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Andrew Lansley: Alan Johnson is a roadblock to NHS reform

It's a pleasure to be here. I want to talk to you today about an institution that is there for us all. All through our lives. It's an organisation that is very important to my family, It brought each of my five children into the world. My father worked for it from the day it started, until he retired in 1982.

What I'm talking about - is of course - the NHS. In a society in which many institutions are weakened, the social solidarity of the NHS has been a source of cohesion.  The NHS belongs to us all. We all have a relative or neighbour who works in the NHS.  We've experienced it first hand as patients.  We're all stakeholders through the taxes we pay.

Today I want to talk about how our values in the Conservative Party shape our view on how healthcare should be delivered in England; and to contrast that with what has happened over the last decade.

<h2>Responsibility</h2>

If I was asked to choose one word to sum up the Conservative Party's vision for a changed Britain, it would be 'responsibility'. Responsibility goes to the core of all the changes we will seek to make

Why? Because so many of our current problems can be traced back to a lack of responsibility in our society.

The fathers that walk out on their families because they feel no sense of duty towards them. The teenagers whose idea of fun is to get blind drunk and terrorise our town centres. The bankers who thought only of profit and not of risk  And of course, MPs in parliament, who have let you down as your elected representatives.  It is the responsibility of those we elect to behave properly. Not just legally. Not just within the rules. But to the highest standards. We believe that those elected for public office should be beyond reproach.

That's why David Cameron and I paid back claims - to show we get it and we understand the need to meet those standards. And that is why David Cameron was the first to set out plans to rebuild our politics and the trust people have in politicians.

We have said for many years now that the modern Conservative Party stands for social responsibility, not state control.  And - as David spoke about earlier this week - to bring about a more responsible society we need to actually give people responsibility.

We need a radical redistribution of power from the state to citizens.  Through decentralisation, transparency and accountability we must take power away from the political elite and hand it to the man and woman in the street. And in public services it demands a radical shift in the distribution of power.  Nurses', doctors', and teachers' professional judgement has been steadily eroded by Labour's tick-box, target culture. That's why a Conservative Government would scrap these top-down targets and instead focus on what matters - results.

We would trust doctors and nurses to do what's best for their patients, and then focus on the outcomes they achieve, rather than the hoops they are made to jump through by Whitehall.

Because when you think about it, there is no greater expression of collective responsibility, of our duty to our fellow citizens, than the NHS. Collectively we are committed to pay for, look after, and care for the frail and the sick in our society, regardless of their circumstances.   That is something of which I think we should all be proud. I am determined that future generations will also be supported by the NHS.  But we can not stand still.  The sense of security and equity the NHS engenders in not enough. Alongside equity, we must build excellence.

So we are determined that the NHS will go from strength to strength under a Conservative Government led by David Cameron. That it will deliver healthcare that is truly amongst the best in the world.  By making the NHS truly accountable to patients not politicians, and achieving results as good as any in Europe, we could save at least 100,000 more lives every year. It is a bold vision that I am confident we can achieve - but if we are going to, we all need to do our bit.

All of us need to face up to what's behind so much of the demand on the NHS, and start to take responsibility for improving such things as our diet, activity levels and alcohol use. NHS managers need to start trusting doctors and nurses to do what's best for their patients, instead of burdening them with boxes to tick and hoops to jump through. 

Nurses, freed from Labour's mountains of paperwork, must get back to the bedside, and refuse to accept excuses for poor standards of care.  GPs, properly rewarded, must step up to the plate and take ownership of their patient's whole journey of care.  For a politician too, I believe that there can be no greater responsibility than to be entrusted with improving our nation's health service.

<h2>Roadblock to reform </h2>

People could be forgiven for wondering whether the present incumbent shares that view.

Instead of driving through key reforms in the NHS, Alan Johnson's been eyeing up another job. And the NHS is suffering as a result. It's incredibly frustrating.  Back in 2006, we offered our support for reforms that would give patients more power through competition and choice. 

We desperately wanted the NHS to succeed in this Parliament, so that it can do even better in the next. It's so disappointing that during the last two years, the reforms that began under Alan Milburn and Tony Blair have completely stalled under Alan Johnson and Gordon Brown.

