Tag: Alan Milburn

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, on 25 April 2001.

Today we launch the NHS Modernisation Agency – part of new have been building over last four years. has a key role in helping organisations reform their services to offer patients better, faster care.

I am delighted David Fillingham is to be the Agency’s first Chief Executive. David is an NHS man. He comes with a track record of delivering impressive changes in those NHS organisations he has run. Now he has an even bigger job. One that sounds seductively simple in theory but is fiendishly difficult in practice. How, as Nye Bevan put it five decades ago, to universalise the best; to make best practice in one part of the health service the norm in all of its parts.

This is the challenge for the NHS today. A decade of improvement in the NHS is underway. The Agency is already supporting 30,000 clinicians and managers to make change happen: to raise standards of service and improve access to services. The Agency’s philosophy is simple: there is nothing wrong in the NHS that cannot be rectified by what is right. Realising the ambitions of the NHS Plan needs a modernisation movement which includes all one million NHS staff.

Over the next few years all parts of the NHS must be reformed, redesigned around the needs of patients. Earlier this year I set out in a speech how reform must fundamentally change the relationship between patients and the service. I said then that patients should have more information, more influence and more power over the services they receive. I called for the balance of power in the NHS to shift decisively in favour of the patient.

Today I want to argue this shift can only happen if the centre of gravity within the health service itself moves from Whitehall to the NHS frontline.

The NHS today stands at a crossroads. After decades of neglect the NHS is finally getting the investment it needs.

Between 1979 and 1997 NHS funding grew by an average of just 3% a year. In the last parliament it grew by even less. Funding for buildings and equipment was cut. Nurse training places and GP registrar numbers were both reduced too. In the final year of the last Parliament the overall NHS budget fell in real terms.

I know that some say we got it wrong in the first two years of this Parliament by putting prudence before investment. But the country has reaped a huge reward for it. Economic stability. Public finances under control. And now – precisely because of the choices we made – more investment, over more years, for more of our key public services.

Today the NHS is experiencing historic levels of growth. Double the rate of the past. As a result the NHS is now the fastest growing health service of any major European country. Expansion is underway. 17,000 more nurses; 6,700 more doctor; last year, for the first time in forty years, more beds in hospitals. The biggest hospital building programme the country has ever seen. 220 accident and emergency departments and 1,129 GP surgeries modernised. 500,000 more operations being done. Waiting lists for inpatients and outpatients both now falling.

There is a long way to go. I know that. Investment takes time to be felt at the frontline – but it is getting through and it will be sustained. The truth about the NHS today is that it is neither totally broken nor totally mended. There is real progress. But there are real problems. Staff are under real pressure. After two decades of almost continual chopping and changing it would be odd if there were not signs of change fatigue. There is weariness – and in some parts of the NHS there is wariness. Uncertainty about what reform will bring. Cynicism about whether it can be achieved.

And yet my message is simple: reform must happen. It was never meant to be easy. Reform is difficult. Much of it takes time. And it requires all of us to change. The NHS Plan will take ten years to fully implement but over the next few years reform must take hold. I say that for two reasons.

Firstly, because the NHS is under test. We have actually succeeded in changing one crucial aspect of the debate on the health service. Until recently virtually the only question about the NHS was whether it was getting enough investment. Now most people recognise that the growth in resources is about right. Today the public debate has moved on. It is about whether even with this record investment the health service can deliver the goods for patients.

Some say it can not. That the very way health care is funded and organised in this country makes it impossible to deliver the level or responsiveness of service modern patients expect. They say we have to move away from the core principle of care being provided according to need and not ability to pay. That more people should be charged for care with all of the manifest unfairness that would bring.

So make no mistake: the NHS has to continually earn not complacently assume the confidence of each new generation. Its opponents want it to fail. Reform is the pre-condition for sustaining public confidence in the health service. Reform to make the NHS more responsive to patients is the best answer to its critics.

And reform is the best answer to the pressures facing NHS staff. I know some people working in the NHS believe it would be comforting if we could first expand the service and then make the reforms. Anything else they say is just too hard because staff are facing rising pressures and simply cannot find the time to reform as well.

I appreciate the strain staff face. They do a brilliant job. I know how difficult it can be to find the time to stand back from the service in order to assess how it needs to be changed.

Expansion in staff numbers will help. There are more qualified staff coming through. And more yet to come. But it is not just expansion that will make working lives easier. It is reform too. We have got to stop seeing reform as a new problem. And start seeing it as the solution.

For example, getting hospital test results and diagnosis on the same day make sense from the patient’s point of view. It makes sense from a staff point of view too: less paperwork; fewer missed appointments; and lower levels of frustration about a system which can seem intent on denying both staff and patients the rapid information they need.

The key to reform relies on making better use of staff skills, overcoming traditional demarcations between the professions. Training paramedics to give thrombolytic drugs to heart attack patients will cut call-to-needle times – and save lives. It will relieve the pressures on hospital doctors in accident and emergency. Getting nurses to triage casualty patients has the same impact – and delivers a faster service. In primary care the same is true. There telephone consultations and reorganised practice appointments are delivering shorter waiting times for patients – and making life easier for family doctors.

This is reform in practice. It is happening in many parts of the NHS. The reforms being pioneered in cancer services point the way for the rest of the NHS. The Cancer Collaborative programme has brought together clinicians and managers from across the whole spectrum of services used by cancer patients. Together they have worked to end some of the delays for patients who have been diagnosed with suspected cancer by examining, and then reforming, the patients’ journey through the system.

The results are impressive. On average, in the pilots, times from GP referral to first hospital appointment have been halved. What is more three quarters of the 51 projects in the programme have achieved or beaten the 8 week target from referral to treatment – 4 years ahead of schedule. Radiology waiting times have been reduced by 60%. In total it is estimated that the Cancer Services Collaborative has so far saved a combined total of more than 200 years of patient waiting time. No wonder patients are reporting higher levels of satisfaction with the services they are receiving.

Sure, we have made some extra investment to help it happen. Many of the big changes haven’t cost a penny. They have come from redesigning the way services are delivered. It is reforms like these which will deliver the NHS Plan. So, from this month every part of the country will benefit from this cancer services reform programme. And it is why we are extending the collaborative programme to services such as cardiac care and primary care.

The reform programme in cancer services has delivered because it puts staff in the driving seat of change. Doctors, nurses, scientists and others using their know-how, making their innovations, redesigning their services. Where staff have been in control they have come up with the goods.

The common thread which links the best reforms is the know-how and commitment of NHS staff being harnessed to improve care for patients. The task for the next few years is how to get that thread running through the whole National Health Service.

