Tag: John Reid

Below is the text of the speech made by John Reid, the then Secretary of State for Health, on 10 June 2004.

We have launched the biggest and most comprehensive consultation, discussion and debate on Public Health that this country has ever seen. It has one objective – to encourage everyone in the country to achieve a longer, healthier life – by adopting a healthier lifestyle.

For many people that may involve a changed lifestyle – changing diet, exercising more, drinking more moderately, or stopping smoking for instance.

If we are to succeed in this all of us know we have to recognise one central reality. We want everyone to change, because everyone can benefit; but we recognise that not everyone will find it as easy as every one else to achieve change.

This is not just because they are weak-willed or lack motivation or because they don’t want to be more healthy or live longer, but because each of us lives our life in different and unique circumstances.

Of course men and women have free will. But they don’t exercise that willpower in the same circumstances as each other, or in circumstances of their own choosing. That is the central realistic point we have to address.

So, if we really want to help people change their lives, then, for many, we will have to help them change their own social circumstances.

That is why it has been so important for this Government to tackle poverty, poor housing, lack of family support and social exclusion.

And we never forget either that when taking into account these different circumstances we are dealing with human beings, not social statistics or medical records.

That is why our great consultation on Public Health is not primarily about what we want to achieve. We know what we want to achieve, what the consultation has been about is how we are going to achieve it and how we are going to balance the health outcomes we want to see, with the personal control and social freedoms that all of us want to maintain.

So we need to discuss issues like obesity, for instance, with a sensitivity that recognises the possible hurt and embarrassment that people, especially obese young people, might feel. We don’t forget that a whole gamut of social, medical and psychological factors may underlie obesity as well as the more obvious factors, and may make combating obesity a greater struggle for some than for others.

When we talk about healthy diets, about fresh fruit and vegetables, we always have to remember that low incomes, single parenthood, large families, or geographical immobility can constitute huge barriers to healthy eating for some people, barriers which simply do not exist for other people in more fortunate circumstances.

And when we discuss smoking, drink or drugs let us never fail to recognise that social deprivation, straitened circumstances or lack of affordable alternative social horizons do make it much more difficult for some of us to kick the habit than it might be for others in more conducive circumstances with greater social alternatives.

Sixty years ago we dedicated ourselves to equal access to health care in this country. We intended that there should be reasonable equity in health outcomes for everyone. And yet, here we are, some six decades later with the glaring differences in health between different sections of our population. One of our great failures has been the remaining inequalities in health, particularly among working class and ethnic communities. I very much want to see those inequalities eroded. But if we cannot even begin to discuss, question and honestly explore the circumstantial setting and cultural factors which might have led to those inequalities – honestly search for the barriers to our message getting through – without the sort of hysterical reaction we have seen in certain quarters in recent days, then it perhaps begins to explain why we have failed in the first place.

So, above all, let’s all be grown up enough to understand that to take these circumstances into account – to try to understand other people’s position, motivation, and point of view – is not to urge people to continue unhealthy eating, excess drinking or smoking. Quite the opposite, because it is precisely by recognising these factors that we can spur ourselves to change social reality for so many, and it is the failure to recognise them which would ultimately condemn us to failure in our quest for better public health.

I truly believe that if we were ever to make that mistake, or to try to proceed by uniform diktats rather than by carrying people with us wherever it is possible – then our campaign will inevitably fall short again – precisely because it will not reach those parts of our community and society that has so far had the worst health outcomes and where it is most needed.

So the message is clear. In our style we should and will be encouraging, assisting, persuading, and supporting people wherever possible – not hectoring, condemning or didactic.

It is my view that in a free society, dictation should always be the ultimate, default position, not an eagerly embraced starting point for everything.

So our task is not to ask people to overcome insuperable social circumstances on their own, nor to dictate how they will live their lives, but to empower them to more easily change their own lives by changing these countervailing circumstances, combating poverty, homelessness or isolation as an integral part of our struggle for better public health in Britain.

Below is the text of the speech made by John Reid, the then Secretary of State for Health, on 26 June 2004.

It’s a year since I made my first major speech as Secretary of State for Health to the Confederation. I remember that very clearly – newly arrived, anxious about the detail and the acronyms that I didn’t know, but sure that I knew and was passionate about the values of the NHS. Those values inspire and invigorate us as we shape the vision for the continuing renewal of the health service in this country.

