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McLetchie: Choice for Scotland's people

Lecture to the Conservative Policy Forum

Introduction

"In my speech at our Scottish Party Conference in September I said that the Scottish Conservatives needed to be the party of change in Scotland. Some may have found this language odd coming from a Conservative as we are supposedly change resistant, but this does not recognise the difference between a conservative disposition and the Conservative political tradition to which we all belong.

A conservative disposition does indeed mean an aversion to change, but this is by no means confined to political Conservatives. Indeed, one might argue that the real political dinosaurs are on the left of politics, not the right. The Conservative political tradition is based not on similarities of personality, but on our attitude to society. What unites us is not an aversion to change, but an aversion to change imposed from on high. We oppose attempts to impose a pre-conceived plan upon society, changes intended to produce a particular outcome or make people live in a particular way. We do not wish to prescribe and then preserve any particular state of society, but to affirm its spontaneity.

Conservatives have always been willing to embrace change when it was necessary. As Edmund Burke said, 'We must all obey the great law of change, it is the most powerful law of Nature and the means perhaps of its conservation.'

We seek to retain, or restore, the conditions under which the pattern of society is not determined by the actions of an individual or a group who try to mould it to fit a vision, but emerges instead from the accumulated inputs of the many. In short, a society created by human action, not design.

This is what Conservatives mean when we talk of a free society. It is a civil association in which people acknowledge the authority of the jurisdiction under which they live. However, this respect for the authority of the law does not imply that every person approves of every law - what commands and demands our respect is both the law as it stands and the law-reforming process.

Our laws specify the conditions to which every person subscribes as each pursues his or her self-chosen goals. People are associated, not because they share the same goals, but because they accept the same conditions. A sense of social solidarity and the legitimacy of the government derive from the shared sense that the social system gives everyone the chance to do the best they can in their self-chosen sphere of life. Everyone has an obligation to act justly towards others and each person enjoys equal status under the jurisdiction. Winston Churchill summed up our aim when he said, 'We seek a free and varied society, where there is room for many kinds of men and women to lead happy, honourable and useful lives. We are fundamentally opposed to all systems of rigid uniformity in our national life.'

Such a civil association has developed in this country over many hundreds of years with a complex of institutions growing up which have ensured that government is limited and power in society is dispersed, thus guaranteeing that no one person or group is allowed unlimited power. It is this complex of institutions which makes possible, not only material prosperity, but progress in all spheres of human existence whether in art, science, education or welfare.

Such progress did not come about as a result of some central plan, but through a spontaneous process of evolutionary growth and development. For this to occur, people must be free to make choices as Winston Churchill recognised only too clearly when he said, 'Let the people use their common good sense, multiply the choices which are open to them at every….. phase in their lives.'

Sadly, socialism sought to replace this organic growth with central planning. In contrast to a civil association, the socialist philosophy led to something more akin to a corporate association in which people are directed in their pursuit of a common goal determined by the government. As a result resistance to change came to mean defending a socialist status quo. It has therefore been the role of Conservatives, not only to resist further moves in this direction, but also to bring back the spontaneity lost to central direction - to roll back the frontiers of the state. That was what Winston Churchill sought to do in 1951 and Margaret Thatcher in 1979.

This effort to roll back socialism has chalked up notable successes over the last 20 years and, particularly since the fall of the old Communist regimes in Eastern Europe, no one serious believes in a centrally planned, socialist command economy any more. The spontaneous co-ordination and co-operation fostered by the marketplace and the rule of law has proved far more successful in creating prosperity for all. However, there is more to a good society than the creation and conspicuous consumption of more goods and services and as Conservatives we must acknowledge that we have been less successful in demonstrating the benefits of applying our principles and values to the provision of our public services.

That is the challenge which faces us today and particularly here in Scotland where the left still holds a self-proclaimed moral superiority it has done little to earn. Although no one would deny that the Labour Party has been forced by Conservative reforms to move away from some of its more extreme positions, there are still plenty of barriers and obstacles erected by the state to change, development and improvement in our vital public services of health, education and policing. Central planning of the economy may have bitten the dust, but central control and direction is alive and kicking in the way Labour runs our public services. It is therefore no coincidence that these are the areas which are currently of most concern to the public and where the public are most dissatisfied with the service which they receive.