There is a harsh reality to be faced, not just for the NHS but for the wider public sector in education, local government and transport. Many people – particularly younger people – feel that public services have become ossified. That they are insufficiently responsive to the needs of parents or patients, residents or rail users. In some cases, those with savings or sufficient income have simply opted out of public services altogether. They have chosen private education for their children or private health care for themselves.

However comforting that choice might be for some people it does not provide a solution for most people. Indeed, there is a real risk that without middle class support public services will end up fulfilling Richard Titmuss’ prophecy – services for the poor which are poor services. Our ambition surely has to be to make the NHS – and our country’s other vital public services – a service of first choice, not last resort.

To realise this ambition there have to be radical changes to the way services are provided. There is here, a real conundrum. On the one hand, there are sometimes low levels of public confidence in the ability of services to deliver the standards and responsiveness people expect. And on the other, there remain relatively high levels of public trust in the doctors, nurses, teachers and others providing these services.

In part this reflects a public view that staff in public services have been simply doing their best inside a system that for too long has been under resourced. In the case of the NHS, people think staff are doing a good job despite the system not because of it. By and large people trust frontline public servants. Harnessing the motivation that these frontline staff have to improve public services is essential then for increasing public confidence in those services. In order to be the ambassadors for improved public services frontline staff also have to be the architects of public service reform.

In our first term our focus has been on setting tough new national standards first in health and education and then in local government and transport. Some say that process has gone too far. That creeping centralisation has crowded out local innovation. That staff have felt disempowered or worse disillusioned.

Getting the balance right is never easy. It is worth remembering that when we came to office, in the NHS there was an absence of national standards. No NHS-defined clinical standards and no means of implementing them. No means of spreading good practice or eliminating bad practice. No national evaluation of new treatments and no external inspection of local services. The anarchy of the NHS internal market had merely added to a long term spiral of decline.

It is easy to forget how far we have come in just four years. There are new national standards for services. For cancer, heart disease, mental health, elderly care. There is greater transparency over local service performance. There is a new legal duty of quality and a new system of clinical governance to enshrine improvements throughout the NHS. There is the National Institute for Clinical Excellence evaluating new treatments. For the first time the NHS has an independent inspectorate, the Commission for Health Improvement. There are new systems for when things go wrong and more help to learn from what goes right. The internal market has gone. Through new primary care groups and trusts family doctors and community nurses have a greater say over deciding the shape of local services.

For the first time in decades there is widespread agreement that these changes are right for the NHS. Indeed by and large not even our political opponents disagree with them. This has been a quiet revolution. But a revolution nonetheless. It is early days but the revolution is producing results. The national drive for improved standards is making a difference – whether that’s in cleaner wards or in better cancer care.

And yet what happens in the National Health Service happens in hundreds of hospitals, thousands of GP surgeries and is determined by almost one million staff. Healthcare is a people business – relying on personal interaction and professional judgement. The NHS cannot be run from Whitehall. But it is too simple to say that everything should be devolved from centre to local.

There is little public appetite for diverse standards between local services. People do worry about a lottery in care. When people hear about problems in one part of the NHS it tends to dent public confidence in the whole NHS. There is strong public identification with the NHS as a national service. That is a good thing. The universalism of the NHS helps to cement national cohesion and to shape national identity.

For all these reasons in our first term we have established a clear national framework within which local NHS services can operate. Now with that national framework in place, in our second term we intend to shift the centre of gravity to the NHS frontline.

The NHS is a high trust organisation. It works on the basis of trust between patient and professional. In the way it is organised the NHS needs to enshrine that trust. It needs to give more control to the frontline. Just as schools now have greater control over resources and how they are organised so local health services must now be given greater control.

We have laid the foundations for this approach. When we came to office GP fundholders controlled just 15% of the NHS budget. Today PCGs/PCTs control over 50%. By 2004 I want them to control 75%. The whole idea behind these new organisations was to give the frontline professionals who deal most with patients the power to reform local services. In some places Health Authorities and PCTs have put their relationship on the right footing. The local health authority provides the strategic leadership and the PCTs have the ability to shape local services to suit local community needs.

I want PCTs to be able to commission the services they decide are needed. In some places that is happening but in too many cases it is not. There, Health Authorities have retained control. They have held on to the pursestrings, sometimes even to the content of the purses. Too many family doctors and community nurses have felt disempowered rather than empowered. There are similar feelings in NHS Trusts. Many chief executives I speak to complain of too much day to day intrusion. From health authorities. From regional offices. From the department of health itself. Too much of the NHS today still feels like a centrally run bureaucracy to those at the frontline. This has to change.

The time has now come to free the NHS frontline. Not a return to the anarchy of the market. But a freedom to shape local services within a clear national framework of standards and accountability. That requires a number of major changes. I now want to set out to you how we will implement this approach for the second term.

There will be greater freedom for successful performance. The NHS Plan proposed that local NHS organisations would be graded according to an objective assessment of their performance. As standards and performance improves greater autonomy for local NHS services will be earned. The best performers will have more freedoms.

Today I can set out the forms some of these freedoms will take:

The best performers will have less frequent monitoring from the centre and fewer inspections by the Commission for Health Improvement.

They will be able to develop their own investment programmes without receiving prior approval and they will retain more of the proceeds of local land sales for re-investment in local services.

They will be used as the pilot sites for new initiatives such as team bonuses for staff.

They will receive extra cash for central programmes without having to bid for it.

They will receive extra resources too for taking over and turning round persistently failing Trusts.

And where a successful local health service is receiving less than its fair share of cash through the resource distribution formula it will automatically receive an accelerated uplift to help close the gap.

In all these cases it will be for the local organisation to decide how best to use extra resources whether as bonuses for staff or as investment in services.

I want to make it more worthwhile for local health services to innovate in the way they deliver care to patients. I want to see a new culture of public sector enterprise in the NHS to rival the culture of private sector enterprise which has developed over recent decades. This requires more local discretion over how budgets are spent. It requires a greater emphasis on rewarding those who succeed and helping – rather than penalising – those who sometimes fail. And it requires organisational change to put the frontline first.

The NHS today feels too top heavy to many PCTs and NHS Trusts. In the end it is they who deliver care – and it is they who will deliver reform. The territory above them looks and feels pretty crowded. As well as the Department of Health itself and the NHS Executive centrally there are eight regional offices heavily focussed on performance management and 99 health authorities. Lines of accountability are confused. NHS Trusts running hospitals report to regional offices. PCTs report to health authorities.

