Speech by Health Secretary John Reid to the NHS Confederation conference at the SECC, Glasgow
Two weeks ago, almost to the hour, I was asked by the Prime Minister to be his Secretary of State for Health.
So I have a steep learning curve. A lot of listening to do. A lot of learning. A lot of dialogue. All of these, I’ll do willingly, because we all have a long way to travel together.
And because there is a debate going on about the direction of travel. Even over the post-war consensus which has now lasted for almost 60 years.
There are some who now want to shatter that consensus because they believe a National Health Service is not capable of meeting the demands, ambitions and expectations of modern men and women.
That’s not my view.
Two weeks into the job, there will be plenty of time to go into the details and Sir Nigel Crisp will be talking about some of those tomorrow. But my aim today is to share with you the broad direction of travel I will be pursuing as Secretary of State – the philosophy that I see shaping our implementation of the NHS Plan. I want to share with you some of the basic points on the compass – four of them – which I will be using on that journey.
I want to lay down four principles that will guide the way.
Firstly, that the dividing line between those who support a National Health Service as envisaged by its founders and those who oppose it lies in the principle that health care should be provided equally to those who need it free at the point of need.
That is the fundamental philosophical and practical watershed of 1948 – and has remained so since. It is a principle that was approved by the British people at the time and has been supported by them ever since.
As the 1944 white paper – A National Health Service – put it:
“The government want to ensure that in future every man woman and child can rely on getting all the advice and treatment and care they may need in matters of personal health; that what they shall get shall be the best medical and other facilities available; that their getting these shall not depend on whether they can pay for them or any other factor irrelevant to the real need.”
These are more than fine words. They are the basis of a national post-war consensus, founded on fairness, which created the institution called the National Health Service which I passionately believe in. It is more than an institution. It was, is and will remain a noble cause. All of us recognise that and never allow it to be diminished by the cynics.
Secondly – and I know this is an ambition you share – in all of our plans, our calculations, our strategic decisions or our debates – all of us should recognise that the National Health Service must become even more of a personal health service, truly patient-centred. The principle of the NHS is defined around the need of the patients, not the needs of the providers.
Of course, this NHS is widely supported by politicians; it is well served by a devoted staff; and it is driven by the determination of committed professionals.
So, of course in carrying through the great improvements on which we’re embarked we will need to persuade politicians, convert commentators, carry staff, convince Trade Unions and reward staff and professions.
But ultimately the goal of all our actions and the benchmark of our success is the well-being and the comfort of patients. That’s why we have plans, and targets, and objectives. They aren’t the end in themselves; they are a means to an end – serving the patient. Ultimately, this isn’t about systems or structures, about some chart on an economists wall, or some entry in an accountants ledger.
It’s not about who lays the bricks, or provides the tea, or even who makes the surgical incision. It’s about whether the pain and discomfort of individual human beings are relieved at the earliest possible moment, in the best possible way, without financial burden at the time of need. In short. It’s about people. People in pain. People suffering. People in fear. And about our determination that in place of that fear and suffering and pain, they will have relief, security and serenity, whatever their station in life.
And my third compass point is that true security, true equity, can only be accomplished if we both increase our comprehensive capacity and increase choice and diversity offered to patients. Capacity and choice are not alternatives – they are partners in progress, like investment and reform. Because the truth is choice will remain theoretical rather than real without the necessary increase in capacity. On the other hand, capacity increases will not on their own achieve their maximum effect unless accompanied by an extension of personal choice. We are developing an NHS which will genuinely meet the needs of 21st century patients – and will do so by strengthening both capacity and choice.
That journey has already started.
I want to pay tribute to my friend and colleague Alan Milburn. He will be remembered as a great Health Secretary. I know from the tributes from those who worked closely with him that you had the highest respect for both his drive and his achievements. He believed in the NHS. More than that, he believed in the potential of the NHS. He made the case for sustained investment in the NHS with the biggest ever increase in cash now going in. He worked with you in the NHS to drive down waiting times and waiting lists, improve cancer and heart services, rejuvenate primary care. He presided over a huge increase in staff with 50,000 more nurses plus 10,000 more doctors that in 1997.
Our NHS today is no longer starved of cash. We may have a long way to go. But we have turned a corner.
And the NHS plan devised in full consultation with many of you in the audience today and professionals across the NHS sets in place a series of reforms that are the most radical since the NHS was created.
- A new inspection regime to ensure equality and national standards
- Primary care trusts to offer new services to patients and act as the bedrock of local delivery
- National Service Frameworks revolutionising care for cancer, heart disease, mental health and the elderly
- Power devolved to frontline staff with a whole regional tier of the NHS abolished
- NHS Foundation Trusts designed to give local people control over their local hospital services.
- Agenda for Change has put the NHS on a new footing.
- New fast track diagnostic and treatment centres to do routine operations faster and more effectively
- Walk in centres to give people fast access on the high street to medical care
- NHS Direct giving people 24 hour a day nurse led service over the phone
All part of an NHS transforming itself irreversibly from top down monolith into a responsive, creative, adaptable, service with an increasingly personal service for patients.
It’s my goal to maintain the momentum of these improvements. To work with you to build on the successes. To turn these radical policies into radical, practical implementation on the ground. To free up professionals and managers to make these changes work best for local patients. I know that there’s only one thing more difficult in carrying through such a radical programme of improvement – that is to be told half way through that there’s going to be an abrupt change of direction. That isn’t going to happen. So the challenge is that the struggle for improvement will continue. But the reassurance is that there will be no change in direction. I believe in the NHS – that’s why I believe in improving it.
I believe in NHS staff too. For a very simple reason. I owe my life to them. – Forty years ago, they saved my life, here in Glasgow. – And everything I have seen in the four decades since then has reinforced my belief in you. Politicians often talk about the dedication of NHS staff. But in banging the necessary drumbeat of reform we sometimes lose sight of what we really mean. The NHS is the largest Army for Good in Britain. And like all armies it has three elements. Two of them, the intellectual and physical resources necessary are instantly recognisable, the ones we always talk about. But there is a third and crucial element of this vast Army for Good, of 1.3 million people. It is called morale, ethos, public service.
The ethos of the NHS remains the glue of the service. The individual acts of medical brilliance from a surgeon to sustain a patient, are matched by the nurturing, the expertise, of the nurse. The urgent, inspirational decision making of the A&E consultant, is matched by the relentless, sustained and heroic courage of the team dealing with the terminally ill cancer patient. The skill of the health visitor in diagnosing a child’s early health issue that nobody else spots is matched by the hospital porter’s capacity to soothe a worried relative. And yes, the manager developing all of this together and the Chair of the trust providing a good sense overview of what is being achieved.
Our NHS is really an NHS of all the talents. It is a collaborative effort and it is working. It is working as a team.
The process of change that we are all embarked upon truly is a team effort. It is designed to give you the tools to do your jobs better, and patients the quality, speed and choices they rightly deserve.
So the direction is clear. The priorities remain the same. But of course, each Secretary of State comes with their own style, emphases, background and passions. I have outlined three of my compass points in the course of my speech – health care free at the point of delivery; a service dedicated to patients and ensuring greater capacity and choice.
Before mentioning the fourth compass point, let’s remember our destination on this journey.
Our objective, yours as well as mine, is much more than looking after the nation’s health for today. This gift of a national health service is too precious to be a gift to only one or two generations. We don’t have to deliver an NHS just for today, but to develop it for tomorrow, for the generations of the future.
To really succeed it has to provide the serenity for future generations that Nye Bevan planned for that of 1948 – for my generation. That is why so much of the work that you are carrying out is about change and improvement rather than standing still. Because we understand that the NHS is a gift for today’s and future generations, not a monument to the past. That’s why the improvements we are making together are so important. That’s why the public – through the Labour government – has provided a five year funding allocation which increases the investment in the NHS faster than any time in the past. This is the British people’s commitment to investment for the future. For everyone’s future health – not just that of a few. But there is another reason this investment is necessary. Because the aim of the 1948 health service to provide equality of access to healthcare has not been fully met.
If we believe in those principles of fairness we have to work differently to bring them into reality. That’s our fourth compass point.
Let’s be clear why equity – fairness – matters. It’s not just a fad of this government. It not just an idea in the Labour Party. It is the cornerstone of the NHS itself. Social fairness in the relief of pain and distress.
And far from becoming outdated, with every passing decade it becomes more relevant. Take the relatively recent advances in genetics. I believe there is no other health care system in the world better placed to harness the potential of genetic advances than the National Health Service. The values on which the NHS is based – providing care for all free at the point of use on the basis of need, not the ability to pay – are uniquely suited to capturing the benefits of the genetics revolution.
But more than anything else, they provide a bulwark against the inequalities of private insurance-based health systems where the prospect of a “genetic superclass” of the well and therefore the insurable, and a “genetic underclass” of the unwell and uninsurable, unable to pay the premiums for medical care, is for many a very real threat.
Our NHS means that citizens in the UK can choose to take genetic tests free from the fear that should they test positive they face an enormous bill for treatment or insurance or become priced out of care or cover altogether. Already in the United States of America, where 40 million people have no medical cover, developments in genetics have stirred precisely these concerns. As our understanding of genetics increases, the case for private health insurance as an alternative to the NHS weakens. And so scientific advance increasingly underpins the moral values which have long lain at the heart of a National Health Service.
