Tag: Alan Milburn

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, on 12 April 2002.

I wanted to come to your conference today because the people here are actually the people who are changing the National Health Service. You are the people who are turning rising levels of investment in the NHS into real reforms and I hope real improvements for patients.

We’ve seen some of that progress reported just this week – with shorter waiting times in hospitals, for ambulances and in GP surgeries too.

Of course there is an awfully long way to go but these are real achievements. They are the achievements that you and your colleagues around the country have made. And I simply want to congratulate you for them and to thank you for the job you are doing.

I know you work under huge pressure every day. And I know that there are lots of problems as well as signs of progress in the NHS today. But I believe the best days of the NHS are ahead of us, not behind us. It’s about time that we, as a country, started to feel a little more pride in the achievements of the million or more staff who work in the NHS and a little more confidence in the health service they provide.

It should be a cause of national pride that health care in our country is free. That no-one asks for your insurance policy or your cheque book before you get the care you need.

The reason the NHS continues to command such affection in the hearts of the British people is that its values are actually the values of our nation – fairness and equality, compassion and community, a belief that we can achieve more together than we ever can alone.

But the NHS should be supported with our heads as well as our hearts. Its values – far from being the backward looking sentimentalism that our critics claim – are actually grounded in the needs of our society today.

Without the NHS the sophistication of modern treatments – and of course their cost – would put individual provision of health care beyond the reach of all but the very wealthiest in society. For me at least the sick paying for the privilege of being sick is hardly the mark of a fair or civilised society. In a world where health care can do more and costs more than ever before having an NHS based on need and not ability to pay is a real source of strength for our country and security for our people.

The truth is most patients – despite the problems the NHS still faces today – get good quality care. Where there are sometimes lapses in the quality of care our job is to tackle them. What we cannot allow is for the bad to detract from the good, for the isolated case to become the perceived norm. To read some of our daily newspapers you would sometimes think that the NHS is full of bad doctors, or bad nurses. It isn’t. It is full of good people – therapists and scientists, cleaners and porters, managers and paramedics as well as doctors and nurses – who come to work to care for others. It is about time we as a country got behind the people working in the NHS rather than trying as some now seek to do to actively undermine them.

It is now clear that those who are opposed to the NHS – including some of our political opponents – are embarked on a quite deliberate and cynical strategy of first undermining the NHS as a prelude to their real agenda of tearing down the NHS and forcing people to pay for the costs of their own treatment.

I say today to those enamoured of a private insurance alternative to the NHS: look to the USA where 40 million people have no health cover at all; see what happens with private insurance rather than community provision; and then ask yourself do we really want health care based on how much you can afford to pay rather than how ill you are? Do we really want doctors in this country reaching for your wallet before they reach for your pulse?

I think not.

Private insurance policies, even with all the exemptions they contain, are consistently more expensive and more bureaucratic for consumers and taxpayers than publicly funded health systems. Giving tax breaks to encourage more private insurance would involve the taxpayer subsidising people who already had insurance policies – a significant diversion of public resources from the NHS for the benefit only of a few.

The examination that we have made, that Derek Wanless has made, that the British Medical Association has made of different systems of funding health care have all concluded one thing: that a tax-funded NHS is a fairer and more efficient way of providing health care for our country than the alternatives on offer. The NHS should be supported with our heads as well as our hearts.

Of course there are bad things about the British health care system – whether it is staff shortages or bed shortages or long waits for treatment. But when people say to me: what about levels of health provision in France or Germany or Sweden, I say: these countries do not have a superior system for funding their health care, they have superior levels of funding for health care.

No-one can escape the simple reality that there isn’t a health care system in the World that is cost-free. Somehow or other it has to be paid for. In Britain we pay from general taxation. In some countries employers and employees pay more. In other countries individuals pay for themselves. No country provides health care for nothing.

As a government, we recognise that the limitations of Britain’s tax-funded health service have not been the system of funding from general taxation but the level of funding from general taxation.

In just a few days time there will be a choice for our country. To go back to the days when the approach on the NHS was one of cutting taxes, cutting spending, cutting services and in the end therefore forcing more people to pay for their own care. Or to continue to move forward with sustained investment matched by fundamental reform.

I believe passionately that the right way forward for our country is to continue investing and to press ahead with reform.

Health care has to be paid for – one way or another – and World class health care costs a little more. In a world of rising health costs and greater health possibilities the NHS is the best insurance policy you can have. Putting the health service on a sustainable footing for the long term will pay dividends for us all in security for ourselves and our families.

What we have started in the last few years we should see through. The NHS today is the fastest growing health care system of any major country in Europe. But there’s a huge amount of catching up to do. And huge problems to overcome. The waiting times are coming down but are still too long. The staff numbers are growing but there are still too many shortages. The system and the people working in it are still working under huge pressure.

What we know is that that when we put extra resources into the NHS that delivers results for patients. Not overnight, nor with a big bang but steadily, step by step. Sustained improvement is by necessity more about evolution than revolution. The only way to keep progress coming through is to keep the investment going in. And to use the resources to reform how health care is delivered.

Nobody I have ever spoken to in the health service – not the public, the patients or the staff – just wants more of the same. People today expect a different sort of service, a different level of service as well. People want services that are responsive, and which offer faster, higher quality care. Increasingly, and rightly so in my view, they want to make informed choices about how to be treated, where to be treated and by whom.

Some say that that sort of service can only ever happen in a private market. I say with the right level of investment and the right programme of reform the NHS can do that better than any private provider.

The NHS Plan that we drew up with people working in the service and patients using it is our ten year programme of reform. National standards and a tough system of inspection. New contracts for nurses, doctors and staff throughout the NHS to get more flexibility and to match pay with responsibility. More choices for patients and more partnerships between the private, voluntary and public sectors. And above all else to get the best from the investment the NHS must be run by the people delivering the care. It cannot be run from Whitehall.

I don’t treat patients. You do. So just as schools now have greater control over resources for education so local health services should have greater control over health resources. That is what the new Primary Care Trusts are all about – with frontline staff in the lead. More than any other change the PCTs signal that half a century of centralised health care in our country is drawing to a close. The old style NHS where everything was run from the top down rather than the bottom up must now be a thing of the past.

It will take time to complete the transformation but the direction is set. Power and resources will now move into the hands of frontline services and frontline staff. Three quarters of the NHS Budget, within just two years, will be controlled not at the centre but at the frontline. And let me just make one thing clear today: 75% represents the starting point not the finishing line in our drive for decentralisation and devolution in the NHS.

With the right level of investment we should be seeking to unleash a new culture of public sector enterprise in the NHS capable of rivalling any spirit of private sector enterprise. It means providing better incentives to get health and social services working more effectively locally as a single care system rather than as two separate systems. It means more discretion over how local budgets are spent and where they are spent. More information and more choice for patients. Greater freedoms and more rewards for NHS organisations which are doing best alongside more help, support – and where necessary intervention – for those that are not.

Above all else it means giving frontline staff the help you need to do the job you want to do. More staff. Fairer pay. Better childcare. Greater flexibility. A bigger sense of involvement in making change happen.

The simple truth is the NHS works best when it harnesses the commitment and know-how of staff to improve care for patients.

That’s why we are putting ward sisters in charge of ward budgets and giving health visitors a greater say over community health budgets. It’s why matrons are being given the power to get the fundamentals of care – like clean wards and good food – right for patients. It’s why nurses are being given new powers to prescribe drugs and discharge patients.

All of this is about unleashing the tide of innovation that exists among staff in every health centre and every hospital. Nothing should provide us with a greater sense of optimism and confidence about the future of the NHS than the Modernisation Agency’s Report that is being published today. In example after example it shows that where staff have been given their heads they have improved services for patients.

In North Hampshire, for example, pre-booked appointments for lung cancer scans have reduced the wait for an outpatients appointment from an average of 20 days to 2 days. In North West London new staff rotas and changed working practices have reduced waits for echocardiography from an average of 130 days down to just 7 days. In Wisbech, at the North Brink Surgery patients used to wait 16 days for a routine appointment. A month after the reform programme was put in place ‘did-not-attends’ had halved. The duty doctor emergency work was down by 85%. Today, 82.5% of patients see whichever GP they want when they want. The surgery has abolished waiting times and the duty doctor is an average of 55% quieter than 18 months ago.

What these examples – and countless others in the Agency’s report- demonstrate is that investment only really works if it is matched by reform. And the essential ingredient that is needed are strong local clinical leaders in charge of making the process of reform happen.

What we need to do is to support more staff through the reform process. Reform isn’t easy. It takes time and effort when on the frontline staff find that each day both are squeezed hard. That is why we will be looking at how we can give staff more protected time to improve services. How we can help more staff develop their skills and their personal potential. How we can use the introduction next year of the new NHS University and an expanded Modernisation Agency programme to develop more local clinical leaders.

What is on offer here is a partnership between the Government and the people working in the NHS. We are prepared to commit more investment for the health service but only if it is matched by a commitment to reform. The reforms are as vital as the resources. More money going into health budgets is conditional on getting more out for patients. In every community, every hospital, every surgery reform now needs to bite. The health service – all across the health service – will need to show that extra resources are producing reforms and results for patients.

Your leadership is vital. Without it reform will not happen. Frontline staff need to be in the driving seat to make the changes and improvements patients want to see.

In the end this is actually not about systems. It is about values. The NHS is the right system because it has the right values. I believe in it – and the people working in it – not out of some sort of old-fashioned sentimentalism but because in the modern world the NHS is more right and more relevant than it has ever been before. Without the health service millions could never afford healthcare. With the health service all of our people can. It is the best one nation policy our country has ever seen.

As a government we have made our choice. Our choice is for the NHS. For a reformed health service. For an NHS that enjoys higher levels of spending. Above all else our choice is for the patients who need the NHS. It is I believe the right choice for Britain.

