Speeches recovered from the Conservative party’s online archive More…

Fox: The Health we Deserve

Recent photographs of bodies lying unrefrigerated and piled on top of one another in a Chapel of Rest brought back powerful memories for many people. Images of the winter of discontent reminded us that while much of our national life has changed beyond recognition in the past 30 years, the NHS remains firmly rooted in the culture of the 1970s.

Before the last Election, Tony Blair told voters that they had 24 hours to save the NHS. Increasing numbers of voters feel that Labour has let them down on health and excuses about having failed to understand the size of the problems cut little ice.

The problems themselves are exacerbated by Labour`s centralising tendencies. Alan Milburn seems genuinely to believe that Whitehall knows best and is determined to micro-manage an organisation of 1 million staff from behind his desk in Richmond House. Further, he has appointed his placemen the length and breadth of the country to do his biding. And in the Orwellian style so beloved by new Labour, he describes as 'decentralising', the new Health and Social Care Bill which brings unprecedented hiring and firing powers to the Secretary of State, draconian controls over patient information and the abolition of the independent voice of patients, the Community Health Councils.

This sorry state of affairs is unacceptable in the World's 4th largest economy. We have recently slipped to 19th in the world life expectancy league, being overtaken by Turkey. It is a symptom of serious structural flaws which go way beyond simple questions of funding. The next Conservative Government will tackle these chronic failings in a way we have failed to do in the past.

It is essential to re-affirm at the outset the Conservative Party's absolute commitment to reviving the NHS. We wholeheartedly endorse the principles underpinning the Health Service. We are fully committed to a comprehensive National Health Service, free at the point of use and funded from taxation - albeit with very different priorities from those applied by this Government.

I have also repeatedly made clear that we rule out charges for access to NHS care, and for any specific procedures covered by the NHS. Not that this has prevented our opponents from deliberately lying about our intentions.

Likewise, our position on NHS spending is crystal clear. The next Conservative Government will spend the same amount of money as proposed by the Labour Party. That said, we shall spend the money differently and better, with particular emphasis on improving the quality of treatment. In parallel with this, we will encourage the development of a much bigger independent sector, to supplement the work of the NHS.

On our first day in office, we will abolish Tony Blair's Waiting List Initiative freeing some £340 million for priority areas of care.

The distortion of clinical priorities perpetrated by Tony Blair`s Government in pursuit of the wrong targets has reached crisis levels.

The Prime Minister`s Election Pledge to cut 100,000 from the In-Patient Waiting List has meant that the success of the NHS has been defined in terms of the number of patients who are treated. Hospitals are rewarded, or punished, according to how many names are taken of the Waiting List.

Astonishingly, the Government has overlooked the blindingly obvious consequence of this absurd way of setting targets. Stories of clinical distortion which mean that some of the sickest patients wait longer than minor cases are legion.

It is a sobering fact that patients who develop, for example, stomach cancer in the UK have only an 8% chance of being alive in 5 years. In France the figure is 24%. In Germany it is 35% and in the USA, over 40%. These figures are bad enough in themselves but when they occur in a system which is reducing the waiting times for ingrowing toenails to make the figures look better we need to question the whole ethical and moral basis of our system.

We intend to see that the sickest patients are treated first.

Our Patient`s Guarantee will give a guarantee to patients, beginning in cardiac and cancer services, that they will be given a specific maximum waiting time for treatment decided by their Consultant. It will be set specifically for their individual case and not arbitrarily by politicians for the "average" patient. Good medicine is about seeing patients as individuals not averages.

Targets will no longer be defined in terms of numbers of patients treated. Instead, we will move to new targets based on clinical outcomes and we will seek new ways to standardise the methodology for determining these outcomes. Targets will be set after consultation with the Royal Colleges as part of our drive to develop care based on quality not quantity. The success or failure of management will, over time, be measured against these outcomes. This fundamental change of approach will, in conjunction with real decentralisation and depoliticisation, begin the much needed transformation of the NHS from a managed to a regulated service.

By re-defining the effectiveness (or often, sadly, the ineffectiveness) of the treatment carried out by NHS hospitals in the way I have outlined, we will reveal those conditions where our standards match those of similar countries, and those where they don`t. You don`t need a crystal ball, however, to predict that we do particularly badly by cancer and cardiac patients.

