    In the seven months since the tragic events of September 11th – like many people in Britain – I have been struck by the resilience and bravery in the face of tragedy that so many living here have shown.

    New York is a city of such global reach – the meeting point of a hundred nationalities and more – that it is a human monument to our interdependence.

    And this interdependence is clearly demonstrated by the alliance we have forged against terrorism since the events of September 11th. An alliance that confirms the profound and pervasive truth that in the new global economy we are, all of us – the richest countries and the poorest countries – inextricably bound to one another by common interests, shared needs and linked destinies.

    Nowhere can this be more clearly seen than in the relationship between Britain and the United States. Travelling to New York from London reminds me of how both America and Britain are stronger because of the shared history that shapes our countries – and because of the shared values that bind us even more closely together.

    Indeed for centuries, your land and the islands of Britain have been linked not only by history but by ideals: a passion for liberty and opportunity for all; a belief in the work ethic and in opening enterprise to all; and a commitment to being open not isolationist – a commitment which in our day and for our generation increasingly depends on the shared convictions that economic expansion through free trade and free markets is the key to growth and prosperity.

    Last autumn, there was widespread pessimism about the global economy, with fears of a global slowdown or even a global recession.

    There was a real danger that each of us would turn inwards and focus on our own country’s domestic concerns at the expense of global cooperation. And some said that globalisation was leading to instability and that we should reign back on our programmes of reform – that it was not the time for change.

    But the last six months have demonstrated that these fears have not being realised.

    Independent forecasters now expect the world economy to grow faster than they did a few months ago.

    And we have seen globally a forward-looking, coordinated response to the events of September 11th, with interest rates brought down and cooperation in the fight against terrorist financing.

    Because terrorists intended to bring the world’s financial system to a halt, to undermine the very prospect of global prosperity, we – Governments and business on both sides of the Atlantic and around the world – must continue to show that we will not succumb or surrender to their threats.

    I believe that now is the time more than ever to push forward the agenda to improve the stability and confidence of the global economy.

    And just as there is growing agreement that as we work together to fight terrorism and to strengthen the international economy, so there is increasing recognition that we must work together to address the causes of poverty – not just because to do so is central to long term national security but because to do so is right – a moral imperative, an economic necessity and a social duty.

    In 1946, here in New York, Winston Churchill spoke about the changing relationship between the US and Europe:

    “nothing can prevent our nations drawing ever closer to each other”, he said, “and nothing can obscure the fact that, in their harmonious companionship, lies the main hope of the world instrument for maintaining peace on earth and goodwill to all men.”

    His words ring with relevance in our own times.

    And later, in 1963 in Washington, he said:

    “I contemplate with high satisfaction the constant factor of the interwoven and upward progress of our peoples. Our comradeship and our brotherhood in war were unexampled. We stood together and because of that fact the free world stands. Nor has our partnership an exclusive nature: the Atlantic community is a dream that can well be fulfilled to the detriment of none and to the enduring benefit and honour of the great democracies.”

    So, as Winston Churchill made clear, it is more than commerce that binds us.

    Increasingly, in this age of globalisation, our national goals are shared international goals, our responsibilities are shared responsibilities, and our opportunities are shared opportunities.

    And we must not underestimate the good that can be done for the whole world, not least for developing countries, if the relationship between Europe and America is deepened.

    So there are continuing challenges that I will focus on today:

    How we entrench our new won and hard won stability: we must lead the process of labour, capital, and product market reform in Britain and in Europe and build a new, more open, market across the Atlantic; and

    How, at the same time, we meet the challenges of globalisation: we must reform the architecture of global economy to secure prosperity and growth for all.

    Stability and enterprise in Britain

    The indispensable imperative is stability.

    Every time in recent decades when the British economy has started to grow, Governments have taken short?term decisions which too often have created unsustainable consumer booms, and sacrificed monetary and fiscal prudence.

    In 1997, Britain needed a wholly new monetary and fiscal framework based on clear policy rules, well established procedures, and an openness and transparency not seen in the past. Hence the independence of the Bank of England, the new fiscal rules, the open letter system, the symmetrical inflation target and our new code for fiscal stability.

    And this new framework makes us far better placed than before to cope with the ups and downs of the economic cycle.

    That is one reason why in the last five years while other countries have suffered recessions the British economy has maintained economic growth. Last year Britain was the fastest growing economy in the industrialized world, with the lowest unemployment since the 1970s and the lowest interest rates for nearly 40 years.

    Having weathered the storm I am cautiously optimistic. And while risks remain and we will maintain our disciplined and forward looking approach, I am more optimistic now than when the IMF last met last autumn and believe that this is a time of real opportunity and challenge for not just the British but the global economy.

    As I stated in my Budget earlier this week, we will continue to pursue a symmetrical inflation target of 2.5 per cent. And monetary policy will continue to be backed by a sound and long-term approach to fiscal policy. In order to meet our fiscal rules and fund sustained improvements in our health care over the next five years, I have raised National Insurance from next year, but the Government has insisted on a programme of radical reform in health and social services to ensure the public experiences and sees better care services.

    But we all know a truth – a truth increasingly understood across the world – that our shared aims for long-term prosperity and social justice with strong public services depend upon rising productivity, growth and economic reform.

    We need across the economy to accelerate the productivity improvements that will increase output, jobs and wealth.

    So – far from deferring our enterprise agenda – this is exactly the time to press ahead with reforms to encourage new investment and higher productivity.

    Building on our supply-side reforms to remove barriers to growth – a new competition policy, a new approach to physical planning policy, new rules for work permits, our education reforms – my focus in the Budget was on measures that encourage higher levels of innovation and investment; and to help small and growing businesses:

    – a new research and development tax credit for large companies;
    reform of substantial shareholdings and tax relief on intellectual property;

    – historic cuts in Capital Gains Tax to 10 per cent for business assets held for 2 years;

    – new cuts in Corporation Tax so that small companies with taxable profits of less than 10,000 pounds pay no corporation tax;

    – simplification of the VAT system and help for small businesses to bring their payroll systems online;

    – and new measures to promote skills.

    Stability and enterprise in Europe

    But it is not just in Britain but in Europe as a whole that both a modern route to economic stability and a more entrepreneurial economy is needed.

    At the European council in Barcelona, Britain pressed for the reforms of product, labour and capital markets that we believe are essential:

    – to complete the single market in financial services – boosting EU GDP by as much as 0.5 per cent per year – we set a rigorous timetable for reform;

    – to open up the European energy market, all member states have agreed to liberalisation of their non-domestic gas and electricity markets by 2004;

    – to adopt a more strategic approach to research and development, we will improve the use of intellectual property rights;

    – and to boost enterprise – because the EU has much lower survival rates for new businesses than the US – we will reduce red tape for firms and improve consultation with business.

    And over the coming months, we will continue to drive forward these reforms to ensure that we see concrete results, for both business and consumers.

    As in Britain, the euro area has also been establishing a new framework for economic stability.

    Our approach on Britain’s membership of the European single currency is – and will continue to be – considered and cautious: one of pro-euro realism.

    Pro-euro because, as we said in 1997, we believe that – in principle – membership of the Euro can bring benefits to Britain.