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

Since Nye Bevan created the health service, there have been 23 health secretaries. I think I am right in saying I am the first to address a conference of your professions.

I wanted to be here today for a simple reason: to acknowledge that the work you do has not always received the attention it deserves and that it is time to put that right.

So I want to start by thanking you for what you do day in day out in the service of others. I know that many of you are working under real pressure.

It is invariably doctors and nurses who grab the headlines in the NHS but without you they could not do their jobs. Without your dedication and professionalism the NHS could not do its job. The work you do – whether as a scientist, therapist, radiographer, podiatrist, chiropodist, dietician, paramedic, orthoptist, prosthetist or orthotist – is absolutely key to unlocking an NHS where services are designed around the needs of individual patients.

In my view it is no coincidence that where reform is taking hold in the health service it is often people from the allied health professions who are leading the process of change. Today I want to set out how I believe you can play a bigger role still in delivering services that are fast and convenient and which promote people’s security and their independence.

We meet today at a critical point in the history of the NHS. When the NHS is not only going through a period of greater change than ever before but when it is subject to greater public expectations than ever before. When there is more scrutiny and where from some quarters there is more hostility than the NHS – and those working for it – have ever faced.

To read some of our newspapers you would think no patient ever got good treatment. Or that the NHS is full of bad therapists, bad doctors and bad nurses when it is actually full of good people doing their best for others sometimes in difficult circumstances.

People working in the NHS deserve fair coverage for their efforts. We as a nation owe the porters, cooks and cleaners, scientists, therapists and paramedics an enormous debt of gratitude. People in the NHS work well beyond the call of duty for something they passionately believe in. I believe your commitment to the ethos of public service is a huge strength in our country and that it must be preserved at all costs.

Of course there are bad things about the NHS – whether it is staff shortages or bed shortages – and there are sometimes lapses in the quality of care. Where there are problems our job is to tackle them. But what we cannot allow is for the bad to detract from the good. The truth is most patients – despite the problem the NHS faces today – get good quality care. Most staff do a good job. And I believe that most patients know it.

So alighting on problems and using them to damn the whole system should be exposed for what it is: denigration for a purpose. There are those who are deliberately talking down the public services as a prelude to their real agenda of running them down and then cutting them back.

In these weeks ahead there will be a choice for our country. To return to the days when the approach on the NHS was one of cutting services, cutting taxes and getting more and more people to pay for their own care. Or to continue to move forward with sustained investment matched with fundamental reform.

I believe passionately that the right way forward is to continue investing and to press ahead with reform.

Our purpose as a government is to break through the barriers that hold too many of our people back: to provide opportunities for all in our nation. To give every child the best start in life through good education. To give communities hope by tackling the causes and the consequences of crime. And above all else to give people in our country the opportunity of good health through decent health care.

For me an NHS that is funded by all and used by all makes for a stronger society for all. I think the values of the NHS are the values of our nation -fairness and equality, compassion and community, a belief that we can achieve more together than we ever can alone. And that these values – far from being the backward looking sentimentalism that our critics claim – are actually grounded in the needs of our society today. The case for collective provision of health care in my view has never been more compelling. Health is not just another commodity. It cannot be bought and sold in a market place. By definition our need for health care is unpredictable. And today the sophistication of modern treatments can put individual provision of health care beyond the reach of all but the very wealthiest in society. My very strong personal belief is that the ill paying to be ill is not the right way forward for Britain.

It is time to remind the public that the fundamental ethos of the NHS is sound. It is a fair and efficient way of providing health care. The NHS providing care according to need not ability to pay is the right way forward for the country.

What the NHS needs is more investment and fundamental reform.

For too long as a nation we have pretended that somehow or other we can have world class health care on the cheap. We can’t. There is no such thing as a free lunch when it comes to health care. If we want world class health care it has to be paid for – one way or another. I believe that investing in the NHS is the right priority for our country.

We have made a start. The NHS today is the fastest growing health care system of any major country in Europe. There’s a huge amount of catching up to do. And huge problems to overcome. The waiting times are coming down but are still too long. The staff numbers are growing but there are still shortages.

Our opponents would like to pretend that the NHS is a bottomless pit. That isn’t true. What is true is that it will take time for improvement to fully come through. The NHS Plan is a ten-year programme not a programme for one or two years. But where we have put resources in it produces real results. You can see that in heart services for example. A year ago people were waiting up to 18 months for an operation. By the end of this month the maximum waiting time for a heart operation will be 12 months – still too long but moving decisively in the right direction. In primary care the prescribing of cholesterol lowering drugs is up by one third in just one year. 1,000 GP surgeries are being modernised. The biggest hospital building programme is underway. Last year saw a record increase in the number of nurses working in the NHS. For the first time in thirty years it saw more beds in hospitals, rather than fewer.

I don’t say every problem has been solved. Far from it. There will be ups and downs along the way but the NHS is now on the road to recovery. The NHS Plan is on course to be delivered.

Delivery depends on over one million people – NHS staff. The biggest obstacle to faster delivery is shortages of staff. That is why we need more of your professions working in the NHS.

Here again we have made a start. Since 1997 OT and dietitian numbers have risen by over 20%, speech and language therapists by 17% and physiotherapists by 14%. But because there are still shortages of the precious skills that you have we now plan to drive forward the efforts to recruit and retain staff in your professions.

First, we will be increasing training numbers. We have reversed the cuts in training places that took place in some of your professions during the mid-1990s with increases of over one third in healthcare scientist, radiography, OT and physiotherapy places. We estimate that over 1,500 more therapists and other health professionals have entered training over these last two years. I am now expecting these numbers to increase by at least a further 1,000 from April this year.

Second, we will be targeting allied health professionals and healthcare scientists in an extended recruitment campaign. On top of our existing efforts in this area I can announce a new £1 million recruitment drive which will start this summer specifically to get more of your professions working in the NHS. I expect that at least 500 more staff who have left the NHS will return in the next year as a result.

Third, we will want to discuss with leaders and representatives from your professions how we can build on the momentum that is underway in expanding staff numbers. What we cannot have is people coming into the NHS through the front door only to find more leaving by the back door. Retaining existing staff is as important as recruiting new ones. Here a fairer deal on pay will play a part. Negotiations on a new pay system have been going well and I am determined to see them through. I am equally determined that the NHS should become a more flexible and modern employer offering staff the support and childcare they need to balance their family and their working lives. So I can tell this conference that in June I will be hosting a summit to discuss how we can not only recruit more allied health professionals but how we can retain more too.

What is on offer here is a partnership between the Government and people working in the NHS. We are prepared to commit more investment for the health service. What we seek in exchange is more reform.

Indeed, the case for more investment will only be won if resources are matched by changes to the way the NHS works.

Nobody I have ever spoken to in the health service – neither staff nor patients – wants more of the same. People today expect a different sort of service, a different level of service as well. People want services that are responsive, and which offer faster, higher quality care. Increasingly, and rightly so in my view, they want to make informed choices about how to be treated, where to be treated and by whom.

Some say that that sort of service can only ever happen in a private market. I say with the right level of investment and the right programme of reform it can happen in the NHS.

The NHS Plan we published 18 months ago is our programme to renew the NHS. In essence it is based on four key principles.

First national standards and proper accountability. In a public service patients rightly expect services in one part of the country to be delivered to similar standards as another part of the country. That is what the national service frameworks for heart disease, elderly care and mental health and the National Cancer Plan are all about. It is why we have the NICE. And it is why we have introduced for the first time a strong independent inspectorate for the NHS, the CHI.

What having national standards does not mean, however, is that the NHS should be run nationally. I do not believe a million strong service can be run from Whitehall. Half a century of experience shows us that this approach limits local leadership and stifles local innovation. Ideas and initiatives developed within the local NHS have too often played second fiddle to circulars delivered from the centre. 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 patient needs.

Where our first term in office was concerned with putting a national framework in place, this second term is about introducing new incentives encouraging greater local innovation and stimulating more patient choice. It is these reforms that will make the most telling contribution to improvements in services. In the weeks and months ahead we must be bold in developing these NHS Plan reforms.

So the second principle involves the devolution of power to frontline services. We are at the start now of a transition where day to day management of the health system will move from Whitehall to the 28 new strategic health authorities in England. They will oversee the work of local NHS Trusts, PCTs and private and voluntary sector providers. The real power and resources in the NHS will move to the NHS frontline with from next month locally-run primary care trusts – involving professionals and patients – up and running in all parts of the country. Within a few years they will control three quarters 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.

Every year CHI will rate local health services according to their performance. Those that are performing best will earn not just more rewards but greater freedom. The better the performance of the organisation the greater the freedom it will enjoy. Where the Commission decides that an NHS organisation is in trouble it will recommend special measures are taken. In the small minority of local health services where there are consistent problems for example new management could be brought in.

Third, devolution will be accompanied by more choice for patients. From July heart patients waiting for six months or more for an operation will be able to choose in which hospital they would like to be treated. In time patients will have the information and the NHS will have the capacity to offer more people the chance to make informed choices about their treatment and care. Where the NHS can use the private and voluntary sector to benefit NHS patients and to extend choice it should do so. Nobody says this is a panacea – but it can make a contribution. The old barriers between the public and private sectors cannot be allowed to get in the way of improving care for NHS patients.

That brings me to the fourth principle and the one that I really want to concentrate on today – securing greater flexibility between services and between staff. The old demarcations between staff and the old barriers between services need to go. This where you can make the biggest contribution to reforming our system of care.

Indeed, your professions were modernising NHS services long before it became fashionable. Whether it is occupational therapists working in A&E to prevent inappropriate hospital admissions, or paramedics delivering clot-busting drugs to heart attack patients or physiotherapists running orthopaedic outpatient clinics – there is a huge effort going on throughout the NHS to maximise how we use the skills of clinical professionals to improve care for patients. These reforms are about liberating the commitment and know how of staff in order to transform the quality and speed of treatment for patients.