We must tackle these shortcomings urgently. That is why these conditions will be the first to which we apply our Patient's Guarantee. That is also why the next Conservative Government will begin by investing heavily the extra spending we have promised in the areas of cancer care and cardiology. Both these measures will mean that we can make the necessary improvements in the standard of our care in those fields.

But simply throwing more money at oncology and cardiology will not suffice. That investment must be soundly based. The system of care we offer must be coherent, from presentation of symptoms to completion of treatment. There is little point, for example, speeding up the waiting time to see a consultant if there is then a delay in access to diagnostic equipment, or if the treatment is not available on the NHS. The problem with Labour is that they have targets for everything and priorities for nothing. We will have fewer targets but clear priorities linked to a matching programme of investment.

In the same way that we will move urgently to end the Prime Minister's Waiting List Initiative, we will begin to reverse Alan Milburn's politicisation and centralisation of the NHS from the outset.

We will create a properly independent Appointments Body, and ensure that the Secretary of State cannot interfere in its workings. Those appointed to positions in the NHS will be there for the expertise they can bring to the system, not the political loyalty they will show to their political masters.

As any member of the NHS staff can tell you, nobody can do anything in the NHS without first being sure that Big Brother in Richmond House will approve. The Conservatives will reverse this trend. We will end the practice of the Secretary of State micro-managing every aspect of the NHS`s work.

There is an inherent and unacceptable contradiction in the role of the Secretary of State as purchaser, provider and regulator that must be tackled. New checks and balances are required.

For example, the evolution of Primary Care Group into Primary Care Trusts will result in purchasing bodies with ever-increasing strength and scope. If these features are combined with a genuine move to set the acute Trusts free, and to allow management far greater freedom on staffing, wages, incentives and local priorities, then a new balance can be created with powerful purchasers and more autonomous providers inside the NHS which will allow the phasing out of Health Authorities altogether, reducing costs and bureaucracy.

Tackling Labour's chronic mis-management of secondary care in the ways I have outlined will go some way towards restoring the NHS to a more appropriate model. But our proposals will not on their own eliminate the two main complaints that are levelled against the NHS, sadly often with ample justification. These are that the Health Service does not provide enough healthcare and, more importantly, that too much of what it does provide is of an unacceptably poor quality.

Before 1997 Labour argued that there was nothing fundamentally wrong with the NHS - merely a lack of funding and a lack of political will to make it work. Increasingly, people realise what a foolish analysis this was and how much time Labour wasted with sloganising and soundbites when it should have been tackling the real challenges facing our healthcare system.

The National Health Service will stay in a state of permanent crisis until we accept this and brace ourselves for change. In particular, we must stop regarding the NHS as a sacred cow. It is not a capital crime to admit that the NHS desperately needs far-reaching reform. On the contrary, until that reform is undertaken, the health of the British people will continue to suffer.

Changing priorities and using funding better in the ways I have outlined will help. But they will not mean that the NHS can suddenly provide all the healthcare needs of the British people. And herein lies much of the problem. Our stubborn failure, perhaps refusal is a better word, as a nation to recognise the blatantly obvious fact that the NHS alone cannot cope is above all what obliges us to endure a fundamentally inadequate healthcare system.

It is inconceivable in this era of rapid advances in medicine that a healthcare system funded from taxation alone can ever bear the full strain. It cannot be coincidence that healthcare standards in countries comparable to the UK are higher than ours, and that all such countries have genuine mixed provision, that is healthcare provided by a combination of a State and a thriving non-State sector.

Some political dinosaurs argue that creating such a thriving non-NHS sector is tantamount to privatising a national treasure. It is no such thing. I have no problem with people obtaining healthcare in the private sector if they can afford to do so and that is their choice. Conservatives must never forget that choice is in itself a good thing - and also that such extra choice in healthcare should be available to the many, not just the wealthy few. In any case, those who do choose to have their treatment in the private sector are in the process off-loading the NHS, thereby reducing waiting times there for other patients.

The time has come to re-define the role of the NHS, so that it properly matches the needs arising from today's health problems.

Since the NHS was for so long at least a partial success, it is right that the starting point for considering how best to reform it should be the relevance of the two main functions it was originally designed to perform. Those were to act as a funding mechanism designed to provide healthcare free at the point of use - which it continues to do reasonably well - and to carry out high quality treatment - which, I am afraid, the poor success rate of much of that treatment shows that it often no longer does well.

