Given by Welsh Assembly Government Health and Social Services Minister, Jane Hutt

Thank you for the invitation to deliver this year’s annual Nye Bevan Lecture. It is, of course, one of the most important honours which can come the way of any health Minister – and particularly a Welsh Health Minister to follow, even at a distance, in the footsteps of the most towering figure of Welsh politics and of the politics of the Labour movement.

I plan to spend time I have revisiting, re-examining and reviving a concept which holds a central place in the traditions of Socialist and Labour movement thinking, which badly needs to be recaptured and revived in the way we go about applying the traditions to which we are heir, in today’s world, here in Wales.

The concept I want to explore is that of trust – trust which, as a recent Reith Lecturer observed, is ‘hard earned and easily dissipated’. My focus will be upon Trust between citizens and the State and Trust between the public and the public services, and, in particular, between those who rely on those services and those who work in them.

Even though it is some 14 years since Mrs Thatcher was ejected from Downing Street, the legacy of that worst of decades, the 1980s, continues to be felt powerfully in our own lives. Nowhere is that more powerfully felt than in the deliberate destruction which Thatcherism applied to the concept of trust as a social good and as an integral part of a progressive, co-operative politics. It was the very essence of New Right thinking that trust relationships had to be broken down in the pursuit of a more competitive, more ruggedly individualistic society – one where inequality was not regarded as the enemy of social cohesion, but as the necessary spur to personal self-advancement. In Thatcher’s world, the compact between the citizen and the State, established in l945, was repudiated and reviled. In that great post-war Labour Government, the bargain was clear – people, by hand or by brain, made their contribution to society in peacetime, as they had in war. In return, the State guaranteed a new set of social rights – to employment, to a minimum income, when not in work, to education, to decent housing and to a National Health Service.

The fundamental foundation upon which that bargain was based was that of trust, trust that, in return for their contributions, economic in paying taxes and National Insurance, social in their roles, parents, trade unionists and when necessary as patients, the State would provide the conditions which can be summed up in that basic socialist promise of social security. That is the foundation upon which we built our trust in ‘our’ hospitals, ‘our’ doctors, ‘our’ nurses and ‘our’ health centres.

And then came the 1980s. In each of the areas I have just outlined, that basic quality of trust came under severe attack.

Government, far from being the vehicle through which collective efforts could be harnessed and brought to fruition was now portrayed, not as the answer to social problems, but the cause of such problems in the first place. “Rolling back the frontiers of the State” was not simply an expression of a new libertarianism, it was a positive rejection of the belief – a belief founded on trust – that Government was the servant, rather than the enslaver of the people. In a trust model of the relationship between the citizen and the State, then the ties between us are ones which we regard as binding ourselves one to another. The touchstone of Richard Titmuss’ ‘gift relationship’, the quality which most directly distinguishes socialists from political creeds of the right, is that the relationship to which Titmuss refers is a relationship between strangers.

Thatcherism’s only duty was to personal self-advancement – whatever the cost to others. Conservative thinking regards social responsibility as extending to family and immediate neighbours – in other words to people you might know or might engage with. Whereas socialism has at its heart a belief that our obligations extend beyond such narrow circles and encompass the total stranger. And, of course, the only basis upon which such an obligation can operate is that of trust – trust that our actions in supplying the needs of others will, one day when the time comes, be met by having our own needs supplied in turn.

The language of the New Right in the 1980s expressed this assault on trust relationships directly. Nowhere was this more apparent than in relation to people thrown out of work in the successive and deliberately induced economic recessions of the Tory years, backed up by a more global assault which the post-1979 Governments made upon the relationship between citizen and State. Implicit in all this was the deliberate dismantling of trust relationships between what came to be known as “consumers” and “producers” of public services.

Now, I do not wish to pretend, for a moment, that there is not a very real and powerful critique to be made of some aspects of the 1945 welfare state model. Heavily gendered, paternalistically delivered, the phrase “the man in Whitehall really does know best” came to be used as a summary of all that was unacceptable in the power imbalance between users of services and providers of them. Instead of regarding users and public service workers as essentially engaged in a joint enterprise, the language of the 1980s severed these relationships, making each party the enemy of the other. Ministers were instructed to ‘take on the doctors’ as they went about tearing up the co-operative model on which the welfare state was founded, creating in its place competitive markets in which, instead of trust, trading relationships would drive up standards and secure flexibility, responsiveness, economy and effectiveness. The impact of this approach was quickly felt in health. The ‘internal market’ produced just what you would expect – a competitive environment in which Trusts jockeyed to put each other out of business and treatment depended not on need but on how your GP happened to be funded.