And they are delivering results. I know that waiting times for therapists can be far too long but for example in Huntingdonshire the PCT has been testing a physio-direct service for patients so they can call and speak direct to a physiotherapist. After triaging by the physio less than one third of patients actually need to be seen but those who need treatment can have an appointment the same day. The patients get seen quickly. The physiotherapists save time. And the burden on family doctors is reduced.

Now we need drive these sort of reforms – this local leadership and local innovation – still further – and we want to help you lead the process. For too long there has been a vicious cycle where the NHS has not been able to perform to its full potential because it has failed to support staff to perform to their full potential. It is simply absurd in my view that in some hospitals therapists can run outpatient clinics while in others they can not. Or that while some radiographers are able to prescribe painkillers others are unable to do so. Limiting the roles you play and the talents you have not only makes your professions and the medical profession the losers. The patient loses out too.

So I can say that next month I will be bringing together leaders from your professions, from nursing and from medicine – and from NHS management too – to agree a programme of action to break down demarcations still further across the whole NHS. The programme will be underpinned by new training and career opportunities for staff. Within the next few weeks for example I expect the first generation of therapist consultants to be appointed in the NHS. Within two years there will be at least 250 of them working as equals alongside nurse consultants and medical consultants. I can also say today that the NHS Leadership Centre will be introducing next Spring a new programme to develop leadership skills for middle managers across all professional groups including AHPs. This is about breaking through the glass ceiling to put you as clinical leaders in positions of authority throughout the NHS.

And there is one further leadership challenge I believe that you can help us meet: to break down the Berlin Wall that for too long has divided health from social care. Health and social services are two sides of the same coin. The one relies on the other. The patient relies on both.

Inevitably the focus of public and media attention is on what happens in hospitals. And there is no doubt that we need to build hospital services up, not least to get waiting times down. But tackling waiting cannot be achieved by more investment in hospitals alone. It needs more investment in social services – alongside primary and community services – too.

We need to stop thinking about the NHS as though it were only about hospitals and acute care. The health service is as much about the call to NHS Direct, about the child receiving speech and language therapy, the elderly person helped to keep mobile by the chiropodist as it is about the life-saving operation or the emergency service in the hospital.

Indeed I believe we need a bigger drive to help more people to avoid going into hospital and provide more help for people to leave hospital. The taxpayer will benefit because hospital based treatment is often the most expensive form of care. And the patient benefits because it helps people – especially the old – maintain or regain their independence.

Securing these changes requires more investment in social services. Again here we have made a start. Compared to the mid 1990s when the resources made available by the Government for social services were growing by only one tenth of 1% a year today the resources being made available are growing by more than 3% a year.

Nonetheless social services are under real pressure and more investment still is needed. That is necessary not least to stabilise the care home market and to develop new rehabilitation, intermediate and home care services that can promote people’s independence. Here the evidence is that putting in resources delivers results. Last October I provided an extra £300 million to help councils reduce the number of patients whose discharge from hospital was being delayed. Even though delayed discharges are down compared with five years ago, about 6% of hospital beds were needlessly blocked. Since then the extra resources have helped free up 1,000 beds that would otherwise be occupied by people who are ready to move on from hospital.

Sustained investment will be needed to maintain this progress. But there can be no question of simply pouring more money in. In social services as well as in the health service, extra investment is conditional on more reform. If more money is available for social services as well as for health services – as I believe there needs to be – there must be no more excuses for shuffling responsibility for people who are old, or disabled or mentally ill backwards and forwards between the two services. Joint working must become the norm for all and not just for some. The powers to pool budgets and to form Care Trusts so that health and social care functions are merged must be taken up. And we will need to explore new incentives to get health and social care working as one to end the decades-old culture of buck-passing and cost-shifting. Reform will mean giving patients what they need – one care system, not two.

Here you can play a leading role. Many of you are already working across health and social care boundaries. In the way you work with your colleagues in social care you can develop a joint approach so that the user of the services can no longer distinguish between what is health and what is social. Use the opportunities of your role in the new PCTs to put in place a single process for assessing a person’s need, led by one professional rather than a multitude of agencies. And you can help develop new community-based services across the traditional divide that has separated the NHS, local government and private and voluntary sectors.

Greater investment and radical reform – this is the path to better public services we are travelling together. It is sometimes difficult. There are competing claims for funding and dilemmas about priorities but resources and reforms are already bringing results. There is no easy route to better public services. No silver bullet which delivers improvement without it being paid for or without there being change.

But there is I believe a real appetite across the public services – from the people running them, working in them, using them – for higher standards to accompany higher spending.

Your role as health professionals – in leading change and improving services – is crucial to the success of our programme of investment and reform.

Your contribution to patient care and recovery – in the community and in hospital – is central to the work of a modern health service.

Your commitment to the NHS – to its values as well as its patients – is the rock on which a better health service is being built.

Quite simply I believe that if we combine the right level of investment, with the right programme of reform, with the commitment of the healthcare professionals, we can continue to move the NHS along the road to recovery.

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.

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.

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.

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, to the CNO Conference in November 2001.

It is a great pleasure to be here today with people who are leading the process of reform and improvement in the NHS.

Wherever I go in the NHS it is no coincidence that where reform is taking hold nurses are often in the lead. NHS Direct – led by nurses. NHS walk in centres – led by nurses. Nurses, midwives and health visitors – leading reform in primary care, hospital services, rehabilitation, maternity services. Nurses were modernising NHS services before it became fashionable.

That’s true because nursing values are NHS values. Caring. Compassionate. Professional. Dedicated. The needs of the patient at the core of all you do. Everything we do has to preserve and promote these values. Our programme of reform and the nursing profession’s guiding values are as one – they are about redesigning the NHS around the needs of patients. That is what reform must mean – tearing down the barriers between health and social care, removing the demarcations between NHS staff, ending the old ways of doing things that stand in the way of more patients getting quicker, higher quality treatment.

Reform and innovation is taking hold out there. It is important that we harness it and that we evaluate it. I know there have been concerns about the level of investment going into nursing research about what works best for patients and what does not. So it is a pleasure to be able to tell you at the outset that I have decided to spend over £6 million over five years on a new programme of research to support the delivery of high quality evidence-based nursing and midwifery care.

Much of what I want to say today is about the greater role that I believe nurses can play in delivering improved services for patients. But I want to try to locate the contribution that I believe nurses can make – and are making – in the context of the wider reform programme taking place today in the NHS.

I want to start by thanking you for what you do, day-in, day-out, on behalf of patients. I know nurses – whether it’s in the community or in hospitals – are working under very real pressure. You are on the front line of many of the major challenges which face our country today – addressing the problems of poverty and deprivation, a growing elderly population, growing public expectations too.

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

People have learned a harsh lesson over the last 10 – 20 years. Today people know a fair society, where everyone in our communities and not just some get a fair chance, can only be built on the sure foundations of a strong economy and strong public services.

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

I say that on grounds of efficiency and equity that view is wrong.

The NHS is the fairest way of providing health care to our people. It is based on the right principles – of care being available according to the scale of your need not the size of your wallet. But I say with equal firmness that failure to deliver reform in the NHS will prove the cynics and the doubters right. Reform has to deliver NHS services that are more responsiveness to the people who use them.

People grow up today in a consumer society. Services – whether they are private or public – succeed or fail according to their ability to respond to modern expectations. People today exercise more choices in their lives than at any point in history. Many can afford to walk away from public services which fail to command their confidence. People will no longer tolerate second rate services, dirty wards, waits of 18 months for an operation or 18 hours on a trolley. That’s why there is such a huge effort going on to redesign services from the patients point of view. To get waiting times down, make services more flexible and more convenient for the people who use them. To provide easier access, round the clock.

These big changes require big reforms:

To put in place for the first time national standards and independent inspection to monitor them.

To provides incentives to reward good performance and help to correct poor performance.

To devolve power to frontline staff in frontline services to encourage diversity and local creativity.

To change how services are organised and how staff are employed so that the needs of the patient always come first.

To give patients more choice including through greater co-operation between the public and the private sectors.

These reforms aren’t easy. Reform is high risk. In the NHS today there is a huge programme of change taking place. There is a lot of weariness and I know there’s quite a lot of wariness. But I believe passionately that the risks of reforming are far less than the risks of standing still.

The stakes are high for the health service. The debate on the NHS has moved on. For years it was all about the need for more investment, since for decades the NHS had suffered under-investment. Today we are putting that right. And because sustained investment will continue throughout this Parliament the debate on the NHS is now very different from what it was just a few years ago.

The debate today is about whether even with this enhanced level of resources the way we organise and fund health care in this country can ever deliver a modern patient-focussed service.

I believe there are good grounds for optimism. For a start the investment is going in with the NHS today the fastest growing health care system of any major country in Europe.

People – staff as well as patients – sometimes ask where the money is being spent. Aside from on staff – including the thousands of new staff the NHS is employing today – it is going on providing better services to patients. For example, waiting times of over twelve months for a hospital operation have fallen by 13% in just one year. Cancer patients are being seen by a hospital specialist within two weeks when they used to have to wait months. There are 3,000 more heart operations, over 150 more chest pain clinics, 17% more cardiologists. Prescribing cholesterol-lowering drugs is up by over one third. We are spending over £250 million on new drugs for conditions such as cancer, heart disease, dementia and arthritis. Free nursing care has started. 7 million callers a year are being helped by NHS Direct nurses. 40 nurse-led Walk in Centres are now open. 1,000 GP surgeries are being improved. Thousands of new intermediate care beds and places have been established. The biggest hospital building programme in NHS history is underway. This year for the first time in thirty years there are more beds in hospitals. The programme we outlined in the NHS Plan is on course to be delivered.

