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David Cameron: The Future of Nursing


Healthcare is changing enormously quickly. Nurses are involved in every aspect of that change. And my argument today is simple. If we get nursing right, we get the NHS right. If we get the proper systems in place for the training of nurses, and if we make sure the NHS respects the motivation and values of the profession, we'll get the healthcare we all want. In so many ways, nurses are the NHS.


Let me start by making two important points before I get into the detail. The first is about my party and the NHS.

I said at my party conference speech in October that my political priority can be summed up in three letters: N.H.S. It's not a question of saying the NHS is "safe in my hands." My family is so often in the hands of the NHS. And I want them to be safe there.

That's why our policy will not be about opt-outs for the few. It will be about improving the NHS for everybody.

We Conservatives pride ourselves on being practical. We're interested in structures, policies, systems: we see the job of government as putting in place the right framework in which people are free to fulfil their own potential, their own idea of what works.

But sometimes, because we are concerned with structures and frameworks, we can forget to talk about the people who inhabit them, and the values that brought them into the NHS. So let me state plainly that the most important thing about the NHS is its people.

NHS staff have a calling, a vocation - a sense of professionalism that transcends the cold questions of pay and conditions and systems. These things are vital - but they are a means to an end, not an end in themselves.

No more pointless reorganisations

The second thing I want to say at the outset is about the relationship between government and the NHS. Governments of all colours have tended to approach to NHS rather like a surgeon approaches a patient on an operating table - or, even worse, a machine on a drawing board. Politicians tend to think it can be reorganised without any consideration of the human factors that make it work.

Recent years have seen an amazing series of changes in medicine and medical technology. But in addition to this, you have had to cope with a bewildering array of organisational changes to the systems you work in. When Labour came in they began a process of revolution that seems permanent. First they abolished the eight regional NHS offices and created 28 new Strategic Health Authorities. Later they abolished the 28 new Strategic Health Authorities and created ten new regional Strategic Health Authorities. Out went GP fund holding - in came Primary Care Groups. Out went Primary Care Groups - in came Primary Care Trusts. There have been nine different reorganisations in nine years.

So let me make this clear. We will accept and maintain the basic local arrangements of the NHS we inherit. No more pointless reorganisations. No more restructuring at the expense of the people who work in the system.

Changing healthcare

But that doesn't mean the NHS can stand still. As I've said, there are massive changes underway in healthcare. There are drugs on the market we couldn't have dreamed of 10 years ago. New frontiers in nanotechnology are being reached all the time. Huge questions in medical ethics are being asked every day.

And the sort of healthcare that most people receive is changing: from occasional major interventions to ongoing health management, delivered not in the acute sector but in the community and the home.

I often feel the political debate misses all this. When the media think of healthcare, they think of the NHS. And when they think of the NHS, they think of hospitals - and major acute hospitals at that.

But much of healthcare these days takes place outside the big hospitals. It is shifting to the community - to GP surgeries and primary care clinics and the home itself. We see the shift in midwifery, as more and more mothers choose to have their babies at home.

And public health is taking on a new importance. Healthcare is increasingly becoming a social responsibility - not something that we simply receive from the state.

Hospital and practice nurses

In this changing landscape the role of nurses is becoming even more vital. There have always been nurses - and midwives - carrying out vital and highly skilled work. But today the range of expertise is dazzling. Emergency Nursing Practitioners carrying out complicated work in A+E. Practice nurses in GP surgeries delivering primary care and managing surgeries alongside doctors. Community Psychiatric Nurses dealing with some of the most difficult medial conditions. Specialist nurses, expert in heart disease or cancer care. Palliative care nurses, consultant nurses, infection control nurses, respiratory nurses, community matrons… the list seems endless.

I've seen for myself the incredible expertise of NHS nurses. Having a disabled son, going in and out of hospitals all the time - the care and attention of nurses is inspiring. I'll never forget the people at St Mary's Paddington, at Great Ormond Street and at the John Radcliffe in Oxford. There is nothing I can say or do to express my gratitude to them, nor my admiration for their professionalism and their compassion.