This is because our main public services are centrally directed bureaucracies characterised by centralised targets, centrally directed funding and rigid national terms and conditions of employment. It is these features we must seek to change.

Health and Education

Everyone in Scotland must be able to rely on the availability and quality of publicly funded healthcare and education. At present, the quality of these services does not match those found in many other countries around the world. It is time we caught up.

We still insist on running our health and education systems as virtual monopolies which can only develop as a result of the decisions and commands of politicians and bureaucrats and in which most patients or parents have no choice but to accept the services on offer whether they are satisfied or not. Our political principles, borne out of experience, tell us that such systems are doomed to failure and this is indeed the case.

As the NHS is a government monopoly, ordinary people have little idea of how the quality of the service provided to them compares internationally. In fact, it compares extremely badly. Post-treatment cancer survival rates are worse in Scotland than in EU countries such as Germany, France and Sweden. The OECD ranked the UK bottom of eleven countries in relation to the care of stroke victims - the only country classified as having a high death rate from this cause. And because queuing is built into our system - it is in fact how we ration provision - patients languish on waiting lists unheard of in other EU countries.

There is no doubt that more money has been spent on the health service under this Labour Government and Scottish Executive, just as it was over the 18 years of the last Conservative Government. This year, over £7 billion is being spent on the NHS in Scotland - an increase of nearly 34 per cent compared to the first year of this Parliament. Yet in the same period, waiting lists have risen by over 20,000 or 23 per cent, the number of patients seen within 3 months has fallen by nearly 10 per cent and the number of patients being treated has also gone down with over 7,500 fewer elective inpatients seen and over 15,000 fewer day cases. So why are we not obtaining better results? Why do these figures stubbornly refuse to improve for the better?

It should not be surprising as it is a feature of nationalised monopolies. In the absence of choice for patients, there is no means of accurately measuring and responding to demand and so resources are misallocated. Such monopolies are also less innovative as they are dominated by an 'aye been' mentality. This is borne out by the Wanless Report which found that by comparison with the US, Canada, France and Australia the NHS was the worst in terms of introducing new technologies which can make a real difference to people's lives.

However, for many Labour politicians the ultimate justification for the NHS is that it is about fairness and access for all - an important part of its plan to create a more 'socially just' society. However, it is failing on these grounds as well, a fact even some Labour politicians have now recognised. Alan Milburn told NHS chief executives earlier this year, 'In fifty years, health inequalities have widened not narrowed. Too often even today the poorest services tend to be in the poorest communities.' He was right - but now retired - because those who defend the status quo on public services defend a model that is one of entrenched inequality. It is a two-tier system.

Conservatives understand that guaranteeing high quality healthcare, available to all regardless of income and wealth requires fundamental reform of the current system. As long as change within it can only come from above, it will continue to fail patients. So the first step must be to move away from a centralised monopoly structure in which the government runs the whole system and acts as provider, purchaser, funder and regulator of healthcare all at one and the same time.

As we have long argued in the Scottish Parliament, the key to successful reform is to put patients first. As the Prime Minister said during the last election, 'I cannot say too often that….the NHS exists for patients, not the other way round.' He was right, but the compromises needed on foundation hospitals have stalled and undermined the cause of reform in England. Here in Scotland, Jack McConnell and Malcolm Chisholm use the same sort of language as Mr Blair, yet neither of them is prepared to take the steps necessary to change fundamentally the relationship between the patient and the NHS.

The essential first step must be to give all patients genuine choice and therefore greater control over the treatment they receive by giving them real purchasing power. Anything else means that no matter how much consultation is involved, the ultimate decision is still at the discretion of the medical authorities. This is the case at present where Health Boards may send patients to other parts of Scotland, or indeed of the United Kingdom, for treatment, but patients can only go where they are sent - ironically, this was one of Labour's main criticisms of our system of GP fundholding in which patients had to follow the contract.