Many in the NHS recognise that this intermediate tier of management must now be rationalised. As PCTs develop capacity and take on more powers the role of very local health authorities will be called increasingly into question. Some are already providing an answer. In various parts of the country health authorities are already preparing to merge.

With Nigel Crisp, the NHS Chief Executive, I have examined very carefully which management structures will be needed in the future. Today’s NHS needs an accountability structure to ensure delivery of a national framework of standards in a way that does not stifle local innovation. We have concluded that the current system cannot deliver.

Organisational change of course carries the risk of bringing instability and so could impede reform. But I have been convinced by people in the NHS that change is now needed to take reform forward and embed a new decentralised approach. Not a big bang tomorrow but a phased programme to put power and resources in the hands of the NHS frontline.

I can announce today then far-reaching changes to the way the NHS is organised.

By 2004 two thirds of existing health authorities will have disappeared as they merge. The 30 or so that remain will each cover an average population of 1.5 million, broadly corresponding to emerging clinical networks such as those for cancer services. Local consultation will shape their exact boundaries. Local services for patients will be unaffected by this change. Indeed there will be greater local control over local services as many of the old health authority functions are devolved to locally-run PCTs. They will be the primary point of contact with local government to develop more joint working. More of the planning to improve services and tackle health inequality will also take place at this local level.

In turn, as we prefigured in the NHS Plan, the new strategic health authorities will have responsibility devolved to them from NHS Regional Offices for performance managing the local health care system. Although both NHS Trusts and PCTs will be accountable to the new strategic health authorities both will have greater operational freedom. NHS trusts will be responsible for providing local hospital and other specialist services. PCTs will be responsible for commissioning them as well as providing primary and community services.

Where they wish to PCTs will be able to pool their sovereignty to realise the benefits of larger economies of scale but otherwise the new health authorities will not have hands-on commissioning responsibility. Similarly, health authorities will be able to come together at a regional level to discharge functions that make more sense at that level.

Following the establishment of the new health authorities, there will be a Regional Director for Health and Social Care with a small core group of staff – part of the Department of Health – there not to second guess local health services but with oversight of their development. The areas covered by these regional directors may be larger than at present. Otherwise the NHS Executive and, over time, the Regional Offices will disappear.

Their residual functions – for example over public health – will be overseen by the Regional Director, accountable to the Department of Health but co-located with Government Offices of the Regions, to encourage more joint working between health, transport, regeneration and the environment. In this way if new regional government structures emerge there will be a ready-made relationship with the NHS.

The new strategic health authorities will be the bridge between the Department of Health and local NHS services. They will have an absolutely crucial role to play in brokering solutions to local problems, holding local health services to account and encouraging greater autonomy for NHS Trusts and PCTs.

They will need to be well run, highly efficient organisations attracting some of the best management. So I can say today that I am examining proposals for ensuring this happens including inviting expressions of interest from the best performing management teams to run the strategic health authority “franchise”.

This new flatter NHS structure will help liberate local services so they can get on with the business of reform. It will also free over

£100 million from bureaucracy for investment in frontline services.

That brings me then to the final major change I wish to make to give frontline services more freedom. Devolution to frontline NHS organisations must be matched by devolution within frontline NHS organisations. As the Cancer Service Collaborative programme has already proved successful reform depends on giving clinicians as well as managers the power to reshape services. That means stopping clinicians – nurses as well as doctors – feeling that reform is a process that is done to them rather a process that they control. I know the whole ethos of the Modernisation Agency will be about change being done with people rather than to them.

At a national level we have worked hard to involve clinicians in the work of the department, in the formulation of new standards and in drawing up the NHS Plan. The same process of engagement must now happen in every local NHS organisation. During the summer I will be asking every local health service to carry out a local modernisation review of what needs to be done to deliver the NHS Plan. Managers will need to work with clinicians across the primary, secondary, social services divide to identify the local obstacles standing in the way of progress and how best these can be overcome.

That process may give rise to new structures. In cancer care, for example, the country’s best cancer networks are already applying to take direct control of local budgets for services. In time I believe we can put the country’s top cancer specialists in charge of new funding for all cancer patients. Other local innovations to put frontline staff in charge of services will be encouraged too.

Health authorities as they divest themselves of direct management responsibility for services should pass cash down to local primary care groups and trusts. Hospitals should consider how to give clinical teams greater control over budgets. We have made a start here by giving each ward sister control of a

£5,000 ward budget and by bringing back matrons to exercise control over cleaning and other basic services. Within the next fortnight I will set out how I intend to take this process further by giving hospital clinicians control over extra resources for new equipment budgets.

In the meantime, we will provide further help for staff to reform services. Staff who work day-in, day-out under great pressure often know there could be better ways of delivering treatment and care. Lack of staff time can be the biggest barrier to reform.

We will include a total of £60 million in local NHS budgets over the next 3 years to allow frontline staff some protected time to look at how they can improve the quality of patient care. The first 20 pilot sites are already up and running.

I want these staff modernisation sessions to become common practice throughout the NHS – just as INSET days have in education. Together with the work of the new Leadership Centre, headed by Barbara Harris, these sessions will give clinicians, working alongside managers, the tools to reform local patient services.

Frankly it should never have needed Ministers to tell hospitals that informed consent, clean wards and good food are basic requirements in a modern NHS. It is a salutory lesson for those who complain about too much central intervention that it was only this process which focussed attention on getting some of the fundamentals of care right for patients.

Change needs to come from the bottom up not just the top down. I am confident that the reforms now taking hold throughout the NHS are putting a new focus on designing services around the needs of patients. This will leave the centre to do the job it should properly do. Provide the resources. Set the standards. Hold the system to account.

Nigel has launched a review of the department to better focus on its core tasks. The review has involved consultation with the NHS and external stakeholders. Just like the rest of Whitehall, the Department faces a fundamental challenge: how to overhaul its apparatus to be better focussed on seeing change through, not just devising policies for change.

Over the next few years the job of the department has to be a single-minded focus on implementing the NHS Plan and the related reform programme for social care and public health. Amongst other changes, this is likely to require more frontline staff being recruited to work in the Department to build on the success of the “tsars”. In this way, the Department of Health can become a model for the modern service-delivery Whitehall department.

There will be democratic accountability – as there should be in a National Health Service – but operational control will be devolved outwards and downwards to the NHS frontline.

To save the NHS we had to a get a grip: to put national standards in place where they were absent; to put resources in place where they had been denied; to develop a programme of sustained reform alongside a programme of sustained investment.

With this national framework in place, the time has come to liberate the NHS frontline.