Community nurses

But I think of other nurses too, alongside those working on the wards. The nurses that have made the most difference to my family's life don't work in the acute sector. They are the nurses working in the community.

It was our local community nurses who advised us on the right special school for our son. They helped us in our negotiations with the social services so that we could get night care. Because of the close observation they made of our son they realised that what was most important was symptom control - and they knew about a team of doctors at Great Ormond Street who could help us.

Most important of all, nurses don't just care for patients. They care for families. And they are often the real gatekeepers to healthcare. Knowing the patient, knowing what services are available - these are the invaluable skills that families rely on.

Ex-NHS nurses

Then there's another aspect to nursing that doesn't get the attention it deserves: all the people who have trained as nurses but no longer work in the NHS.

Britain's care homes and nursing homes are often staffed by ex-NHS nurses. The great voluntary bodies and charities like Marie Curie and Macmillan Cancer Care depend on them to do their vital work.

There is a national community of nurses, working in and outside the NHS, who share common training but more important, common values, a common ethos. This ethos represents an expertise of its own - one we have to do everything we can to nurture and preserve.

Trusting the professionals

So what should be the priorities for policy?

First, most important of all, we need more trust. It's extraordinary that we train doctors and nurses for years, we give them a wealth of clinical experience - and then we second-guess their every judgement.

We need to trust the professionals who deliver healthcare at the front line, and the local managers who ensure the service works for patients.

That means scrapping the top-down targets which distort clinical priorities.

I was in Basra a few months ago. I visited the British army medical centre at the airport and I met a civilian nurse from Liverpool. I asked her what she was doing there - what possessed her to sign up for work in a warzone. And you know what she said? "I just can't bear the four-hour A+E treatment target any longer. At least out here they let you get on with the job."

That's an extreme case - but I fear that disillusionment with the target culture is now endemic in the NHS.

Yesterday Andrew Lansley, Stephen Dorrell and I set out the next steps in our policy programme. In a nutshell, we want clinicians to focus on treating patients - not on meeting Government targets. That's why we will scrap top-down targets which measure processes, and put in place objectives which measure outcomes.

Instead of judging the NHS on how much money goes into it, or how many patients it treats or how fast, we need to judge it on how good it is at making people better.

How many people are surviving with cancer? How long are people living after a stroke or a heart attack. These are the real measures of healthcare, and we will make them our priority.

Tony Blair and Gordon Brown made their target raising NHS spending to the European average. I have a different objective. I want the NHS to exceed European averages in health outcomes like survival rates and recovery rates.

A distinctive Conservative health policy is now emerging that will be a real tonic for the NHS. No more pointless reorganisations. Scrapping top-down targets. Making sense of Labour's reforms. All hospitals to be foundation hospitals. Proper commissioning by GPs, to make sure the NHS puts patients first. And next, our proposals for making the NHS independent, taking politics and politicians out of the day-to-day running of the NHS.

And all this will lay the ground for our final step - to make the Department of Health the Department of Public Health. In our country half of all children don't eat a single piece of fruit in a week. Health inequalities are widening - in some parts of Glasgow life expectancy is lower than in Gaza. That's why public health will be our top priority.

Workforce planning

Of course, any discussion of nursing must address the enormously complicated area of workforce planning.

We have a real problem with surges, then falls, in the demand and supply of nurses. This problem is largely of the government's making. Ill-considered management of reform imposed major cost pressures on trusts. The result was serious deficits across the NHS. This has led, in this financial year, to considerable cutbacks, as the government insists that trusts generate surpluses to pay their debts. The NHS is trying to find around £1 billion in cuts.

Patricia Hewitt has admitted that the burden of these cuts has fallen on the budget for new staff. But trusts have not been able to afford to fund the necessary placements for newly qualified nurses. So a whole cohort of new nurses is leaving the first stage of their training without work to go to. Meanwhile, behind them, the number of nurses entering training is being reduced.