With a monopoly such as the NHS, choice is really only available at present to those who can afford to pay twice - once through their taxes and then again for private treatment for themselves or their families whether paid through insurance or directly.

Our aim is to extend this choice to everyone through a patient's passport. The entry to the system would still be through a patient's GP and consultant, but once diagnosed the patient would be able to take the standard tariff funding for their treatment anywhere within the NHS so money would follow the patient through the system. For the first time, they would have access to a truly national health service, not a regional one where access is determined by your postcode. Although many patients would undoubtedly choose a local hospital for their treatment, others would exercise a choice based on a shorter waiting time or on acknowledged expertise. What matters is not the basis for patient decisions, but that the choice is in their hands and the role of the GP would be to advise on comparative waiting times, outcomes and locations and act as a professional advocate for patients.

So every patient will have greater freedom to choose within the NHS. However, we wish to go further and extend the Patient's Passport so that a much higher proportion of the population is able to receive treatment from providers other than the NHS. We would thus enable patients to take a proportion of the standard tariff - probably around 60 per cent - with them to the voluntary, not-for-profit and private sectors which would provide this treatment. At first, this extension of choice will be limited by the fact that these sectors are relatively small in this country. However, one of the main benefits of our policy is that it would provide a clear incentive for greater investment in capacity, something which is essential to improving health services overall and expanding patient choice.

For reform to be successful, putting patient choice at the heart of the health service must be accompanied by reform which sets the providers of health care free to cater for those choices. This is based on the principle that in providing services, the state should treat itself no differently from any other potential provider. We see the role of the government as being largely to fund and purchase healthcare and monitor standards, whilst increasingly freeing up the provision of health services. The key difference is that in our system the funding provided by government would flow through the system from the bottom up, reflecting the choices of patients. This would be a marked difference to the current system in which everything flows from the top down.

The central control of the NHS must end with politicians taken out of the running of the service by ending the target culture so beloved by Labour. This would trust staff to use their clinical judgement and recognise that they should be accountable to their patients, not the bureaucrats and politicians responsible for setting the targets. This does not mean an end to the information essential for doctors and patients to make informed decisions, simply those targets which are an instrument of central control. The problem of political targets is that they become an end in themselves as opposed to a means to improving the service for patients. This is clearly shown by the fact that once the Executive met its target for cardiac patients it was happy, irrespective of the needs of other cardiac patients. So this shows what was more important in the command and control NHS - meeting a political target and moving on to the next rather than treating people who needed cardiac surgery when we had the capacity to do so.

And the Executive is not shy of using other means of central control. Malcolm Chisholm stepped in to order local managers to employ more permanent nursing staff rather than agency nurses, even though staffing arrangements are supposedly devolved to local hospitals. And even more blatantly when the Daily Record ran a story about the scandalous length of time one of my constituents had to wait for treatment - over 5 years - Malcolm Chisholm was embarrassed into meeting him personally and arranging an appointment for him. I think even the Daily Record would recognise that we can't have a health system in which a newspaper determines who gets a hospital appointment.

As well as freeing staff from this central direction, we will free the institutions in which they work. As we made clear in our manifesto for the 2003 Scottish Parliament Elections, we will enable hospitals in Scotland to apply for foundation status. They would continue to be part of the NHS, but would operate as not-for-profit organisations with their own directors and far greater operational freedom with for example the freedom to determine pay and conditions, borrow money and develop their own sites. This greater independence will enable them to meet the needs of patients more effectively and as money follows patients, well-run hospitals will become well-funded hospitals.

The problems which face our schools stem from the same centralising tendencies. Although formally our schools are run as a system of local monopolies, in effect they are directed by centrally set rules and regulations. This stems from a longstanding view that progress within our education system can only come about as a result of political action. As Tom Devine's excellent history of Scotland 'The Scottish Nation' makes clear, this flies in the face of the historical evidence. This shows that before the intervention of the state following the Education Act of 1872, the diverse pattern of provision which had grown up in Scotland over the preceding centuries had resulted in near universal levels of both attendance and basic literacy. State intervention did not create this and, as the educational historian E.G. West put it so aptly, when government got involved with education, it was 'as if it jumped into the saddle of a horse that was already galloping.'

