Brown tells MPs of ‘wider’ private sector role – December 2007

Health secretary Alan Johnson has put NHS restructuring on hold “for the foreseeable future” to create stability and focus on improving care. In a statement to the Commons on 4th July, he set out the government’s new approach to the health service which will put a break on continuous structural reform.

Johnson said that substantial improvements to the health service had taken place in the last 10 years due to increased funding, but he acknowledged that there were still problems and challenges.

“Subjectively and anecdotally there has been confusion and frustration in the National Health Service,” the health secretary said. “The public are rightly concerned to know that their taxes are being wisely spent to build a health service that will meet their needs. Doctors, clinicians and nurses complain that they are fed up with too many top down instructions and they are weary of restructuring.”

As a result the government would place less focus on structures and more on outcomes for patients. Johnson said: “We now need to forge a new partnership with the professionals. Having addressed the funding shortfall and put the necessary reforms in place we will give the NHS the sustained period of organisational and financial stability it requires. There will be no further centrally dictated, top-down restructuring to primary care trusts and strategic health authorities for the foreseeable future.”

Instead the government is setting up a wide-ranging review, led by health minister professor Ara Darzi, to ensure that “a properly resourced NHS is clinically led, patient-centred and locally accountable”.


Brown Government Labour Party health policy

Gordon Brown’s Coronation Speech on 24th June included the following passage.

And let me say also that in the fourth richest country in the world it is simply wrong – wrong that any child should grow up in poverty.

To address this poverty of income and to address also the poverty of aspirations by better parenting, better schools and more one-to-one support, I want to bring together all the forces of compassion – charities, voluntary sector, local councils so that at the heart of building a better Britain is the cause of ending child poverty.

I’ve spent a lot of time in the last six weeks talking to patients and doctors, nurses and NHS staff. Let me say: every person I have met believes in the principles of our NHS – and like them I am proud that in this generation Britain will uphold an NHS free at the point of use, available to all on the basis of need, not ability to pay. But I know also from everything I have heard round the country, that we need to do better – and the NHS will be my immediate priority.

We need to and will do better at ensuring access for patients at the hours that suit them; better at getting basics of food, hygiene and cleanliness right; better at helping people to manage their own health; better at ensuring patients are treated with dignity in the NHS; better at providing the wider range of services now needed by our growing elderly population, and while implementing our essential reforms, better at listening to and valuing our staff.

And in the NHS we will also make progress by putting more power locally in the hands of patients and staff. So I propose that as we approach the 60th anniversary of the NHS we discuss a new settlement for a modern NHS free at the point of need – clear about where accountability lies – clear where Government should set overall objectives, clear where it should not interfere, and clear how independently local people should have their voice heard and acted upon in shaping the future of the NHS.

And it is right that this party that created the NHS, that has always invested in the NHS, that has always believed in the NHS, will be the party that for the coming generation, renews the NHS.


We asked the candidates for Deputy Leadership of the Labour Party to answer three questions for us:

1. How important is it to you that the next Labour Government reduces inequalities in health? How does that compare with the need to bring down waiting times in the NHS, to combat threats from terrorists or expand the economy?

2. Are there public services which would not benefit from marketisation?

3. Would it be possible for a Labour Government to devolve decision making in the NHS to locally elected organisations and not interfere with local decisions, even when there are complaints about postcode prescribing?

The answers – in the order they arrived – are below:

Hazel Blears:

1. How important is it to you that the next Labour Government reduces inequalities in health? How does that compare with the need to bring down waiting times in the NHS, to combat threats from terrorists or expand the economy?

Reducing health inequalities remains one of my abiding passions. I was public health minister, but long before I even got into parliament I was concerned with practical measures to reduce the stark inequalities between social classes in terms of life expectancy and chronic disease. Ever since the publication of the Black Report 30 years ago, the evidence is clear: there is a link between social class, income, where you live, what job you do, and how long you will live and how healthy you will be. Yet for 18 years the Tories claimed no such link existed. I was chair of my Community Health Council in Salford, as well as a local councillor on the council which was the first in the country to introduce health visitors. I have always believed that local councils should have more powers to secure improved public health.

We’ve made some strides forward since 1997. The ban on smoking in enclosed public places stands out. But there’s so much more to do, for example action on junk food advertising and obesity, on mental health, on sexual health, and on drug addiction.

I am determined that Labour should make the Department of Health just that, not the Department which simply runs the NHS (or worse – the other way round!).

We’ve talked too much about the NHS and not enough about health in the past ten years. As deputy leader I will place health inequalities and the so-called ‘inverse care law’ centre-stage in the public debate.

But the question is about ranking them in order. I would argue that in a prosperous economy, there is no need to make it an ‘either/or’ choice. We can tackle terrorism, expand the economy and do far more to reduce health inequalities at the same time.

2. Are there public services which would not benefit from marketisation?

I don’t accept that we’ve introduced free markets into public services. The NHS, for example, is making use of independent sector treatment to supply NHS services to NHS patients, free at the point of use. It’s been one way, along with the heroic efforts of NHS staff, that we’ve managed to reduce waiting lists, and so virtually eradicate the private sector market for hip and knee operations that thrived under the Tories. There are ways in which the private sector can add value to public services, but most of the impressive improvements and innovations I’ve seen in public services come from within, or from other sectors such as the co-operatives and mutuals.

3. Would it be possible for a Labour Government to devolve decision making in the NHS to locally elected organisations and not interfere with local decisions, even when there are complaints about postcode prescribing?

I have come out in support of direct elections for some element of NHS Primary Care Trust boards; I believe I am the only deputy leadership candidate to do so. My vision is for an NHS which guarantees high standards for all, in every community, but which on top of those high standards offers even better services in specialist areas in different parts of the country. The harsh fact is that we’ve never managed a universal health service. Poor people still have fewer GPs than affluent areas, for example. We need a massive levelling up of standards, if we are to fulfil Bevan’s ambition for the public’s health.

Jon Cruddas:

1.How important is it to you that the next Labour government reduces inequalities in health? How does that compare with the need to bring down the waiting times in the NHS, to combat threats from terrorists or expand the economy?

Working to eradicate health inequalities is critical to the building of a just and inclusive society. It is something I regard as being interlinked with many other issues – including building an expanding economy, preventing further terrorist attacks and reducing waiting times.

Primary Care Trusts should have a duty to publicise their per capita health spending, and should be ambitious about closing the health inequalities that exist in their locality. As the World Health Organisation advocates, investment in developing high quality, properly resourced preventative and primary care health services with equitable access are crucial to reducing health inequalities.

Health inequalities and lower life expectancy are closely linked to poverty and deprivation, inadequate housing and lower educational attainment. In my own constituency, average life expectancy varies between wards from 72.4 years to 79 for men, and 78.1 to 82.4 years for women; a difference of years over just a matter of miles. To reduce health inequalities, housing, poverty and access to education all need to be tackled, and achievement in one area will complement work towards the others. In short, reducing health inequalities is not just about NHS services, it is also about investment in social housing stock, ensuring every child receives a decent education and has the option of further study or university and tackling poverty. It also involves looking at wider social policies, such as pension levels, stopping what appears to be a race to the bottom of the labour market and working with bodies such as the Commission for Equality and Human Rights to tackle the discrimination – all of these factors, and others, contribute to poverty and inequality of service access. An example of this can be seen in the recent Joseph Rowntree report. The report found that Black, Asian and minority ethnic communities are twice as likely to live in poverty as white Britons. We know that Black African and Caribbean people are treated for mental health problems at a disproportionate rate and that the majority of pensioners in poverty are women.

As well as impacting on health inequalities these policies are all key components of building an expanding economy and making sure that everyone benefits from our prosperous society. The current mismatch between the Government’s security agenda and the material insecurity that people within communities experience contributes to sections of society feeling isolated; addressing the issues outlined above must be seen as integral to preventing further terrorist acts, rather than eroding civil liberties.

We should also recognise the great strides forward that have been made in reducing waiting times under the current Labour government – they are part of reducing health inequalities and will continue to be so – providing people with swift access to care saves lives and can help return people’s independence and dignity. We also need to acknowledge that there are still areas where waiting times are unacceptably long, for example, in audiology.