To expand staff numbers and to value staff more.

To encourage their innovation which will reform the health service.

To foster their initiative on which better patient care can be built.

To realise the immense potential of our million, brilliant staff.

And above all else, now to shift the balance of power from Whitehall to the NHS frontline.

This approach is a huge vote of confidence in the doctors, nurses, managers who run frontline services.

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

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

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

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

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

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

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

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

I want to set out:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I want to set out:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Health care as social investment

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

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

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

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

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

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

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

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

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

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

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

The link between health and economic success

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

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

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

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

The contribution of healthcare

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

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

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

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

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

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

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

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

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

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

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

Modernised NHS for a modern economy

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

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

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

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

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

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

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

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

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

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

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

The health of workers

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

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

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

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

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

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

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

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

The health of older people

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

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

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

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

Conclusion

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Below is the text of the speech made by Alan Milburn on 17th October 2013.

This State of the Nation Report was laid before Parliament this morning. The Commission on Social Mobility and Child Poverty is required by statute to report each year on what is happening on these issues in our country. This is our first annual report. I would like to place on record my thanks to my fellow Commissioners and our excellent Secretariat for their efforts in compiling this comprehensive survey of trends past and present and what we believe is likely to happen in future.

When Ministers created the Commission they explicitly asked us to hold their feet to the fire. I hope the report fulfils that remit in a way that is both authoritative and fair. Much of its focus is on what the UK Government and, to a lesser extent, those in Scotland and Wales are doing to tackle poverty and improve social mobility. We also look at schools and universities and the role that employers and professions, local councils and communities are playing. They are all players on the pitch when it comes to improving life chances. In future years our reports will subject each of them to greater scrutiny.

It is part of Britain’s DNA that everyone should have a fair chance in life. Yet compared to many other developed nations we have high levels of child poverty and low levels of social mobility. Over decades we have become a wealthier society but we have struggled to become a fairer one. When 2.3 million children are officially classified as poor it exacts a high social price. There is an economic price too in wasted potential and lower growth.

By definition, reducing poverty and increasing mobility is not easy. It requires a long-term effort. Some say it is an impossible task. The Commission does not succumb to that pessimism. We have seen enough evidence from around the world – and in our country’s own history – to know that with the right approach it is possible to break the transmission of disadvantage from one generation to the next. We have grounded much of our analysis and our recommendations in this global evidence.

We know these are challenging times in which to make progress. Britain faces a triple squeeze on economic growth, family incomes and public spending. In these circumstances it would have been all too easy for Government to abandon the aim of ending child poverty by 2020 and to avoid the long hard haul of making progress on social mobility. We believe the UK Government deserves credit for sticking to these commitments and making new ones. The test we apply in this Report, however, is not about good intentions. We take those as read. It is about whether the right actions are being taken. We find in our Report a mix of good and bad news.

On child poverty the UK has gone from having one of the highest levels in Europe to a rate near the average over the last 15 years. Since 2010 there has been a dramatic 15% decline in the number of children in workless households but recently there has been a big rise in the numbers of poor children measured as being in absolute poverty and in working poor families.

On employment we find that there are more people in work than ever before but that the numbers of young people unemployed for over two years is at a twenty-year high and the Government has been too slow to act.

On living standards we find that real wages were stagnating before the recession and have fallen by over 10% since 2009. Real median weekly earnings are now lower than they have been for over a decade, putting many more families under pressure and forcing many more low-income earners below the poverty line.

On public spending we find that some services, such as schools, have been relatively protected from cuts but that overall fiscal consolidation has been regressive with the bottom 20% making a bigger contribution than all but the top 20% and an inter-generational injustice which sees better-off pensioners protected but families with children bearing two-thirds of spending cuts.

On schools we welcome the Government’s energetic focus on reform to drive social mobility and find that the gap between the poorest and the rest has narrowed at primary school and GCSE but widened at A-level. The most deprived areas still have 30% fewer good schools and get fewer good teachers than the least deprived.

On moving people into work we welcome the big expansion in apprenticeships but not the decision to abolish the Educational Maintenance Allowance. We find that the Universal Credit could be transformative in encouraging more people into paid employment but its impact is weakened by high childcare costs.

On universities the worst fears about the negative impact of tuition fees have not been realized so far but big falls in applications from mature and part time students and the failure of top universities to diversify their social intake are causes for concern.

On the professions we find greater efforts to open doors to a wider pool of talent but new research for this Report finds that class is now a bigger barrier than gender to getting ahead in a top professional career. Senior professionals are still more likely to be privately schooled and privileged men.

There is much to welcome in what Government, employers, schools and universities are doing. We see considerable effort and a raft of initiatives underway. The question is whether the scale and depth of activity is enough to combat the headwinds that Britain faces if we are to move forward to become a low poverty, high mobility society. The conclusion we reach is that it is currently not. We conclude that the statutory goal of ending child poverty by 2020 will in all likelihood be missed by a considerable margin, perhaps by as many as 2 million children We challenge all political parties to say how they would make progress.

We conclude too that the economic recovery is unlikely to halt the trend of the last decade, where the top part of society prospers and the bottom part stagnates. If that happens social inequality will widen and the rungs of the social ladder will grow further apart. The promising reforms we see in schools and some aspects of welfare will not, on their own, offset the twin problems of high youth unemployment and falling living standards that are storing up trouble for the future. We see a danger that social mobility – having risen in the middle of the last century then flat-lined towards the end – could go into reverse in the first part of this century.

To avert this we believe that policy-makers need to come to terms with a new truth that emerges from the mass of evidence contained in our Report. Although entrenched poverty has to be a priority – and requires a specific policy agenda some of which the Government is pursuing – transient poverty, growing insecurity and stalling mobility are far more widespread than politicians, employers and educators have so far recognised.

Too often – in political discourse and media coverage – these issues are treated as marginal when in fact they are mainstream. Poverty touches almost half of Britain’s citizens at some point over a nine-year period and one third over four years. Today child poverty is overwhelmingly a problem facing working families, not the workless or the work-shy. Two-thirds of Britain’s poor children are now in families where an adult works. In three-quarters of those households someone already works full-time. The principal problem seems to be that those working parents simply do not earn enough to escape poverty.

Then there is the growing cohort of low and middle-income families squeezed between falling earnings and rising house prices, university fees and youth unemployment, who fear their children will be worse off than they have been. Many of today’s children face the prospect of having lower living standards than their parents when they grow up.

These are profound challenges. We believe, however, that they also present an opportunity: to make the pursuit of a society with less poverty and more mobility something that is relevant to the many not the few in Britain.