Of course, the main justification for the one-size-fits-all system which politicians have created was that it was fairer and more equal. The reality has been very different. There is an enormous gulf between the best and worst performing schools and, overwhelmingly, it is those children in our most deprived communities who are trapped in poor schools.

The solutions to the problems of our schools are essentially the same as those for health. Parental choice must be at the heart of the system, as is the case in countries as diverse as Sweden and Chile. In Scotland, choice currently exists only for those parents who can afford it - the small number who can afford, and are prepared, to pay twice. This is obviously true of those who pay their taxes and then pay for private education on top. However, it is equally true of those who use the state system but can afford higher mortgages to buy houses in the catchment areas of the best schools. Such a system is designed to entrench inequality and that is exactly what it does.

That is why we are offering a Better Schools Passport which will enable taxpayers' money to follow children to the schools of their parents' choice. This clarifies the role of the government, which is to act as the funder of education. However, the purchasing power would be transferred to parents and money would follow pupils to the school of their choice. This would be equivalent in value to the current revenue cost of providing primary and secondary education plus a capital element which would allow popular schools to expand and new schools to be created.

The Better Schools Passport will enable parents to send their children to any school, whether run by the council or an independent educational trust, which is prepared to offer their child an education at a price equivalent to its value. We want to foster a whole network of state funded, but independently run schools to extend choice beyond what is currently on offer from our one-size-fits-all, council-run, comprehensive system.

Schools would be given greater autonomy to respond to parental demand for different types of school. Although government will still have a regulatory role to ensure that parents receive accurate information on the performance of schools, head teachers and school boards would otherwise be given greater control over budgets and more freedom to determine staffing, the curriculum in all its aspects and policies on discipline and uniforms. New schools would be established to respond to parental demand and the professional status and independence of our teachers would be enhanced. This is essential as good teachers are the most important factor in whether children benefit from school and undermining their autonomy only drives out good teachers and protects poor ones.

The reform we are advocating in both health and education is vital as it moves both systems away from monolithic systems which can only develop at the behest of politicians and bureaucrats. By removing the obstacles to independent growth and development, we would create the potential for evolutionary change reflecting the wishes of patients and parents.

The potential benefits of this change are enormous. All patients and parents, not just the privileged few, would be empowered through choice. Services would have to be more responsive to those they serve and so resources would be allocated more efficiently, whilst the greater freedom for providers would mean uniformity being replaced by innovation and diversity which will lead to higher standards for all.

Policing

The approach to policing is inevitably different to that required for health and education. They are essentially personal services where the key to reform is to make them more accountable to patients and parents by extending consumer choice. However, policing is a genuine public good and the mechanism of consumer choice is absent.

Policing is the premier public service because law and order is the foundation on which everything else is built. Although the private sector can be used to good effect in some parts of the criminal justice system such as prisons or escorts or civilian support for the police, there is no doubt that the delivery of law and order can only be the responsibility of the state. It is a responsibility which is not being fulfilled adequately at present in too many of our communities.

Although we used to pride ourselves on having a less crime-ridden society than others, the reality is that in Scotland there are 8.3 crimes per every 100 people, one of the highest rates in the European Union and well above the EU average of 5.9. Whilst the most recent International Victim Survey shows that the percentage of the population who were the victims of eleven specific crimes, such as vandalism, assault and theft, was higher in Scotland at 23 per cent than in the United States where the figure was only 21 per cent.

Such high rates of crime are not inevitable. In the longer term, the best way of reducing crime is by strengthening the bonds of what Oliver Letwin, when Shadow Home Secretary, called the 'Neighbourly Society.' However, such a society will not develop unless we tackle the crime that still blights far too many communities in Scotland and initiate a virtuous cycle of good order. In this respect, we know that effective policing can cut crime.