You will know that this morning I made a statement to the House of Commons about the next steps in delivering the National Health Service Plan.

My preface to the plan we published today starts by saying, “The NHS was founded on two fundamental principles. The first is that there should be equal access to treatment for all, based on clinical need and regardless of ability to pay. The second is that collective funding of the NHS, through national taxation, is the most effective way to ensure that quality care is available to all”.

For me, these are not empty words. They are a real guide to our actions. And to carry them out, to bring them into reality we will all have to work very hard and very differently.

Lets remember the context of 1997, we inherited public services in a state of widespread dilapidation – a claim almost no-one would deny. This wasn’t because public services and their staff were somehow inferior. The problem was too little resource, and therefore grossly inadequate capacity in terms of staff and facilities.

By 1997 the hospital building programme had ground to a halt. Waiting lists were rising at their fastest rate ever. Nurse training places had been cut by a quarter. Training places for GPs were cut by one fifth.

There was no maximum waiting time either for a GP appointment or for hospital treatment – although the hospital waiting lists stood at 1.1 million and many patients were waiting more than a year, with rates of death from cancer and heart disease amongst the highest in Europe.

It was in response to those conditions that together we developed the 10-year NHS Plan launched by the PM with the words:

“The challenge is to make the NHS once again the health care system that the world most envies.”

I can report to you today that we are making good progress towards this goal, and that’s down to your work and your staffs’ hard work. I thank you most sincerely.

In the last four years we have succeeded in expanding the capacity of the NHS. I hope you know these achievements off by heart, but just in case you don’t, there are now:

– 67,500 more nurses working in the NHS compared with 1997
over 19,000 more doctors

– 68 major new hospitals built, underway or planned the largest ever hospital building programme.

But these are just the means to the real end, improved services for patients. There are now:

– over 258,000 fewer people on the inpatient waiting list compared with March 1997

– virtually no waits of over 9 months for a hospital admission – down from over 18 months in 1997

– over 97% of people can see a GP within 48 hours

– almost 19 out of every 20 people seen, diagnosed and treated within 4 hours in A&E departments.

We said that we would put in place reforms to ensure services improved. We have brought in new contracts, new institutions and new services such as NHS Direct and NHS Walk-in Centres and we have embarked on the world’s largest health related IT programme.

Most importantly we said that outcomes for patients would improve as a result of this investment and these reforms. They have.

– Cancer death rates are down by over 10% since 1997

– Cardiovascular disease death rates are down by over 23% since 1997

– It’s because of figures like that that I am sick and tired of hearing NHS staff constantly maligned as unproductive bureaucrats.

The truth is that we are delivering more treatment, more quickly, to more people than ever before and there are thousands of people alive and well who would not have been even a decade ago.

But I have always claimed significant progress, never perfection. That is why we are making a radical new set of proposals to develop the NHS plan. By 2007/8 we will be spending over 90 thousand million pounds of public money on the NHS. In return for such expenditure we must be ambitious.

Our vision must be to meet the expectations and ambitions of people. We must provide a service that is fair to all of us and personal to each of us, offering the same access to, and the power to choose from, the widest possible range of services of the highest quality, based on equality of access, clinical need and not ability to pay.

But, I want to start off by saying what there isn’t in this programme. There are no changes in structure; there are no changes of direction. What we will do is make the present structure work and move faster in the agreed direction.

There are four main issues. We must ensure that we are able to transform the way patients experience the health service. With the continued increases in capacity and as waiting times come down, we are now in a position to aim for a maximum limit to the whole patient journey of 18 weeks, from GP referral, through outpatients and diagnostic tests, to treatment. The whole journey.

Then, with dramatically shorter waiting times for treatment, “how soon?” will cease to be the major issue. “How?”, “where?” and “how good?” will become increasingly important. Patients’ desire for high-quality personalised care will drive the new system. Giving people greater personal choice will give them control over these issues, allowing patients to call the shots about the time and place of their care, and empowering them to personalise their care to ensure the quality and convenience that they want.

Second, alongside this improvement in access, we want to give patients a greater degree of choice in where they access treatment. We want all patients to be able to choose from a range of services that best meet their needs and preferences.