We find, for example, that there has been a change in the geography of educational inequality. London state schools, which used to be the worst in the country, are now among the best. 100 per cent of secondary pupils in Camden, Hackney and Tower Hamlets are now in good or outstanding state schools, but in Middle England places like Bournemouth and West Berkshire it is just over 50 per cent. The nature of the problem has changed – and so too must the policy response.

For decades the focus has been on moving people from welfare to work. With 2.5 million people still unemployed and appallingly high levels of youth unemployment renewed effort is still needed there. A job remains the best safeguard against being poor. But it is not a cure for poverty. Over the last decade earnings growth has been lagging behind prices. More and more people are at risk of poverty as a result. Today the UK has one of the highest rates of low pay in the developed world. Five million workers, mainly women, earn less than the Living Wage. These are the people that heed the urgings of politicians of all hues to do the right thing, to stand on their own two feet, to strive not shirk. Yet all too often the working poor are the forgotten people of Britain. They desperately need a new deal.

During the late 1990s and early 2000s, public spending through higher tax credits subsidized stagnating earnings and propped up living standards. Austerity removes that prop. The taxpayer alone can no longer afford to shoulder the burden of bridging the gap between earnings and prices. We conclude that Government will need to devise new ways of sharing that burden with employers in a way that is consistent with growing levels of employment. Making headway on reducing poverty and improving mobility requires a fresh settlement between what the state does, what the market does and what the citizen does.

Our key recommendations for Government are that it firstly, aims to end long-term youth unemployment by increasing learning and earning opportunities for young people who should be expected to take up those opportunities or face tougher benefit conditionality. Secondly, that it reduces in-work poverty by getting the Low Pay Commission to deliver a higher minimum wage, rewards employment support providers for the earnings people receive not just for finding them a job and reallocates Budget 2013 childcare funding from higher rate taxpayers to help those on Universal Credit meet more of their childcare costs. Thirdly, that it better resources careers services, pays the best teachers more to teach in the worst schools and helps low-attainers from average income families as well as low-income children to succeed in making it to the top, rather than aiming to simply get them off the bottom to succeed at school.

Next, employers will need to more actively step up to the plate. Our key recommendations are that, firstly, they will need to provide higher minimum levels of pay and better career prospects, enabled by higher skills. Secondly, we call on half of all firms to offer apprenticeships and work experience as part of a new effort to make it easier for those who aren’t going to university – “the other 50 per cent” – to pursue high quality vocational training. Thirdly, we call on the professions to to end unpaid internships and recruit from a broader cross-section of society than many do at present.

Finally, and perhaps most importantly, we say that every citizen who can should be expected actively to work their way out of poverty by seeking jobs, working enough hours and seizing the opportunities made available to them. We say that the key influencers on children’s life chances are not schools or governments or careers services. They are parents. And we urge Government to break one of the great taboos of public policy by doing far more to help parents to parent.

We recognise that these, alongside the other proposals we make in this Report, are very challenging recommendations. A far bigger national effort will be needed if progress is to be made on reducing poverty and improving mobility. That will require leadership at every level. Government cannot do it alone. But it does have a special role to play in setting the framework for policy and mobilizing the country to action.

To play that role effectively we believe Government will need to do more to embed social mobility considerations in its own processes. Currently, we see good intentions and initiatives undermined by too little clarity and coherence. We suggest that the Office of Budget Responsibility is charged with producing independent analyses of key government decisions to ensure that Ministers are getting the maximum mobility-enhancing, poverty-reducing bang for the buck.

Just as the UK government has focused on reducing the country’s financial deficit it now needs to redouble its efforts to reduce our country’s fairness deficit. If Britain is to avoid being a country where all too often birth determines fate we have to do far more to create more of a level playing field of opportunity. That has to become core business for our nation. We look to Government and others to make it happen.

Below is the text of the speech made by the then Health Secretary, Alan Milburn, to NHS Executives on 11th February 2003.

I would like to begin by thanking you for the leadership you show in the NHS. It has never been more vital.

In the months to come that leadership will be more important still. We are a critical juncture for the NHS. It is over two years since the NHS Plan was published. Investment in the NHS is rising fast. This April taxes will go up to pay for the extra resources.

As a result, capacity is growing. From the late 1970s to the mid 1990s only ten major new hospital developments were completed. Since 1997 13 have been built, seven more are under construction and a further 34 are in the pipeline. In each of the five years before 1997 the number of GPs in training fell. In each of the last five years they have risen. There are 10,000 more doctors, 40,000 more nurses, and 11,000 more therapists and scientists working in the NHS now than then. In primary care prescribing of cholesterol lowering drugs has doubled in 3 years. For decades acute and general beds in hospitals were cut back. For the last two years they have grown.

The local plans PCTs and NHS Trusts are concluding for the next three years will need to increase capacity further: in primary and community services, not just hospital services; in staffing, especially in doctor numbers; in new ways of working, not just the old ways of doing things.

Extra capacity is needed because the NHS is still working under very real pressure. It is tough out there. It is easy to lose sight of the fact that the journey we have begun is well underway. Of course, there is a long way to go but the momentum is now forwards.

Take waiting times. Thanks to your efforts waiting times – which had risen for decades – are falling – and doing so on virtually every indicator. In heart surgery, for example, the maximum waiting time which was eighteen months at this time last year will have been halved to nine months by April this year. So, in what remains of this financial year, it will be important to deliver the continued progress we have promised towards an NHS where waiting times are lower and quality is higher.

For patients, progress will be judged not just on whether waiting times are shorter but on whether their own experience of the service is better. There is no doubt that waiting – whether it is to see the family doctor or the hospital specialist – is the single biggest public concern about the NHS. But unless we can improve the quality of the patient experience we could end up hitting every target and ticking every box – and finding that the public believe the NHS is no better.

That is why the resources have got to lever in reforms. The investment cannot be used to ossify the system. It must be used to change it.

Last week I argued for devolving power and resources from Whitehall to the NHS frontline. The move to a more diverse, more devolved NHS will help make local services more responsive to the needs of the local communities they serve. Today I want to set out another crucial element of our reforms: greater choice for patients. I want to describe why I believe choice is important and how we plan to make it happen.

The starting point is this: when the NHS was created expectations were lower; deference was greater. Today it is the other way around. Some argue that in today’s consumer world the only way to get services that are responsive to individual needs is through the market mechanism of patients paying for their own treatment. I believe that is wrong and would fail. In a world where health care can do more but costs more than ever before, such an approach would make the best health care an exclusive club for only the very wealthy. The new possibilities brought by medical advance and – in our generation, the genetics revolution – make the case for an NHS where care is free and based on the scale of people’s needs, not the size of their wallets.

