Tag: 2003

Below is the text of the speech made by the then Health Secretary, John Reid, to the Amicus Conference at Bishop’s Stortford on 17th September 2003.

NHS values are at the core of existing and future policy of this Government. Equal access to health care free at the point of need paid for out of general taxation. We need to say much more loudly how important these principles are in the improvement of the NHS.

Especially since the consensus which has held for almost six decades has now been shattered by a Conservative Party which is more extreme on the issue of health than even Mrs. Thatcher. In that, they are at odds with the British people.

Independent MORI survey data shows consistently that three quarters of the British people believe the NHS is critical to British society and we must do everything to maintain it.

Satisfaction with the NHS is higher than 10 years ago. And the NHS – and the future of the NHS – is not only a key issue. People feel it is more important than any other issue – including crime and immigration. They are committed to this idea of collective provision.

And one of the central aspects of that is the belief that everyone in the country should have equal access to care – that no one should be discriminated against in their access to health care because they have less money or because they live in the wrong part of town.

This value of equity rests at the heart of our people’s affection for the NHS and their trust in it.

That is why the Government have regarded it as so important. This is why we set up NICE in order to overcome inequity in treatment.

People believe strongly that if we all pay for the NHS out of the taxation that we all contribute towards, then we all have the right to use the NHS equally.

People recognise that the introduction of money directly into the health service transaction would add a considerable barrier to access for those people who had less money than others.

If money was involved as a part of each health service transaction – whether at the GPs, when seeing a nurse, or at hospital – those people who had more money would be able to increase their access. We would therefore not have a system of equal access.

So it is not through individual meanness that the British people reject any form of payment for health services. Rather it is because they recognise the inequity this would inevitably cause.

As today’s Datamonitor report on private medical insurance shows the number of people taking out private medical insurance has fallen by more than 10% this year. Their own analyst points out this is because “recent hike in premiums has priced some out of the market”. As the NHS gets better, private medical insurance is getting dearer.

This is a major challenge to the Tory patient passport plans, and they will now have to recost their plans. On last year’s figures the Tories needed to find £1billion to fund this subsidy skewed to the wealthy. As the premiums go up, the potential tax relief liability goes up. So now they’ll need to make even more cuts to the NHS to fund their policy. Given the escalating and unsupported cost of this policy, Liam Fox should today dump his ridiculous proposal and return to the principles of the NHS. Equal access to treatment free at the point of need.

This is a value with which the British people agree. Only around 1 in 10 people feel that the Government should encourage people to go private if they can afford it. And only 5% feel that NHS money should be given to people to buy private health care. As far as health services are concerned, inequity is simply not acceptable to most of the British people.

The original White Paper on the NHS written in 1944 expressed this simply: “Everybody in the country…should have an equal opportunity to benefit from medical and other services”. That was an important aspiration then – it is important now.

So equity is not an ‘add on’ to the NHS. It is a cornerstone of the NHS itself. Social fairness in the relief of pain and distress.

And yet, for all our success in combating preventable pain, the National Health Service has not as yet achieved that aim. At the moment, the NHS principle of equity provides the opportunity for a universal and equitable service, since it does not introduce the barrier of cost to the patient into the process.

But we must be honest – the present system does not yet meet this goal. We must do more.

The first thing this needs is extra investment to provide the resources and the capacity we need. The extra investment that is now taking place in the NHS over the next five years we will see the biggest sustained funding increase in history.

That massive increase – and those extra 55,000 nurses, 6,500 doctors, tens of thousands of additional workers – provide us with the possibility of moving further towards the goal of equality of access.

But we need more than just increases in capacity.

In July, I outlined the developments that will help us work towards our manifesto commitment on choice, which said:

“We will give patients more choice…… By the end of 2005 every hospital appointment will be booked for the convenience of the patient making it easier for patients and their GPs to choose the hospital and the consultant that best suits their needs.”

Today I want to explain to you that one of the main reasons for increasing choice in the NHS is to increase the fair distribution of access to health services.