    Realist because to short-cut or fudge the assessment of the five tests we have set out, and to join in the wrong way or on the wrong basis without rigorously ensuring the tests are met, would not be in Britain’s national economic interest.

    Around the future of the Euro there is, of course, an ongoing and wider debate on the future of Europe: a debate on economic reform amidst the challenge of globalisation; enlargement into the east; and the wider agenda for 2004, to make decision-making in Europe more open, accountable and relevant to the population as a whole.

    At one time the case for Europe was simply peace – the opportunity to set aside old enmities and feuds, to contribute to a mission that has helped secure half a century of peace in western Europe, and is now helping to cement peace and democracy in central and eastern Europe as we have done in the west.

    But today the case for Europe must be not only that, working together, we can maintain peace but that, working together, we can maximise prosperity.

    Indeed the more Europe extends its single market, the better it is for the prosperity of Europe and the world.

    The more Europe embraces economic and institutional reform, the better it is for all.

    The more Europe looks outwards, the better it is for all.

    And indeed the more Europe and America work closely together, the better it is for Europe, America and the world.

    And we must not let slip the unique opportunity we have to build stronger relationships.

    Let me explain.

    The transatlantic relationship

    In the post-1945 period the shaping of the European Common Market took place in the shadow of war, as our predecessors resolved to move forever beyond the recurring and devastating conflicts of the past.

    Today, there is a second reshaping of Europe happening not just as a result of the internal forces making for enlargement, but in response to vast global changes.

    Over the last 30 years, world trade has increased from around $300 billion to $6,000 billion: a twenty fold increase; the amount of international capital from around $250 billion to over $24 trillion: a ninety-six fold increase. And foreign investment has increased from around $10 billion to over $1,000 billion: a one hundred fold increase.

    One particularly astonishing change has been the growing economic interdependence between Europe and the US. The annual two way flow of goods, services, and foreign direct investment between the United States and Europe is now nearly a trillion dollars. One fifth of total US merchandise exports, and one third of total US services exports go to the EU. And in one decade direct European investment in the USA has increased more than ten fold.

    But are we making the most of these opportunities?

    With the seismic shifts brought by the Cold War’s end – and the new challenges symbolised by the events of September 11th – all nations had to reconsider the geopolitical landscape, reassess their positions, and rethink their relationships in this very new world.

    That is a smart, sensible and essential thing to do.

    But it would be tragic indeed if the annals of the future record that the late 20th century, when history turned towards freedom, was succeeded in the early 21st century by a regressive period in which those who had carried the cause of freedom turned inwards.

    So I want to answer those voices on both sides of the Atlantic who believe that detachment is preferable to partnership; that isolation is more secure than a wider and deeper alliance. In short, all those who wrongly believe that somehow in the post-Cold War world, Europe and America need one another less, not more.

    I could not disagree more profoundly – not merely with such arguments as expressed but with their very premise.

    Neither America nor Europe has fully grasped the moment for a new age of economic interdependence – the full realisation of Winston Churchill’s vision.

    But I believe that the conditions now exist for the expansion of our economic partnership – not just incrementally, but comprehensively increasing the trade and commercial links between the EU and the USA.

    So instead of the end of the Cold War and the advent of new challenges inviting a weakening of transatlantic ties, this is the time for a new era of enhanced engagement between America and Europe – a new transatlantic alliance for prosperity.

    We in Britain and Europe plainly disagree with the new restrictions the United States have imposed, unjustifiably in our view, on steel imports. The EU is taking our case to the WTO.

    But we must not let steel, however strongly we feel; banana exports, however strongly the United States has felt; or, to cite another example, the genetically modified product – become sad symbols of a frayed transatlantic trade relationship. Nor must we let one dispute over a merger, however large, or another dispute over a sector, however important, obscure the scale of two-way investment and trade across the Atlantic which amounts to over $2 billion each and every day.

    It has been estimated that the annual income gain to the EU from a transatlantic marketplace would be of the order of 1.1 per cent of EU GDP – or $140 billion – and for the US 0.5 per cent of GDP, the equivalent of the estimated US gain from NAFTA.

    And the gain together for the EU and the US if we also eliminate industrial tariffs on an MFN basis could be as high as $150 billion a year – a figure that means more prosperity and more jobs for both continents.

    So there are potential gains in total of nearly $350 billion.

    I believe that what we need now is a programme to turn this vision into reality.

    Specifically, we must establish a framework for deeper integration. In 1988, when Europe was at the outset of the huge project to move towards deeper economic and trade integration via the creation of a genuine single market, we commissioned the so-called Cecchini Report that examined in depth, and quantified the economic potential that a single market entailed. The figures were so impressive that European policy-makers saw the necessity of moving forward, and could explain to their citizens what was at stake in terms of growth, jobs and prosperity from changes which, at the time, looked dauntingly difficult.

    I believe what we need now is a Cecchini-style report that investigates the potential benefits for growth, prosperity and jobs on both sides of the Atlantic from a wide-ranging effort to tackle all the remaining barriers to a fully open trading and commercial relationship between Europe and America.

    Preliminary studies show that removing bilateral tariff and non-tariff barriers in goods and services could raise employment by 1.3 million in the EU and cut EU prices by at least 2.5 per cent. And even by only removing tariff barriers on protected goods the US could gain up to 300,000 jobs.

    With high level political commitment we can then make a wide-ranging effort to end the remaining industrial tariffs multilaterally, achieve deeper liberalisation of trade in services, remove unnecessary non-tariff barriers, increase competition and develop more effective ways of pre-empting damaging transatlantic trade disputes.

    Because in some areas reform cannot wait, we must, without delay, implement a rolling programme of initiatives, endorsed by both sides. I have discussed this with EU trade Commissioner Lamy and I particularly welcome his and US Trade Secretary Zoellick’s efforts to draw up a list of priority issues. We must launch this process by agreeing our priorities at the EU-US summit in May.

    Action in areas such as financial services, common accounting standards, e-customs, trademarks and public procurement should be pursued now.

    To take one example – in the area of financial services we should establish a new EU/US structure for regular consultation on bilateral issues. This “financial services dialogue” should promote better understanding, seek to avoid future conflicts, address bilateral market access and regulatory issues, and examine possibilities for mutual recognition, such as in the electronic delivery of financial services.

    And we must extend the transatlantic economic agenda to regulatory cooperation so that domestic regulations do not put up new barriers to trade. If we do not act now, regulatory disputes will become the greatest strain on our economic relationships.

    The same is true also of direct investment. We must continue to look for opportunities to remove barriers to investment, cutting legal and administrative burdens for business; and we must also continue to guard against new legislation that erects new barriers.

    So we need more cooperation between our Governments to assess the impact on trade and investment before legislation is introduced, and we need better early warning mechanisms to alert us to possible conflicts. When disputes do occur we must move away from damaging old style retaliation and move to a rational system of compensation in the form of tariff cuts as the first choice remedy. That is the best way to balance domestic regulation with transatlantic economic integration.

    But deepening the transatlantic economic relationship should not be and must not be at the cost of an ambitious multilateral agenda.