I believe that the NHS should continue as a funding mechanism, building on the successes to which I referred above.

In terms of the treatment which it carries out, however, I believe the time has come for the NHS to worry less about providing all the care itself, and instead to focus more on ensuring that the treatment which it does undertake reaches the required standards.

In parallel with improving the standard of the treatment which it undertakes, under the next Conservative Government, the NHS will significantly increase the role which it plays as part of the "enabling state".

In its present form, the NHS by and large decides which of those hospitals that it runs should treat its patients. This system is geared very much to the needs of the supplier of the care, that is the hospital, rather than the recipient of the care, that is the patient. The sick are therefore at the mercy of an archetypal State-run monopoly. There is minimal incentive for the hospital to improve the standards of the care which it offers, since it knows that it will continue to receive the patients regardless.

Working as part of an "enabling state", the NHS would continue to be funded centrally by taxation. However, in its new guise, its first task would be to identify all those healthcare providers which offered the requisite standard of care. Unlike under the current arrangements, these providers would include both NHS and non-NHS facilities. The "enabling state" NHS would then decide which facility offered the patient the best quality of care and the taxpayer the best value for money. More importantly, it would give patients and doctors greater choice than is currently allowed. We will enable this to happen by setting GPs free from the shackles imposed by Labour and allowing them far greater freedom of referral. The real horror of Labour's provision of more health information is that patients may know that they live in a health ghetto but they have been left powerless to escape.

In considering which facility should treat NHS patients, it is imperative that decision-makers break an age-old taboo hampering the development of a rational healthcare system. It shouldn't and it mustn't matter where a patient is treated. What is important is when the patient is treated and the quality of that treatment. If a member of my family were ill, I would want the best treatment as quickly as possible for them. I wouldn't care whether the provider of the treatment was an NHS-run facility or not. Nor, I am certain, would most other people.

What matters is whether patients get better, not whether the healthcare system operates in accordance with out-moded, albeit well-intentioned principles. The sooner we get this into perspective the better.

The arrangements I have put forward here reflect that new perspective. They would also offer patients and doctors something hitherto virtually unknown in the NHS, the notion of choice.

For the NHS to perform effectively its enhanced role as an `enabling state`, we need to create an environment in which top quality healthcare services are available from a wide range of providers. Government can play a valuable role in such confidence-building by allowing the NHS to purchase more widely. Labour`s concordat with the private sector took an important, albeit depressingly short, step down this path. We must take further, bigger steps, and do so quickly.

First and foremost, what will matter is ensuring that any would-be provider offers services of the requisite standards. The NHS would then simply have to decide which provider offered the best value. By definition, it will be possible to operate this kind of system only if all regulation of NHS and non-NHS facilities is conducted by a single body, responsible for inspection and standards - it would be unacceptable for a single pool of money, the NHS budget, to be used to buy services with different guarantees of quality.

The Conservatives will legislate to introduce such a system of single regulation. It is time we started regulating for the patient and not the provider.

As for the patient, the impact of the shift of NHS focus towards work as an enabling state could be only for the better. Patients would know that, whenever the NHS paid for their treatment, they would receive prompt, high quality care - and given the widespread concern now about the inadequacy of much of the care offered in NHS hospitals, it is hard to imagine anyone objecting to that! Otherwise, patients would notice little difference. As now, they would not pay for the care they received. Again as now, that care would be made available through the NHS.

A practical example of how the NHS could work as part of an "enabling state" would be to encourage the further development of the creation of "stand alone" or specialist surgical units, run by independent healthcare providers - mirroring a recent trend in the most forward-thinking NHS Trusts. The Government's moves in this direction are welcome, if timid.

An increasingly frequent occurrence, which causes patients at best annoyance and disruption and often considerable distress, is the last-minute cancellation of surgery because of such unforeseen events as staff illness, or the need to treat other patients whose need for treatment is more pressing.

Since the NHS can never be only about life threatening conditions, we support the idea of "stand alone" surgical units for procedures such as cataract surgery or knee or hip replacements. These units, dedicated to a single type of treatment, could work more efficiently (perhaps even round the clock), enabling us to end the scandal of operations being cancelled at the last minute. Patients would continue to be funded by the NHS, but could attend such units run by the independent sector to reduce waiting times.