Choice and capacity building are partners, not enemies.

I recognise that for some people this may appear counter-intuitive; for some time now it has been simply assumed that any increase in choice would automatically lead to a decrease in fairness. Many commentators have expressed the belief that it is inevitable that an increase in patient choice would automatically mean we lose the equity that they believe is a cornerstone in the provision of NHS services.

I disagree with them on two counts.

First, they are wrong to assume that the existing NHS distributes access to health care in an equitable manner.

Second they are wrong to see choice as inevitably increasing inequity.

The Government’s commitment to fairness in the health service is so strong that to help to extend fairness we will extend choice for patients in the NHS.

The fulcrum of my argument is not just that fairness is central to the NHS, but an honest acceptance of the fact that the aim of the 1948 health service to provide equality of access to healthcare has not been fully met.

Therefore, if we take this principle seriously – if we really want to achieve fairness in access to health care rather than just talk about it in resolutions – the NHS will have to work differently to bring it into reality.

In the past, the collective responsibility to achieve equity in access to health was demonstrated by providing health services for ‘the general public’. For decades it was felt that in order to meet the health service needs of masses of people we would need to mass-produce a health service.

It was felt over these decades that uniformity would create equal treatment for all. It was believed that delivering everyone the same sort of service would ensure that everyone would be treated fairly. The idea seemed to be that all of the British people were all the same and therefore if we were treated all the same it would create fairness.

This was not the case. The mass production of any service ultimately fails to meet the individual needs of each service user. We have understood that lesson in industry; and we increasingly understand it in service delivery. Since the 1970s we know that uniform services have failed to meet the needs of women, people from ethnic minorities and others in the population who are without sufficient confidence and resources.

We need a service which is comprehensive, fair to all, and personal to each.

The problem of unfair health service access is not a new one. Researchers have been pointing it out for some time. A famous left wing critique of the NHS, Tudor Hart, as far back as 1971 created the famous “inverse care law”.

His point is that, for a variety of reasons, the areas where there are poorer people with greater need simply have less health services than better off areas.

We recognised that a part of the inverse care law is caused by material factors. More resources had to go to poorer areas. So our distribution of investment to PCTs last December gave the largest increases to those areas where there is the greatest health need.

This emphasis on revenue spending has been matched by some of the larger inputs on capital expenditure. So for example there is a £707 million programme of investment in the infrastructure to support the continuing expansion of cardiac centres and diagnostic facilities in District General Hospitals. In cancer, new scanners have been delivered to the 6 most deprived health authorities in the country.

It is not possible to change the distribution of health resources overnight but we have begun to tackle the past distribution.

But the inverse care law is not just about the distribution of resources. There are what we can call cultural issues involved where some are much more likely to have the information and the confidence to use that information than others. Any system which tries to limit information and fails to support people in using that information will inevitably be unequal.

That is why our policy on choice in the area of elective surgery for instance will also further our aim of equity. At the moment, there are real problems of equity of access to current health services. For example, in cardiac care there is evidence of inequitable access in the past to treatment in both diagnosis and operations. Studies of cardiac care have shown that deprived patients appeared to wait longer for surgery and were less likely to be rated urgent.

Doctors, nurses and administrators do not deliberately deliver health care in a discriminatory way. They work with patients and provide them with care to the very best of their ability and with the resources at their disposal.

However, whilst the existing system is set up to provide a fair chance for everyone, we know that there is room for the patient to intervene and ‘work’ the system. People with more information, confidence and general knowledge of public services are in a better position that others. The existing system, in fact, distributes access unequally.

There is considerable evidence of differential access to other elective surgery. There are, for example, lower levels of treatment rates for hips, gallstones and hernias for lower socio-economic groups relative to need. There are further differentials according to poorer socio-economic group between consultation rates with GPs and hospital treatment rates for cataracts and tonsillectomies.

If we believe in the value of fairness in the NHS then we need to do something about this.