    Indeed the scale of our interdependence makes the case that Europe and America together not only create the stability and growth upon which the world economy depends, but that it is possible by common endeavour for that stability and growth to be enhanced to benefit not just our nations and regions, but all nations and all regions.

    So our first great challenge is to move forward the economic reform agenda – both at home and abroad – and take advantage of the opportunities offered by a strengthened transatlantic relationship.

    But our second challenge – what I want to discuss in the remainder of my speech today, in advance of the spring meetings of the IMF and World Bank in Washington this weekend – is to forge a new deal for the global economy: a new strategy for prosperity based on new obligations but also new opportunities for developed and developing countries, the international financial institutions and the private sector.

    The ideals of Bretton Woods

    In Churchill’s time, more than half a century ago, leaders who were still engaged in global war took the time to prepare for global peace and prosperity. In a breathtaking leap into a new era, the world created not just new international institutions – the IMF, the World Bank, as well as the UN – and a whole set of new rules for a new international economy, but gave expression to a new public purpose based on high ideals.

    A generation of leaders who had known the greatest of depressions and the greatest of wars knew also that just as peace could not be preserved in isolation, prosperity could not be maximized in isolation.

    Bretton Woods defined a new public purpose characterised by high ideals. The conference was about more than exchange rates, the mechanics of financial arrangements or even new institutions. As the American Secretary of the Treasury said at the very start of the opening session:

    “prosperity has no fixed limits it is not a finite substance to be diminished by division. On the contrary the more of it that other nations enjoy the more each nation will have for itself.

    “prosperity like peace is indivisible. We cannot afford to have it scattered here or there amongst the fortunate or enjoy it at the expense of others…”

    So the post-war arrangements were founded on the belief that global action on a new and wider stage could advance a new and worldwide public purpose of high ideals rooted in social justice: to achieve prosperity for all by each co?operating with every other: new international rules of the game that involved a commitment to high levels of growth and employment. In short, the job of every economy was to create jobs for all.

    The challenge for us today

    What our predecessors did for the post-war world of distinct national economies we must now do for the global economy where economically no nation is an island and where the social and political dimension of economic crises can be far reaching.

    Our aim must be an international financial system for the 21st century that recognises the new realities – open not sheltered economies, international not national capital markets, global not local competition. It must be one that captures the full benefits of global markets and capital flows, minimises the risk of disruption, maximises opportunity for all and lifts up the most vulnerable – in short, the restoration in the international economy of public purpose and high ideals.

    Some critics say that the issue is whether we should have globalisation or not. But in fact the issue is whether we manage globalisation well or badly, fairly or unfairly. And we have a choice.

    Managed badly, globalisation can – and will – leave millions of people in the developing world marginalised. But managed wisely, it can lift millions out of poverty and become the high road to a just and inclusive global economy.

    Many benefits have already been secured from globalisation – since 1970, life expectancy in developing countries has increased by nearly ten years, child mortality has almost halved and the proportion of people who can’t read or write has reduced by a quarter.

    But millions are still excluded – half the world’s people live on less than $2 a day, one in five children don’t go to school and preventable diseases like malaria and TB kill seven million children every year.

    But whatever our concerns about the sheer scale of the challenge of globalisation, we must reject the false choice between retreating from globalisation to old protectionist ways or clinging to the discredited laissez faire of the 1980s. To succumb to either temptation would hurt both the powerless and the prosperous.

    Instead, the way forward is not to cut cooperation across the world but to strengthen that cooperation, modernising our international rules and reforming the institutions of economic cooperation to meet the new challenges. And in doing so create a global economic system which recognises the rights and responsibilities of all the parties involved.

    So we need to step up the reforms that will help create a new stability and purpose in the international financial system, focusing on challenges in three main areas.

    First, a new framework for better economic decision-making and crisis prevention, based on greater openness, transparency and increased surveillance;

    Second, effective, speedy and decisive procedures for crisis resolution; and

    Third, helping the poorest countries compete and engage in the global economy by creating the right conditions for trade and investment, and putting in place mechanisms for a decisive transfer of additional resources from the richest to the poorest countries.

    In short, we need a new deal for the global economy which seeks to build a virtuous circle of stability, growth and development.

    First, a new framework for maintaining stability and preventing crises

    In a world of ever more rapid financial flows, we know that capital is more likely to move to environments, which are stable and least likely to stay in environments which are, or become, unstable. And such flows today are swifter than ever they have been before. And we know that countries who need capital most are, at the same time, the most vulnerable to the judgements and instabilities of global financial markets.

    So for every country, rich or poor, macroeconomic stability is not an option but an essential pre-condition of economic success. And I have become convinced that it is in the interests of stability – and of preventing crises in developing and emerging market countries – that we seek a new rules-based system: a reformed system of economic government under which each country, rich and poor, has a responsibility to adopt agreed codes and standards for fiscal and monetary policy for the financial sector and for corporate governance.

    This adoption of clear transparent procedures – essentially new rules of the game – in monetary and fiscal decisions – for example, presenting a full factual picture of the national accounts, usable central bank reserves, foreign currency borrowings, and indicators of the health of the financial sectors – would improve macroeconomic stability, deter corruption, provide to markets a flow of specific country by country information that will engender greater investor confidence and reduce the problem of contagion.

    The adoption of codes and standards is not, as some have argued, a modern version of imperialism – demands from the rich countries on the poor in the interests of the rich. For all countries – rich and poor – would be responsible for operating the codes and standards and they are a means to fairness for all – with markets working more effectively in a more secure and transparent environment, advancing the public interest, and securing growth and prosperity.

    Codes can also support countries along the way to liberalisation of their capital markets, helping to avoid destabilising and speculative inflows. A dash to full capital liberalisation was once thought of as the best signal of a modernising economy. But we know that instability often followed. Our approach – the introduction and operation of transparent codes and standards with proper sequencing of capital liberalization – is a better guarantee of both an investment friendly environment and long-term stability.

    Implementing these codes will mean radical changes in the way governments and financial markets operate. So just as I believe that – over time – the implementation of the codes by individual nations should be a condition for IMF and World Bank support, I also believe that the international community has a responsibility to offer direct assistance and transitional help for early implementation.

    And where countries do operate transparent and effective systems, fully monitored by the international community, they have the right to expect the support of the international community if hit by financial contagion. These rights and responsibilities are now enshrined in the IMF’s contingent credit line: a commitment to countries implementing sound economic policies that the international community will stand by them if the markets turn against them.

    The CCL should be seen as an attractive tool to help country’s prevent crises and the IMF should take a more pro-active approach to encourage countries to benefit from this facility:

    – assessing, through the surveillance process, which countries are in a position to benefit from the CCL; and

    – explaining the benefits of the CCL and encouraging countries to take the steps needed to advance to a position where they can benefit.

    But I believe we need to go further. The IMF should review the design and operation of the CCL, and consider how it can be enhanced to encourage maximum take-up, to ensure it becomes, as intended, a cornerstone of the IMF’s crisis resolution capacity.

    Codes and standards will only work if there is an effective surveillance mechanism to monitor implementation so that the public has confidence in the transparency on which stability depends.

