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I know these are difficult times for people working in the NHS. It is hard for anyone to understand that after years of record investment, we are dealing with financial problems. After years of needing more staff and training and employing more staff, there are now some parts of the service facing some job losses. Above all, there is a sense that the service no longer knows where it is going. “Where will we be in five years, ten years, fifteen years’ time?” That is the question I hear increasingly. But as I will argue today, it is a central part of our reforms that we put into your hands – the hands of the local NHS – the power to answer that question.
We start, as always, with our values - the values of a health service funded by all of us, available to each of us equally, free at the point of use, with care based on our need and not our ability to pay. Those values are non-negotiable. They make the NHS unique - the institution that perhaps most of all makes people proud to be British. They inspire people to work in the NHS. They make it the fairest health service in the world. We will never compromise those values. Indeed, I go further because I believe that the changes and reforms we are making are not only consistent with our traditional values: they are essential if we are to protect those values for another generation. So we are not changing the end, only the means to the end.
What threatens these values is not reform, but the changes taking place in the wider world around us. To know how to safeguard the values of the NHS, we have to understand how the world is changing - and why the NHS has to go on changing with it. Every healthcare system in the modern world faces three big challenges:
The first is people's expectations. Patients don't understand why the NHS can't provide them the same level of control, choice and convenience they expect from other services. Education has marked the end of deference and the internet facilitates the spread of knowledge. More and more patients now know more about their conditions and want a greater say over how, when and where they are treated. NHS staff are rightly proud of the fact that no-one now waits more than six months for an operation like a hip replacement for which thousands of people waited twelve, fifteen or eighteen months not many years ago. But patients, rightly, want more - and we have promised that, by the end of 2008, no-one will wait more than 18 weeks, maximum, from GP referral to hospital operation.
The second challenge is demographics. Already, in many parts of the country, the NHS and local social services are struggling to meet the needs of disabled and elderly patients. By 2025, the number of people over 85 will have increased by two- thirds: each of them needing, on average, five times as much care from the NHS as the average 16 to 44-year-old. Add to that the health risks of modern lifestyles. By 2010, we predict almost 13 million adults in Britain will be clinically obese - and already we can see the rise in strokes, in heart attacks and type 2 diabetes that's creating. So the NHS has to become a world leader at promoting health, well-being, independence as well as treating illness, if we are to cope with this silent epidemic of long-term illness.
The third challenge is
medical science and technology. Hardly a week goes by without a press
report of a new treatment for which extraordinary effects are claimed. In
a few years' time, doctors will be able to use drugs that are pharmaceutically
engineered to the unique DNA of the individual patient. Indeed, some
scientists claim that by 2015, there will be a cure for up to a third of today's
life threatening diseases. And already, as we are seeing with new cancer
drugs, we have to ask:
"Will the NHS be able to afford the new drugs and treatments, to provide them
comprehensively and universally as its values dictate?"
Our system
must rise to these common challenges and, in doing so, protect the founding
values of the NHS.
When the NHS was
created, nearly 60 years ago, it was fashioned by necessity on the model of the
times, the model of the centralised, top-down organisations around it. Nye
Bevan's phrase - "If a bedpan is dropped on a hospital floor in Tredegar, its
noise should resound in the Palace of Westminster"
- may have haunted Health
Ministers ever since, but at the time it reassured people. The centrally
governed NHS that emerged from the 1946 White Paper was the right system for its
time. It delivered British people from their fear of illness. But
the structures that were right in the 1940s aren't right today. The
structures that were right in the 1960s - when the model for the district
general hospital was defined and planned- aren't right today.
As we said in the NHS
Plan just six years ago: "The NHS is a 1940s system operating in a
twenty-first century world. It has:
· a lack of national standards
· old fashioned demarcations between staff and barriers between services
· a lack of clear incentives and levers to improve performance
·
over-centralisation and disempowered patients."
We've already started to tackle many of those problems.
In the next stage of the NHS journey, we have to make good the promise of the NHS Plan - put more power in the hands of patients and the local NHS itself. Too often, when I meet staff who are transforming the care that patients receive, they are doing it despite the system - not because of it. National targets and top-down performance management were essential to get improvements needed in the short-term. But heavy performance management, command and control demoralises staff and risks distorting priorities. Instead, we need to give NHS staff far greater freedom to work with local partners to reshape services for the benefit of local people. As we said in the plan, we need to create the right incentives for continuous improvement, innovation and better value for money. We asked the public to pay higher contributions to fund the record investment in the NHS - and we have to convince them that those resources are being used in the most effective way possible. For all the extra money, all the extra staff and extra patients treated, NHS productivity has remained almost unmoved. Statisticians argue about how best to measure it. If you just count the number of patients treated, you conclude the service has become a bit less efficient. If you take account of better quality care and more lives saved - which is what really matters - then the NHS has become a bit more efficient. But if we are to match people's rising expectations, care for an ageing population, provide the best new treatments, the NHS needs to become not just a bit more efficient, but dramatically more efficient and more effective. That is why we still have to reform, why there is such urgency about the changes we are making.