Some people can work the existing system better than others. Information, confidence and support are differentially distributed. The existing system tries to exclude this, but in a modern society this is just not possible. The history of command and control systems demonstrates that no system can ever tell people what to do with sufficient force to stop people finding their way through it. All over the world that has been tried and failed. We cannot tell people what to do and where to go. It does not work. And it does not work equitably.

If we are a Government committed to equality of access then what we must do is try and tackle this.

We must start by equalising the information at people’s disposal. We are putting more and more information about NHS health services into the public domain. The British Heart Foundation makes information available to patients, and some local cardiac centres, for example Liverpool, publish their own local information for patients. Only two years ago this information was known only if you were part of a small circle of people and it was kept secret from most patients.

Every single piece of public information open to all increases the possible power of patients. But it is our job to make sure this is known and used by everyone, and not just the chosen few.

When in doubt about whether patients want this information and choice, ask the patient!

Over the last year, we have been carrying out a number of pilots for patients’ choice in surgery. These have been instructive. From July 2002, all patients who had been waiting longer than six months for heart operations have been offered the choice to go somewhere else if they want. Some 2,896 patients – around 50% of those offered the choice to move to another hospital – have chosen to do so. Since October 2002, patients in London have been offered a choice for cataract surgery. And from this summer, all patients in London waiting more than 6 months for any form of elective surgery have been offered choice of an alternative hospital. To date, 7,180 London patients have chosen to have faster surgery in an alternative hospital – over 70% of those offered this choice.

Let’s be clear what we have done to date and why we have done it. Everybody within a certain clinical category, at a certain time of waiting, and in a certain part of the country gets this choice. Not those with money. Not those that are friends of doctors. Everybody. Everybody gets the same chance through this sort of choice – the same information and, crucially, the same support to help make these choices.

This choice for people has not only improved their experience of the NHS, but it has also increased the use of capacity within the system. If a patient is ‘stuck’ on a single waiting list there is likely to be a hospital somewhere else that can treat them a lot earlier. By bringing all waiting lists together to provide people with choice, you increase the utilisation of the whole system. In London, in the past it was the case that some people waited for a cataract operation for 8 months and some were waiting for 8 weeks. By giving people the choice to move, you make much better use of the capacity and also encourage those hospitals that are operating well to do even more work.

Next year we will roll out this choice at six months across the country.

But even this is not enough. By the end of 2005, choice at the point of referral will be there for everybody, for all elective operations. By that stage we will be able to offer at least 4 different choices for people to make. Each hospital on offer will be backed by detailed information, which will be on hand in the GP’s surgery. Whilst this information will be in the public domain in general – it is when this information goes hand in hand with the GP’s real support that it will provide all patients with the same starting point.

From the point of view of equity I want to explain what this will mean. It will mean that the information base will be open to everybody. It will mean that the GP will be on hand to assist everyone to use that information. It will mean that people will be able to make decisions that fit into their own lives and their own calendars. Not just those who know a hospital consultant – but everybody for every referral.

That’s why our approaches to increasing choice and increasing equity go hand in hand. We can only improve equity by equalising the information and the capacity to choose. And we can only provide those choices when we have increased the capacity of the NHS.

I know some believe that providing everyone with choice automatically biases the system against those who are socially disadvantaged and will lead to inequity. There are two problems with that position. First, as I’ve said, the existing system of not providing everyone with choice has not created equity.

They are wrong for a second reason. Working people, poorer people, people who have disadvantages in their lives are quite capable of making difficult choices. Living the lives that they lead, they make very difficult choices every day.

– Trying to make the most of a small income.

– Coping with a world where English is not your main language.

– Trying to tussle through a bureaucratic maze to get your rights.

These are everyday activities for disadvantaged people and they need great capacity to survive and thrive. Such people – if given the information and the support of their GP – will be able to make choices for their health and their health service. And anyone that denies this is simply patronising people.