Back in 2006, Tony Blair said that: "Changes in health and education are difficult, challenging but essential to deliver the 21st century services the public expects" (6 June 2006).

The point I want to make today is that Alan Johnson's lack of progress is doing real harm to our NHS. 

Tony Blair said in his speech in 2006 that he believed there were four drivers for reform in the NHS: patient choice; independent sector involvement; practice-based commissioning and Foundation Trusts. Each of these are necessary, if not necessarily in the form envisaged by Tony Blair, to create a 21st-century NHS that delivers world class healthcare for patients. Although, as I will describe, they are not sufficient.

Even so, let's stick for now with the Blairite reforms. Let's take the first - patient choice.

Alan Johnson published a Primary Care Strategy in July 2008 which sounded good.  The headlines claimed that we'd all be able to choose our GP. 

But when you looked at the detail, it rang hollow.   The strategy made clear that GPs would still have fixed practice boundaries.  And they still wouldn't be allowed to accept patients beyond these boundaries.  Practice boundaries are a solid wall of defence against real choice.  While they still stand, Alan Johnson's promise to give us the right to choose our GP is meaningless, nothing but empty words.   

And then there's the choice of a hospital.  By April 2008 everyone was supposed to be offered a choice of hospital for their first outpatient appointment. But patient's experience choice has stuck at just 46 per cent since July last year.  And it's gone up by just 3 per cent since Alan Johnson took over as Health Secretary. 

The thing is, it's hardly surprising that patients aren't being offered a choice of hospital.  The majority of us are still in the same situation we've always been in.  That's where the second driver of reform comes in - opening up the supply of NHS healthcare to new providers.   

Even before Alan Johnson took over at the Department of Health, all the Government had really done was negotiate some contracts for Independent Sector Treatment Centres. These contracts were badly designed because Labour didn't get value for money. According to one study, it could have wasted as much as £1 billion.   Yet instead of creating the environment to support any willing provider to, Alan Johnson decided to cancel the roll out of Independent Treatment Centres.

So, on the second principle of reform - independent sector involvement - he actually went into reverse. He said the independent sector is about capacity, not competition. And he's wrong. Opening up providers is about competition as well as capacity.

On Tony Blair's third driver of reform - giving GPs notional power over budgets for their patient's care through practice-based commissioning - it too, has stalled.  The reality is that offering patients a choice of hospital will only be effective if it is backed up by power in the hands of GPs.  That's because they are the ones who can really take responsibility for helping us manage our care.

They are the interface between us and the health service. With patient input, they can hold hospitals and services to account by simply refusing to send patients there if standards are not up to scratch.  If GPs don't have their hands on the purse strings, then patients don't have any real power. 

Since December 2008, the number of GP practices holding notional budgets has actually gone down by 5 per cent.  And GPs know that notional budgets are pretty pointless anyway - there's no ability to reinvest savings; and no ability to negotiate and hold contracts. Real budgets will give GPs power to respond to patient choice.  But the Government won't let go.

And what about the fourth driver of reform - Foundation Trusts? Supposed to be completed by December 2008. Their roll-out has also stalled. So we still have an NHS bureaucracy which controls both commissioners and providers, twenty years after we were supposed to have a purchaser-provide split.

The tragedy of Blair's healthcare agenda is that the only "driver of reform" he really delivered on was the one that was always going to achieve the opposite - introducing more and more process-driven top-down targets set by bureaucrats in Whitehall.

I couldn't phrase the problems linked to targets better than a former adviser to Tony Blair, who said:
"The downsides of targets are several: One is that you get perverse outcomes - people focus on one target at the expense of others...a second problem is that people cheat....but perhaps the biggest problem of targets is that they deny autonomy to frontline managers."

Week in, week out, I speak to NHS staff who agree with that.  I'm not saying their intentions were bad.  Tony Blair wanted the NHS to raise its game.  Holding hospitals to account for measurable aspects of performance seemed like a way to drive reform. 

But he didn't bargain for all the perverse side-effects.  Where boxes have to be ticked there is little space for professional judgement.  Where targets are the priority, non-targeted parts of a patient's treatment get left behind. Where parts of the process are the target, quality and outcomes are not the target.