If all this sounds rather bleak, then it is one of the most positive conclusions which this audience might wish to draw which emphasises just how unsuccessful, on the whole, this huge onslaught on the notion of public service turned out to be. Particularly here in Wales, the Tory tide simply failed to flow, as the outcome of the 1997 General Election so emphatically demonstrated.

Why should this have been?

When we are ill then, it seems to me, that one of the least likely personas we are likely to adopt is that of a suspicious shopper, hell-bent on turning this experience into some sort of Which magazine encounter in which, at every step of the way, rather than receiving reliable, professional advice and care, we demand a range of goods from which to make our personal choices. As Richard Sennett says in his exploration of a concept of liberated welfare, ‘All patients suffer a kindred difficulty in shopping for doctors or hospitals. Consumers of welfare need disinterested advice; in a market, no seller is disinterested. A cancer patient trying to chose a surgeon would hardly benefit from selecting the best salesman.’ Trust, at this point in any of our lives, is a fundamental component not simply of being made better, but of recognising the reciprocal relationships and shared decisions upon which improvements can best take place.

This has underpinned our approach to reducing waiting times in Wales. Recognising clinical priorities as the basis for targeted action, maximum limits have been set for cataracts, cardiac, orthopaedics, inpatient and day-case treatment, with planned reductions of those limits, year on year. Recognising the inequities which have arisen across Wales as a result of pressures, as well as ‘under-performing’ Trusts, we sought a way forward to reduce waits for our citizens. Of course, ‘personal choice’ routes were being tried and tested elsewhere in the UK, offering patients ‘a right to treatment at another hospital’ and leaving it up to them to exercise that choice. Instead, we sought to offer all patients who were waiting beyond the maximum limits, a ‘second offer of treatment guarantee’. With a central team managing this across Wales, all patients in this position have been made such an offer with travel costs and personal support and guidance if they choose to take up the offer.

Six months into this new scheme, we can learn a great deal from the response. Over this period, almost 1,100 patients have been offered a ‘second choice’ at their local Trust, with 3,730 more offered an operation at an alternative hospital. A G.P from the Valleys told me of a long-suffering patient who came to him to say, ‘Right Doc – it’s top class for me, I’m going down to Cardiff for my op!’ Talk in pubs, on the street, in the corridor and you will find someone who knows someone who has had the ‘surprise’ offer and taken it up.

As First Minister Rhodri Morgan said in his speech to the ERSC Devolution Conference in Cardiff earlier this year

‘Equality means reaching out hardest to those who are hardest to reach. And that is what our Second Offer Guarantee Scheme aims to do – it caters not just for those who can help themselves, but for those who need that extra bridge between their own circumstances and what only a dedicated public service can provide.

But 18% have said, ‘no thank you’. They would rather wait for their turn in their own hospital. A sample survey of the ‘no thank yous’ is revealing:

  • ·262 patients said they did not want to travel;
  • ·92 wanted to stay with ‘their’ consultant;
  • ·299 said it was to do with social reasons, such as being able to be visited by friends or relatives or going on holiday.

Importantly, the scheme has had the effect of driving up performance and activity in the NHS in Wales, aided by the new Consultant Contact, supported further by the continuing investment we are making, of which last week’s announcement of £30 million for Day Surgery Centres and diagnostic equipment is only the latest example of and which will help our teams to do their jobs.

The way to ensure that we have a system which combines sensitivity to individual needs and circumstances with the pursuit of equality is to understand the contribution which both users and staff make to public service encounters. These are emphatically not, as the 1980s model suggested, people on opposite sides of a battle for supremacy. Trust is the key which allows us to understand both user and provider as jointly engaged in a common pursuit.

In health, this is a lesson which we have already begun to learn. As Julian Tudor Hart has put it:

‘Provider-consumer relationships in the market are essentially adversarial. Optimal development of patients as co-producers of a health society…depends on developing new, socialised relationships’

‘Though the market model may give patients a louder voice, this will be the shrill cry of consumer choice, not the sceptical thought and responsible voice of the citizen’.