So we start from a position that recognises a painful truth. 55 years of a ‘uniform service’ has not created equality of access. If we believe in greater equality of access we need to empower not just the few but the many. To do this we need to put the information and support in the hands of every patient and encourage them to take a greater say in where they have their treatment.

The Government this week has been accused of being “ideologically timid”. But the course I have outlined is not for the fainthearted. This is not a hunker in the bunker policy. It is a real challenge to those who mistake the structures of the NHS for its values. If we were not addressing the issue of equity then thinktanks could rightly claim we had “lost our way”. But we have not.

It is by developing choice and capacity in the NHS that Labour will increase equity in health in his country. If we were timid or had lost our way we would not – painfully at times – be reforming the NHS. But this would be the ultimate betrayal of modern working families since a failure to reform the NHS would soon be rightly seen as a failure to defend the NHS.

Below is the speech made by the then Secretary of State for Health, John Reid, to the NHS Chief Executives Conference on 3rd February 2003.

You are the leadership of the NHS. And coming as you do from both a clinical and a managerial background the fact that you are the NHS leadership demonstrates how vital it is for nurses, doctors and managers to work together. And I would like to thank you for your leadership.

Last September, in my first speech to you, I argued for the importance of values for the NHS. Values matter, not because they make us feel good about ourselves, but because they are awkward, difficult, bloody minded guides to action. They stand judgementally outside of our practice and argue with us to do better.

The other thing about values, is they don’t go away, They are not just for Christmas. If you believe in them they last for a long time and they go on arguing with and improving your practice.

The more we believe in these values; the more the values argue for reform to bring them about. And as I hope you notice, I believe in them strongly. So meeting the challenge of holding strong values argues for policies and practice of strong reforms. That is what my speech today is about.

Lets look at where we are – the work you all do. The main value we are working towards is equity of access to health services free at the point of delivery. That value cannot be met when some people were waiting 18 months for their operations. The target for inpatient waiting times that you met last April, hopefully the targets you meet this April and will meet next year are all about equalising access to hospital treatment. The same is true of the 48 hour access to GPs. Without access there can be no equity of treatment. That’s why our first priority as a government has been to respond to patient demand and grow the treatment capacity of the NHS at an unprecedented rate.

Delivery now and in the future has and will come about because of massive investment plus reform. This is now beginning to deliver real improvement and with the new contracts for all our staff and the growth of new capacity there will be more. With this new capacity the NHS is beginning to produce real results.  We continue to see an increase in elective admissions for patients into hospital and a large growth in procedures in outpatients and primary care. Taken together they show that on current trends about 400,000 more people than last year will have elective procedures. And both the NHS and independent sector Treatment Centres are playing their part in delivering additional capacity. Waiting times – the publics number one priority – are coming down. This is important because it improves equity of access.

But this is not enough. In December we published Building on the Best, which demonstrated how we need to personalise our NHS.

In the past the NHS has believed that uniformity of provision would create equity. To create that uniformity, decisions would be taken away from the individual patients and carried out by a centralised system. Sameness however, did not created equity.

And that is why in Building on the Best we have been so careful to ensure that equity remains a goal for choice. People will get support and information in making those choices including interpretation for black and minority ethnic patients.

Choice can and should be a part of our journey to greater and greater equity of access. As the Long Term Medical Alliance says

“Choice is often seen as a prime example of inequity in health care. LMCA  believes it is possible to use choice as a lever to improve equity, but only if this has been made a specific objective”

So, just as increased delivery was aimed at meeting the value of equity of access so to is our second policy aim of personalising the NHS. Equity and personalisation go hand in hand.

But this is not enough. The NHS needs to, along with the rest of government and the rest of society, work with all the members of the public in helping them to improve their own and their families health. It is obviously in the interests of the NHS that people look after their health. The better the public improve their own health, the more the NHS will achieve. The NHS needs to play an increasing role in that process too.

This too is about equity. One of the first facts I heard when I became SofS has truly shocked me. The fact that a boy born in Manchester lives ten years less than a boy born is Dorset is a disgrace and is palpably unequal. Of course that’s not just a matter for the NHS, but all of us, health service, government, and above all society itself should not let that situation continue.