    In the past we have seen the IMF as firefighters. Now with the codes and standards and countries required to report all the relevant information, the IMF’s role and responsibility will be to identify potential difficulties before they become major problems.

    The crises of the 1990s in Latin America and Asia – and now Latin America again – have demonstrated that surveillance and vigilance cannot be based on ad hoc arrangements.

    The IMF Article IV surveillance process is already an invaluable international asset – indeed it has some of the characteristics of a global public good. And it has a crucial responsibility to identify the policy environments that are likely to prove unsustainable – poor financial regulation, an inappropriate exchange rate regime, a government budget or balance of payments deficit in danger of spiraling out of control – and identifying them early so preventative action can be taken.

    Over recent years we have seen greater openness in publishing Article IV assessments and their press notices; set up the independent evaluation office; and established the Article IV process at the centre of the monitoring of codes and standards.

    But there is a case for doing more.

    Enhancing the IMF’s role in Article IV surveillance of the world economy – making it more transparent, more independent, more accountable and, therefore, more authoritative – would contribute to greater stability and ensure it is seen to be providing impartial advice independent of the inter-governmental decision-making process. Whilst governance of the IMF and decisions about financial support for countries are, of course, matters for its board, there is now a case for enhancing the IMF’s surveillance and monitoring functions so that surveillance is – and is seen to be – independent of decisions about crisis resolution.

    I believe we must implement reforms to promote:

    – greater independence: ensuring the fund applies objective, rigorous and consistent standards of surveillance to all member countries, and that there is a clear separation between surveillance and lending activities;

    – greater transparency: introducing the presumption that all surveillance reports by IMF staff will be published when they are presented to the board; and that concluding statements will be published at the end of each surveillance mission; and
    greater accountability: with the IMFC setting a surveillance remit;

    – IMF management reporting each year on the Fund’s performance; and an annual assessment by the IMFC of the effectiveness of Fund surveillance.

    This weekend we shall call on the Fund to prepare concrete proposals to strengthen surveillance and report back to this year’s annual meetings.

    But in the modern world of global capital flows, surveillance needs to look beyond national boundaries.

    To tackle national financial sector problems which have international repercussions, the Financial Stability Forum – which brings together the combined expertise of the IMF and key regulatory authorities – should evolve into an effective early warning system.

    These new responsibilities for openness and transparency must also apply to the private sector. Building on the international standards of best practice for multinational companies drawn up by the OECD, on the global compact – introduced by Kofi Annan in 1999 – and on the global reporting initiatives – through which one hundred major companies already report their activities – multinational companies should assess and make public their economic and social impact in developing countries.

    But crisis prevention depends not only on spotting problems early but on providing the right incentives for lenders to take responsible decisions and minimise the risks of self-fulfilling crises of confidence which can do untold damage. When trouble hits an economy, or one of its neighbouring economies, private sector investors must be prepared to do more than simply pull money out and accelerate the panic.

    So with codes and standards the foundation, and more effective systems for surveillance built upon them, including new responsibilities – for governments to be open, for the IMF to scrutinise and for the private sector to engage – there is a real opportunity now to provide a guarantee of both an investment friendly environment and long-term stability.

    Our second challenge is crisis resolution

    Because however successful we aim to be at avoiding crises, we should recognise that, from time to time, crises will happen, so we need to ensure there are effective methods in place for crisis resolution, in a way that will ensure the burden of adjustments is not placed on the poorest and most vulnerable.

    Each time the international community encounters a national financial crisis, it is faced with the dilemma of either standing aside or putting taxpayers money at risk bailing out lenders. There is a better way.

    The IMF is now meeting the call from Governments, academics and debt campaigners, for a new system to deal with unsustainable private debt in vulnerable countries.

    The way forward is both clear and urgent.

    We need radical reform of the contractual arrangements for debt. Debt contracts which specify the arrangements for collective action to re-negotiate terms when it is clear that a restructuring is necessary can help countries reach a speedy resolution with their creditors, protecting against rogue creditors and vulture funds. The UK Government has already agreed to include collective action clauses in our own foreign currency denominated debt. I call on other countries to follow this lead, to agree new standards for international best practice in sovereign debt contracts and a strategy for encouraging their adoption worldwide.

    Next – since there will be extreme circumstances in which countries will be unable to meet their obligations even over time, and a voluntary agreement with creditors is not possible, despite best efforts – the international community should be prepared, where other reasonable options have been exhausted, to support a country that must impose temporary capital controls, or a standstill on its debts, as part of an orderly process of crisis resolution.

    We also need to be much clearer about the normal limits to IMF financing, and set more transparent and objective criteria for going above the limits. We cannot send a message that bad decision-making by lenders is encouraged by the expectation of an unlimited bail-out by taxpayers, or bad policies by debtor countries will be condoned by more financial support by the international community. We must provide more certainty about the respective roles of the private and official sectors in a crisis situation.

    Finally – as the IMF’s First Deputy Managing Director has proposed – we need to continue work on a new, more comprehensive, legal framework – an international bankruptcy procedure. While much can, and must, be achieved in the absence of legal changes, we know from our experience of corporate bankruptcy arrangements that an independent process for adjudication is necessary for an orderly and comprehensive resolution to occur.

    Under this new framework, it should be the duty of countries to inform, the duty of international financial institutions to monitor and make public and the duty of the private sector and the official community to engage.

    In this way we can move from letting crises happen and then intervening to a new paradigm:

    – systems that in themselves diminish the likelihood of crises;

    – earlier awareness as difficulties arise; and

    – more measured orderly responses when crises have to be resolved.

    But stability is only the precondition.

    Our third challenge is to ensure that the poorest countries have the capacity to compete and engage in the global economy so they can earn a fair share of the benefits of global prosperity

    Open, transparent and accountable national policies, internationally monitored, are the foundation for macroeconomic stability. But to ensure growth and development, we must also take steps to promote investment and make progress on trade.

    The least developed countries suffer a double handicap of low foreign investment – around $35 a head compared with $805 in higher income countries – and low domestically generated savings and investment.

    To encourage greater investment – both domestic and foreign – developing countries must work to establish a more favourable business environment. Already the country-owned poverty reduction strategies – imaginatively led by Horst Köhler at the IMF and Jim Wolfensohn at the Work Bank – are focusing on creating the right domestic conditions for investment and have highlighted the importance of:

    – investment in infrastructure;

    – sound legal processes that deter corruption;

    – and the creation of an educated and healthy workforce.

    As good practice emerges, the lessons learned from country-by-country experiences can region-by-region be applied. I therefore propose investment forums, bringing public and private sectors together to share best practice, examine the current barriers to investment and seek to build consensus on how to secure higher levels of business investment and intra-regional trade.

    In the last forty years, those developing countries that have managed to be open and trade have seen faster growth rates than closed economies. Indeed, it is a matter of record that in the last half century no country has managed to lift itself out of poverty without participating in the global economy.

    Full trade liberalisation could lift at least three hundred million people out of poverty by 2015. Even diminishing protection by fifty per cent in agriculture and in industrial goods and services would increase the world’s yearly income by nearly $400 billion: a boost to growth of 1.4 per cent. All countries and regions stand to benefit, with developing countries gaining an estimated $150 billion a year and higher than average increases in GDP growth.