Already, we can see the NHS locally finding new answers to these challenges. Let me illustrate this with a story. Take Martha for instance. She's 85, widowed and lives on her own. Martha has been admitted to hospital five times in the last 12 months, either after an accident or to treat one of her long-term conditions. When she is taken to A&E, she is seen within four hours. The national service framework on older people - one of the commitments in the NHS plan - sets out the standard of care staff should give her. The independent Healthcare Commission monitors the hospital so she knows she's safe and her hospital's published figures show it has an average length of stay for a hip fracture of just eleven days. In some other hospitals, that stay is an average of 45 days. Martha says the care she gets from the hospital staff couldn't be better. But could the NHS as a system do more for Martha and the almost three million elderly people like her who suffer a fall each year?
Of course it could.
When Martha comes out of hospital this time, I want her to be met by someone like Brenda Tompkins. She runs a community nursing team in South Somerset which runs a short-term re-ablement service that cuts across traditional health and social care boundaries. Sister Tompkins says 'It's been a total eye-opener for me and the staff. There's a big difference for patients from being in hospital, to being on your own. How do you carry a cup of tea when you're walking with a frame? So you get into people's homes and see all sorts of things that need doing - a new piece of equipment, for instance. We can help people to be able to stay in their own homes if that's what they want.' Even better would be if the NHS could prevent Martha having a fall in the first place. In Easington, in County Durham - one of the poorest communities in our country where Health Inequalities are most severe - the primary care trust went out and replaced worn-out slippers for elderly residents. Their 'sloppy slippers' campaign was mocked by the press as a waste of money: but it helped cut the number of falls by 60 per cent. Around the county modern medical technology is revolutionising our ability to watch over the frail and the elderly. West Lothian council and NHS have cut hospital bed days by more than 3,000 by partnering with a private company and putting Telecare technology into pensioners' homes. Touch sensitive pads that turn on the lights as soon as you get out of bed in the middle of the night, monitors to stop rooms getting too hot or cold and sensors that raise an alarm if a person stops moving for a prolonged period. If the NHS can reduce the number of elderly people suffering a fall by just 15 per cent, you transform the quality of life for thousands of people and save the NHS more than a quarter of a billion pounds a year - more than enough to pay for the community services Martha and others like her need.
But how are we going to achieve this transformation of services nationally? How are we going to fulfil the commitments in the White paper 'Our health, our care, our say' and move more services into the community and patients' own homes? How are we going to get rid of the huge variations in care - 11 bed days for a hip fracture in some hospitals, 45 in others - and reduce the shocking inequalities in health and care that have bedevilled the NHS for nearly sixty years? We will do it - as we always said we would - by matching investment with reform. By combining national standards with local initiative.
There are four key elements of reform.
· First of all, more choice and a stronger voice for patients - backed up by strong commissioning.
· Second, a range of providers so that patients and commissioners can get the right services in the right place at the right time.
· Third, money following the patient.
· Fourth, a regulatory system that will guarantee quality - enabling patients and commissioners to tailor care to the different needs of different patients, without compromising on NHS standards.
I want to say a little more about commissioning - because it is at the heart of the answer to the question I started with: 'where will we be in 5, 10 or 15 years' time?' Primary Care Trusts, GPs and their colleagues in primary practice are central to the new NHS. They will be fairly funded - so that people with the same condition can get the care they need, wherever they live, and areas with the biggest health needs get the biggest budgets. They will be charged with helping everyone achieve the best health for themselves and their families - narrowing the terrible gap in life expectancy and wellbeing between rich and poor. They will be accountable to local people and involve them more and more in decisions about services. They will work increasingly closely with hospital colleagues to redesign and reorganise services. And because every service has to live within its budget, they will take responsibility for securing the best value for the money they are spending on our part on healthcare. Of course, the services they commission must meet national standards: without that, there would be no national health service. So, PCTs and practices will have to take into account National Institute for Clinical Excellence guidelines to smooth out the postcode lottery. And national targets will still have to be met - but there will be fewer and fewer of those, as we give patients more choice, give the local NHS more freedom and publish more information about the outcomes that different providers are achieving. Strong local commissioners will have the information they need about the different communities they serve and where the health risks are greatest. They will know how their local hospitals compare with others all over the country and be armed with evidence about what works best. They will have a real incentive to work closely with local government and other partners to support people with long-term conditions, to cut emergency admissions and make the best use of hospital staff. As commissioners become even more effective, the emphasis of the NHS will shift to prevention as well as cure. We know that is what the public wants. We know that it is clinically right. And we also know that it is the only way to prevent the NHS from being overwhelmed by new diseases and chronic illness. So public health - instead of struggling for its place as it still is today - will become central to the new NHS.