How will combining these three themes work for an issue  that you are looking at this afternoon – chronic disease management. There are 17.5 million people suffering from a chronic disease in England. We could just try to manage chronic diseases through increased capacity of our present system . Whilst this would provide us with a full range of different healthcare options, it does not fully engage the patient.

Look at what the NHS could do as we develop our more personalised approach to health services, which gives the patient an opportunity to self manage and navigate their own way through the different ways of getting help with their chronic diseases. This will not just create a better experience for the patient but will improve medical outcomes.

But we need to go further to develop an integrated prevention strategy as well. A genuine set of preventative health improvement measures would play a direct role in chronic disease management. It would reduce the numbers of people at risk, and mean fewer complications for people who already have the disease. The core business of the NHS draws us towards the wider agenda of the health of the public. We will mainly do this because it is the right thing to do, but it is also the case that – as Derek Wanless pointed out – the task of the NHS is less difficult if the public are engaged in their health.

As a part of this process of developing our core business I want to endorse the conversation that you will be having with Nigel and Trevor Philips later on about leadership and race equality. For decades now people have been extolling other people to do more about race equality and far too little has actually happened. I want to explain why today is different. If you look at these three building blocks of our core business, we can’t do any of them without creating more opportunities for different black and minority ethnic groups.

Look at delivery. Go into any part of the NHS and our staff our capacity to deliver anything at all, is as diverse as the nation. If we don’t make sure there is more internal race equality for those staff, we will not deliver.

Look at personalisation. The need for personalising the health service is a medical one. Peoples bodies and needs are different. We need systems that treat them differently, and one of the main themes of difference is ethnicity. People live different lives and as such they need a different approach. Without greater race equality we can’t deliver a service that is personal to everyone.

Look at improving the health of the public. The public we have is the public we serve. It is their health we have to help improve not some public in the image of the late1940s. In 2004 our public is wonderfully diverse, if we are going to engage them in improving their health, then we have to engage them all in their diversity. Without greater race equality we cannot do that.

From here on in we cannot do our core business without it – and to signal that, in the near future Trevor Philips and I will be publishing a pamphlet making out that case.

On the wider front of the health of the public, I am announcing today a very broad consultation leading to a new White Paper on the next stages of action to improve  the health of the public. I am making this announcement to you as the leaders of the NHS because you will be key in both developing and implementing this policy.

However, and I want to stress this, the prime responsibility for improving the health of the public does not rest with the NHS nor with the Government, but with the public themselves.

Indeed, the public recognises this. We are seeing a huge upsurge of interest in improving people’s health and wellbeing. It dominates pages in the Press everyday – and not just for the New Year resolution season. Our newspapers, magazines, television programmes are full of material about how to be fitter, healthier, and happier. We are seeing debates across whole cities about how to develop approaches to transport, to smoking, to housing, to find what works best for local communities. Only last week we saw the results of a survey about who should take responsibility for our children’s diet and the problems of obesity and ill health.  Individuals, organisations, communities are all looking at how to make things better. It is this drive for improvement coming from the people themselves that must be the core of our work.

If people and their communities are the core to the development of the health of the public, does that mean that the Government should do nothing? Just as it is wrong to see the health of the public as solely a matter for the Government, so it is wrong to say that Government has no role. The consultation process we will be going through over the next few months will develop policies and practices for all different levels of Government. But we need a clearer understanding of what that role and its limitations should be.  Is it, as some suggest, the Government’s role to make rules and regulations? To ban things? Should the Government simply try to stop people doing what they enjoy? I can’t speak for every one of my colleagues but that was not what drove me to become a Secretary of State.

But the Government must provide clear information, we must play our role in helping more people have the opportunity to make healthy choices. We must also be prepared to take action to protect the vulnerable in society – particularly children.

These are issues that we need to debate seriously and in a grown up fashion. We all have a stake in getting this right. None of us wants to see our children or grandchildren growing up to be less healthy than we have been.