So public service values are right. But winning the argument for investment and reform means accepting that the era of one-size-fits-all public services is over. At the heart of public concerns about the NHS is the sense that its services are simply too indifferent to the needs of its patients. Staff and patients alike are up against a system that feels too much like the ration book days of the 1940s. Public confidence demands not just a change in structure but a change in culture too.

In our first term we tried to make services more responsive from the top down through service targets, inspection regimes and national standards. This national framework of standards is important to guarantee equity but in the period we are now in the transition is towards improvement being driven from below. Hence these three crucial elements of our reform programme:

Devolution – with Primary Care Trusts having the power to commission local services to meet the needs of local communities.

Democratisation – with NHS Foundation Trusts transferring ownership from a centralised state bureaucracy into the hands of local people.

Diversity – with different providers – public, private and voluntary – providing NHS services to NHS patients according to a common ethos, common standards and a common system of inspection.

These reforms make possible greater choices for patients. There are of course limits to choice in the health service, just as there are in any other service. For one thing, health care is often an emergency service. The last thing the patient in the back of the ambulance wants is to be asked to name their A&E of choice. They want the nearest, fastest service. And for another, patients do not just have a relationship with the NHS as consumers. They are also citizens who recognise that in A&E it is necessary for the less serious injuries to give priority to the more serious ones. In other words patients have both rights and responsibilities. Indeed I believe that as we strengthen rights and choices so we can demand more responsibility from patients – to use services appropriately and to treat staff respectfully.

But the NHS is a lot more than an emergency service. In fact, only one in three NHS hospital admissions are for emergency cases. Half are for routine, planned surgery where patient choice could play a role. A further one in seven are for maternity services where many mums and dads already exercise choice: between this hospital and that, between a midwife-delivered service and a doctor-delivered one, between a birth at home and one in hospital.

Indeed, it is precisely because women have been able to exercise choice for themselves that those services have become more sensitive to their needs. When we publish the new national service framework on children’s services later this year it will include proposals on how we can extend choice further in maternity care.

In other parts of the NHS patients also exercise choice. In primary care for example, most patients are able to choose their own family doctor. Between July and September last year almost quarter of a million patients, through their GPs, booked the time of their hospital appointment at their own convenience rather than the hospital’s.

No health care system, whether it is public or private, however, can provide unlimited choice. Most private health insurance schemes, for example, exclude maternity care and primary care as well as psychiatric and other long-term treatments.

But I believe we can open up more choices to NHS patients. The issue is firstly, whether we should and secondly, how we could.

Let me deal with the first of these issues. It is often argued that capacity constraints mean that choice on the NHS is not possible. It is certainly true that choice can only grow as capacity grows. What is not true is that some capacity is not already available or that more cannot be grown.

In London, for example, today the average waiting time for elective surgery in different hospitals varies between 10 weeks and 25 weeks. With the right incentives some hospitals would take on more work. When UCLH bought the London Heart Hospital from the private sector last year that doubled local heart surgery rates. In that area today only 40 patients are waiting more than one month for a heart operation, many for personal reasons. That hospital could easily take on more patients. There will be others elsewhere in the country which could do the same. Many more will be able to do so as extra resources produce extra capacity. So the capacity argument against more choice does not work.

The main argument against more choice has been that it will bring less equity. I want to argue the reverse: that greater choice can mean greater equity.

We do not start from a position where uniformity of provision in the NHS – with precious little choice for patients – has guaranteed equality of outcomes. In fifty years health inequalities have widened not narrowed. Too often even today the poorest services are in the poorest communities. Choice has only ever been available to those with the ability to pay. Those with the money have been able to exercise more choice – and buy faster, if not better, services as a result.

This institutionalised two-tier health care is anathema to those of us who believe care should be based on need and not ability to pay. The real inequity is to force the pensioner with modest savings who has worked hard all their lives and then needs a heart operation to choose between paying for treatment or waiting for treatment. That is a dilemma I want to solve.

We can do so by making choice more widely available on the NHS so that it is extended to the many not just the few. Some say poorer people do not want to exercise choice or are not able to do so. I disagree profoundly. That is patronising nonsense.

When I grew up on a County Durham council estate it didn’t much impress me that it was the council, not my family, who chose the colour of my front door. Perhaps unsurprisingly hundreds of thousands of council tenants opted out of council ownership when they had the chance to do so. The old-style, often paternalistic take-it-or-leave-it, like-it-or-lump-it relationship between council housing services and council tenants weakened public attachment to public services. Expanding choice can strengthen it.

And by linking the choices patients make to the resources hospitals receive – alongside the systems of standards, inspection and intervention we have put in place – we can provide real incentives to address under-performance in local NHS services. As we know poorer performance is often concentrated in poorer areas. Giving people the power to choose between services will drive standards up. In this way, greater choice can enhance equity, not diminish it.

The world has moved on from the days when Henry Ford said you could have any colour car as long as it was black. The Ford Motor Company is 100 years old this year. Today, Ford produce cars so that you can have any colour – including five different shades of black!

Of course, choice in public services is more complicated than choosing the colour of a new car but unless the NHS offers some choice to patients, more of them – at a time when personal disposable income continues to rise – will simply take their custom elsewhere. More will abandon collectively funded public services for privately paid-for services. In the mid-1950s only half a million people had private cover for health care. Today it is almost 7 million. Ironically, those who rail against choice in public services on the grounds that it is a market-based reform risk ending up strengthening private markets not weakening them.

The trap we must avoid, is that identified by Richard Titmuss four decades ago, of middle class people opting out so that public services become only for the poor and then end up being poor services. By strengthening the appeal of NHS provision across social classes, greater choice can enhance social cohesion not diminish it.

The question in my mind is not whether NHS patients should have more choice but how to make choices more widely available.

We have made a start. And again I want to thank you for the role you have played. Since July last year heart patients waiting more than 6 months for surgery have been offered the choice of early treatment at an alternative hospital – public or private – which has the capacity available to treat them. Over 1,700 out of 3,800 patients – almost half – decided to make that choice.

They are not the only patients to benefit. Since October last year patients in London waiting for a cataract operation have been able to go to another hospital for treatment if they have waited 6 months. Over two thirds have chosen to do so.

I now want to explain how we intend to build on these first pilot schemes. We want to extend choice to other geographical locations and other clinical specialities. In the next year around 100,000 extra patients will be able to choose in which hospital they are treated. The sites we have chosen include those where waiting times are longest and where electronic booking of hospital appointments is being tested.