So the values of the National Health Service are absolutely right for now and for the future. The value of fairness and equity is enduring, is attuned to the needs of our times. But whilst this provides the opportunity for a universal and fair service – because it removes the barrier of cost to the patient – they do not guarantee greater equality in health outcomes. To create the personalised health service we want, it is necessary to accept a fundamental and important truism: that the NHS has not as yet fully succeeded in providing equality of access to health care.
And I think it’s important here to have a word about our existing targets. As I said I don’t want any target to be met to simply tick off a box. And I recognise that you, and your staff feel pushed around by targets so I want to explain to you in terms of both fairness and quality – why they matter.
In terms of fairness. If you wait for an operation for 18 months and the rest of the country gets the operation in 12 months – then that’s unequal and it’s unfair. And that’s been the situation up until the last few years. In some places at the moment no one is waiting for an operation more than 6 months – but in many other places they are. That’s unequal and cannot fit in with the basic NHS principle of equity.
Secondly, in terms of quality, some people speak as though the reduction in waiting times is somehow completely separate from what they term the quality of service. As though the time you have to wait is quite separate from the quality of care you then receive. Of course waiting time isn’t everything. But the length of time you have to wait for an operation is an integral part of the quality of the service you receive.- other wise why would it be the most important factor in prompting those who want “quality service” to pay for it in the private sector.
So those targets are about quality of service and the NHS principle of fairness, as well as practical improvements. And so is choice – real choice.
Choice, of course, always exists in theory. One of the obvious things about our world is that if you’ve got a lot of money you can translate that theory into reality. All of us here have the perfect right to choose to buy a Ferrari. But not many of us have the money to exercise that right. The same is true for health services – there is a theoretical choice that is rationed in reality through access to financial resources – or the lack of them. That is why the question of capacity – of putting more resources into the NHS – is essentially linked to getting real choice.
It’s our ambition to turn what has so far been for so many a theoretical choice into a reality inside the National Health Service. But the alarming fact is that despite the egalitarian principles of the NHS, inequality of access has persisted with the NHS too. Doctors and managers have tried their best to ensure equality of access. But the statistics on inequality of access shows this has not always worked.
There has been considerable differential class access to specific services. Over the last 30 years studies in specific services and the NHS has shown sharply differential access to different groups in society. For example, a study based on the population of Sheffield in the 1990s found that more affluent wards had around twice the number of revascularisations per head of the population with angina than less affluent wards. Other studies have found that while lower socio-economic groups have roughly a 30% higher need for hip replacements, the operation rate was around 20% lower than in higher socio-economic groups.
Why should this be the case?
‘Finding your way round the system’ presents some people with choices that others do not have. The history of the distribution of any goods and services shows that better knowledge of the exact way in which the goods are distributed will mean that some will receive more of the goods and services than others. These choices provide them with better health care and usually better health outcomes.
The challenge for us as we change the system is to extend choice to all, not to deny it to those who have it but to help every patient to be an informed patient. To ensure that the choice and convenience of service does not depend either on where you live or how much you can afford.
Not a modest ambition, but a worthy one. And that process has already started. Patients are already beginning to make choices about when and where they should be treated. When given the right support and information individuals were perfectly capable of exercising choice and willing to do so. In London, the take up rate of 70% or so from those who have been offered choice is the same for the poorest as well as the wealthiest Strategic Health Authority.
These approaches and lessons are now being extended to other parts of the country. From next summer all patients waiting for 6 months for any form of elective surgery will be able to choose at least one alternative hospital and normally four – public or private for treatment.
As Labour’s 2002 manifesto said, by the end of 2005 every hospital appointment will be booked for the convenience of the patient making is easier for patients and their GP to choose the hospital and the consultant that best suits their needs. From December 2005, by when extra capacity will have come on stream, choice will be extended from those patients waiting longest for hospital treatment to all patients. Millions of patients a year will benefit.
We are not simply introducing choice without consideration of other issues. I’ve already said that for people to choose there needs to be an increase in capacity. But in addition, for people to choose well there needs to be a standardisation of information so that everyone – and not just those in the know – can have it. And there needs to be sufficient support towards transport and other considerations to make sure it is open to all. I say this because choice for all is equality of opportunity for all in health care. Equalising choice creates more equal access.
If the NHS is not about equity of access to healthcare then I don’t see what it’s about. In 1997 we inherited an NHS which did not deliver equity of access. Lack of investment hampered the drive to equality. We have started to improve that system that with an admittedly national system of targets. We have continued that with the collaboratively produced National Service Frameworks. We have piloted some experiences of choice for elective surgery and now we will aim to roll that out to every person going into hospital.
These are my values. These are the NHS values. This is why we are changing the way in which the NHS is run.
Thursday 26 June 2003