When we talk of co-producers, then we are recognising the contribution to health and to recovery from illness which both professionals and patients provide. Trust is the pivot around which co-production turns. It recognises the user of health services as an active asset, rather than a passive recipient. This can start with the individual in developing responsibility for shared decision-making in the surgery or hospital bed and can be extended to active partnership in research and clinical trials. It builds from an understanding of shared public outcomes, in just the way that Derek Wanless has written of a ‘fully engaged’ scenario for the future of health.

Nor does this new sense of jointness between citizens and services operate only at the level of individual encounters – teachers with students, nurses with patients and so on. Let me offer you three examples of the way in which this idea has been influential in Welsh policy formation.

One of the most fundamental ways in which the Labour Assembly Government has gone about reforming health services in Wales has been through the work which Peter Townsend has led in developing a new resource allocation formula, so that we have a better match between health need and patterns of spending. The new formula is driven by our unique Welsh Health Survey – a ‘scientific breakthrough’, as Professor Townsend refers to it – which has allowed us to go beyond proxy data or mortality data and to allocate money according to the distribution of illness and disability as the people of Wales themselves report it. The voice of Welsh patients is thus heard directly at the very heart of our policy-making – and amplifying ‘voice’, rather than relying on ‘choice’ is, of course, a strategy which the Socialist Health Association is a leading advocate.

A second example of the new relationship between citizen and service is to be found in our Expert Patient programme in which people with chronic diseases are brought together, collectively, to learn from one-another about ways in which they can manage conditions better and plan positively for the future. The programme recognises the expertise which patients themselves bring to the table when coming for help from the health service. I am delighted that, later this week, around half the short-listed entries for the Welsh NHS Confederation annual awards reflect this new sense of an equal partnership between patient and provider.

My final example is that of the ‘equity training grants’ which are now funding 26 different projects in Wales. These projects allow local groups and health professionals to explore how equality of access to good health, as well as to health care services, can be delivered. They are helping us to address what the National Consumer Council recently described as an ‘inverse information law’, where the people most in need are the least likely to be able to access information.

The NCC’s Report focuses mostly on the ‘choice’ agenda and the issue of ‘health literacy’. The answer which we are developing in Wales, and which each of the examples I have just outlined demonstrated, is that collective capacity has to be built up, as the springboard from which individual actions can best be made. And this is because in Wales, particularly, we recognise that the active relationship we are trying to promote between citizen and public service is not simply an exchange between of individuals. To quote another great Welshman, Archbishop of Canterbury, speaking recently at Lambeth Palace to the Meningitis Trust:

‘We’re talking here about the empowerment of communities in this country in their own health care. Not just about providing bits of information and bits of encouragement, but about a whole philosophy of how communities should think about, and act on, questions of health.’

Professor Gareth Williams, last year’s Bevan lecturer, at a recent New Statesman round-table discussion on health, here in Cardiff, drew out the iterative way in which the well-being of whole areas and communities is shaped by the life chance available to individuals within them – just as those individual pathways are moulded by the structural features – housing, environment, transport, education and so on – of the places where individual lives are led. There are different pathways to be followed in health policy and the way we think about community is one which helps to decide between some of the different paths on offer. Let me quote from Gloria Jones Powell, vice chair of the Board of voluntary organisations in Powys, who told the same New Statesman discussion how, since devolution, she had seen doors which were once closed gradually opening up to include groups beyond the usual circles of public engagement. Well-being, she argued, is not confined to the health service, but is more broadly about quality of life. The challenge we face, she suggested, is to gather the previously disparate strands of community groups, health boards, academics and local authorities to work in unison towards the same ends.’

The Public Health White Paper which was published by the Department of Health ten days ago contained much very valuable and important material – indeed, to the untrained eye much of it could be said to have been taken from our own Health Challenge Wales. Yet, some of the ways in which we will go about promoting public health will be different. I have no plans to introduce Personal Health Trainers here in Wales. I have no such plans because the direct evidence of our Health Inequalities Programme projects suggests that a community, rather than individual approach provides a more effective way of making a difference in this area. To address this we need to follow the comprehensive approach offered by Health Challenge Wales, supported by targeted action at local level to identify needs and ensure that the health and social care system respond effectively. At the centre we are working to ensure that the health budget is distributed fairly in line with relative health need across Wales. But that is only a starting point – the key issue is how resources are used locally to respond to that need.

The principles are clear:

  • we must do better in reaching those in greatest need of support, care and treatment at an early stage, otherwise inequalities in health status will continue to get worse.
  • Our response will only be successful if we involve people more effectively in service planning and delivery.
  • We must translate equitable budgets into equitable service delivery against evidence of local needs and priorities. Professor Peter Townsend sums this up as ‘prevention through equity’ and I think that is a good summary of what we are trying to achieve.