    That is why we strongly welcome the WTO agreement in Doha to launch a new trade round focused on development. And in the next phase we must take forward the agreements to open up trade in agriculture, build the capacity of developing countries to participate more effectively in the negotiations and open up greater access to medicines.

    Indeed all developed countries should offer access to all but military products from the least developed countries and by banning export credit guarantees for unproductive expenditure discourage and diminish the diversion to arms expenditure of resources needed for education and health.

    Codes and standards, investment and trade all play a part, but there cannot be a solution to the problems developing countries face without a substantial increase in development aid to those nations most at need and willing to focus on the fight against poverty.

    Huge progress was made at the UN Financing for Development conference in Monterrey last month. The European Union agreed to increase the proportion of its national income going to development assistance from an average of 0.32 per cent to 0.39 per cent, generating an extra $20 billion in total between now and 2006 and at least an extra $7 billion a year thereafter.

    And we welcome President Bush’s announcement of $10 billion more in aid between 2004 and 2006, and an additional $5 billion a year thereafter – a fifty per cent increase in US aid levels.

    Together, these pledges mean that, from 2006 onwards, the US and Europe will be contributing an additional $12 billion a year for education, health and anti-poverty programmes in our poorest countries.

    But more must be done.

    The Zedillo Report, whose authors included several prominent Americans, costed meeting the Millennium Development Goals – including halving world poverty, cutting child mortality by two thirds and guaranteeing every child primary education – at a total of $50 billion a year up to 2015, including $20 billion for anti-poverty programmes and nearly $10 billion for education.

    We must agree a new development compact that will ensure that no developing country genuinely committed to poverty reduction, good governance, investment in human capital, economic reform and private sector development, should be denied the chance to progress because of lack of finance.

    Key to this is for both developed and developing countries to increase aid effectiveness.

    Developing countries have an obligation to show that the funds they receive are properly and effectively used. As a condition of aid, they must end corruption, meet their obligations to pursue stability and create the conditions for new investment, and ensure that resources go effectively and efficiently to fighting poverty.

    And, by insisting on untying aid by developed countries from the award of contracts, more effective in-country use of aid and better collaboration among donors, current aid could be made fifty per cent more efficient, releasing substantial extra funds for anti-poverty programmes in the poorest countries.

    At the same time, developed countries have a responsibility to move from providing short term aid just to compensate for poverty to a higher and more sustainable purpose, that of aid as long term investment to tackle the causes of poverty by promoting growth.

    But this alone will not be enough. We need a new and creative way to reach the $50 billion target.

    By channeling the extra resources promised at Monterrey internationally – possibly through an International Development Trust Fund, with national government offering a guarantee – either through callable reserves or appropriate collateral as security – additional aid contributions could be levered up to raise extra funds.

    For every dollar contributed to the Trust Fund, it would be possible to lever in two or three dollars more. In this way each year $50 billion could be made available to the poorest countries for investing in economic development.

    These proposals are challenging but they are achievable.

    This weekend at the spring meetings of the International Monetary Fund and World Bank, I will be asking each country to accept their responsibilities and go further than they have been prepared to go in the past.

    Conclusion

    Not since Bretton Woods has a generation had so broad a challenge in the global economy – and such profound responsibilities.

    We each have a part to play:

    – as Governments keeping our economies in order and reaching out to the wider world;

    – as businesses fully engaging in the global economy as reliable and consistent partners and adopting high corporate standards;

    – and as an international community which now more than ever, must become a forum not just for debating issues but for reaching decisions and implementing them.

    The challenge is immense. But in the Bretton Woods spirit, the answer is not to retreat from globalisation.

    It is not for Britain to stand off from Europe, or for Europe and America to withdraw from each other, or for the advanced nations to neglect those left behind.

    Instead we must build an integrated transatlantic market while advancing economic reform and social justice on a global scale to the benefit of all. And we must do so with more global cooperation not less, and with stronger not weaker international institutions.

    We must realise Winston Churchill’s vision of interdependence – which once seemed a distant vision, but in truth saw so clearly into the future. And we must extend its possibilities not because it will benefit some but because it will benefit all.

  • Gordon Brown – 2002 Speech at Odyssey Centre in Belfast

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    Below is the text of the speech made by Gordon Brown, the then Chancellor of the Exchequer, at the Odyssey Centre in Belfast, Northern Ireland on 2 May 2002.

    It is a great privilege to be back in Northern Ireland, to be in Belfast with the Prime Minister, and to congratulate all those who throughout the troubles, through dark days and dark years, have kept alive the dream of peace with prosperity: men and women of courage and foresight who have invested in Northern Ireland, who have built up businesses; men and women of courage and foresight who have worked together to tackle social tensions in some of the worst-hit unemployment areas of Northern Ireland and who through their actions have brought hope.

    And it is a result of the hard work, the enterprise, and the commitment of thousands of men and women at work in Northern Ireland – mangers and employees – that since 1997 Northern Ireland has grown by 10 per cent, inward investment has continued to expand, and 22,000 new jobs have been created with employment today at record levels, and unemployment half what it was five years ago and at its lowest since the mid 70s, after the largest fall of any region in the UK.

    I would like to thank the First Minister, David Trimble, and the Deputy First Minister, Mark Durkan, and the work of the Northern Ireland Executive together with the Secretary of State, John Reid, through their determination and hard work in partnership with the men and women of Northern Ireland for making – what may have seemed a distant dream 4 years ago – a reality.

    And today I wish to reinforce your efforts for prosperity with an economic settlement for Northern Ireland that backs up the political agreements you have reached: a new economic settlement that in the spirit of devolution:

    – releases new funds for economic developments that you wish to make;

    – offers the Northern Ireland Executive new powers to lead in ensuring greater prosperity;

    – sets up new economic institutions that can advance economic prosperity;

    – and proposes a long term strategic way forward for Northern Ireland’s public services.

    First, ex-army bases and prisons scar Northern Ireland’s landscape and symbolise the period of conflict.

    We want these sites to symbolise peace and prosperity and become the engine of economic and social regeneration in local areas.

    I can announce that the Maze Prison, Ebrington Barracks, Crumlin Road Gaol; and security bases at Magharafelt and Malone Road Belfast will be transferred to devolved control within Northern Ireland, free of charge to be redeveloped.

    In place of the symbols of the old conflict and despair, there will be symbols of the new progress and hope — barracks and prisons of the past replaced by businesses and prosperity for the future.

    Later this year I will announce the Government’s spending settlements for the three years up to 2006.

    But in advance of this announcement and in addition to it, and as a special initiative to accelerate the development of the social and economic fabric of Northern Ireland now, we are today making available £200 million for reinvestment and reform in public infrastructure in the following way.

    The Northern Ireland Executive will, for the first time, have new powers to borrow on its own account – raising spending power and offering greater economic freedom to make important decisions about new investment in infrastructure and public services.

    And in the spirit of devolution, it will be for the Executive to decide how far and how fast to make use of this new flexibility.

    But over the next two years they will be able to finance borrowing of up to £125 million from what is already raised from Northern Ireland ratepayers. A further £75 million will be made available from the Northern Ireland Executive in un-allocated resources for new investment in infrastructure.