I know there is a long way to go. There are very real problems to set alongside the real progress being made. Patients wait far too long for treatment. Staff shortages. Dilapidated buildings. Outdated equipment. Decades of neglect have taken their toll on the NHS and indeed on people work in the NHS. Only a fool believes that decades of neglect can be reversed in a few years of investment. The NHS Plan is not for one year or two years: it is for ten years.

So it really is time that we had a bit of balance in the debate about the NHS. Not only is the glass half full and not half empty – it is being topped up. No one should fall for the fallacy that unless we solve every problem in the NHS no problem is being solved at all. We know in these next few years we must deliver improvements and by working together we will deliver.

Delivery crucially depends on one million NHS staff. Without you it simply will not happen.

That is why we need more nurses at the frontline – in primary and community services as much as in hospital services. We’ve made a start. Nursing vacancies – while still too high – are falling. There are 17,000 more nurses working in the NHS today than just four years ago. And there are 20,000 more to come.

The cuts in nurse training that took place in the 1990s have now been reversed. Indeed, there has been a 40% increase in nurse and midwifery university places. Applications for nursing degrees are up by over 80%. And I can report today that the latest figures show that the number of nurses who left the NHS but who have now returned is well over 9,000.

We’ve turned the corner on nurse recruitment. But we can’t have people coming in through the front door and leaving by the back door. Retaining nursing staff must now be the priority.

A fairer deal on pay will play its part. We do need a fairer pay system for rewarding nurses and other staff for the enormous contribution they make to patient care. Negotiations are going well and I am determined to press ahead with final negotiations on all elements of the new pay system. The aim will be to complete this work as early as possible next year so that a final agreement can be reached as soon as information on future NHS resources are available. Following consultation by the NHS trade unions, this will enable us to begin the process of implementation during 2002/3.

Providing we can reach agreement, many nurses will be significant gainers from the new pay system we envisage. In the meantime we will continue to target extra help to aid both recruitment and retention including in those parts of the country where the cost of living is highest.

More pay alone will not do the trick. The truth is we will not be able to get more nurses at the NHS frontline unless we offer more support at the frontline. By offering nurses more flexible employment, as every NHS employer will have to do within the next few years. By using the £100 million we will save as health authorities and regional offices are abolished to invest in extra childcare to help nurses balance their family and their working lives.

As an organisation – throughout the organisation – the NHS must now focus on removing those barriers that stand in the way of nursing staff being able to use all of their skills to improve services for patients.

Our reform programme for the NHS has at its core an absolute determination to harness the commitment and know-how of staff to improve care for patients. Where nursing staff have been given their heads they have delivered far-reaching change. I see that wherever I go in the NHS.

Matrons empowered to get the fundamentals of care right for patients. Hundreds of nurse consultants now in post. Reforms which have used nursing skills to make same day tests and diagnosis the norm and not the exception. Reforms which have cut waiting times for dermatology treatment from months to days by putting nurse consultants and GPs in charge of providing the service. Reforms which have used the skills of nurses to speed up treatment for cancer patients. Reforms which have allowed nurses in accident and emergency departments to assess patients and so cut waiting times for treatment.

These reforms – alongside the investment in more nurses, more doctors, more skilled professionals – are about using skills to best effect, with care delivered by teams and with flexibility around the needs of patients. These reforms are breaking through the old demarcations. They are liberating the skills of nurses to transform services for patients. What is happening in some places now needs to happen everywhere.

The people at this conference today are central to this reform programme. Your job is to empower nurses to deliver patient-centred care. You already have some the authority to do that. Now I want top give you more authority still.

A year ago the Chief Nursing Officer published her ‘Ten Key Roles for Nurses’ in the NHS Plan. She set out the functions that appropriately qualified nurses should be allowed to perform to improve care for patients. In the best places nurses have been allowed to take on these new roles. In too many places they have been stopped from doing so.

In my view it is just absurd that in some hospitals nurses can order x-rays while in others they can’t. Or that in one hospital nurses can discharge patients but in a neighbouring one they can not. Limiting nurses roles and holding back nurses talents not only makes nurses and doctors the losers. The patient loses out.

For too long there has been a vicious cycle where the NHS has not been able to perform to its full potential because it has failed to support staff to perform to their full potential.

Today I can tell you how we intend to change this situation so that nurses everywhere are able to use their skills to the full. The key will be the modern matron. Matrons will champion the interests of the patient within the hospital so matrons must also champion greater power for nurses within the hospital.

That’s why I will be asking matrons in every hospital to report annually on how the 10 key roles for nurses are being implemented. I am going to ask them to produce an annual report which will go to their Chief Executives, who have the ability to remove organisational blocks to greater nursing influence. It will go to the Chief Nursing Officer, who will be able to remedy legal and professional blocks as well as identify variations between different hospitals. And most importantly, it will go to their hospitals new Patients’ Forum so that patients can see whether the necessary reforms have taken hold.

This is about allowing nurses to break through the glass ceiling that has for too long held them back. It is about unlocking the talents of nurses to improve care for patients. And there is one further development that I can announce today to help make that happen.

I am convinced we need more clinicians in key leadership roles throughout the health service. That is why I was disappointed to see the results of the survey of Nurse Directors we commissioned through the Modernisation Agency. Only around half of Nurse Directors who apply for Chief Executive posts get an interview.

The majority apply only once because they are put off by the selection procedure which, ironically, makes them feel that they are unsuitable for a Chief Executive post because they are a nurse. Often they play down their nursing role and clinical expertise, yet it is precisely that clinical insight and understanding of patient care that is the experience we ought to value most in our top people. It is precisely because nurses are closest to the patient in the NHS that we need nurses closest to the power in the NHS. Nurses need to be in positions of leadership right across the NHS. There must be no glass ceilings for nurses.

We have already made funding available to provide leadership development programmes for over 30,000 frontline nursing staff. I can announce today a new programme to develop nurses as potential Chief Executives. The programme will be specifically designed for nursing, medical and allied health professionals to put them on an equal footing to compete for Chief Executive posts. Next year it will provide up to 100 places for senior clinical leaders.

All of this is about one thing: to unleash the tide of innovation that exists amongst staff in every surgery and in every hospital.

In our first term, the Government established a clear framework of national standards and policies to help us address the postcode prescribing and postcode performance which existed across the NHS. With these in place from our first term this second term is all about shifting the centre of gravity to staff at the NHS frontline.

The NHS is a high trust organisation. It works on the basis of trust between patient and professional. In the way it is organised the NHS now needs to enshrine that trust. It needs to give more control to the NHS frontline. I don’t treat patients. I don’t work in the GP surgery or the local NHS hospital. You do. The NHS can not be run from Whitehall. Just as schools now have greater control so local health services must now be given greater control too.

Last Friday, we published the NHS Reform Bill to ensure that by 2004 the GPs and nurses, patients and local communities who run primary care trusts will control three quarters of the total NHS budget.

By then two-thirds of existing health authorities will have been abolished. The NHS regional offices will have been abolished too. Power will have been devolved to frontline NHS services. Cash for local health services will be allocated directly to local primary care trusts so that they can decide how to commission services for the local communities they serve. I have heard from too many people too often in the NHS that resources have not been getting through to the frontline. The NHS Reform Bill will mean resources going directly to the NHS frontline.

The government’s reform programme has to breakdown the monolithic structures of the NHS in favour of a more decentralised pluralist and responsive health service. A modern health service can not be run like an old style centralised bureaucracy but should instead devolve power and resources to frontline services and frontline staff. The advent of Primary Care Trusts – in which nurses must play a leading role – is the biggest devolution of power in the history of the NHS.

I want to see a new culture of public sector enterprise in the NHS to rival the spirit of private sector enterprise which developed during the last few decades in our country. That requires more discretion over how local budgets are spent. It requires greater freedoms and more rewards for organisations which succeed. It requires greater help and more support – rather than blame – for those which do not. And it relies on you using your authority to innovate and develop new ways of delivering services to patients.

As standards and performance improve so greater autonomy will take hold. Good hospitals will get extra resources to help turn round persistently failing hospitals. And devolution to NHS organisations will be matched by devolution within NHS organisations. More qualified nurses should have the power to prescribe. Matrons will have the power to fine cleaning contractors that fail to keep wards cleans. In hospitals ward sisters will have control over ward budgets. In the community health visitors will have control over community budgets.

We need to go further still. Many hospitals already involve ward sisters and charge nurses in managing their ward staffing budgets. I can announce today that the Modernisation Agency, will over the next 12 months, lead a management programme to support the devolution of staffing budgets to those ward sisters and charge nurses in England’s hospitals who do not yet have that control.

An Audit Commission report on ward staffing, being published today estimates a typical ward budget for a cardiology ward at £560,000 a year. Within 12 months I hope all ward sisters and charge nurses will be in control of ward staffing budgets.

Ward sisters and charge nurses are best placed to know the day to day needs of patients and the hour by hour demands on staff. It is because they understand that they should be in control. They should be able to decide the mix of grades, the mix of skills, the mix of jobs they need on the ward. Patients on a ward, particularly the elderly and most vulnerable, need caring skills alongside clinical skills. Some feel that over the last few decades these caring skills have got lost. I believe it is time to re-emphasise them. That is why we have placed such a strong emphasis on cleaning up the wards, improving the food and introducing new jobs such as ward housekeepers to make sure that patients day to day needs are being met. Meeting patients’ needs will be enhanced by allowing ward sisters to decide the number and mix of nurses, care assistants and ward housekeepers. It will be the job of matrons to support ward sisters and charge nurses to discharge these functions.

After almost half a century of central control Whitehall must devolve NHS resources to the NHS frontline. To decentralise decisions to staff at the NHS frontline. To deliver better care for patients at the NHS frontline.

This is the programme of reform we are embarked upon.

It is a programme where local communities will have greater say over the local health service.