Worse still, Labour's tick-box culture has created layer upon layer of bureaucracy for the NHS.  All too often, doctors and nurses have been forced to prioritise paperwork over patients.  Nowhere was this shown more clearly than in the tragic events that took place at Stafford Hospital.  The Healthcare Commission's report was damning. 

Here's what staff at that hospital thought: "the approach of the trust meant that the care of patients had become secondary to achieving targets and minimising breaches". 

That shameful statement shows the deep harm Labour's central targets have done to our NHS.  What can ever be more important than caring for patients?

Yet Alan Johnson isn't responding to the problems. He has looked the other way when people have told him about the damage targets and box-ticking are doing.  He is stubbornly defending Labour's approach in the face of all the evidence. Since the tragedy in Stafford came to light, we've heard him say over and over again: 'Targets are not responsible for what happened in that hospital'.

<h2>Alan Johnson's record</h2>

It's nearly two years since Alan Johnson was appointed as Health Secretary.  It's time to ask ourselves, what has he achieved? After nearly two years, it's difficult to see where Alan Johnson has delivered.

Sure, he has tinkered a little here and there.  With prescription charges and with yet another Government pledge on mixed-sex wards.  But overall, I suspect his engagement has more to do with a fear of bad headlines than actually delivering the change the NHS needs.  We know his strategy was simply to take health out of the headlines.

So we are left with a "hear no evil, see no evil, speak no evil", Health Secretary.  We have seen this failure in Alan's response, first to Maidstone and Tunbridge Wells, and then to the tragedy at Stafford Hospital. To fail to act once is unfortunate; to do so twice is careless. I don't think that doing nothing and saying nothing to move the health service forward is acceptable.

The Health Secretary himself said 'I just drift along'. But that's not good enough, especially when you're responsible for a public service upon which so many lives and jobs depend. And beyond that, the critical need to support it with a positive long-term vision - ensuring that the NHS is the best it can be.

<h2>No delivery on the big issues facing the NHS</h2>

We need a Health Secretary who gets the importance of consistent reform.  A Health Secretary who doesn't try to dance around big problems, but one who tries to tackle them head on.

<h2>Health inequalities</h2>

Take health inequalities for instance. Labour talk and talk about equality.  In one of his first speeches as Health Secretary, Alan Johnson told us:

"'My principal objectives as Secretary of State must be two-fold: to improve the health of the nation, and to ensure that the health of the poorest improves the fastest."

Yet what do we see?  No change. No action. 

Instead, a gap in life expectancy between the richest and poorest in our country that is now greater than at any time since the Victorian times. A gap that, according to the latest figures, is getting wider. The life expectancy gap for men between the fifth of areas with the worst health and the population as a whole has actually doubled. A government that is on course to miss its targets on reducing inequality in both infant mortality and life expectancy at birth by 2010

<h2>Obesity</h2>

And then there's obesity.  A colossal challenge.  The best Alan Johnson could come up with to grab the headlines in his latest initiative on obesity was a 'dance working group'. But Alan's big idea quite simply is not sufficient in the face of one of the biggest and costliest health threats:

A quarter of adults and a sixth of children are now obese. The UK now has more obese people than any other in the OECD country except Mexico and the US.  Obesity is set to cost the NHS £10 billion a year by 2050 and society a further £50 billion. 

<h2>Dentistry</h2>

And then there's NHS dentistry. Alan Johnson knows there's a huge problem.  Almost a million people have lost access to an NHS dentist since the Government introduced a new system for NHS dentistry in April 2006. Loopholes in the system mean that almost a fifth of those who do have a dentist are being called back too often.  So they're being forced to pay double.  This exploitative practice means patients are paying up to £109 million per year more in charges than they should be, and precious NHS appointments are being used up by people who don't need them.

Alan Johnson has admitted there's a problem. 

He's said:

'It is disappointing that despite this investment there remain areas of the country in which people are unable to find an NHS dentist'

But all he's done is launch another review.   That's not much use to those out there - especially children - whose teeth are decaying.