Changes in how the NHS measures its performance, the introduction of new priorities, set by doctors, and the devolution of powers to the Trust level will make a significant difference to patient care. But they will not be enough on their own to tackle all the NHS's problems. The quality of the care which patients receive in the acute sector is determined above all by what happens on the Wards.

Here, again, there is a chronic separation of responsibility and authority. Ward Sisters are held responsible for the well-being of their patients. But they do not have authority over many of the processes which determine the effectiveness of the care they provide, notably cleaning the wards and feeding the patients.

The next Conservative Government will address this problem by requiring Trusts to put in place arrangements which re-establish "Matron`s Values" on hospital wards. The cleaning staff, and those responsible for feeding patients, will be answerable directly to the Ward Sister. If she thinks that a bed should be changed, dust swept from the floor or a patient fed, it will be done.

I want to see the reintroduction of Matron posts within the NHS to provide a clear chain of command throughout the hospital so that there is someone personally responsible for overseeing and supporting the nursing staff.

When considering the work of nurses, we need at the same time to re-emphasise a much under-used word - vocation. It was a theme of William Hague's speech when he said that nursing, like other medical professions, is more than just a job. Policy makers must show greater respect and appreciation for those who want to help others, often at rates of pay well below their earning potential.

Nursing now faces enormous challenges, though also considerable opportunities. Nurses must be respected for their dedication and expertise. I want to see a profession in which it is recognised that comforting the anxious is as important as operating complex equipment, where vocation is valued and family commitments accommodated, and where patient need, not political interference, determines priorities. Only thus will we see better morale among well-motivated professionals.

We will therefore look at reforming nurse training to encourage a wide and flexible skills base where academic skills are seen as an extension of, not a substitute for basic patient care. We will also look at new ways to organise nursing rotas so that, for example, more medically-trained nurses are available in the winter months when they are most needed, while surgically-trained nurses are available in greater numbers in summer when surgical activity is at its peak.

Realists know, even if politicians refuse to admit it, that rationing exists in the NHS. However much you improve the workings of the secondary sector, rationing will continue as long as medical science is able to grow faster than our ability to fund it. So although these new arrangements I am advocating would ensure that NHS patients received the highest quality care available, the volume of such care that the NHS could provide would still be limited by the size of its budget. That is why we must increase the overall capacity of the system - in both funding and provision - by both enlarging the NHS and encouraging growth of the independent sector.

Until we create enough extra capacity, the overall standards of our healthcare system will lag behind those of similar countries.

The solution is not difficult to find. It is evident in most of our near neighbours` systems. All have flourishing private healthcare sectors, which complement their equivalents of the NHS. We must consider the approaches which they adopt, and apply here those which are suited to our needs.

We need not only the expansion of private provision of services, but also an increase in private purchasing of services if the total capacity of our health care system is to be increased.

This can be done in different ways. Individuals can directly purchase complete episodes of care, such as a specific surgical procedure. This is usually paid for from savings. Since 1997, 450,000 people have opted for this route (nearly four times the size of the fall in In-Patient Waiting Lists), often for highly complex surgery because patients have despaired of receiving the treatment they need from the NHS. We need to look at ways in which this burden could be eased.

Alternatively, purchasing of healthcare services can be done through insurance, taken out either as an individual or as part of a company scheme. We favour expansion through company based schemes because it offers the price advantages conferred by community rating. This means that benefits would be spread far more widely than if tax incentives were offered for individual policies. The choice in healthcare should not be restricted to the wealthy but made possible for a wide income range in the way home ownership became available in the 1980s.

Research tells us that if the public believed the NHS would deal properly with cardiac and cancer care, two of the most expensive items, then they would not seek all inclusive, and expensive, private insurance products. This could reduce premiums by up to 30%, bringing them within the reach of many more people still. This would be a tangible benefit of a real public- private partnership and a direct benefit from our Patient's Guarantee.

Labour subjects company schemes to heavy taxation penalties. Employers who offer such schemes pay an additional £100 million in Employers National Insurance while individuals are taxed as a benefit in kind to the tune of £368 million. We will abolish both these taxes when it is prudent to do so in order to boost this part of the private sector.

We also intend to help the self-employed by creating a large umbrella scheme to which they can affiliate, run by the private sector and offering the same costs and benefits as large company schemes. If we are serious about wealth creation, we must give special thought to the wealth creators.