Where the health service is more diverse. Where services are more responsive to patients and where patients have greater choice over services.

Where public and private providers work together to deliver the core NHS principle – care that is free, according to need not ability to pay.

It is a programme where the power of nurses, as professionals, as practitioners, will be vital to delivery.

By working together it is a programme that we will deliver.

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, on 21 October 2001.

Nye Bevan’s shadow hangs over every health secretary, especially Labour secretaries. He was the architect of a care system based on values community, solidarity, and belief that we achieve more together than ever can alone.

Our commitment to the values of NHS binds today’s generation Labour Ministers Bevan generation. And yet our pride in creation last century must not stand way its necessary re-creation for this century. attachment has too often been structures when it should have values. end do change with times. endure over time.

Bevan’s greatest success was not to overcome the intransigence or conservatism of those opposed to creating the new NHS, enormous though that achievement was. It was not to forge a particular structure for the NHS because as Bevan himself later conceded there may have been better ways of organising the new health service. It was neither of these things. His greatest achievement was to build a national coalition behind the values of the NHS. A system based on need not ability to pay, free to all and available to all. A system which removed the fear of becoming ill and having to face the doctor’s bill. The boldest ever attempt to break the vicious circle where poverty brought illness and then illness brought ever greater poverty. These were the right principles then. They remain the right principles now.

But Bevan’s was a structure forged out of the experience of war. It took a particular structural form – state ownership through nationalisation. After all the Second World War had been won by a society committed – after five years of total war – to the notion of collective action to solve national problems. People had made sacrifices in their own lives – many of their own lives – in pursuit of the common good. During the War the values of solidarity and the actions of the State converged. The State was the focal point for the solidarity of the British people.

Conscription meant that everyone had to take common risks. Rationing was treated the same.

And this approach worked. We won the war. And when Labour peace same was applied. took on big national problems by creating institutions. Coal Board – to take over a failing industry. British Transport Commission railway system. Health Service care

In 1948 there were 1.334 voluntary and 1,771 municipal hospitals. A confusion of different systems. No clear standards. No national planning. The NHS brought order out of chaos. It provided the basis for the first time in our history for a national system of health care.

And yet it was far from perfect. Indeed elsewhere in Europe governments, many of them socialist or social democrat, forged institutions which favoured greater community ownership over state ownership. Here in Britain centralised control still means, in Bevan’s famous phrase that when a bedpan is dropped the noise reverberates throughout Whitehall.

Indeed throughout the last two decades of structural upheaval in NHS essential post-war structure top down control has remained largely intact. result been that too often governments have defended interests as a provider services when they should focussed on patients consumers services.

It is right of course that there should be national accountability for the workings of our country’s health care system. For fairness sake there should be clear national standards applied across all parts of the country. It is right too that government should allocate resources to ensure that NHS cash meets health needs.

But beyond that I believe the old top-down model of the 1940s cannot deliver in the twenty first century. Vesting control at the centre has diminished control where it counts – in local communities where local health services interact with local people. In the modern age that will no longer do. For public services to command public confidence today they have to give greater control and more choice to the people who use them,

This is the key challenge we face in government as go about our fundamental task for this second term of reforming great public services: how to reconcile maintenance equitable access all with greater choice individual. policy education example, give parents more school and diversity provision within a framework rising national standards.

In health I believe we can best meet this challenge in three ways. Firstly by reforming the NHS to deliver improved and more responsive services to match modern needs. Secondly, by ensuring patients have more power and greater choice over services. Thirdly, by empowering communities to have greater involvement with local services.

First then modernising health care. People grow up today in a consumer society. Services – whether they are private or public succeed fail according to their ability respond modern expectations. Bevan’s was an era where expectations among the were lower, deference institutions and professions greater. exercise more choices lives than at any point history. Many can afford walk away from which do not command confidence. one nation Britain cannot be built on two tier care but failure deliver big improvements NHS will if we careful inevitably make case for

The way NHS services were provided in Bevan’s generation simply will not do for this generation. People no longer tolerate second rate services, dirty wards, waits of 18 months an operation or hours on a trolley. That why there is such huge effort going to redesign from the patients point view. get waiting times down, make more flexible and convenient who use them. provide easier access, round clock. Alongside problems today progress.

The record investment and far-reaching reforms we outlined in the NHS Plan are beginning to bite. For first time there is a sensible relationship between public private sectors expand care available patients. clear national standards means implement them. real incentives reward good performance alongside help end poor performance. getting health social working together rather than against each other.

And yes, progress takes time. The problems remain in the NHS but today the NHS is the fastest growing health service of any major country in Europe. This year there are 3000 more NHS heart operations. Prescriptions for drugs to prevent heart attacks are up by a third on last year. People with suspected cancer, who used to wait for months to see a specialist, are now being seen within two weeks. There are more beds in hospitals this year for the first time in thirty years. New hospitals, more staff, new equipment – are all coming through at record rates.

But investment alone will not do the trick as today’s Audit Commission makes very clear. Making progress is not just a question of resources but of reform. So whilst we will invest
£100 million to reduce waiting times in A&E that must be accompanied with organisational improvement in individual departments and management change across the hospital.

At the heart of public concerns about NHS is sense that its services are simply too indifferent to needs patients. Staff and patients alike up against a system feels much like 1940s. confidence demands fundamental change not just in level investment but culture today – put parents pupils first schools hospitals surgeries.

That brings me to my second point: a health service designed around the needs of patients must give more power patients. Better education, greater leisure opportunities and easier access information mean that people today are less likely accept passive role as recipients care. Crucially meet’s expectations, NHS, true its values, offer not just fairness but choice.

The NHS has always been strong on fairness but weak choice. It was born into a world where everyone given the same rations. In top down model there rationed care, capacity shortages and culture of paternalism, strove for equity population at expense choice individual. Today we have an opportunity to reconcile As expands its capacity, our task – make investment reforms necessary over months years ahead – is demonstrate that can expand without compromising equity.

That is why we say choice in health care should not be about forcing patients to pay for their own care. privatising NHS services. It expanding capacity and reforming can only happen with a greater plurality of provision through longer-term relationship between the public, private voluntary sectors providing more patients.

In other words what we must not do, as we seek to embed choice within the values of the NHS, is to abandon equity. We must not throw the baby out with the bath water. Let me give you an example. Some commentators argue that patients getting access to hospitals only via GPs limits choice. The truth is, however, our list-based GP system is not only genuinely envied abroad, it enjoys high satisfaction levels among patients at home. It brings major health benefits through continuity of care. It engenders high levels of trust between patients and professionals. And it manages the 90% of common illnesses better and cheaper than a hospital ever could.

But even here we need to make changes get a better balance between choice for the individual and fairness society as whole. Patients can already choose their GP but there is limited information about choices open them. improve on that by ensuring primary care trusts available people in local community they serve availability of services, specialisms female GPs, alongside data waiting times other aspects performance. provide bigger range services cater different lifestyles choices. More GPs who specialise treating particular diseases. NHS Direct advice treatment. Faster surgery appointments. walk centres where lack instant access.

Crucially, modern GPs should not just be gatekeepers. They should be navigators, guiding patients through the system and helping them make informed choices about their care. And here there is much more we can do to improve choices for patients. When we abolished the internal market in the NHS we restored GPs’ rights to refer patients to different hospitals. In most places though there is only one local hospital. That is why we have to raise clinical standards and cut waiting times in every hospital. From all the evidence I have seen, at home and abroad, the fundamental choice patients want to see is the choice of access to a good local hospital. Unlike the Tories’ botched internal market this is Labour’s primary objective. Over the last four years we have developed an array of means to deliver that – including cash that is tied to outputs and now a ratings system that gives greater freedom to the best performing hospitals and that franchises the management of the poorest performing hospital.

These levers are producing change. But the problem is they all top down. entail hospital responding to centre when what hospitals need be able do respond patients. So alongside these we should give patients greater choice over location of their treatment as another more direct means getting directly in other words not just about making patient feel good NHS. It giving power

From April next year patients will have more power. Any patient who finds their operation is cancelled at the last minute and are not then re-admitted within 28 days be able to choose an alternative hospital for treatment. They can public or private NHS pay there. This act as a powerful incentive hospitals improve performance on operations which causes misery frustration staff.

As capacity grows in the NHS we can now consider how to extend this choice principle to other aspects of hospital care. By March next year 5 million patients will have already chosen dates for hospital appointments convenient to themselves. By 2004 two thirds of all in patients and outpatients will be booked at the convenience of the patient not the system. By 2005 all patients will be in that position. And by then of course waiting times should be much lower.

Even then some patients will find themselves stuck with a longer waiting time at their local hospital than is available in other hospitals. London today for example the average all inpatient specialities varies between 7 weeks and 23 weeks. If we could extend choice of particularly to those who wait longest it would give patient greater control over own times treatment. Provide another incentive hospitals improve performance.

At present it is difficult for patients to choose opt a shorter waiting time. The way hospital funding rules work, deter rather than enhance patient choice. Many cannot exercise choice because they travel far afield. And there limited information available – or their GPs on times in different specialities hospitals. We are examining how these blocks can be removed I will bringing forward proposals near future.

Some within the NHS will see it as a threat. I can understand that. It is certainly a big change. But I believe it is the right thing to do. Today the patient has to be in the driving seat of change.

This brings me to the third point I want make: an NHS that is open choices by local patients must be better able respond needs of communities. way was set up took ownership away from It invested instead in State. course brought huge benefits. But there a cost. gulf grew between communities and running services. Today we find bridge it. all know strength feeling retain for their health You can see when walk into any hospital are met team volunteers drawn community. formal structures need embrace community support rather than keep at arms length.

I believe a key task for this second term is to reconnect public services with the communities they serve.

The wider social determinants of ill health – from poverty to poor housing call for the NHS be actively involved with others in local community improve and tackle inequalities. By devolving power frontline services most notably primary care trusts there is now an opportunity public re-engage communities they serve.