On our own, any one of us might struggle – to give up smoking, to change our eating habits, to take up exercise – and so on. It is government intervention which must secure the interests of the most vulnerable or disadvantaged in promoting smoke-free places, a decent standard of social housing and free prescriptions for those with chronic conditions and low incomes. It is collective strength which Health Inequalities projects mobilise as one of the most powerful levers of change.

The Community Heart Disease Prevention Programme in Llanelli, for example, has estimated that the exercise referral arm of the project will have seen approximately 600 people by the end of this year. The project is also improving knowledge and skills on nutrition within primary care, the youth sector and older people through initiatives such as ‘Get Cooking’, by introducing a healthy eating module and youth achievement training with staff from the local youth centre.

In Newport, the ‘Dharkan’ project has developed a blood pressure monitoring and advice clinic in a Bangladeshi Mosque on Worship day and the service may now be offered to other Mosques in the area. With health literature now available in Urdu, Bengali, Chinese, Hindi and Arabic, it is estimated that the project has reached around 3,500 people. The collective strength which these projects, and many others like them, have mobilised needs to be matched by a service which provides, as the recent SHA document Citizens’ Voices or Consumers’ Choices, puts it ‘ trust, respect and knowledge of social context’.

That message was brought home very powerfully to me at the Alzheimers Society Conference in Llandudno last week on Living With Dementia. At the session which I attended Linda spoke of her shock and disbelief when the diagnosis of Alzheimers rocked her life in middle age. She spoke passionately about the importance of her local ACE Club, which had brought her new friends and opportunities, helping her to live with dementia. Funding problems meant that some of the service had been lost. But her words to me were, ‘We want our centre to open an extra day, but I think we need more clubs for other people in our situation. That is more important. At least we’ve got something.’ That concern for fair shares for others is so often the response from those who use and need our public services, as citizens, rather than as consumers or dependents. The strength of that care and respect for others, for the wider community, sums up that socialist ‘gift relationship’ to which I referred earlier – one which strengthens the trust-based services which we are building again here in Wales. But, equally, the erosion of trust, when things go wrong, makes our job of securing the sort of public services we want to see in Wales, doubly difficult.

And things do go wrong. I still receive too many reports of encounters between patients and health professionals in which patients feel that they are acted upon, rather than engaged with. I still hear, too often, the language which regards patients, and the public at large, as the problem rather than an asset in the process of change in which the health service is inevitably and always embarked. I still have to become directly involved myself in too many local disputes where an insensitivity to public perceptions has produced a breakdown in the very trust which, as I have argued here this evening, is the life blood of the sort of collective, collaborative, fundamentally socialist health system we are trying to build.

As Health Minister you can be sure that I receive my share of letters of complaint from within my own constituency, some of them very personally directed. These complaints are very rarely about the technical standards of service which people have received. They can be boiled down to a single issue – the respect, or the lack of it, in recognising needs, even if they cannot always be met. My approach is simple. Wherever possible, I contact the complainant directly, by telephone or by visiting people at home. And what do I find when I get there? A response which is very consistent with the sort of reaction which I outlined earlier in relation to complaints which are made to the health service itself. Even some of the most aggrieved individuals are motivated mostly by the wish to engage with someone about the problems they have faced – and providing them with that opportunity goes at least some way to repairing the breach of trust which has taken place. And the nature of that engagement is what you might expect – it is all about making sure that problems are put right and that poor experiences are avoided for others. Underlying even these worst experiences, then, is a huge sense of commitment to the health service itself – and a wish to see it live up to our enormous expectations.

That is why I remain so optimistic about its future here in Wales – because we have this vast reservoir of good will from which to build the sort of trust relationships, characterised by qualities of reciprocity and mutual respect, which I want to see between professionals and patients. These are not the paternalistic approaches of old where professionals possessed a monopoly of wisdom. I don’t, for a moment, seek to persuade you that what we need in our public services is some sort of automatic trust, in which the doctor or the police officer, or even the Minister, knows best. What I have argued for is a trust rooted in good judgement and have tried to demonstrate that such judgements are rooted in dialogue between partners – between the citizen and the state, between public service users and providers and between people and politicians – and where that dialogue is characterised by mutual respect and reciprocity.