People will be able to book their hospital appointments for a time that suits them, from a choice of hospitals:

From April 2005, patients who need a heart operation will be offered a choice of provider from the time they are referred for treatment

By December 2005, all patients who need surgery will be offered a choice of 4 to 5 alternatives at the time they are referred for treatment by their GP.

We want to go further. By December 2008, every patient will be able to choose to be referred to any treatment facility that meets NHS standards and which can provide care at the NHS price for the procedure that they need.

That choice will be for all – not just for those of affluence or influence and will be available because of the extra capacity and lower waiting times.

This is not a false choice such as the one advocated by some, which is available to those with the money to jump the queue. This is choice for everyone, paid for by the NHS, equally.

Third, we will also extend the greater personalisation of patient care to people with chronic and long-term medical conditions. Some 17.5 million people – have their life dominated by conditions that cannot be cured – diabetes, asthma, heart failure, some mental health problems. Providing them with the personalised support and care that they need and deserve to live fulfilling lives will be a priority. We will do this by providing thousands of community matrons, rolling out the Expert Patients Programme across the country and ensuring that the new contract for GPs delivers the best care for patients.

Fourth we also need to ensure that the NHS becomes more than just a sickness service. We have a duty as a Government to ensure that everyone has the chance to live a healthy life.

The White Paper that I will publish in the autumn will set out in more detail our plans to tackle the major causes of ill health, including smoking and obesity. We have called that White Paper ‘choosing health’, because our policy is to encourage more people to make more healthy choices.

We also want to work with people to improve the conditions that effect their choices – giving people a better chance to make those choices.

These improvements will be underpinned by strong reform. By 2008:

– The national IT programme will ensure that patients can make informed health choices and can increase the efficiency and effectiveness of NHS staff

– NHS Foundation Trusts will have become the norm for hospital care, enabling local hospitals to respond more quickly to their patients’ needs;

– PCTs will be able to commission care from a wide range of providers, including those in the independent sector;

– The new system of payment by results will have been fully implemented, supporting patients as they exercise choice and ensuring that there are strong incentives for the NHS to make the best use of resources.

The NHS University will ensure that NHS staff are given more help to train and learn new skills

Fewer national targets will be set, ensuring a greater degree of local flexibility to respond to local health needs and reducing still further the extent of central involvement in the running of the NHS.

I am also pleased to formally announce today that our plans to establish a new employers’ organisation under the umbrella of the NHS Confederation are coming to fruition and the new organisation will be in place in October.

The employers’ organisation will provide an authoritative voice for NHS employers. Within the context of Government policy and resources, it will have responsibility for conducting national negotiations on pay and conditions. It will represent employers’ views and support them through guidance, advice, information and research.

These are improvements that will re-define the service that patients can expect from the NHS. An NHS characterised by:

– Commitment, not ambivalence

– Investment, not cuts

– Access based on need, not ability to pay

– Queue cutting, not queue jumping

– Fair for everyone, not just the rich few

– Personal to each of us, not just those who can afford it.

Conclusion

Over the next four years we all have a big chance to develop an NHS which will meet the aspirations of today’s people. To secure the NHS as a part of the personalised world of today and to demonstrate that the greatest gift from the people of this country to the people of this country is able to meet the expectations of people in the 21st century.

Below is the text of the speech made by John Reid, the then Secretary of State for Health, on 23 September 2004.

Philosophy, Policy and Priorities: The philosophy of health improvement

I’d like to thank the Health Development Agency for the timing of this debate, since improving the health of the public has never had such a high-profile in the Government, in the media or in the public mind.

As you are all aware, we will shortly be publishing a Public Health White Paper, which will bring about action to produce real change. I am not going to tell you the detail of that White Paper today, but I do want to describe the philosophy behind it and how that philosophy informs the new Labour Government’s attack upon inequalities.

I don’t want to alarm you, but I would like to start with the Enlightenment. At that time it was recognised that mankind collectively and individually could make the world, rather than be made by it. Making things happen was not magic. It was nature, and we could all begin to fully understand nature, and then given that understanding we could control it.

This is not abstract philosophy; in terms of health it is very concrete indeed. Over the last 200 years we have systematically understood aspects of health and disease and illness and then turned our attention to mastering them. Decade after decade, mankind has mastered more about health and disease and kept millions alive and in good health.