Devolution will help re-engage NHS staff too. The NHS is a high trust organisation. It works on the basis of trust between patient and professional. In the way it is organised it needs to enshrine that trust by giving more control to frontline services where patients and professionals interact. The simple truth is the NHS cannot be run from Whitehall. It employs over one million people. Improving services relies on them having a greater say over those services.

That is why we are slimming down tiers of management above the NHS frontline. It’s devolving resources to locally run Primary Care Trusts. Within three years they will control quarters budget. want unleash a spirit public sector enterprise that can rival any private enterprise. framework new national standards have established, use commitment and know-how staff improve for patients. give local freedoms innovate, develop services.

Patients should be at the heart of this process. present structures for giving patients a voice in NHS – most notably through Community Health Councils lack teeth and are out date. Just as reform is needed elsewhere here too. Alongside our plans forums to strengthen say local communities have over services we also need consider how can build on flowering experiments with citizen juries panels that has taken place recent years. I now asked Nigel Crisp, Chief Executive, work managers best Trusts advise me concept earned autonomy could relationship between they serve.

There is an analogy here with developments in urban planning the 1960s and 1970s which were supposed to usher a golden age of housing. That too was era expansion extra investment. Huge sums invested tower blocks council estates. intentions good. But outcomes – as we all know not. Estates became rundown almost quickly they put up, destroyed communities when intention create communities. Investment failed to deliver a new dawn social. It because people who be its residents never involved creation.

That’s why the relationship between citizens and public services in this 21st Century should be based on principles of decentralisation and empowerment. In health, in education, in housing, in local government and elsewhere we need to decentralise and empower staff and citizens alike. We must decentralise from the nation to the region. We must decentralise from local councils to local schools and to local housing estates. And in the NHS we must give communities more voice as well as giving patients more choice.

Our agenda for government must be about empowering citizens as well providing first class public services. It have at its heart a commitment to involvement much investment; reforming the way we engage deliver services; decentralisation key part of delivery.

For this generation of Labour Ministers our commitment to the values NHS must mean creating a more direct relationship between public and their services than was possible – or even conceivable in Bevan’s generation. That will require some big reforms. We need look at how can forge new settlement patients, professionals service. To open up choices for patients and recast structures so control means something simply state control.

Nye Bevan would not have been afraid of any these changes. For Nye winning elections was about gaining power over society. It using to change Indeed his whole philosophy summed up in that one phrase: “the purpose getting is be able give away.”

In conclusion then, I believe that just as the weakness of free markets are now clear, the shortcomings of monolithic, paternalistic public services are self-evident. Our answer is not just a stream of extra investment but a strategy of fundamental reform. To reshape public services, safeguarding equity of access whilst empowering the individual; to decentralise from Whitehall, ensuring greater local accountability within a framework of national standards. To deliver consistent quality and patient choice within an NHS which itself has more plurality of providers. This is an ambitious agenda for public service reform. It is an essential programme for this second term.

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

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

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

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

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

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

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

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

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

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

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

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

There can be no such thing as a fair society – or a strong economy – if the education system is geared to success for some but not for all, or if whole communities are laid waste by the ravages of drugs and crime. And we certainly cannot have a fair society if health and social services deny people help when they need it, where they need it.

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

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

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

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

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

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

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

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

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

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

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

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

First, high national standards and full accountability

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

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

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

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

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

So let me begin with standards and accountability.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The poor performers must receive direct support to do better.

The big improvers must spread the lessons of improvement.

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

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

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, on 6 July 2001.

The NHS is a graduate of the school of hard knocks. You only have to read a few of the daily newspapers to know that. The NHS was born in the face of fierce opposition. Today, still facing opposition from some quarters – some opposed to NHS principles, some opposed to NHS reforms.

Those of us who are wedded to those principles, who believe in those reforms, should draw confidence from them. For me, I have never been more confident about the NHS:

– the people working in it;

– the ethos they espouse.

And more confident about its ability to deliver far reaching improvements in the care it provides to patients.

My confidence stems from meeting people like those who received awards last night; ordinary people doing an extraordinary job, making reform happen in the work they do each and every day.

And when people had a choice at the General Election a few weeks ago, they backed public services and they backed the people who work in public services.

Today people know a fair society, where everyone in our communities- and not just some – get a fair chance, can only be built on strong public services alongside a strong economy. There can be no such thing as a fair society – or a strong economy – if the education system is geared to success for some but not for all. There is no such thing as a fair society if whole communities are laid waste by the ravages of drugs and crime. Above all else, we cannot have a fair society if health care denies people help when they need it where they need it.

In the five weeks of the election campaign I met staff and patients up and down the country. I visited good places and some less good places. I heard what NHS staff had to say. I saw what they were trying to do.

As a Health Visitor said to me on one visit, “it definitely feels better but it does feel like rolling a big boulder up hill.” There is an enormous effort going on throughout the NHS to bring about the improvements both staff and patients want to see.

As the election showed all too clearly people will no longer tolerate second class services. They will not put up with dirty wards or sluggish services. They quite rightly want health services which are responsive and which put their needs first. As we all know for too long the NHS has not been able to meet these tests. And people are impatient for improvement. The stakes are high for all of us who believe in the NHS.

Delivery – bringing about visible improvements in services – has to be the priority. A failure to deliver reform in the NHS will play directly into the hands of those who say that the NHS can never deliver.

The debate on the NHS has moved on. For years it was all about the need for more investment, since for decades the NHS had suffered under-investment. Today we are putting that right. With funding growing at twice the rate of the past the NHS is now the fastest growing health service of any major country in Europe. And because sustained investment will continue throughout this Parliament the debate on the NHS is now very different from what it was just a few years ago. It is now about whether even with this enhanced level of resources the way we organise and fund health care in this country can ever deliver a modern patient-focussed service. And you only have to read the comment sections of some of the daily newspapers to know that waiting in the wings are those who say that the fundamental principles of the NHS cannot work and must be abandoned.

I believe those newspapers are wrong. I believe those politicians on the Right who advocate their cause are wrong. I have a different set of beliefs. I believe in the NHS – in its principles and, above all, in the people working in it.

People do not work in the NHS to make a mint for themselves. They work in the NHS to make life better for others. It is the ethos of public service – its burning ambition to serve people regardless of their wealth or worth – that lies at the heart of public support for the NHS. It is the ethos of public service that can light the way to a fairer, more decent society in Britain today. But just as surely as it is that ethos of public service that makes the NHS, losing that ethos would break the NHS.

We risk the ethos of the NHS, its values and its principles, at our peril. That is why we say while we will forge a new relationship with the private sector, it is just that: a relationship, not a takeover. NHS values are not the same as private sector values. Health care relies on trust between patients and professionals. The fundamental reason the NHS is still trusted by patients today is because they know that decisions about their treatment are based on the scale of their needs not the size of their wallets. You only have to look across the Atlantic to see what happens when frontline health care is compromised by a clash of motives. Trust is lost. Competition replaces co-operation. Two tier care develops. In America, 40 million people have no health care cover whatsoever. A free market in health care does not work.

It is not the right way forward for health care in Britain. NHS values are British values – compassion, fairness, a belief in the strength of community, co-operation with others as the basis for individual progress. It would be folly to sacrifice these values and these principles. So while some subscribe to the philosophy that all things private are good, all things public are bad I say: that philosophy belongs not today but to yesterday.

There is no saviour of the NHS other than the NHS itself. But we do need every bit of help we can get to renew the NHS. That’s why we will not close our minds to the NHS and the private sector co-operating where private sector expertise or finance can bring benefit to NHS patients. The point is to define the nature of the relationship – what it is and what it is not. It is not about creating a mixed economy of care. It is about maximising the care that is available to NHS patients, based on NHS principles.

Some have said our proposals are too opaque. I say we have taken a hard look at where the private sector can help. First, using spare capacity in the private sector, such as in private hospitals, to perform operations on NHS patients. Second, getting private sector management to run some of the new stand-alone surgery centres our Manifesto commits us to building and which will specialise in precisely those procedures where private hospitals have some expertise. Third, extending PFI beyond the hospital sector where it has already helped deliver the biggest hospital building programme the NHS has ever seen into new PPPs in primary care, social services and the provision of equipment. And fourth using private sector management expertise such as in the provision of IT systems.

It is around these four activities that we will forge a new relationship between the NHS and the private sector. This is not privatisation – the taking of services out of the NHS. It is bringing into the NHS private sector help in those areas where it has a track record and where there are benefits for patients. The private sector will help but the NHS is – and will remain – Britain’s dominant health care provider.

It is for this reason that reform in the NHS has to come from within the NHS. It has to be led by the managers, doctors, nurses, therapists, scientists and all the other staff who hold the knowledge and the skills to improve services for patients. The best in the NHS making sure the best is available to all who use the NHS.

Reform from within is not an easy option. It means grasping nettles that for too long the NHS has failed to grasp. It means big changes – in the way the NHS is organised and in the way NHS staff work. It means overcoming old boundaries between services and traditional demarcations between staff. It means changing the relationship between NHS services and NHS patients. In all these ways reform is already underway. It is being led by NHS staff. It strengthens my belief that there is nothing wrong in the NHS that can’t be put right but what is best in the NHS. The test for the NHS today is to prove it can make these changes from within, not just in some services and in some places but for every patient, everywhere.

The choice for all those who care about the ethos of the NHS is straightforward: to stand on the sidelines carping, as some do, or to join in the process of reform as thousands of NHS staff are already doing. We will work – I will work – with all of those who genuinely want to make reform happen. But I say to those who would stand in the way of reform: there must be, there can be, there will be no veto on reform any more than there can be a veto on the pace of reform. The best way of supporting the public service ethos is to support public service reform.