I want to encourage and stimulate a real debate within our party to develop new policy ideas for the Labour party and the next Labour government to meet this challenge.

2.Are there public services which would not benefit from marketisation?

The clearest example of where the marketisation of public services is inappropriate is the in NHS. Ensuring equitable and universal access to healthcare cannot be left to the vagaries of the market – by its very nature it would mean different levels and standards of care for people, and some losing out altogether. The current reforms of introducing competition and contestability into the health service, and the drive for PCTs to commission, rather than directly provide, healthcare threaten the universal ethos of the NHS. I share your anxiety that the creation of an increasingly complex structure of ‘choice’ will primarily benefit those most able to take advantage and the resources to ‘work the system’. Also, by establishing a system of multiple providers competing against each other for, ultimately, their income providers may increasingly travel down the route of charging for services that should be available to everyone. The creation of a multi-tier health system will increase inequality, rather than working towards eradicating it.

The key thing in building our policy within the Labour Party – in all areas, not just public services – is that it is built in the real world around us. It needs to be formed through the involvement of members and trade unionists at all levels and speak to the wider public about Labour’s core values. At the moment it is too often formed through a ‘top-down’ political structure with consultations over decisions already made and an adherence to a dogma that competition and markets always have the answers.

3.Would it be possible for a Labour government to devolve decision making in the NHS to locally elected organisations and not interfere with local decisions, even when there are complaints about postcode prescribing?

I believe complaints of postcode prescribing often arise from particular services being unavailable or of low quality in certain areas; this needs to be distinguished from the existence of any local variations.

The NHS can and should be tailored to local needs, and there should be local accountability with the involvement of local councillors. But it is important that this is underpinned by robust minimum standards of the services that should be offered and their quality to ensure that no community or region misses out. Legitimate local variation should not slide into unacceptable inequality in health outcomes, and ensuring this may occasionally require intervention. These occasions can be limited. I believe that we need to reconnect and rebuild our activist and grassroots base. This is not a separate issue when looking at local decision making in the NHS, and in other policy areas. Active, local Labour Party members and councillors are well placed to take forward progressive policies in healthcare, housing, education and social inclusion in their local areas which will make a huge difference to tailoring their local health services and reducing health inequalities. By overhauling our party’s policy making processes, national policies can benefit from the first hand experiences of our activists engaged with their local communities. A Labour government and a re-invigorated Labour Party is the only party that can deliver this.


Harriet Harman:

1. HOW IMPORTANT IS IT TO YOU THAT THE NEXT LABOUR GOVERNMENT REDUCES INEQUALITIES IN HEALTH? HOW DOES THAT COMPARE WITH THE NEED TO BRING DOWN WAITING TIMES IN THE NHS, TO COMBAT THREATS FROM TERRORISTS OR EXPAND THE ECONOMY?

For all the undoubted importance of issues such as hospital waiting times, our overriding health policy priority has to be to tackle the wide disparity in health outcomes that still exists in Britain today between people from different regions and social backgrounds.

We know these inequalities have economic costs both to the NHS itself and in terms of the number working days lost. So, it makes economic sense to tackle them – but the most powerful reason for putting this issue at the heart of our party’s policy agenda it is the social and human cost of these inequalities.

Consider for example the gap in birth weight between babies born to families in the lowest and highest incomes groups, which is perhaps the most glaring example of health inequality that we face. Babies born underweight are statistically far more likely to die before their first birthday. They are also much more likely to develop behavioural problems, have a low IQ, and suffer from chronic ill health later in life. Moreover, there is strong likelihood that they themselves will then grow up to have babies of their own, who are also of a low birth weight; thus perpetuating the cycle of inequality.

In the last ten years we have done a great deal to address health inequalities. Maternal health and well-being for example is an issue that receives more attention in Whitehall today than it has ever done in the past. We now need to address the human cost of these inequalities. We need to move the in Parliament and the media from secondary care issues to prevention and health inequalities. As a party and a Government therefore, I believe that we need to become more vocal on the issue of health inequalities. We need to highlight their pernicious effect on society and to try to put them at the forefront of the debate on health, rather than on the margins.