Although my focus here has tended to be on the secondary sector, we must remember that most patient contacts occur in primary care and in the community, and that there is a need to restore the correct balance between the primary and secondary sectors.

There has been far too much structural change in primary care with disastrous results for staff. Most can no longer tell if they are at the end of the last reorganisation or the beginning of the current one. The Conservatives will not reorganise General Practice. Instead, we will work with the structures we inherit from Labour. Our task will be to make them work better for the benefit of patients.

In order to provide a much needed breathing space we will not allow any move from PCT to Care Trust status for a minimum of four years. This will allow for some much needed stability.

One of the most pressing tasks in the longer term will be to ensure that we use our skills base appropriately. For example, at the moment many GPs undertake sessions in acute hospitals as clinical assistants, usually in Out-Patient Clinics. These occur in areas of specialist clinical knowledge or experience. The economy of scale offered by PCTs could enable these doctors to cross refer, in certain specialties, in their own locality. This would build upon, not substitute for their generalist role and they would rightly expect to be paid for it. It would give improved access for patients and allowing hospital Out-Patient Clinics to be reserved for those who genuinely require a Consultant level service.

This diminution of the gap between primary and secondary care could only be achieved, however, by expanding the role of practice nurses to take on many of the tasks currently undertaken by GPs, especially in the areas of chronic disease management. Without this willingness to operate at the skill ceiling of all staff, manning constraints will limit the scope for the innovation we require.

The Conservatives will also re-introduce far greater freedom of referral, with devolution inside PCTs down to the practice and, where possible, individual doctor level. This will maximise clinical freedom without structural upheaval and the imposition of further red tape so beloved by New Labour.

All these changes would go a long way towards establishing the depoliticised, decentralised and refocused healthcare system we require. They would also contrast markedly with Labour`s programme.

Where the Conservatives want a reduced role for the Secretary of State, Labour intend to extend it through the Health and Social Care Bill. Where we see decentralisation as a priority they attempt to apply a one size fits all blueprint made in Whitehall. They talk of cooperation with the private sector yet attack it through the taxation system. They collect data but deny doctors and patients the means to act upon it. And their obsession with Waiting List numbers blinds them to clinical distortions and the need for proper outcome-based targets.

Our changes will confer many advantages. They will set management free. They will allow prioritisation once again to be undertaken by doctors. They will open up a golden era for nursing with wider responsibilities than ever before.

But I do not believe that the changes are in themselves the be all and end all. For while they will enable patients to benefit from a more flexible and expanded system, choice will still be operated on behalf of the patient rather than by the patient. The role of "gatekeeper" to the wider NHS will continue to be played by individual GPs or PCTs.

Real empowerment of patients as individuals will remain restricted. Our changes, enormous though they are, should therefore not be seen as an end in themselves, but as a stop on a journey. It is a journey which will take us from a paternalistic system, however benevolent, to one where patients themselves have far greater choice about the sort of health care they receive, drawing on the information ever more accessible to the public. After all, they are paying for the healthcare. It is not charity we are receiving from the State.

Many people will rightly find it astonishing that the state of the NHS, and healthcare generally, should have been allowed to plummet so far before major surgery has been considered. For this, I am afraid that responsibility rests squarely at the door of politicians - unwilling to face unpalatable truths about the real state of our health services.

The health debate has been bedeviled for years by Labour`s dishonest accusation that the Conservatives want to privatise the NHS, and our timid approach to policy-making when confronted by this. This has resulted in the UK having unacceptably poor outcomes in many areas, and little of the state/private partnership from which other countries benefit.

For the sake of the British people, we Conservatives must expose Labour`s lie. We must break out of the vice-like grip of Labour scare-mongers, who shamelessly argue that anyone who utters a word against the NHS cares nothing for patients, and is motivated exclusively by profit. Until we drag the debate about healthcare out of the 1970s and into the 21st century, the British people will continue to be condemned to insufficient and inadequate healthcare.

In many respects the public are ahead of the politicians. They, unlike Ministers, seem all too familiar with long waits in casualty, patients lying on trolleys and waiting two weeks to see their GP. They know real change is required. It is time for the politicians to wake up and catch up.

The real political prize will surely go to those who can embrace and develop the agenda where the patient really does come first and we all get the health we deserve."

Keyboard shortcuts

j previous speech k next speech