So a curious paradox is that we have an oversupply of nurses now, with a shortage of jobs for them to do - but in a few years the position will be reversed: there will be a shortage of nurses, and a whole lot of vacancies. Indeed it is estimated that there are around 14,000 nurses leaving training without jobs now - but by 2011, there will be 14,000 vacant jobs without nurses to fill them. If only we could send today's unemployed nurses four years into the future!

One way of helping address problems of supply and demand is the way that nursing training is organised in Scotland. There, nurses are guaranteed a year's employment once they leave education. This allows them to consolidate their training and gain first-hand clinical experience. It also means that, if no appropriate jobs are available for them after the year ends, they have the skills to seek nursing work in other organisations or the voluntary sector.

Let me be clear. I cannot make a pledge today along these lines. But we are going to look at whether a similar scheme in England would assist the recruitment of NHS nurses.

I also want to see Trusts reduce their dependence on agency and bank nurses, who cost more and - because they work on a temporary basis - tend to have lower scores of patient satisfaction. I am confident that a better system of workforce planning, plus greater freedom for front-line professionals to make their own clinical decisions, will reduce the attrition of nurses. This will mean we don't have to rely so much on agency staff.


I have argued that in many ways nurses are the NHS - that if we get nursing right, we get the NHS right. That includes the perennial issue of healthcare-acquired infections.

The basic principle of medicine is "first, do no harm". Yet it is one of the great paradoxes that exposure to healthcare can make you sick.

Every year 5000 people die from healthcare-acquired infections. I know how difficult it is to control bacteria. Advances in antimicrobial agents have had the side-effect of prompting complicated mutations. But although it is hard to stop bacteria mutating, it is possible to stop them spreading.

One factor which ensures the spread of MRSA and other healthcare-acquired infections is, quite simply, dirt. It's hardly surprising - a large hospital will be visited by many thousands of people every day, walking straight in off the street. But whereas dirt is usually introduced by visitors, it can be passed around the hospital by the staff who work there.

That is why we are holding a debate at Westminster today for more urgent action: more isolation facilities, more infection control nurses, more effective cleaning, for example new techniques which will eliminate the reservoirs of bacteria which threaten patients. Most of all we must ensure that pressures on waiting times aren't allowed to threaten infection control.

And we need to take steps to ensure that NHS professionals are able to observe the highest standards of hygiene. A recent RCN survey found that the number of nurses with access to changing facilities has actually dropped - from nearly two-thirds in 2000 to only half today. Only a third of nurses have access to showers, and a similar proportion are able to get their uniforms cleaned at work. Without changing rooms or laundry facilities, nurses have to travel home in their uniforms.

That's not good enough. We need to change the Code of Practice in the 2006 Health Act. The Code should ensure that NHS Trusts are under an obligation to provide changing and laundry facilities for staff.


I want to conclude by making one vital point. Why are nurses so important to patients and their families? It's partly their training and their brilliant medical skills. But it's also time.

The reason nurses so often get it right - why they find the best treatment for a patient, why they are able to reassure a patient's family, why they can give the doctor advice he or she could never get from looking at the medical records - the reason for all this is the time they spend with patients.

The great danger with grand schemes of reform - and with many of the necessary changes that must be made - is that they can often ignore this reality.

I am conscious of, and I welcome, the modernisation of healthcare and the new responsibilities this means for nursing professionals. But if we modernise at the expense of time, if we end up reducing the contact that nurses actually spend with patients, we will have achieved nothing. Worse - we will have gone backwards.

That is why we will take time to introduce reform. Change must be made at a pace that is comfortable to the people who have to implement it.

So this is my pledge to you today. More freedom for front-line professionals. Better workforce planning. Proper facilities to stop the spread of infection. And most all, an NHS which puts the time that nurses spend with patients at the heart of healthcare."

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