It has done so in New York, where under Mayor Rudolph Giuliani more police were put on the streets and a 'Zero Tolerance' approach adopted. This is based on the 'broken windows' theory which maintains that low level crimes such as vandalism and graffiti must be firmly tackled as they often lead to more serious crimes and a vicious downward spiral which sees neighbourhoods decline and communities demoralised and demotivated.

Closer to home, this approach has proved effective in Hartlepool and Middlesbrough where Ray Mallon has put it into practice. This shows that there is nothing exclusively American about the NYPD approach. Its success, as in New York, is based on the belief that the overriding objective of policing is to cut crime, to which all other objectives are secondary.

This is undoubtedly a view shared by the public who have expressed time and again their desire to see a more visible police presence on our streets to deter and detect crime. Despite much talk of neighbourhood policing and more 'bobbies on the beat', this has not been translated into a more visible police presence on our streets. This failure to deliver is fuelling public cynicism and disillusionment.

We need to restore public confidence in policing and that means increasing the accountability of our police forces to deliver results within a framework of clear public policy objectives set by people who are accountable to voters through the ballot box.

We believe that this cannot be achieved through central direction from the Scottish Executive as this reduce the local ownership of decision making which is fundamental to achieving results. It is why in order to bridge the credibility gap between the public and the police we believe that Police Board conveners should be directly elected at the same time as we elect our councils. Police Boards will still be made up by councillors drawn from the local authorities in the Board area, but a directly-elected convener would have the authority to drive forward neighbourhood policing plans and be answerable to local people. He or she would also act as a powerful champion of the police service in negotiations with the Scottish Executive over funding for the police and reforms of the criminal justice system drawing on local experience.

The operational independence of the police would continue to be guaranteed, but the public would be aware of the clear aims and objectives which the police were expected to meet and regular statistics on local crime would have to be published as happens in New York. This is the best way of ensuring that the public receives the policing it demands and deserves.

Conclusion

The programme of reform that I have outlined shows that there are alternatives to the present provision of public services which is failing to meet the needs of people in this country. We can transform our public services so that they are organised to serve the interests of the patient and parent. And we can tackle crime by making our police forces respond to the wishes of their local communities.

Extending choice in this way extends opportunity to the most disadvantaged in our society who currently have almost no choice at all. The major indictment of our public services is that they fail the very people for whom they were designed. No one doubts that these centralised monopoly services were introduced by people with the best of intentions. However, they should recognise that they have not worked. This invalidates the claims of moral superiority so often made on their behalf.

The reforms are also in line with the Conservative political tradition because the future shape of our health and education services will be the product of human action and not design. This will allow them to develop in an evolutionary way so avoiding the political upheavals which have been the only means of effecting change until now.

And there is considerable evidence that the public now wants such a change. The systems shaped in the aftermath of the war were designed to deal with a very different world to the one we face today - a world of rationing, lower expectations and lower life expectancy. Today people are used and expect to make choices over all aspects of their lives - not content to accept their appointed lot and rightly so. And progress in this period has been dramatic, but not in the areas controlled by government.

ICM polling has confirmed the disillusionment with the current situation in relation to our public services which has fuelled dissatisfaction with politics in general, as we saw in the recent Scottish elections where only 49 per cent bothered to vote. What can attract people back to politics are new ideas to tackle the major issues that affect them. ICM found that 88 per cent of all voters thought that the NHS was in need of fundamental review including 83 per cent of Labour supporters. Whilst 74 per cent thought that education required the same fundamental reform, including 67 per cent of Labour supporters.

And Scottish Conservatives should be encouraged by the support found by ICM for our solutions of greater choice in education and health as well as zero tolerance policing, particularly amongst the young, women and the less well off. It is now up to us to tap into this latent support for these policies by showing that only the Scottish Conservatives can turn them into reality.

It is time for a change. As we survey the political landscape of Scotland, only the Scottish Conservatives can be the engine for change through choice, which can transform our public services for the better."

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