First, from this summer all patients in London waiting more than 6 months for any form of elective surgery will be offered the choice of an alternative hospital.

Second, from July patients in West Yorkshire needing eye operations will be offered choice when they are referred to a hospital specialist by their GP. In Greater Manchester those needing orthopaedic, ENT and general surgery will also be offered choice if they have been waiting longer than 6 months.

Third, also from July, choice will be extended to patients, mainly older people, needing cataract operations in the south of England where waiting times are currently longest. Patients will be able to choose, initially from two and then normally from four hospitals, where to have their cataract operation. The aim is to cut waiting times to 6 months by 2004 and to 3 months by 2005. For cataract patients in the south, this means that the NHS Plan target will be achieved three years ahead of schedule.

Fourth, the lessons learned from these areas will inform the extension of choice across the whole of England’s health service. From summer 2004, as the Prime Minister announced recently, all patients waiting six months for any form of elective surgery will be able to choose at least one alternative hospital and normally four – public or private – for treatment.

Fifth, from December 2005, by when extra capacity will have come on stream, choice will be extended from those patients waiting longest for hospital treatment to all patients. They will be offered choice at the point the GP refers them to hospital. Patients needing elective surgery will be able to select from at least 4 or 5 different hospitals, again including both NHS and private sector providers. Millions of patients a year will benefit.

Sixth, as capacity grows further in the NHS so choice will grow. Beyond 2005 patients needing surgery will be able to choose more hospitals in which they can be treated.

And choice needs to be embedded across other parts of the NHS where it is appropriate to do so. In primary care, for example, pharmacists will help more patients manage their medicines. More drugs will be sold over the counter rather than needing a doctor’s prescription. NHS Direct will provide more advice and information to more patients. And more NHS Walk-in Centres will allow more patients the choice of where to be treated.

There need to be other changes too. In a busy mobile society patients should be able to register with a GP practice near where they work if that is more convenient for them. The published Framework Agreement for a new GPs contract also opens up the prospect of greater choice. Patients who have traditionally been referred to hospital for minor surgery or for outpatient consultations could be seen instead in their local health centre by a specialist GP.

These reforms are about embedding choice across the NHS – from primary care to hospital services. They will require changes in the way the NHS works.

Patients will need help to make informed choices. Knowledge is power. To make choice work, the NHS will need to provide reliable and relevant information to patients in a way people can understand.

In primary care, for example, PCTs will need to use the annual patient prospectus, they issue to all the households in their areas, to highlight where women patients are able to see a woman GP. I can also announce today that later this year we will publish local guides to maternity services so that mums and dads-to-be are better informed about the choices available to them.

More generally we intend to make available easily accessible information on hospital performance, quality and waiting times so that as capacity grows in the NHS patients are able to exercise greater choices. The job of GPs, nurses and other members of the primary care team will increasingly focus on helping navigate patients through the care system so that they can make the choice that best suits them.

To make choice work there has to be better IT across the whole of the NHS. The huge investment we are making in IT will support this extension of choice. Electronic booking of hospital appointments from the GP surgery will be a reality in all parts of the NHS by December 2005. There will be more information to compare hospitals not just on the internet but through NHS Direct and touchscreens in GP surgeries, pharmacies and other locations. We are also exploring experience from other countries. In Bologna for example, patients themselves, after they have been seen by their GP, can book their hospital appointment, not just through their family doctor or pharmacist, but through a specialist call centre. The system gives patients more direct control and relieves burdens on GPs.

Choice requires diversity in capacity. A new generation of DTCs will be providing care to 250,000 patients a year by 2005. Insulated from emergency work these will be able to concentrate on elective surgery and shorter waiting times. Some will be run by NHS providers. Others by private sector providers. In making their commissioning decisions PCTs will need to consider how best to use both existing and new private sector provision for the benefit of NHS patients. They will also need to consider how best to use voluntary sector providers. I can tell this conference that, following discussions with key voluntary health care providers, I am planning to draw up a concordat to extend the relationship between the NHS and the voluntary sector.

And choice will only work if there are the right incentives in the system. From this April we will begin to move to a new system of payment by results for NHS hospitals. Resources will follow the choices patients make so the hospitals which do more get more; those which do not, will not. We will put in more help for hospitals that are struggling to improve. And, alongside this external assistance, these new incentives will act as a spur to improvement. Over the next four years an increasing proportion of each hospital’s income will come as a result of the choices patients make. Choice in other words is not just about making patients feel good about the NHS. It is about giving the patient more power within the NHS.

All these changes will take time of course. Giving patients greater choice in the NHS requires a fundamental culture change in how the health service works. It will put patients in the driving seat – at the heart of the health service – and not before time. Patients will be able to choose hospitals rather than hospitals choosing patients. There will be more choice in primary care and in maternity care too. This is a world away from the 1940s take-it-or-leave-it top down service.

For too long, for too many, the choice has been to pay or wait. Mrs Thatcher talked about getting treatment at the hospital of her choosing, at the time of her choosing. Her choice though was to opt-out of the NHS altogether. Our choice is for the NHS but a reformed NHS.

An NHS where more can have that choice of time and place of treatment; where more can share in choices previously only enjoyed by the few who could afford to pay; where people choose to stay with the NHS not opt-out. An NHS which genuinely puts need before ability to pay. That is what our reforms are about. That is what we intend to deliver.

Below is the text of the speech made by the then Chief Secretary to the Treasury, Alan Milburn, to the PFI Transport Conference on 2nd February 1999.

Introduction

Thank you Adrian for your warm welcome. We have been very privileged to have Adrian Montague to head up the Treasury Taskforce on PFI. Under Adrian’s leadership the Taskforce has done a first class job – getting actively involved with projects on the ground and enabling progress where previously there was deadlock.

What I would like to do today is to outline the Government’s progress on PFI, the further plans for reform we have in mind and our wider commitment to developing and defining other forms of PPP.

Government’s progress with PFI

Indeed, since we came to office in May 1997, this Government has revitalised PFI so that today we can rightly say that it is a key tool in helping provide effective and good value public services. Since the election, we have signed £4 billion worth of PFI deals and we have got PFI working in sectors like health where it had not worked before. By the end of this year, we estimate private sector investment in PFI projects will account for around 14% of overall public sector investment. Accompanying this turnaround has been a tremendous upsurge in confidence both in the public and private sectors that PFI can deliver the goods. And we are now seeing its benefits spread to other parts of the public services such as our schools.