    And I hope that consistent with the peace process there will be particular emphasis on cross community projects. Not only communities working together and sharing in the prosperity of Northern Ireland, but shared facilities developed to foster, for example, partnership between Protestant and Catholic schools.

    Third, setting plans for the long term.

    Too often we have had to take short-term decisions for short term and immediate reasons.

    It is now time to take a long-term view – breaking from the short-termism of the past to set economic plans for the long-term, for an era of peace and prosperity.

    And it is time to put in place a mechanism that will not only prepare the ground for a Northern Ireland of greater prosperity but also send a signal round the world that the economic focus for Northern Ireland is one of building for the future together.

    In the last few months we have been working with the First and Deputy First Ministers, on behalf of the Executive, to help develop plans that would bring together all the necessary skills, management and finance expertise to ensure not only best value from the additional investment being made available, but enabling Northern Ireland to make public funds go further: drawing on best value, allowing public and private sectors to work together for public interest objectives.

    The First Minister will be setting out the Executive’s plans in more detail. But I can announce that with their agreement we will make provision for a Strategic Investment Body for Northern Ireland responsible for:

    – clearing the backlog of urgent work necessary;

    – offering a strategic and fully coordinated approach to infrastructure investment in public services;

    – bringing together, within one centre of excellence, the best expertise available;

    – working in partnership with the private sector matching new investment with modernisation and reform to achieve best value
    helping to raise growth and competitiveness to the benefit of the people and business community of Northern Ireland.

    But this new momentum for reinvestment must be matched with reform.

    And just as in Britain we are demanding modernisation to match investment to achieve the best results in health care – so too here in Northern Ireland we know that reinvestment, including in our public services is to be matched with reform. Through more efficient use of resources and better managed services, delivering best value for money and high quality investment for the people of Northern Ireland.

    This initiative represents a further example of devolution: the centre letting go in the interests of local power – local people making local decisions about local needs. Not just for health, social services and education but about the development of the Northern Ireland economy in the years to come.

    The message is: if you want to develop in Northern Ireland, grow your business in Northern Ireland, invest in Northern Ireland we are on your side, ready and willing to help you, as we ourselves invest in the long term future of Northern Ireland.

    The Good Friday Agreement offered peace for Northern Ireland – a way out of 30 years of violence. The economic settlement we are announcing today – a new economic settlement that in the spirit of devolution releases new funds; offers new powers to lead in ensuring greater prosperity; sets up a new economic institution; and proposes a long term strategic way forward – is a concrete demonstration of what can be achieved with devolution and offers faith in the future: the chance to build peace with prosperity, and to create an economy of opportunity for all.

    So we can look forward with new hope to an era of opportunity, leading Northern Ireland to a new age of achievement.

  • Gordon Brown – 2002 Speech to AMICUS Conference

    gordonbrown

    Below is the text of the speech made by Gordon Brown, the then Chancellor of the Exchequer, to the AMICUS Conference in Blackpool on 10 June 2002.

    Today I want to talk about the National Health Service, full employment, the future of our economy, and our international agenda.

    National Health Service

    I believe that the case for the NHS system of funding – free at the point of need – is not weaker but stronger now than it was even in 1948 when it was founded.

    Look at what your members faced in 1948 and now.

    In 1948, the scientific and technological limitations of medicine were such that high cost treatments and surgery were rare or very rare:

    – no chemotherapy for cancer;

    – cardiac surgery was in its infancy;

    – intensive care barely existed; and

    – hip and knee replacement almost unknown.

    Now, the standard of technology and treatment is such that unlike 1948 some illnesses or injuries could cost £20,000, £50,000 or even £100,000 to treat and cure, and some drugs cost as much as £8000 per prescription.

    Because these costs of treatment and of drugs are higher than ever, the risks to family finances – if there was in Britain a requirement to pay privately – are greater than ever, not just for poorer families but for comfortably off families up the income scale. And therefore the need for comprehensive insurance cover of health care stronger than ever.

    So I would say that in 2002 it is because none of us ever know in advance whether it is you or your family that will need that expensive care for acute or chronic illness that the best policy is clearly an insurance policy that offers cover to all of the people, whatever their income, for all illnesses and diseases without the ifs, buts and small print of private insurance policies.

    So while some present the current NHS system of funding as an ideological hand-me-down, to be supported only out of sentiment rather than hard headed calculation; and while others dismiss the NHS funding system as an impossible dream – “fine in principle, a failed experiment in practice”; we now need to campaign to show people that the NHS system of funding – comprehensive and inclusive insurance with treatment free at the point of need – is demonstrably the modern rational choice: the best insurance policy in the world not just for poor or low income families in Britain, but for the vast majority of families in Britain. Not just for today but for tomorrow too. And more so than in 1948.

    The issue now is between those who want to invest in the NHS and public services and those who want to charge and introduce private insurance.

    I believe we should now expose the costs and inequity of private insurance – under which typical family premiums in the United States are around £100 pounds a week, rising by 13 per cent a year, and 40 million Americans are left uninsured – and thus insure only some of the people for some of the time when we wish to insure all of the people all of the time.

    And I believe we should together expose the costs and inequity of charging for clinical services – £8,000 for a hip replacement, £40,000 for a heart transplant, £10 for a visit to a GP or to stay for a day in hospital – the unfairness of the sick paying for being sick.

    And so I want to ask you today to help us ensure that we continue to prevent the introduction of a private system under which poverty would bar the entrance to the best hospitals; under which the only health care you could be sure of is the health care you were able to pay for.

    And so let us affirm that it is because we recognise the rising costs of health technology, the risks that any family in this country face to their health, and the equity and efficiency of the NHS tax funded system that, for us, a reformed and renewed NHS – with the largest sustained increased investment in any decade of its fifty year long history – must be and remain a public service free at the point of use with decisions on care always made by doctors and nurses on the basis of clinical need – the best insurance policy in the world.

    Economic stability and employment

    The foundation of our sustained increases in public investment in health is economic stability not boom and bust.

    It is because we rejected short-termist free for alls, the take-what-you-can, irresponsibility – and it is because we put faith in our values of economic responsibility – building from solid foundations, looking to the long term – that with Bank of England independence, tough decisions on inflation, new fiscal rules, hard public spending controls, we today in our country have had economic stability not boom and bust, the lowest inflation in Europe, long term interest rates and mortgage rates for homeowners lower than for nearly 40 years.

    It was not by lucky chance but by difficult choices that we now have a more stable economy. And we will continue to reject the soft options, the quick fixes and short-termism in favour of a foundation of economic stability that enables us to move towards our goal – the goal we share – of full employment.

    Since the time I went to school and grew up beside a mining community – since the first factory closure I remember being announced in my home town – and for a whole generation – our lives have been dominated by unemployment: long-term unemployment, youth unemployment, the fear of unemployment, the poverty and insecurity caused by unemployment.

    I remember when I first became an MP a young couple coming to see me, both in tears, who having lost their jobs, knew they would lose their homes too.

    I remember too the tragedy of the miners in my constituency, steel workers, dockyard workers, transport workers, engineer workers – redundant in their forties who feared they would never work again.