But does that mean the NHS will only be a commissioner, a kind of glorified insurance system buying services from the private sector? Just an NHS logo to stick on the door of a private hospital? Of course not. In my second speech, I will deal much more fully with the issue of providers. But there are three points I want to make briefly this morning.
First, the NHS will
always remain a provider because of the quality and commitment of its staff, in
and outside hospitals. As we stressed in the White Paper, primary care
trusts will remain free to run their own services and employ their own staff, as
most do today - of course, with clear governance procedures. And the great
majority of hospitals will remain, as they always have been, publicly owned. But
instead of being owned and run by the government and by the Department of Health
in Whitehall, they will be owned by the public, led by their board and run by
their staff. In other words, NHS Foundation Trusts. Not "the end of the
NHS as we know it"
as some of our critics said when we introduced FTs - but
a new form of public ownership that gives hospitals the freedom they need to
innovate and improve in response to local needs.
Second, the NHS has always been a mixed economy of care. State-owned hospitals have worked happily with GPs - the majority of them private businesses dependant on the profits from their practices - since the founding of the NHS. This isn't new and hasn't just happened under this government's watch. When 40% of secure mental health beds and nearly half of NHS abortions are provided in the private or not-for-profit sector, we should not try and set arbitrary targets or limits on one provider or another. If independent providers can help the NHS provide even better care and value for patients, we should use them. If they can't, we shouldn't. I know people are concerned this may cause fragmentation. That is why, in my next speech, I will say more about the principles that should bind together every organisation and every employer within the NHS family.
And thirdly, where a particular service is not meeting the needs of local people, commissioners will be free to find the best organisation or partnership to provide the services that are needed. That's what we are doing in under-doctored areas with PCTs going out to secure new practices. The test is not who owns the organisation - public, private or not-for-profit - but whether they can provide the best services for NHS patients with equal access for all, free at the point of need, with the best value for the public. That is why there needs to be competition - as well as co-operation - in the system.
The golden thread
running through all this is that the NHS will increasingly be proactive not
reactive. It will look at patients as individuals and in their families
and communities and do what's best for them, not what it's always done. It
will provide the right service, in the right place, at the right time. And
that is why you - all of you working in the NHS, not I - will answer the
question:
"where are we going?"
I am not going to lay down from Richmond House
how many hospitals, how many beds, how many staff of each grade and each
qualification, what kind or how many different providers there should be.
Instead, together, we will decide the results we want to achieve and the
national standards by which we want to abide. We will give you the tools -
fair funding and a sound financial framework; support and guidance on
commissioning; payment by results; a modern regulatory system. Above all,
we'll give you the freedom to deliver the best results locally. This is
fundamentally different to the top-down system of the past 60 years.
Not because what went before was wrong, but because what is coming in the future
needs to be different. The new NHS will be more empowering for
patients and enabling for clinicians and staff. It will reward and support
organisations that can meet patient demands and challenge those that want to
carry on as they always have done. The reforms will drive productivity and
incentivise the NHS to keep people well not just treat them when they are ill.
Is this privatising
the NHS? Never. Is this changing the NHS? Absolutely. We are using
all the new means at our disposal to achieve the original ends of the NHS.
Just remember the White Paper 60 years ago that led to the creation of the NHS:
'The Government … want to ensure that in future every man, woman and child can
rely upon getting all the advice and treatment and care which they may need in
matters of personal health; that what they 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.'
None of that has changed. Our goal, quite simply, is to deliver the founding
aspirations of the NHS. I started with the question "Where will the NHS
be in 5, 10 and 15 years time."
The answer to that question will
come not from me or my successor or officials in Whitehall, but from the choices
of patients, the decisions of local commissioners and the creativity of hospital
and community staff, seizing the opportunities that medical technology and our
reforms offer them to do the best for patients.
The founding values of the NHS are at stake here. If we fail, we open the way to those - and there are many of them -who are already saying that a tax-funded health service, free at the point of need, cannot survive in the face of modern challenges. I profoundly believe they are wrong. But if we stick to our course of investment and reform then the NHS will provide better, faster, safer care. By the end of 2008 we will effectively have abolished waiting lists. Patients will have more choice and more control over their services. Together, we will have created a self-improving system that can both deliver the step change in productivity and the transformation in patient care that all of us want to see. I beliee that is how we will safeguard the founding values of the NHS for another generation. I look forward to working with you all to ensure we achieve that goal.