Reform is difficult. There may be a rocky ride. Reform is a risky business as well as a rewarding one. Sometimes we’ll get things wrong as we try to put things right. That’s what leadership is all about. You know that in the organisations you lead – there is no improvement without innovation, no innovation without risk.

But we have to take the risks, make the changes, earn the improvements now because the clock is already ticking. Now is the time – with the foundations laid from our first term and a clear mandate for delivery in our second – to up the pace of reform. Not because we can promise an overnight transformation but because we know that we need to deliver progress towards that transformation. Patients and the public alike will stand for nothing less.

The NHS Plan is unashamedly long term in its ambitions. Expansion in staff and improvement in services takes sustained time and sustained effort as well as sustained resources. And we should all be clear about one thing: public confidence demands real progress – not just over this whole Parliament but over these next few years.

That calls for an absolute focus on what matters most to patients. How long they wait. The standards of care they receive. The sense that theirs is the only vested interest that counts in today’s NHS.

We have made a start – and I want to thank you for what you have done. In managing change, in navigating last winter, in making expansion happen. But now we must go further and we must go faster.

There is a big agenda to implement. The NHS Plan is an ambitious plan for improvement. I know it can’t all be done at once. There are some things that are more important than others.

Today I can set out to you the five areas where progress should now be focussed. These five are what matter most to patients.

First, on the conditions with the greatest clinical priority – cancer and heart disease and services for the elderly and those with mental illness. Rehabilitation services to build a bridge between the hospital and the home. Prevention and treatment services that improve outcomes and tackle inequalities. By 2005 we will be spending an extra £1 billion a year on cancer and cardiac services alone. Our ambition is to give our country levels of cancer and cardiac care that are no longer behind the rest but up with the best in Europe.

Second, primary care – the point of contact most patients have with the NHS. GPs and other staff are doing a good job under real pressure. That is why our priority has to be to increase the number of GPs as fast as we are able alongside expansion in nursing and other primary care professions too. And it has to be about getting extra investment directly to the frontline in primary care both to improve services for patients and to relieve pressures on staff. Together with the reform programme outlined in the NHS Plan – more specialist GPs, more personal medical services, a new GP contract – this investment will help give patients easier access to primary care services.

Third, emergency care – the point of contact patients most need to know is there for them when they require it. We will invest more in ambulance services, in accident and emergency departments and in expanding NHS Direct. We will also work to integrate these services so that better, faster care is there for patients. Far-reaching reforms and a better division of labour amongst clinical staff will, by 2004, have reduced average waiting times in accident and emergency departments to 75 minutes. Inappropriate trolley waits for admission and assessment will by then have been ended.

Fourth, cutting waiting times. The biggest concern about the NHS today is how long patients wait for treatment. It is frustrating for staff and distressing for patients. So building on what has been achieved to reduce waiting lists in our first term, our focus in this second term will now move on to reducing waiting times for treatment. In primary care. For ambulance services. In outpatients clinics, for inpatient treatment and in accident and emergency too. Today I am allocating £75 million to take forward reforms in orthopaedic, dermatology and ENT services so that patients do get better, faster treatment.

Fifth, getting the fundamentals of care right. Focussing on the patient experience to make sure that the wards are clean, the food is good, the care is there. That the buildings and equipment look good and feel good for both patients and for staff. That patients have more information and more influence over the services that they use.

Our priority then is simple: it is not an avalanche of new initiatives. It is delivery. To deliver progress on the NHS Plan. To deliver faster waiting times. Higher standards. To prove to public and staff alike that the NHS can be a service of first choice, not last resort.

I cannot make this happen. I don’t treat patients. I don’t provide GP services. I don’t manage NHS hospitals. You do. There are only one group of people who can transform the NHS. The people here today. The people in the service. The managers who lead change. The chairs and non-executives who can engage local communities in change. The frontline staff who are the key to change.

Delivery depends on more than a million people. Without them – without you – it simply will not happen. Right now NHS staff are working under real pressure. That is true in GPs surgeries, in community services and in hospitals too. Frontline staff – doctors especially – are feeling the strain. I know that. And I know we need to take action to address that.

Your top management priority is to engage with your staff – to support them so we can get more staff at the frontline and keep them at the frontline – to help them through the process of change so they can exercise power at the frontline.

First, then more staff and more support for staff. Here progress is coming through. What is more it is set to accelerate. The cuts in nurse and GP training places that took place in the 1990s have been reversed. Indeed, there has been a 40% increase in nurse and midwifery university places. There are also more scientists, more therapists, more doctors in training than ever before.

This year the NHS training budget is rising by 11%, the largest increase the NHS has ever seen. Investment in training will help sustain an unprecedented period of growth in NHS staff for a decade or more.

In the more immediate term, the NHS recruitment campaign is bearing fruit. Over 8,000 nurses and midwives – who left the NHS – have returned in the last eighteen months alone. And the campaign is now being targeted at groups like radiographers, midwives, clinical scientists.

Year by year to 2005 we can now be confident that the number of staff working on the NHS frontline will rise sharply. By then there will be 20,000 more nurses, 10,000 more doctors, 6,500 more therapists and scientists.

The corner is being turned on recruiting staff. We will maintain our efforts but our focus must now be on retaining them.

The biggest asset we have in the NHS is the one million people we employ. I know the newspapers are often full of stories about bad doctors. But we know that the NHS is full of good doctors. And good nurses, midwives, health visitors, scientists, therapists, cooks, porters, cleaners – and all the other staff who make the NHS tick. Our job is to get the best from all of them. Improvements in the way we treat patients can only happen if there are improvements in the way we treat staff. Our focus should be on removing the barriers that stand in the way of staff achieving their full potential.

We can’t get the best from staff if the NHS continues as an old-fashioned and rigid employer. Nowadays there is growing demand for more flexible employment from staff. Part time employment is becoming more popular. Some NHS employers have responded well to these changes. Others have not. Within two years every NHS employer will need to offer staff flexi-time, annual hours, flexible retirement or career breaks. The NHS has to be a more flexible employer if it is to become a model employer.

We won’t get the best from NHS staff if they are not helped to balance their family and their working lives. We know that 25,000 nurses alone say that help with childcare would encourage them to return to the NHS. That is why our manifesto commits us to extra investment in childcare. On top of the £30 million a year we are already pledged to invest by 2004 we will be investing an extra £100 million in improved childcare for staff.

As an organisation – in every part of the organisation – the NHS must now focus on removing those barriers that stand in the way of NHS staff being able to do their best for patients. Staff deserve to be valued – and to feel valued. That way we will get more staff at the NHS frontline. We will keep them working at the NHS frontline. And we will liberate their talents for the benefit of patients at the NHS frontline.

Our reform programme for the NHS must have as its core purpose an absolute determination to harness the commitment and know-how of staff to improve care for patients. Where staff have been given their heads they have delivered far-reaching change. You can see that in the cancer collaborative programme where joint working between clinicians, managers and patients has already reduced outpatient waiting times by 50% and radiology waiting times by 60%. The collaborative principle and the collaborative process now need to be spread to all parts of the NHS.

This second term is all about embedding far reaching reform in all parts of the health service and in social services too. Reform to reorganise services from the patient’s point of view – to make same day tests and diagnosis for example the norm and not the exception. Reform to overcome traditional demarcations between staff – to release the talents of nurses and therapists and relieve the pressures on doctors. Reform to break down barriers between services – to get health and social care working as one part of one organisation rather than competing organisations.

What we need now to do is to support more staff through the reform process. That is what giving staff protected time to improve their services is all about. It is what the Modernisation Agency and the Leadership Centre are all about. It is what Individual Learning Accounts for unqualified staff are all about. In time it is what the new University of the NHS will be all about too.

All of this is about one thing: to unleash the tide of innovation that exists among staff in every surgery and in every hospital.

With a clear framework of national standards and policies in place from our first term this second term will be all about shifting the centre of gravity to staff at the NHS frontline. The NHS is a high trust organisation. It works on the basis of trust between patient and professional. In the way it is organised the NHS now needs to enshrine that trust. It needs to give more control to the NHS frontline. The NHS cannot be run from Whitehall. Just as schools now have greater control so local health services must now be given greater control too.

Four years ago through the fundholding scheme GPs controlled just 15% of NHS resources. Today through the primary care groups and trusts they control 50%. Our manifesto commitment is to give the PCTs control of 75% of the NHS Budget. Working at the NHS frontline, the PCTs can harness all that is best about the NHS – good managers, strong clinical leaders, clear community involvement. The PCTs need to be the engine of change in the NHS, driving new partnerships with NHS Trusts, with social services, local agencies and the communities they all serve.

So I can confirm today that within two years PCTs will receive direct allocations of cash rather than cash being directed through health authorities. And I can announce today that in future resources for block capital, as well as for revenue, will be directed not just straight to PCTs but straight to NHS Trusts too.

For the first time in the history of the NHS the majority of NHS resources will go directly to the local services which provide and commission frontline care. By 2004 PCTs and NHS Trusts will be receiving at least £44 billion of capital and revenue direct at the frontline.

I want to give the local leaders of change the cash and the clout to get on with the job. That means slimming down tiers of management above the NHS frontline. It means by April next year abolishing the existing 95 health authorities. It means introducing a reduced number – of around 30 – more strategic health authorities with responsibilities, not for hands-on commissioning of services, but for oversight of local services. It means the existing NHS Regional Offices must go by April 2003.

I know this will be difficult to handle. I know it is not risk free. But we have got to get power and resources devolved to the NHS frontline.

What I want to foster is a new culture of public sector enterprise in the NHS to rival the spirit of private sector enterprise. That requires more discretion over how local budgets are spent. It requires fewer directives from the centre. It requires a clearer focus on what is a priority and what is not. And it requires devolution to NHS organisations to be matched by devolution within NHS organisations. Ward sisters to control ward budgets. Matrons to have the power to fine cleaning contractors who fail to keep wards clean. Hospital consultants and other senior clinicians to decide on how new equipment budgets are spent. It requires greater freedoms and more rewards for NHS organisations which succeed. And it requires greater help and more support for those which do not.