    20 years ago, 10 years ago, even 5 years ago young people tried as hard as now to find work – they were applying for jobs, they were training for jobs. Don’t tell me these generations of young people didn’t have talent or potential, couldn’t learn or hold down a job. What they needed was a government on their side.

    So the day we came into government we acted – starting with a windfall tax to pay for our New Deal. And I say it was right that £5 billion be transferred from the richest utility companies in our land to create employment opportunities in the poorest and most deserving communities of our country.

    If only one person had benefited from the New Deal that would have made it worthwhile. But in total 660,000 people, two thirds of a million of our fellow citizens have benefited.

    Every time a young person denied a job under the previous government gets a job under this one we should be proud of the New Deal – that this is what can happen when we work together.

    In the mid eighties 350,000 young people were unemployed for more than a year.

    Today it is 5,000.

    And I can report to you today that the full total of jobs Britain has together created since 1997 is 1 million 500 thousand jobs – more people in work today than at any time in the history of our country.

    Unemployment among men the lowest since 1979.

    Unemployment among women the lowest since 1976.

    Youth unemployment now the lowest since 1975.

    Long-term unemployment now the lowest since the early 1970s.

    But as long as there is unemployment we will not be complacent.

    So let us send the message from this conference: that the next stage is to do even more to help those people and those places still too often forgotten and left behind.

    Because too many disabled people are denied the right to work, we have introduced the New Deal for the disabled and a guaranteed minimum in-work income for disabled men and women of £194 a week to give disabled people denied chances in the past – to develop their talents and potential to the full.

    Because for too long too many lone parents have been denied the right to live their lives as they want, we have put in place a new programme of choices, underpinned by a national child care strategy to push up employment rates from just over 45 per cent when we came to power to 70 per cent by 2010.

    Because for too long too many people have had doubts about whether it is worth their while working, we will make work pay: building on the Minimum Wage, from next year we will introduce a new Working Tax Credit to tackle poverty in work.

    So, for the first time, there will be a minimum income for all those in work over 25 – creating a tax system where the rates range from 40 per cent at the top to minus 200 per cent as we create fairness and justice in the workplace.

    And because child poverty is a scar on the soul of Britain, we are bringing together payments for children in a new Child Tax Credit from next April. Creating a new seamless system of support, built on universal Child Benefit, with one single payment through the tax system – improving work incentives and ensuring for the first time that all child payments are paid to the main carer:

    – from the £11 a week mothers received for the their first child in 1997 to the £26.50 most will receive this time next year;

    – from £28 a week for the poorest child in 1997 to £54.25 a week next year and £92 a week for a family of two.

    Taking, as a result, thousands of children out of poverty.

    And in the same way we are creating social justice for families, our aim is social justice for pensioners with our £1.5 billion rise in pensions next year: the basic state pension rising each year, pensioners with modest occupational pensions and savings gaining up to an extra £14 a week from the pension credit, with a minimum income guarantee rising in line with earnings that takes thousands of pensioners out of poverty. Our aim that in our generation we abolish pensioner poverty and ensure every pensioner has dignity and security in retirement.

    And because securing the future of company pensions is important not just to those whose pensions are at risk but to the whole country, the government will not only be vigilant about what is happening to pensions but will publish a document on pensions later this year.

    Productivity

    Having been winning the employment battle just as we have been winning the stability battle, we must win the productivity war.

    And in particular creating modern manufacturing strength. Let us be clear about the future: the countries that succeed most in the future will be internationalists not insular – in our case playing our proper role in Europe – and will not be those who compete on low wages but compete on high skills, high technology and high value added.

    And because increasing productivity in our economy depends on increasing opportunity in our society – increasing the opportunities for jobs, to get education qualifications and skills, to make the most of your inventive talents, to start and expand a business – I can say today that our public Spending Review will continue to do what government can and should do to remove four barriers to British productivity growth and prosperity:

    – first, removing the barriers to innovation and science so that Britain leads again in science, technology and engineering;

    – second, removing barriers to enterprise so we have thousands more small and growing businesses;

    – third, building a modern infrastructure in transport, planning and housing so we have regionally balanced growth; and

    – fourth, and most of all, investing in skills and education – because we cannot be number one in the world as an economy if we are number two in education. And as we expand the numbers of men and women able to benefit from the new economy – through world class education, lifetime learning and portable benefits we need to replace what is too often a poverty of aspiration among too many people in Britain with a wealth of ambition.

    Science and innovation

    Two thirds of growth comes from innovation so take science, technology and engineering which as you as a union have told us we have as a country neglected for too long.

    To create the virtuous circle of innovation we need from the university lab and the science park to the workplace of every company, we will – in addition to the new Research and Development tax credit, worth half a billions a year to company innovation and research, and £1.75 billion re-equipment of university science – take new steps in the Spending Review next month to:

    – improve science education and the science and technology skills base;

    – re-equip science and engineering laboratories in colleges and universities;

    – fund science technology and engineering postgraduate researchers to tackle skill shortages in key disciplines;

    – invest in increasing the quality and quantity of science, technology and engineering research;

    – and continue in the regions the work of science enterprise centres to spin-off companies from research and provide the capital to finance inventions – to ensure we tackle our long-term failure to transform pure research into British products and ensure that more British inventions mean more British manufacturing and more British jobs.

    So our Spending Review can and will do more to sustain and build UK science in the face of increasing global competition – including improving the recruitment, retention and training of skilled scientists and engineers.

    With new investment in research, science and innovation let no one think that manufacturing is a sector of the past, to be praised for its historic role but somehow not relevant to the future.

    Let us tell the critics that manufacturing accounts for 60 per cent of our exports, 80 per cent of our research and development and is vital to this and every region.

    And with world beating firms from aerospace and pharmaceuticals to motor vehicles and general engineering meeting the difficulties of a low Euro, with a world lead in electronics design, photonics, mobile network broadcast technologies and knowledge intensive industries and services, the challenge we face and will meet is to build for our country modern manufacturing strength.

    And as we do so for Britain, our policy for Europe remains consistent – to be at the centre of Europe, to pursue economic reform and to make our decision on the single currency on the basis of the five economic tests that we have set down.

    Enterprise

    We know that our small and growing businesses are the large businesses of the future and because for too long barriers have restricted small business creation and development and a Britain where you can work your way up, we will – by our small business and Capital Gains Tax cuts, by our competition policy and by our support for the Small Business Service and enterprise lessons in our schools – open up new opportunities for new businesses and build a stronger enterprise culture in Britain.

    And I hope this union which played so big a role in demanding the creation of Regional Development Agencies will work with us to build up their strength – local people making local decisions about local economic needs, and in particular regenerating old industrial towns and cities from local high streets to urban estates.

    Infrastructure

    Because for too long there has been chronic under investment in our infrastructure, our Spending Review will update our £180 billion ten year plan to modernise our transport system – the biggest public investment programme in transport history – and we will do more to remove barriers to planning and housing, so that – instead of congestion, overheating and pressure on house prices in one part of the UK and emigration, depopulation and unemployment in other parts – we can ensure balanced economic growth in all parts of our country.