As Lord Whitty will explain later, transport is a sector that led the way in PFI. It’s worth remembering that it was John Prescott a decade ago who first proposed the sort of public private partnerships arrangements that are now delivering the goods in transport. Schemes on the stock range from those of national and indeed international significance such as the Chunnel high speed rail link to smaller schemes such as the Nottingham Express Transit where PFI is making possible an integrated public system within a busy urban area.

The Government is proud of our record on PFI. We have been able to get it moving for three reasons.

Firstly, because when we came to office we were prepared to take tough decisions. In my previous job as Minister for Health for example we had to prioritise a number of major new hospital projects in order to break the logjam that had been allowed to build up. Health service need now dictates which PFI projects get the go ahead. To date 25 new hospital developments have been given the green light as part of the biggest hospital building programme in the history of the NHS. Work on 9 is already under way. The challenge now in the NHS is to get PFI working in smaller scale projects in primary care, mental health and at the interface with social services.

The second reason we have made been able to make PFI work is because we have been prepared to take head on some of the logistical problems that bedevilled PFI in the past. As you know, one of our first actions was to appoint Malcolm Bates to review the PFI process. He did a great job in analysing problems and more importantly finding solutions. Since Malcolm reported we have fully implemented all of his recommendations.

We have also recognised the importance of getting the management of staff right when evaluating bids and contracts. Openness between bidders, trade unions and staff is an essential part of any well run procurement process. PFI should not be a secret process because it is about providing better services to the public. That is why we have published guidelines for the consultation of staff and other interested bodies.

The third and final reason why we have been able to rejuvenate PFI is because this government is committed to public private partnerships in general and PFI in particular. In the past, the dogma of the right insisted that the private sector should be the owner and provider of public services. And the left insisted this was all the responsibility of the state. The modern approach to public services rejects these arguments both of the old right and the old left.

In some areas, the private sector is best able to provide the services. In others, the public sector is in the best position. And in many cases the best way forward is through new partnerships between the public and the private sectors. Where each brings something to the table. Where we combine private sector enterprise experience with public service values. For this Government the key test is what works. We recognise that what the public want is better quality, more responsive public services. Quite rightly, they want their services to be both dependable and modern. Their concern – like the Government’s – is about outcomes not ownership.

This is where PFI fits in. One of the main drivers behind it is to give the public sector what the private sector has long expected to be the norm – modern, well-designed purpose-built buildings that maximise savings over the whole life of the project. Better designs means less wasted space, more efficient energy management, lower maintenance costs. It also means more savings that can then be reinvested in frontline services.

Take the example of the contract recently signed by Falkirk Council, involving the replacement of five schools. It has been enthusiastically received by teachers and pupils alike who all stand to benefit from a decent environment for education. It is also delivering a 15% saving over the life of the contract compared to conventional procurement.

So we are pioneering new ways of doing things. New partnerships between the public and private sectors. A new understanding that improved public services and better value for money go hand in hand. The Government is committed to investing in our key public services. From April this year there will be an extra £40 billion for health and education. But it is not something for nothing. It is money in exchange for modernisation. PPPs and PFI are one way we are pursuing our investment for reform agenda.

And we will go on doing so. We have come a long way in the last 21 months. We are proud of what we have achieved but we recognise that there is more to do to make PFI and PPPs more generally a genuine national success story.

First, then we will be taking action to make PFI deals easier to complete. We are now looking at how to streamline the process of putting a PFI deal together. There is little doubt that the similarities between many PFI deals means that both time and money could be saved by having more standard template contracts. We will publish a guidance paper on standard model clauses by the end of this month. And next month we will publish guidance on accounting treatment that will help determine the optimal level of risk transfer that will deliver value for money.

These are both important developments in PFI because they will improve the efficiency of procurement, reduce transaction costs and secure better value for money.

Bates II

Second though we will continue to improve, identify and develop new opportunities and partnerships with both the public and private sectors. As many of you will know, with the impending expiry of the Taskforce’s 2 year mandate this summer, we have asked Sir Malcolm Bates to take a second look at the PFI and public private partnerships more generally to see how the government could further improve our approach.

I am not able to speculate about the contents of Sir Malcolm’s report but I am looking forward to reading his report in a few weeks.

Looking beyond PFI

What I can say at this stage is that the Government is committed to taking forward a whole range of public private partnerships. That will of course include PFI but not to the exclusion of other forms of partnership. We are committed to making PFI work even better. But not all of our eggs will necessarily be in the PFI basket. Again for us what counts is what works.

One of the reasons we extended the terms of the second Bates review is that we want to develop PPPs further to exploit all commercial potential and spare capacity in public sector assets.

Because we are not wedded to a single model for financing arrangements, it means there are new opportunities opening up to enable us to modernise the infrastructure and improve the quality of public services. We need look no further than the Channel Tunnel Rail Link to see the benefits of our flexible approach. Here we are completing the fast rail links between London, Brussels and Paris by restructuring the deal so as to make it commercially viable.

Elsewhere in transport we are developing very different forms of PPP. In the case of London Underground and National Air Traffic Control, for example, we are restructuring public ownership. Here PPPs are allowing investment above and beyond what would be possible directly through Government. And so we can begin to tackle the legacy of under investment and inadequate maintenance in those organisations.

Elsewhere we are pursuing other public private partnerships that involve greater commercial freedom for services with a core public function. The Post Office and the Royal Mint are good examples.

Our Wider Markets Initiative takes a different approach still. It is looking at how we can make better use of the public sector’s great many under-utilised assets. Some assets are surplus – so it seems a nonsense to hold on to them. Other assets can’t be disposed of but are under-utilised. So we are looking at how we can use these assets to the benefit of both the private and public sectors. So for example, the private sector might take a lease, run it, and bring private sector work and services into it. Or make recreational use of Forestry Commission land. Or commercially exploit the intellectual property derived from defence research.

Each project is different. That reflects different problems and different motivations in very different settings. Improving the quality of public services. Getting value for money. Providing incentives for effective business management. Correcting under-investment. Sweating public assets. Optimising capital investment flow. This diversity calls for the development of new approaches to enable public and private to work together. The Government will be taking a lead in that process in the months ahead.

Conclusion

In developing and defining PPP models we will build on our success in getting PFI working. Ours will be a twin track approach. One, improving and extending the PFI. Over the next three years we expect that PFI deals will contribute £11 billion pounds worth of investment in our public services. And two, building on the reservoir of expertise that is growing by the day in both the public and private sectors in finding forms of PPP that best suit the specific needs of particular public services. Today’s conference will help build that capacity still further. I am sure you will find it productive. Thank you for listening.