In this country in 1900 most people died before they were 45 years of age. Now only 5% do. If control of nature by mankind means anything it means being alive longer. The speed of growth in our understanding and control of disease has been such that most interventions we carry out today were science fiction in my youth. Where a nation has the resources, humankind is winning the fight against disease. All of that is progress.

Alongside our collective knowledge and mastery of disease there has been a growth in individual mastery. More people in our country have the resources and the knowledge to be more in control of and have more power over their mental and physical health than ever before. In terms of health and health policy, we know what to do to make us healthier and we know that both for ourselves and for the nation.

As we approach the White Paper on health it is clear that knowledge is not our problem. So, given 200 years of the enlightenment, and all this knowledge, what is the problem?

Put simply, it is that whilst we constructed an ever greater intellectual mastery, this intellectual power was developed in a society where the economic, social and political power was not equally distributed. This imbalance did not effect the creation of ideas but it has had a big influence on the application of these ideas – the way in which those ideas had an impact on society. One example of this is the way in which the people who developed the ideas conveyed them to the public. So, at the time the great philosopher Hegel was writing, only a very small part of the population could read and understand him. No one bothered to ensure that important ideas were distributed to the great mass of the people.

Consequently, the conditions under which the mass of the population lived meant that these powerful ideas passed them by. Until people had more control over their lives, they could not use these ideas. And, unless the ideas were actually in the hands of people, they could only change a part of the world.

Over time, of course, more people become better educated and therefore more powerful. More people became more affluent and therefore more powerful. And more people understood more about how to improve their health and became more powerful.

Some of the more impatient amongst you may be beginning to ask “What on earth has this got to do with health improvement and inequalities”?

Well, mastery is increasing in health. Now, more people are trying to control their health than ever before. Two thirds of smokers want to give up and struggle to do so. Millions of people try to go on a diet and millions more try to increase the amount of exercise that they do. People have got the ideas right. They know what the intellectual answer is. The problem is the doing of it.

But still, many people are left behind in this mastery of their health environment. For too many, their environment masters them and overcomes their ability to act. Ideas do not by themselves give people the mastery of the world, or mastery of their health. To do that we have to work with them to change their environment.

Therefore, men and women make their own health, but do not do so under conditions of their own choosing. So, whilst the engine of health improvement is the individual’s control over their own life, it is not enough to say to all the individuals in our society that you can choose to make your own health, because the different economic and social conditions under which we live either differentially hinder or help our choices. Those with more financial resources generally have more choices, as do those with more educational qualifications.

So, the priority this Government has given to improving health and tackling health inequalities is rooted in the fact that health and life expectancy are linked to social circumstances in adulthood and childhood.

Political, social and economic equality only improves when previously disadvantaged people work to change their position in society. Government and public services can and must assist this process, but people’s own motivation is at the core of change. The core of my philosophical approach is to increase the power that people have over their own lives and opportunities – to empower them and to enable them to effect changes in their circumstances. If people don’t do the hard work of taking up that opportunity, of exercising that power – very little happens at all and equality of outcomes does not improve.

Work is a crucial part of the social and economic experience and to be excluded from it is a very serious inequality. Being unemployed can be bad for your mental and physical health as well as excluding individuals from society and benefits that others have access to. This is why we have very specific employment policies for very specific groups of unemployed people.

Our employment policy does not come through diktat from the centre but through personalising policies for certain groups. 493,000 young people have moved from the New Deal into work and, without New Deal, long term youth unemployment would have been twice as high. New Deal 50 plus has supported 110,000 older workers in taking up work. And over 260,000 lone parents have been assisted to move into work through the New Deal. The proportion of single parents in work has increased by 8%.

Each of these people has taken up a difficult opportunity to change their lives. They have each changed the conditions under which they live and have gained more control. This puts them in a better position to take more control over their health.

Gaining educational qualifications are another area where people can gain more control over their lives. Some time ago, the Government introduced policies for the teaching of literacy and numeracy in primary schools. At the time, it was felt by some that if 11 year olds were being judged against a standard it would be bad for students who had disadvantaged backgrounds. The accusers’ expectation therefore was that this policy was NOT about improving equality, but that the pressure to achieve would make matters worse for disadvantaged children.