    Education and skills

    And having raised the share of education in our national income during the last Parliament, we are pledged to increase significantly the share of national income devoted to education over the course of this Parliament – not just because education is crucial for social justice but because it is key to improving the productivity of the British economy.

    And our focus in our Spending Review will be not just on resources but on reforms to break down the educational barriers that at whatever point in the life cycle – from access to nursery education to new opportunities for workplace training – deny opportunity and hold people back.

    The challenge, because we waste too much of the talent of Britain, is to open up opportunities for education to an extent never before seen in this country so that every child, young person and adult will have the best possible chances in life.

    And it is time to ensure that not just a minority have access to higher education but for the first time a majority by opening up recruitment and widening access so that our colleges and universities can draw on the widest possible pool of talent.

    So our pre-five year old Sure Start and nursery programme will provide opportunities for children to be better prepared to learn when they get to school, and we will improve standards in secondary as well as in primary schools, so that unlike the past when too many children were destined to fail even before their life’s journey has begun, we invest in developing not just some of the potential of some of our children, but we invest in the development of all of the potential of all of our children.

    And our Spending Review will offer new opportunities to stay on at school, to study at college and university, to enjoy the benefit of lifelong learning into the third age, with new support with resources tied to reform for the colleges supporting 4 million students now in further education.

    And in the work place in addition to increasing modern apprenticeships – many of these in the manufacturing sector with 15 per cent in engineering – we will, from September, pilot a new approach to in-work training combining direct financial support for business, especially small business, with time off for their employees for training so that once again productivity in our economy rises to the benefit of not just a few but to the benefit of everyone. And we have responded positively to the proposals put forward by the TUC-CBI skills group, with additional funding to help small organisations attain Investors In People status – creating a Britain where what matters is not where you start from but what you aspire to, not what your background is but what your ambition is.

    And just as we improve productivity in the private sector so, by matching resources with reform, we must increase the productivity of the public sector.

    Those of us who believe passionately in public services understand that just as we cannot serve the public if investment is low, we cannot serve the public well either if service is poor, if performance is faulty, or if there is resistance to necessary change.

    And we know that in the new Spending Round – not just for health but for education, policing transport, housing and social services – there can be no blank cheques; that the days of something for nothing are over; and that resources must be tied to results.

    And the requirements for reform that will dominate decisions not just on NHS spending but in our public Spending Review later this summer will be securing the highest national standards with proper audit and accountability to ensure standards are met; ensuring local devolution of decision-making – our policy being “front line first”; greater flexibility to achieve greater results; and – for the public – extended choice.

    International agenda

    But the challenges we have to address for Britain – unemployment, poverty, inequality, access to education and health – the challenges of economic and social development –we have to address for the world.

    The global campaign for debt relief in which many of you through churches, NGOs and local organisations have been engaged is now lifting the burden of unpayable debt from 26 of the most highly indebted countries, cancelling $62 billion in debt. And as we have seen with Uganda pupil teacher ratios as a result of debt relief is falling from 100-to-1 to 50-to-1 and every child at school will have a roof above his or her head.

    But what drives us forward are not the achievements we can point to – important as they are – but the gains still to be made:

    – 113 million children – two-thirds of them girls – who are not going to school today because they have no schools to go to;

    – 30,000 children facing death each day from diseases we could prevent;

    – in total 600 million children in developing countries living in the most disfiguring, grinding poverty imaginable – condemned to failure even before their life’s journey has begun.

    In my five years as Chancellor I have visited Asia and seen young children living above open sewers and yet their eyes still bright and full of hope – and I know we must help.

    And I have been to Africa and I have seen young people living on the knife’s edge of bare existence asking why their new found political freedom cannot bring economic and social freedom from unemployment and poverty.

    Yes, before us are threats we must face and defeat – from terrorism, to exploitation, to the easy temptations of indifference.

    But before us there is also an unprecedented possibility of progress.

    Unique to our time we have in our hands the opportunity to banish the worst of poverty from the earth.

    And our commitment should be that:

    – every child be in education;

    – avoidable infant mortality is banished from this planet; and
    we half world poverty on the road to its abolition.

    Recognising that we are all – rich and poor, old and young – bound in one vast network of mutuality across all the lines that might otherwise divide citizens of different countries – members of the same global community, the same moral universe.

    And what we need is a new deal for the global economy, that is a new deal for the world’s poor – that in return for developing countries pursuing corruption-free policies for stability and for creating a favourable environment for investment, developed countries should increase vitally needed funds to achieve the agreed millennium development goals, so that no country genuinely committed to good governance, poverty reduction and economic development should be denied the chance to cut infant mortality and poverty and achieve schooling for every one of its children.

    This week I travel to Canada for a G7 meeting to prepare the way for the African plan that will be agreed by world leaders in three weeks time when they meet in Canada

    And we must act.

    Take hunger – today a fact of life for too many children. And in some countries – in southern as well as sub Saharan Africa – it is tragically getting worse not better. Even when there is adequate food available, poverty often prevents poor people from feeding their children.

    So the British government proposes today to take not only short term immediate action – as Clare Short our International Development Secretary is doing – to help those countries currently affected by food shortages, including Malawi, Zimbabwe and Zambia, but that we finally recognise the importance of the trade round for long-term food security – opening up agriculture in all our countries to fair competition, and opening up trade in everything but arms.

    Second, because we have been far too slow in advancing our education goals – because as things stand 88 countries will not achieve primary education for all by 2015 and indeed, because instead of raising educational aid as a share of national income the world has been, disgracefully, cutting it – the government’s proposal today is that the richest countries back the new World Bank initiative with the funds it now needs to fast track our commitment to meeting the goal of primary education for all by 2015 and to ensuring that in all countries education is not subject to fees but free for everyone.

    Third, half child deaths are from four avoidable diseases – acute respiratory tract infection, diarrhoea, malaria and measles – a loss of millions of children’s lives unnecessarily each year. So building on this years new global health fund for drugs and treatments in HIV/Aids, malaria and TB, I propose that just as we fast track investments in education for countries who have a plan, so too for health we should fast track support for helping to build health care systems.

    Fourth, because too often the world has set goals like the millennium development goals and failed to meet them; because too often, we have set targets, reset them, and recalibrated them again; because too offer our ambitions, in the end, only measure our lack of achievement, this time, it can be, and must be, different.

    So to build a virtuous circle of debt relief, poverty reduction and sustainable development for the long term, I propose to do more than increase debt relief and agree that the cost of meeting the millennium development goals is $50 billion a year.

    Our aims: every child the best possible chance, every young person the prospect of education, every adult the reality of a job, every pensioner dignity in retirement, every citizen the best public services, every country playing its part in a just and inclusive world. Not just some but everyone – whatever their birth, background or race – having the chance to achieve their potential.

    National and international goals which show the sheer scale of our ambitions for Britain – goals that for economic as well as equity reasons we cannot postpone or defer, goals that taken together can advance a new progressive consensus for Britain.

    Goals for our country worth fighting for, goals that show there is purpose in politics.

    Good causes worth fighting for.

    We can build a Britain worthy of our pioneers; we can build a Britain worthy of our ideals.

    And we achieve our ideas best when we achieve them together.