They are reciprocal in the sense I outlined earlier – where both user and provider bring their different contributions to the table and combine those contributions to secure best results. These are relationships characterised by respect which recognises the enormous skill and learning which health professionals bring to their duties, but applies these skills and abilities in a way which understands that public service encounters are encounters between one human being and another and in which the unique humanity of each individual deserves that quality of respect. No hospital can cure every illness which is presented to it. No health service can meet all the needs which are presented to it.

But what matters, in the end, to people who come through its door, is that the service they receive is permeated by quality of care that shows that they are being treated as one human being in difficulty and distress would wish to be treated by another. When that quality shines through, as it does in so much of what the health service provides, then people go away with that cementing sense of trust reinforced and reverberating in a sense of social solidarity. When that sense is absent then the harm it inflicts is not just to the experience of an individual service, but to that wider sense of what public services ought to mean in creating the kind of society in which we each matter as part of one another.

Let me add something here about one of the tools which we have adopted, over the past decade and more, for dealing with break-downs in trust when this occur – the regimes of inspection and regulation with which many of you here will be familiar. Onora O’Neill, in the 2002 Reith Lectures to which I referred earlier, identified two key problems. Firstly, far from reassuring the public, she argued, the whole regulation industry had fuelled a ‘massive culture of suspicion’, in which the ‘gigantic, relentless and expensive’ attempts to scrutinise every aspect of public life only adds to the belief that something must be amiss. Far from reducing untrustworthiness, therefore, the new ‘audit explosion’, she argued, fed the flames of the problem it had been set up to counter.

Secondly, she argued that new regimes had placed unnecessary burdens on front-line service providers, producing ‘defensive medicine, defensive teaching and defensive policing’.

As the document makes clear, inspecting every service area with the same intensity can mean spending expensive resources on looking at services that are generally safe and effective. We are committed to simplifying the layers of regulation and inspection of public services in Wales, making reporting structures clearer and more effective, so that providers of services will be freed up to concentrate more their own jobs.

I want health and social care to be in the forefront of this new, streamlined approach with a concordat being developed between bodies inspecting, regulating and auditing health and social care in Wales. The Care Standards Inspectorate for Wales is moving forward in this respect with an emphasis on meeting people’s needs and supporting front-line staff as they strive to raise standards of care provision.

Rob Pickford, Chief Executive of CSIW recently said:

‘Of most concern in the need to ensure that the basics are always in place – clear plans to ensure that people receive the day to day support they need, arrangements to ensure that those needs are met on a consistent basis and support to frontline staff who deliver these services’

I am confident that we can produce an approach to regulation an inspection in Wales which works with the grain of the service, provides the necessary assurance and helps to bolster, rather than obliterate, the trust which, as I have argued, provides the bedrock of the sort of public service we are trying to create.

Let me try to sum up the argument which I’ve tried to outline to you this evening. Professor Alan Deacon in the most recent edition of the Social Policy Journal, reports the outcome of a large scale ESRC study conducted in the North of England which researches the way in which individuals go about making those thousands of social decisions which make up the daily round. The key conclusion which the researchers draw focuses on the ‘moral texture’ of these decisions, the way in which ‘when people act they do so not simply with reference to themselves but in and through their relationships and commitments to others’. Far from being ‘self-centred’ in making daily decisions, respondents reported a complex web of values about care and commitments in which interdependency rather than independence was the crucial consideration.

Deacon summarises the approach which people bring to these daily encounters as one of ‘compassionate realism’ – one which recognises the real constraints which shape individual lives and circumstances, but which operates within those constrains on the basis of our shared responsibilities one to another. It is just such a sort of compassionate realism which I have been advocating to you this evening as the basis for a socialist rebuilding of our health and public services, as expressed in the First Minister’s Making the Connections statement. It is a phrase which I think Nye Bevan would easily have recognised – passionate in our commitment to equality for all, compassionate in our sense of obligation which extends beyond ourselves and reaches out to strangers,realistic in knowing that everyone of us is fallible and that politics, as well as public service, is about doing the very best we can in the circumstances in which we find ourselves. If that is a prescription which we can live up to, then I believe we have a chance, within our grasp, to create that citizen-focused, trust-based health service we are looking for here in Wales.

What do you think?

This site uses Akismet to reduce spam. Learn how your comment data is processed.

Subscribe to Blog via Email

Enter your email address to subscribe to this blog and receive notifications of new posts by email.

Join 499 other subscribers

Follow us on Twitter

%d bloggers like this: