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David Cameron: The NHS at 60

In a keynote speech to mark the sixtieth anniversary of the NHS after visiting Trafford General Hospital in Greater Manchester, David Cameron said:

"60 years ago, in 1948, one of the great British institutions came into being.

The National Health Service - like the BBC or Parliament itself - fulfils a practical function: but it also binds the nation together.

The 5 July 1948 - the day the NHS began - must have been an enormously exciting time for anyone working in medicine.

People like Andrew Lansley's father, who was working in the pathology lab at Highland Hospital in North London.

And people here in Trafford - the place where Nye Bevan symbolically inaugurated the NHS that day - by receiving the keys of the hospital on behalf of the state - know it more than anyone.

I'd like to take this opportunity to extend an invitation to a celebration this summer, for anyone who was working in the health service in 1948.

Andrew and I want to meet people who were there - to hear what it felt like, and what the creation of the NHS did for our country.


There are many things that Conservatives would want to improve about the NHS. But, I believe that Conservatives should never attack an institution which so many of our fellow countrymen and women look to as one of the great achievements of our past it's an institution which embodies, in its very bricks and mortar, in its people, in its services, something which is great about Britain.

That something is equity, the founding value of the NHS: the spirit of fairness for all, of dignity in age and in pain and weakness the idea of our equality as human beings and the equal right of everyone to care and comfort when they are born, when they are ill, and when they are dying.

A system which strives for equal access to healthcare is not a dream of socialism. It is not a hideous Marxist intrusion into the pure beauty of the free market.

It is an institution I acknowledge and respect as a Conservative - and for that matter, an institution I am happy and proud to use as a father.

Labour's management

That commitment I know is shared by Labour politicians and by Gordon Brown himself. But I feel passionately that Labour has badly mismanaged the NHS.

I've said before that in their drive to 'modernise' the NHS, Labour haven't improved it, so much as ripped out its heart and installed a malfunctioning computer instead.

It's one of the most shameful and disgraceful aspects of Labour's record: the way they fall for the sales patter of the management consultants and the big IT firms, who make them think they can cut corners to success.

Spend a few million on these consultants, they're told, a few billion on this computer project, and everything will be ok.

Well it isn't.

The NHS is suffering from the shoddy jargon-ridden schemes served up on powerpoint and swallowed whole by the people who are supposed to be custodians of the health service and custodians of taxpayers' money.

The NHS is suffering from the hopeless gullibility of Labour ministers.

NHS Constitution

So let me spell out, in black and white policy, my party's support for the NHS as an institution, and our commitment to its founding principle of equity.

First, George Osborne and I have committed ourselves to delivering rising resources for public services - using the proceeds of growth to fund investment. That means more money for the NHS.

Second, we will do what, surprisingly, has never been done - properly establish the NHS as an institution.

At the moment the NHS has no charter, no articles of incorporation, no governing document at all.

And now, in the 21st century, as the pace of social and medical change is accelerating so fast when, as I shall explain, so much needs to improve about the way we organise healthcare I believe that now more than ever we need to protect the cardinal, core values of the NHS against the sort of pointless upheavals we've seen so much of recently.

Back in June 2007, Andrew Lansley published a White Paper proposing an NHS Constitution, enshrining the basic principle of equity as the foundation of publicly funded healthcare in Britain.

I am delighted - if unsurprised - to see that this is now Government policy too.

Yesterday Gordon Brown proposed the same idea. So once again it is the Conservative Party setting the agenda - not just on tax but on the public services too.

Changing medicine: sophistication

I have said that the core value of the NHS is equity. I have made clear my commitment to that value by promising rising resources and an NHS constitution.

I now want to turn to my main argument today - that the NHS needs to adapt to the world of the 21st century.

Two great changes are happening to health and healthcare in the new century.

The first is the extraordinary rate of technological and medical development.

This has been a constant feature of the NHS, of course.

As one medical historian put it, "in medicine more has happened since 1948 than in all the centuries back to Hippocrates".

In 1948, penicillin had only been on the market for three years. The greatest threats to health were still the big epidemics: diphtheria, whooping cough, measles.

Today those diseases are almost history, defeated by the science of immunology.

And we've taken huge steps forward in other fields. Drugs in psychiatry. Anaesthesia and antibiotics in surgery. Steroids. Organ transplants. IVF.

And now, at the start of the 21st century, we are on the cusp of a further evolution - a revolution, really - as we face the amazing possibilities of genetics, nanotechnology and robotics.

It's as if, having scratched away using open-cast mining for thousands of generations, we've suddenly discovered the far richer seams that lie deep beneath the surface - and we're quickly developing the technologies to reach them.

The 21st century is going to be the most exciting time in the history of medical science - with many terrors too, of course - but I am hugely optimistic about mankind's potential to cure some of mankind's oldest fears.

Changing patients: personal responsibility

So the first trend in health and healthcare is the increasing sophistication of medical science.

The second appears to run counter to this.

Because, if healthcare has got more complicated in one respect, in another it has got much more simple.

We are realising just how central personal behaviour is to our health and wellbeing.

Of course there are still big infectious diseases we must fight: HIV, drug-resistant TB, the danger of global flu pandemics.

But today, we also face new public health threats which were totally unfamiliar to the days when the NHS was founded: obesity, for instance, or widespread drug abuse and addiction.

These are the direct consequences, not of external circumstances like bad sanitation, or ignorance about contagion, but of personal choices made, by and large, in the knowledge of the dangers.

And we cannot rely on the first trend I identified to overcome these dangers. We cannot rely on the increasing sophistication of science to save us from the consequences of our own decisions.

The body remains subject to the will of its inhabitant that is to say, the personal choices that we make impact on our health far more profoundly that any remedial work doctors can do after the event.

We must not put our trust in science to do what we can only do for ourselves - stay in shape by taking exercise, avoiding toxins, eating and drinking in moderation. As patients we need to be active, not passive.

But we must be careful what we mean by that. People pay tax all their life - they rightly expect treatment and service as a result.

Gordon Brown's blundering into this subject at the start of the year was so depressing. So depressing because it was so familiar. Brief the press, a tough gimmicky message - no treatment if you're fat or smoke or drink too much; then shambolic denials the next day.

This is the worst sort of government-by-gimmick, policy-by-press-briefing, and initiative-by-insinuation that he promised to get away from.

At the start of 2008 we have discovered something I long suspected to be true - that when it comes to short-term sound-bite and tricksy politics, Brown is worse than Blair.

Changing doctors: life-long care

If the nature of medicine and the role of patients are changing, so too is the role of doctors.

In a phrase, in the 21st century healthcare is for life, not just for emergencies.

In the 1940s, you went to a doctor rarely, when you were very ill.

The NHS was created to organise what doctors did in those days: deal with major events, of the sort that happened only once or twice, if at all, in the course of a patient's life.

This helps explain the centrality of the large hospital to the design of the NHS. In the debates that led up to 1948, the hospital consultants won the argument against the general practitioners - Nye Bevan created an NHS which prioritised secondary acute care over primary and long-term care.

Yet today both GPs and hospital doctors work very differently to how they did in 1948 - even though the basic structure in which they work hasn't changed.

Whether they are treating cancer, a chronic condition like Alzheimer's or Parkinson's, or working to improve mobility or quality of life for an elderly patient, doctors are now a regular part of life: a constant presence, not a remote authority.

They deliver, not occasional intrusive treatment, but lifelong care.

Rather than the doctor being a benevolent dictator he's more a specialist adviser, helping you both to make complex choices about medical care, and to make useful changes to your lifestyle.

That's especially true in light of the most profound change of all: our ageing society.

This means more treatment, for longer: proportionately less of the sophisticated interventions that happen in hospital, and more of the long-term care and social care that happens in primary care settings and in the home.

Changing society: post bureaucratic age

Progress in medical science. An increase in personal responsibility. A shift towards life-long healthcare. Changes to medicine, to patients, and to healthcare professionals.

Next I want to highlight a change that is happening to society itself.

I have described the 21st century in Britain as the 'post-bureaucratic age' we are in the moment when monolithic, centralised structures, with a monopoly of knowledge and power, are giving way to decentralised, open systems, where knowledge and power are diffused and democratised.

Instead of the national mainframe, we are entering the age of the local network.

This applies especially to health and healthcare.

In 1948 medical knowledge was carefully stored in the great teaching hospitals, where it was slowly crammed into the heads of the nation's doctors.

Today Google has three million medical articles online, there for public viewing and easy searching - far more information than any doctor can carry in his head.

And so much medical knowledge is being created by patients themselves. The experiences of patients can be distributed horizontally, from patient to patient, through online networks, rather than vertically as before through doctors and hospitals.

I've done it myself. If your child is ill, as soon as you hear the name of their condition, you get home and Google it on the internet.

You join the international support group. You pick up ideas about drugs and treatments. All too often you then bombard your doctor with questions about these things - but often these are the right questions to ask and sometimes you might even pick up an idea before they do.

And it's this horizontal diffusion of knowledge that makes me so confident we can do better than the Government's proposal for a vast, centralised, NHS database.

Surely recent events have shown how dangerous government IT systems are - just think of the potential for disaster when everyone's health records are stored centrally.

Of course we need different NHS professionals to be able to access medical records. But those records should be owned by the patient, and stored locally, under the control and protection of his GP. We need local servers with interoperability.

In this context let me congratulate the IT team at Trafford NHS Trust - they recently won an 'e-health' award from BT for the system they developed to track donated blood from donor to recipient. That's the sort of thing local specialists can do - why on earth do ministers and civil servants think they can do better?

Excellence as well as equity

So these are the trends in healthcare: increasing technological sophistication; growing recognition of the personal responsibility of patients themselves for their own wellbeing; a shift in the role of the medical profession towards providing lifelong care to an aging population; and lastly, a new and extraordinary development in human communications and the dispersal of knowledge.

These trends help explain why the founding principle of the NHS - equity - is more elusive than ever. NHS patients still suffer the inverse care law defined by Julian Tudor Hart in the 1970s: the people who need the most care, get the least, and vice versa.

And these trends also explain why Britain is below the European average in terms not just of equity, but of overall health outcomes: people don't get the standards of care they need.

I have put on record my commitment to equity, the founding principle of the NHS.

I believe this principle is widely shared throughout our society. Yet I also believe that there is a growing disquiet about the standards of care on offer in the NHS - and a growing public clamour to know why.

You can see this in the increase in the number of public enquiries after local scandals in the NHS.

Between 1974 and 1979 there were two public enquiries.

In the 1980s as a whole there were five. But between 1990 and 2002 there were 52 separate enquiries - the last being into the scandal at Bristol Royal Infirmary.

And the researchers who looked into these enquiries noted what they called the 'eerie parallel' between the first and last of these - problems which have become endemic to the NHS.

I quote: 'poor clinical leadership, an isolated and inward looking culture, inadequate management structures, and inadequate resources' at the front-line.

These features are not only inhibiting equity - they are inhibiting excellence. And that's the second priority I want the NHS to pursue: to deliver excellence as well as equity, quality as well as equality.

A Conservative Government will pursue these in two ways: empowering patients and empowering professionals.

Empower patients

The best way to enhance the power of patients is through the mechanism of choice.

Quite simply, the option of gaining or losing patients is the most effective spur to improvement on the part of doctors, hospitals and other care providers.

So we will give people a choice of GP.

We will allow patients to choose, in consultation with their GP, where they get their secondary care.

And we will ensure that hospitals and clinics and other care providers are paid according to the results they achieve.

Now I know that to some people the principle of payment by results trashes the motives of NHS staff - it suggests doctors and nurses need financial inducements to do the right thing.

And the same people say that competition pits parts of the NHS against each other, hospital against hospital and doctor against doctor.

I don't agree.

It should be a basic rule of social policy that you don't pay for what you don't want more of. Money should attend success, not failure.

So, for instance, I don't think hospitals should be paid - or paid in full - for a treatment which leaves the patient with a hospital-acquired infection like MRSA.

So-called 'treatment following adverse events' should be the responsibility of the provider, not the purchaser - the hospital, not the GP or primary care commissioner.

GPs can spend the money that they save in this way to improve care elsewhere.

This is a means of hard-wiring infection control into the system. Rather than a top-down system of targets which encourages 'throughput' above all else, we propose a bottom-up system which prioritises quality as well as quantity.

This will make managers concentrate on the effectiveness, not just the volume of treatment.

In the same way, we want to explore new measures of patient-reported outcomes, which enables money to follow excellence in terms of the actual experience of people who use the NHS.

Re-empower professionals

So patients need empowering.

But let me emphasise that this must never be at the expense of the professional ethos, the Hippocratic vocation of doctors.

We also need to re-empower the professionals who deliver care.

Raymond Tallis, one of Manchester's great doctors and a philosopher too, has a particularly grim vision of the future:

"if we are not careful, the patient-as-client will receive service-with-a-smile from a 'customer-aware' self-protecting doctor delivering strictly on contract."

I do not share Professor Tallis's despair at the direction of the health service. But I know that far more goes into the behaviour of individual doctors, of hospitals and trusts, than the simple calculation of profit and loss.

So I am not ashamed to say that I want to see medical professionals recover their professional freedom.

As Chancellor, Gordon Brown imposed 64 Treasury targets on the NHS with the Department of Health and its regional bodies - Strategic Health Authorities - imposing many more.

The burden on the NHS created by this workload is immense: a total of around 250,000 data returns are demanded by the Department of Health from all NHS organisations in a given year.

Last month research was published showing that over the last five years £2 billion has been spent on pursuing targets - money that was supposed to be used to improve patient outcomes.

That's why a Conservative Government will scrap all centrally-imposed process targets, and enable the NHS to focus instead on outcomes.

We will stop the clinical distortion that results from ministers chasing headlines - and let doctors decide the right treatment for their patients. Payment by results should reflect the whole experience of care.

I'm not proposing ending the system of measuring doctors' performance - far from it.

But we'll stop the health department endlessly measuring processes, and concentrate on outcomes - the 'what' not the 'how'.

We'll measure cancer survival rates, for instance - not the number of radiotherapy courses delivered per month in a particular oncology unit.

That means that health policy can become evidence-based rather than target-driven - delivering not only equity, but excellence and value for money too.


I have gone on at some length because this is a huge subject and I wanted to do more than the usual politician's skim over the surface.

Few things matter more to our country than the NHS - as I said at the outset, it's an institution which binds our nation together.

I know the fear that all families feel when they think they won't be able to get the care they need; and I know the relief you feel when a kind, competent nurse or doctor or technician is there when you need them.

And in this, the NHS's 60th year, the Conservative Party has an historic opportunity: to replace Labour as the party of the NHS.

That's quite an aspiration - but I believe it is our duty to live up to it. To be the party of the NHS is an honour that must be earned.

So I pledge today, here at the place where the NHS began, that I and my Party will work tirelessly this year to earn that honour to deserve the trust of the patients and staff of the NHS and to be what I believe we should be: the party of the NHS."

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