Very often the poorest services are in the poorest communities. That cannot be right. So while we will celebrate success, we will encourage innovation, we will incentivise improvement, we cannot stand idly by where there is persistent failure.

Public service reform will be led by public service entrepreneurs. The NHS has bred its own entrepreneurs – people with a track record of transforming local services. I want to give them a bigger stage to apply their talents. That’s why Nigel Crisp was right when he talked yesterday about the best people from inside the NHS having a bigger role in the NHS – not just to turn around the handful of consistently failing organisations but earning greater freedom to make their own organisations even better.

I want to get the best people in the NHS to get the best out of the NHS. Let’s have a bit more confidence in ourselves. We’ve got the best people in the NHS. Reform is already being led from within the NHS. The NHS has the means to improve the NHS. As the awards ceremony put it last night: Together we can.

The people at this conference today are leading change. Now we have to drive it forward: engage with all the staff, work with them, motivate them. Get staff and patients involved in the local modernisation reviews, change how staff work so we can change how the health service works.

Your priority for reform – our priority for reform – is to free the NHS frontline. Not a return to the anarchy of the internal market but a freedom to shape local services in this second term within the clear national framework of standards and accountability we established in our first term. With a reformed Department of Health doing only what it can properly do in an accountable public service. Providing the resources. Setting the standards. Holding the system to account.

I know the Department needs to devolve and decentralise. That is why we have set up an appointments commission so that trust boards are appointed independently and not by ministers. It’s why I have set up an independent reconfiguration panel so that expert managers, clinicians and patients can provide advice to ministers on contested local service changes.

And there is one further aspect to this process of devolution I can announce today. The BMA, the NHS and the Government all want to see a new contract for GPs. Negotiating a new employment contract will not be easy. Negotiations never are. I have come to the view that the process of negotiation will be helped if the NHS rather than a government department or government ministers speak for the employers side of the table. In the end GPs – whether they are independent contractors or salaried employees – work for the NHS. It must be right for the NHS to speak for itself as these negotiations begin. I have therefore asked the NHS Confederation if it would lead the negotiations. The involvement of the NHS Confederation will help ensure that any new contract is both good for GPs and meets the needs of local NHS services and most importantly the needs of local NHS patients. Clearly we need to finalise the details of these arrangements and the NHS Confederation will need to consult on this proposal. But I believe it is the right thing to do and I hope we can get on with it.

Government alone can not change the NHS: real and visible improvement to patient care only happens – is only happening – because NHS staff make it happen. In this second term, NHS staff will be given the power, resources and responsibility to reform the NHS.

There is now a mandate for investment. And there is a mandate for reform. Of course there will always be differences over detail and negotiations over contracts. But I believe there is a natural alliance between NHS staff striving to improve care for patients and the Labour Government striving for sustained investment, far reaching reform and devolution of power to the NHS frontline.

Our commitment – my commitment – is to work with all those who want to see the NHS succeed. It can not be done without you. It can only be done with you.

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

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

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

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

People today recognise that if we are to have a fair society where everyone in our communities- and not just some – get a fair chance to succeed then we must build strong public services to set alongside a strong economy. There can be no such thing as a fair society – or a strong economy – if the education system is geared to success for some but not for all. There is no such thing as a fair society or a strong economy if whole communities are laid waste by the ravages of drugs and crime. Above all else, we cannot have a fair society or a strong economy if health care denies people help when they need it where they need it.

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

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

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

It is important to recognise that the debate on the NHS has moved on. For years it was all about the need for more investment since for decades the NHS had suffered under-investment. Today we are putting that right. With funding growing at twice the rate of the past the NHS is now the fastest growing health service of any major country in Europe. And because sustained investment will continue throughout this Parliament the debate on the NHS is now very different from what it was just a few years ago. It is now about whether even with this enhanced level of resources the way we organise and fund health care in this country can ever deliver a modern patient-focussed service. And you only have to read the comment sections of some of the daily newspapers to know that waiting in the wings are those who say that the fundamental principles of the NHS cannot work and must be abandoned.

I believe those newspapers are wrong. I believe those politicians on the Right who advocate their cause are wrong. I have a different set of beliefs. I believe in the NHS – in its principles and in the people working in it. And I know that NHS staff can deliver, that they want to deliver – and are already beginning to deliver – the changes needed to redesign the services of the NHS around the people who use them.

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

Now is the time – with these foundations laid and a clear mandate for deliver – to up the pace of reform. Not because we can promise an overnight transformation but because we know that we need to deliver progress towards that transformation.

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

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

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

First, on the conditions with the greatest clinical priority – cancer and heart disease and services for the elderly and those with mental illness. These will be our top priorities for investment and reform. Rehabilitation services to build a bridge between the hospital and the home. Prevention and treatment services that improve outcomes and tackle inequalities. By 2005 we will be spending an extra £1 billion a year on cancer and cardiac services alone. Our ambition is to give our country levels of cancer and cardiac care that are no longer behind the rest but up with the best in Europe.

Second, primary care – the point of contact most patients have with the NHS. GPs and other staff are doing a good job under real pressure. That is why our priority has to be to increase the number of GPs as fast as we are able alongside expansion in nursing and other primary care professions too. And it has to be about getting extra investment directly to the frontline in primary care both to improve services for patients and to relieve pressures on staff. Together with the reform programme outlined in the NHS Plan – more specialist GPs, more personal medical services, a new GP contract – this investment will help give patients easier access to primary care services.

Third, emergency care – the point of contact patients most need to know is there for them when they require it. We will invest more in ambulance services, in accident and emergency departments and in expanding NHS Direct. We will also work to integrate these services so that better, faster care is there for patients. Far-reaching reforms and a better division of labour amongst clinical staff will, by 2004, have reduced average waiting times in accident and emergency departments to 75 minutes. Inappropriate trolley waits for admission and assessment will by then have been ended.

Fourth, cutting waiting times. The biggest concern about the NHS today is how long patients wait for treatment. It is frustrating for staff and distressing for patients. So building on what has been achieved to reduce waiting lists in our first term, our focus in this second term will now move on to reducing waiting times for treatment.

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

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

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

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

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

Reform to reorganise services from the patient’s point of view – to make same day tests and diagnosis for example the norm and not the exception. Reform to overcome traditional demarcations between staff – to release the talents of nurses and therapists and relieve the pressures on doctors. Reform to break down barriers between services – to get health and social care working as one part of one organisation rather than competing organisations. And reform too which rejects ideological objections to the NHS working with the private sector – as well as rejecting ideological obsessions with the supposed superiority of the private sector – in favour of a modern relationship which best suits the interests of the NHS patient.

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

Our reform programme will have as its core purpose an absolute determination to harness the commitment and know-how of staff to improve care for patients. Where staff have been given their heads they have delivered far-reaching change. You can see that in the cancer collaborative programme where joint working between clinicians, managers and patients has already reduced outpatient waiting times by 50% and radiology waiting times by 60%. The collaborative principle and the collaborative process now need to be spread to all parts of the NHS.

I know that for some in the NHS, reform can feel like another burden to be confronted rather than a means of relieving the burden. There is real pressure on staff. It is hard to find the time to reform services. And yet when reform happens it is quickly seen as a help not a hindrance, to staff as well as to patients. GPs who have got waiting times for appointments down by changing how their surgeries are organised have found their working lives better not worse. In hospitals, doctors, nurses and therapists who have changed who delivers outpatient services have found greater job satisfaction not less. What we need now to do is to support more staff through the reform process. That is what giving staff protected time to improve their services is all about. It is what the Modernisation Agency and the Leadership Centre are all about. It is what Individual Learning Accounts for unqualified staff are all about. And in time it is what the new University of the NHS will be all about. All of this is about one thing: to unleash the tide of innovation that exists among staff in every surgery and in every hospital.

With a clear framework of national standards and policies in place from our first term this second term will be all about shifting the centre of gravity to staff at the NHS frontline. The NHS is a high trust organisation. It works on the basis of trust between patient and professional. In the way it is organised the NHS now needs to enshrine that trust. It needs to give more control to the NHS frontline. I don’t treat patients. I don’t provide GP services. I don’t manage NHS hospitals. You do. The NHS can not be run from Whitehall. Just as schools now have greater control so local health services must now be given greater control too.

Four years ago GPs through the fundholding scheme controlled just 15% of NHS resources. Today the GPs, the nurses, the patients and the local communities who run primary care groups and trusts control 50%. By 2004 they will control 75%. By then – if not before – two-thirds of existing health authorities will have been abolished. The NHS regional offices will have been abolished too. Power will have been devolved to frontline NHS services.

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

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

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

The priority for reform will be to free the NHS frontline. Not a return to the anarchy of the market but a freedom to shape local services in this second term within the clear national framework of standards and accountability we established in our first term. With a reformed Department of Health doing only what it can properly do in an accountable public service. Providing the resources. Setting the standards. Holding the system to account.

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

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

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

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

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

Government alone can not change the NHS: real and visible improvement to patient care only happens – is only happening – because NHS staff make it happen. In this second term, NHS staff will be given the power, resources and responsibility to reform the NHS for themselves.

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

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

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

There is now a mandate for investment. But there is also a mandate for reform. There can be no veto on either investment of reform. Of course there will always be differences over detail and negotiations over contracts. But I believe there is a natural alliance between NHS staff striving to improve care for patient and the Labour Government striving for sustained investment, far reaching reform and devolution of power to the NHS frontline.

Our commitment – my commitment – is to work with all those who want to see the NHS succeed. With all those who know that it is not just sustained investment that the NHS needs by far-reaching reform.

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