<h2>Dementia</h2>

Then there's the strategy for dementia. In February this year, after much delay, Alan Johnson published what he claimed was a 'landmark' strategy to tackle dementia.   He has since admitted that the £150 million he announced in the strategy was not new money.   He also confessed that despite his claim that there would be a memory clinic in every town - it will probably never happen. Worse still, the strategy pushes one of the biggest issues dementia sufferers face into the long grass.

Anti-psychotic drugs are all too often given out in care homes to sedate dementia patients - in order that carers don't have to worry about looking after them. Over 120,000 people have to suffer the indignity of inappropriately being treated with these drugs.  They're really designed for people with schizophrenia.  The strategy does nothing to end this scandal and the pain it causes.  

<h2>Leadership ambitions coming first</h2>

Leadership matters. I want to give leadership to the NHS. Alan wants the NHS to be a stepping stone towards the leadership.  For the first time last weekend, we discovered that he has a long-term vision.  Except it wasn't for patients.  It wasn't to provide long-overdue reform in the NHS. 

When you look at his record on health there has been a failure to deliver on crucial reforms started by Tony Blair. A failure to deliver the necessary response to on major threats to our nation's health  Whether that's obesity, the health of the poor, or the dignity of patients being forced into mixed sex wards. No delivery for patients and no delivery for health professionals.  He boasted in the House of Commons two weeks ago that, as a postman, he always delivers. I'm sorry Alan, you haven't.

<h2>The Conservative promise</h2>

I recognise the years ahead won't be easy.  The Chief Executive of the NHS, David Nicholson, recently advised healthcare organisations to find efficiency savings of between £15 billion and £20 billion across the service from 2011 to 2014.   In the coming years the NHS is also going to have to grapple with major challenges:  an ageing population; longer life expectancy living with chronic conditions; new technologies and rising expectations.  The NHS cannot successfully respond to this unless we root out waste.  Unless we get rid of the underlying inefficiencies that mean patients don't always get the treatment they deserve.
  
That demands consistent reform. Not the stop-start approach that we've witnessed under this Government, uncertain of a clear direction forward. Reform takes time to work through. 

Under Labour, investment has come without reform. Under a Conservative Government, reform will be pursued consistently and effectively.

Including patient choice, a plurality of independent  providers and devolved decision-making. But also including a clear distinction between commissioners and providers, a revolution in information on access, service quality and results. With accountability for outcomes, not processes. And, not least, a new priority for public health.

Public health reform, with a stronger infrastructure, separate funding and a focus on strategies to energise individual, family and community responsibility. Across private and public sectors, a shared responsibility in providing the impetus and the means for us to change our lifestyle and behaviour, building self-esteem amongst young people and self-respect, responsibility for everyone, at every age.

Within the NHS, reform, not reorganisation.

To put patients at the heart of the service. To empower health professionals. With an information revolution, making access, quality, standards and results transparent. Information will drive choice. Choice which makes front-line care accountable to patients. A focus on results which make the NHS accountable to taxpayers for outcomes.  A service focussed on outcomes, not top-down targets.

Where we, as Government, are clear about 'what' we are asking the NHS to achieve, not trying to tell professionals 'how' to achieve it.  A service empowered to provide quality care, focussed on improvements, which is therefore also incentivised for innovation. Not through yet another Quango, but through innovation and excellence at every level of the NHS.

As Conservatives, we will keep what works and we will reform what doesn't.  We will drive reform through our principles of choice, devolution, competition and professional responsibility.  In place of constant upheaval will be consistent reform.  All over the world, countries are looking for health systems which provide equity, efficiency and excellence.  Universal coverage, sustainable costs and high-quality care.

In this country, unlike many other countries, we have an equity-based service. We used to be efficient. But over the last decade, we've seen unit costs rise and productivity fall.

In the years ahead, we will maintain equity through a taxpayer-funded system, fair allocations and evidence-based standards.  But by giving patients control through choice and competition, we will drive efficiency and rising productivity.  Through professional empowerment, a focus on outcomes and the provision of meaningful information, we will drive excellence.  Equity, efficiency and excellence. That is my vision. That is the leadership to which I aspire.  Focussed on the future of our NHS, with a determination to deliver.

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