It is interesting, even if with a few years of hindsight, to look at the outcomes. One of the proxies used in education for poverty and inequality is whether the child receives free school meals. A school where less than 8% of children receive free school meals would represent a school represented largely by better-off parents. A school where over 50% of them received free school meals would represent worse-off parents. If the first group of schools improve faster than the second group, then inequality can be deemed to be getting worse. If the second poorer group of schools improve faster than the first then by implication equality improves.

In 1997 there was a gap in Key Stage 2 English achievement between the better-off and the worse-off schools of 35%. In the poorer schools less than half – 42% – achieved the required level with nearly twice as many in the better-off schools reaching that level. Over the 6 years from 1997 to 2003, under New Labour plans and programmes, both groups of schools improved. But the better-off schools improved by 8%, while the poorer schools improved by 17%.

In short, since 1997 it is not just the fact that more 11 year olds can read and write, but it is the fact that children from poorer schools have been improving at twice the rate of children from better-off schools.

In maths the rate of improvement of the poorer schools is nearly three times that of the better-off schools and in science it is two and a half times better.

New Labour’s literacy and numeracy hours have reduced educational inequality despite all the initial criticism. They have done so by assisting pupils in schools with poorer backgrounds to develop the motivation and opportunities to learn.

Let me return to my main theme. If we want people’s health to improve, then we have to unlock their motivation to gain more control over their health. If we want to achieve that for everyone then a prior condition for disadvantaged people is to unlock their motivation to improve their condition perhaps through work, perhaps through education.

All of these policies for reducing health inequalities, either directly through addressing health, or indirectly through addressing the constraints on people’s ability to chose, recognise the importance of unlocking motivation.

The Government needs to support disadvantaged people as they struggle to get motivated to either improve their health or take more control over their conditions, but it is their motivation that is the defining characteristic of change.

Our philosophical approach is that our health and our inequality policies must be about empowerment. Getting a job improves the amount of power a previously unemployed person has over their life. Learning to read and write improves the amount of power that people have over their lives. Choosing the time you go for a hospital appointment and choosing the doctor you see, gives you power over your life, and yes, giving up smoking gives you power over your life. Government policies to reduce inequality must give you more power over your life. The Government that achieves this will enable people rather than just instruct them, hector them or try to dictate to them. In fact the Government that only instructs people takes away from the power of people and reduces their capacity.

The problem with the enlightenment philosophers was that they thought that having the great ideas was enough to provide control of the world. What we learnt in the 19th and 20th century is that people needed to be economically, socially and politically emancipated to enable them to work to develop not just the idea of controlling their own life, but to make that idea a reality. Throughout the last 200 years it has been the people’s own struggle for improvement that has been the bedrock of economic and social progress.

So I believe that the lessons for us in health improvement are clear. We know the ideas that need to be applied. Enjoy the good things of life, but in moderation. Cut out the bad things of life as much as possible. But the problem is in doing this. It is not just a matter of motivation. The millions of people trying – and failing – to improve their health are a signal of this. They know what needs to happen, they try and try, but it is just too hard.

Given this philosophy the aim of Government is two fold.

First, we need to provide clear leadership to our whole society about what are healthy choices and how important it is to struggle to gain control of your health. This leadership must recognise that these healthy choices are sometimes very hard choices for some individuals, but through clear and consistent information we must bolster and increase individuals motivation to improve and gain control of their health.

Second, whilst this whole struggle depends upon individual motivation, Governments need to provide the support for people to improve their health. This involves the NHS in developing smoking cessation services that are convenient and are easily accessible. It involves ensuring that the services for sexually transmitted diseases can be easily accessed without shame. It involves the NHS recognising how important and how difficult health improvement is for patients and providing real and sympathetic help.

So our philosophy is clear. Without people’s motivation very little health improvement will happen, but people have a right not to do this hard work on their own. They have a right to look to Government for practical support and we aim to provide it.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

But we need more than just increases in capacity.

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

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

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

Choice and capacity building are partners, not enemies.

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

I disagree with them on two counts.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

– Trying to make the most of a small income.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What assistance should Government give to parents in tackling obesity?

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

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

Or, to take a different challenge,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Below is the text of the speech made by John Reid in Belfast on 4th April 2001.

I am delighted to be here tonight to celebrate the very best of business in Northern Ireland.