2. ARE THERE PUBLIC SERVICES WHICH WOULD NOT BENEFIT FROM MARKETISATION?

Outside providers have undoubtedly helped the NHS to cut waiting times for elective surgery and reduce pressure on NHS hospitals. It is clear, however, that independent sector treatment centres have not always proved to be more efficient or innovative that NHS-run elective centres. When we consider bringing in outside, we must make sure we do not jeopardise one of the important developments in the NHS – the very welcome shift towards greater multi-disciplinary working. Fundamentally the NHS must remain a public service within the public sector.

3. WOULD IT BE POSSIBLE FOR A LABOUR GOVERNMENT TO DEVOLVE DECISION MAKING IN THE NHS TO LOCALLY ELECTED ORGANISATIONS AND NOT INTERFERE WITH LOCAL DECISIONS, EVEN WHEN THERE ARE COMPLAINTS ABOUT POSTCODE PRESCRIBING?

With power and resources now being devolved from Whitehall to local health care providers, we now need to strengthen the way in which these local organisations are held accountable to the public. The freedom of PCTs for example to commission services and to set health care priorities to suit the needs of the local population, is one that I welcome, but these decisions shouldn’t be taken in a political vacuum. Each community should be able to hold their local trust to account for the decisions that they take. There is a strong case for having directly elected officials on each primary care trust board, making local decision-making more open and transparent, and helping to restore public trust in NHS management

We need to be careful that in addressing this democratic deficit in the NHS, we do not undermine the progress that has been made since 1997 in ensuring that all patients, wherever they live, receive a consistent level of care in key clinical areas based on national targets. We would also need to make sure that in deciding what their priorities should be, trusts do not sideline some of the strategically important, but less politically sensitive services such as public health and health promotion activities.


Peter Hain

1. How important is it to you that the next Labour Government reduces inequalities in health? How does that compare with the need to bring down waiting times in the NHS, to combat threats from terrorists or expand the economy?

We know that a modern health service is about much more than treating people when they are sick. It must also be about tackling health inequalities and giving people the practical support they need to lead healthier lives.

I think we can learn from experience in Wales, where Rhodri Morgan’s Assembly Government, with whom I have worked very closely, have pioneered a number of schemes to help improve people’s health, such as free breakfasts in primary schools, free swimming for older people, and Health Challenge Wales, as well as introducing a ban on smoking in enclosed public spaces last April. The Assembly Government has also established a Health Inequalities Fund, with plans to extend it to help improve treatment for patients with complex and chronic health conditions, such as Parkinson’s and heart disease.

2. Are there public services which would not benefit from marketisation?

Labour has delivered tremendous improvements in healthcare over the past ten years. The process of improving and therefore reforming the NHS must continue. But we must have a debate about the kind of reform we want, about the limits of marketisation and private sector involvement, how we protect the rights of public sector workers, and how we maintain standards of fairness and social justice.

I believe the way we’ve approached reform in Northern Ireland provides a model for future reforms in the rest of the United Kingdom.

For example, we inherited waiting times that were unacceptably long. It was right, in that case, to engage the private sector to help clear backlogs where there was insufficient public sector capacity, including bringing in surgeons from abroad where necessary. But there was no move to a private sector free for all, an internal market and contestability. This would have resulted in hospitals being pitted against each other, and resources diverted from patient care to managing the market.

Similarly, there are occasions when public-private partnerships are the only way of affording the new capital buildings needed to deliver excellence. But no need for caterers and cleaners to be contracted out. That’s why I insisted catering/cleaning were brought back in or excluded from the bids. In Wales Welsh Labour pledged at the recent Assembly elections to end competitive tendering for hospital cleaning contracts. Because there is no reason why value for money should come at expense of good employment rights or standards of cleanliness.

3. Would it be possible for a Labour Government to devolve decision making in the NHS to locally elected organisations and not interfere with local decisions, even when there are complaints about postcode prescribing?