We know what the big challenges to health are. In the White Paper Our Healthier Nation, we identified the big killer diseases, the scandals of inequalities, the “healthy behaviours” that we all know would make a difference, the continued need to work with people to tackle Beveridge’s giants of want, idleness, ignorance, disease, squalor, so as to create the circumstances in which individuals and communities can thrive.

And many strands of action have begun. Local initiatives in neighbourhoods, communities, councils, healthy living centres, National initiatives, like smoking cessation clinics, the school fruit scheme.

We have made excellent progress on reducing premature deaths from CHD by 20% and cancer by 10% since 1997. Also, the 10% fall in under 18 conception rates since 1998 is a very encouraging sign. But the focus on some of the challenges needs to sharpen. For example, obesity levels are rising at an alarming rate. They have trebled since the 1980s, are responsible for more than 9,000 premature deaths a year in England, and are linked to both CHD and cancer. The cost of obesity to the NHS is an estimated £1/2 billion per year.  Most alarmingly, over a third of children are now overweight or obese and we are now seeing increasing case of Type II diabetes in children.

There has been a lot of sometimes, noisy debate about who should do this or that, to make the difference. We will be posing a wide range of questions to start off this consultation.

Who should take prime responsibility for obesity in the nation’s children?

What assistance should Government give to parents in tackling obesity?

What contribution might schools, the food industry, retailers, advertisers, or others have to make?

How far is it the business of Government to regulate the advertising of food and drink?

Or, to take a different challenge,

How does society as a whole take seriously the issue of increasing mental well being?

What role could employers play in improving the health of our nation?

And in the same way we need now to debate how best to support and promote improvement in health. As Michael Barber and Nick Macpherson might put it to you this afternoon, have we got our “delivery strategy” right yet?

A good example is our Smoking Cessation Services. We have a comprehensive network of Stop Smoking Services at PCT level, backed by an investment of £138 million over 3 years.

Since 2000, over 300, 000 have set a quit date and were still not smoking 4 weeks after with the help of the service. Many of those helped will have quit for good.

We know that the Services do work and that they are very cost effective, but at present they are serving a very small proportion of smokers.

On the one hand, we have this great demand with the vast majority of smokers wanting to quit, and on the other a NHS wide Service that is waiting to assist them.

So, the challenge for us is to encourage more smokers to go through the door of their local Service, and in parallel, to ensure that the Services which are provided actually meet their needs.

So now is the time, with Derek Wanless soon to report, to move on to a focused debate about what will help make the most improvements to the health of the public, individuals and communities over the next 5 years; and what are the most important actions for the longer term. This debate must generate some real momentum for social action, in response to the huge individual and public appetite for progress.

Returning to you specifically as leaders of the NHS. The NHS this summer will start to plan for the next 3 years, the time is right to move upstream and put the same effort and energy into improving health itself, working with all those who have a contribution to make.

Let me restate my position. I firmly believe that the government should take a lead in addressing these issues. But I also believe that no government or doctor can make a person healthy.

Ultimately, that responsibility has to lie with the individual. Only they can make the choice to healthy lives, to change their lives for the benefit of themselves and their families. I need to be personal here. After 40 years I chose to give up smoking because at this stage of my life there were personal reasons that gave me the will to do it. I was helped by chewing gum. I was certainly informed by all the science which linked cigarettes and cancer. Lots of things helped me to do this. But no one could have made me do it.

The role of government is to help its citizens to make those choices, by creating a supportive environment in and by helping them to stop smoking, improve their diets and take more exercise.

This may sound relatively straightforward, but in reality it is a massive undertaking and I do not think we – the government – have the answers yet.

It is clear from the current debates on public health that we all have a stake in the future of our health and the health of our children. Real progress will depend upon the concerted efforts of the NHS and other public bodies, local government industry, the media and the voluntary sector. Above all it will depend on working with peoples own desires to lead better healthier lives.