We are here to celebrate your achievements. In different ways all of you are pushing forward the boundaries of what is possible. Exploring new avenues, forging new partnerships.

And we are here because we share a vision. All of us are actively seeking to build a new Northern Ireland:

– a new political landscape, based on equality, mutual respect and lasting peace

– and an economy based on innovation, enterprise and investment.

And everywhere there is evidence that peace pays:

– unemployment continues to fall – unemployment in Northern Ireland now stands at 5.9% – well below the EU average of 8.1%.

– investment in manufacturing is up 75% over the last 5 years (compared to a UK average of 16%).

– overseas investment is pouring in. Last November Fujitsu announced that they were setting up a £29.4 million engineering centre in Belfast. This will create 400 jobs for skilled engineers over the next 4 years.

– new domestic investment has been just as impressive, with £564m invested in the last 4 financial years.

There has never been a better time to do business in Northern Ireland. But you don’t need me to tell you that we cannot rest on our laurels.

The world is changing. The coming years will bring advances that our minds cannot even conceive of today. They will bring new political alignments in Europe and further afield.

But these rich promises come with a warning: as the globe shrinks, as the communications revolution permeates even the remotest areas, we will have to fight harder not to be left behind.

Because business is changing.

E-commerce and e-business are radically changing the nature of individual businesses and indeed entire economies around the world.

Northern Ireland has made a good start. It is at the leading edge of the design and development of communications hardware and software for a worldwide market.

There is an advanced and reliable telecommunications network that ensures fast Internet access. An environment that encourages and rewards innovation through support for research and development in knowledge-led areas.

And the educational infrastructure is in place: university research centres of excellence, working alongside industry. A supply of quality IT and electronics graduates, post-graduates and experienced personnel. And there is already a significant cluster of internationally successful IT companies.

But business will only get faster, competition fiercer. And Northern Ireland simply cannot afford to be left behind.

Thousands of new jobs could be created in Northern Ireland over the next five years and hundreds of thousands of existing jobs sustained if we immediately grasp the exciting opportunities presented by the Information Age.

It presents us with a simple choice: we can do what we’ve always done and lose out. Or we can transform the economic landscape, with the simple tool of human intelligence.

Education is the single most important weapon in our fight to promote innovation, excellence and inclusion.

In this new world it will be knowledge that divides the haves and the have-nots. So, above all else, we must equip our younger generations to lead the line in technological advances.

We must build a society, a political culture and the sort of progressive, innovative economy that makes young people want to stay here in Northern Ireland.

For too long we have had a political culture of ‘name and blame’ rather than one that seeks collective solutions.

For too long, too many young people have felt that their talents are wasted here, that their lives are less than they might be elsewhere. They are the forgotten casualties of past conflict.

For too long the images that have gone round the world associated with Northern Ireland have been those of conflict and there are still those like the bombers who placed the device outside the BBC in London who are determined to condemn Northern Ireland in the eyes of the world. Every television bulletin that carried those pictures was one less potential job for Northern Ireland.

That is the perception that we must reverse. That is why we all – Governments, political parties and people – must accept our responsibilities as well as our rights under the Good Friday Agreement.

Opportunity for all, matched by responsibility from all.

That is our duty to the next generation.

The political progress of recent years has helped to stem that haemorrhage. But we must do more: we must attract the Northern Ireland diaspora back from Silicon Valley and from the Boston corridor.

We must build centres of excellence of our own.

Northern Ireland has a talented, motivated, educated young population. They are crying out for the chance to fulfil their potential where their homes are and where their families live.

Already that outward migration has been reversed. For the first time in our history, more people are streaming back than are leaving our shores. But I want to turn that stream into a tide.

That should be our promise to the next generation.

They – and the world – will not understand if we choose to cripple ourselves in parochial disputes, to channel our potential into destruction, not creativity.

We will only survive if we command respect, not inspire sympathy.

The last century in Ireland was one of almost continual political conflict. A century of devastating, futile violence. Of wasted lives.

This must be a Century of opportunities seized, not squandered.

Tonight I can tell you: this Government will not shy away from change – social, political or economic. In partnership with business we can take this new world by the scruff of the neck. We can shape it and make it work for us.

And we can look our younger generation in the eye and say: there need never be refugees from Northern Ireland again.