A key part of my philosophy, and one very much in keeping with Labour’s “libertarian socialist heritage”, is that we need to push power downwards and outwards to the representative institutions closest to the people. My record in office both in Wales and Northern Ireland shows that not only do I believe in that principle, but that I have also acted upon it, and achieved results. Our watchword should be that of the architect of the NHS, Nye Bevan who said that: “the purpose of getting power is to be able to give it away.” For example, the exciting initiatives I described above, in relation to Wales, could not have been achieved, without the establishment of the Welsh Assembly, which will now have greater law-making powers in relation to health in Wales as a result of the new Government of Wales Act.


Hilary Benn

How important is it to you that the next Labour Government reduces inequalities in health? How does that compare with the need to bring down waiting times in the NHS, to combat threats from terrorists or expand the economy?

All of these matter, but no Labour government should accept health inequalities. Why is it that for all the difference we have made in government, if you grow up in the East End of London you will die many years earlier, on average, than if you grow up just a few tube stops further west? Why are deaths from stroke and heart disease highest in the poorest parts of my constituency?

We know it’s because of poverty. We also know we need as broad a response to as possible. Because this isn’t primarily about healthcare; it’s about poverty, inequality, education, housing and information as much as it is about the treatment people ask for and receive.

Are there public services which would not benefit from marketisation?

The most important thing is to maintain an NHS that is free at the point of use. Who provides a service should depend on what serves patients best, and that will vary.

In making decisions, we need to make sure that we listen better to people on the front line and get them involved in making decisions about what needs to change. Because often they know better than anyone in Whitehall. Our doctors, nurses and support staff should also have the time and support they need to do the best job they can.

Would it be possible for a Labour Government to devolve decision making in the NHS to locally elected organisations and not interfere with local decisions, even when there are complaints about postcode prescribing?

The honest answer is that it would depend. Balancing the need to encourage all areas to improve and to give the best performing services the space and freedom to innovate, and ensuring that no-one is disadvantaged simply by where they live is not easy. Sometimes we have to take steps to intervene in the general interest.I actually think there is a bigger question here that we need to ask first. And that’s to have a really frank debate within Britain about what we expect from our National Health Service, and about how much diversity of provision we are prepared to accept. We should try and involve local people as much as possible in these decisions but we have to ensure that minority and rarer diseases aren’t overlooked. Targets have helped to make big improvements in waiting times, and cardiac and cancer care – but there’s a balance to be struck here too.


Alan Johnson

1. How important is it to you that the next Labour Government reduces inequalities in health? How does that compare with the need to bring down waiting times in the NHS, to combat threats from terrorists or expand the economy?

I see combating inequality across the board as a major priority of the government. There are still too many children growing up in poverty, there are still too many people growing up in deprived areas and there are too many people who are not given the standard of care that they need and they deserve. We should not see improving healthcare and reducing inequality as a choice. We should never pursue a course of reform that makes us choose between economic growth or improved services. We must continue to bring down waiting times and this has been a major achievement of this government but tackling health inequality remains the major problem.

2. Are there public services which would not benefit from marketisation?

I have always been clear that the priority for a Labour government should be in improving health outcomes through building a more responsive NHS delivering high quality care when, how and where people need it. The reforms brought in under the Labour government combined with greatly increased levels of spending have delivered improved results for patients. I feel that we should be judged on the experience of the users of health care and that we should pursue the best means to delivering the best possible service. In addition, people will no longer accept, and no longer should they accept monolithic, ‘one size fits all’ health service delivery. People want a degree of choice in their service and we have begun to respond to this by delivering, for example, Walk in Centres and more flexible means of care.

3. Would it be possible for a Labour Government to devolve decision making in the NHS to locally elected organisations and not interfere with local decisions, even when there are complaints about postcode prescribing?

It is important for decisions to be taken locally when possible. The Government has already sought to devolve power from central government. I recognise that a Minister or Secretary of State is not necessarily best placed to make decisions on the micro management of every hospital, or every clinic in the whole country. It is important to consult local people on their health services to ensure that services are responsive to local need.

However, I am not yet convinced that the local decisions would best be made by elected local bodies. There remain questions on how service could be guaranteed to be delivered at a universally high standard. My first priority would be to improve health services across the board and to tackle health inequalities before setting up a new system of elected local health organisations.

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