Speech to the Somerset Local Medical Committee Conference
"Thank you for the opportunity to join you today and to offer a view on the development of the Health Service. I do so benefiting from the work done by my predecessor Liam Fox, who goes on to great things in the political world. I have no medical qualifications - I'm not even a 'proper' doctor a la Dr Reid, but health care and health policy has been a continuing priority for me, before and since I entered the House of Commons, way back to the days when I was waiting for the end of a 1in 3 with prospective cover rota.
No-one who considers the current condition of the NHS can be unaware of three underlying factors:
· First, throughout the service, staff are working hard, many over-stretched, seeking to deliver high-quality care, often doing so, but often feeling prevented from doing so because of pressure, lack of resources or bureaucratic constraints.
· Secondly, while resources for the NHS are increasing, relatively little is translating into capacity for growth. One hospital trust chairman told me that the combined effort next year of the Consultants contract, Agenda for Change, Working Time Directive and new guidelines from NICE would mean a 12 per cent cash increase would be needed just in order to deliver the same services. Many of these are one-off changes, but they follow many other centrally-driven cost increases, so the increase in capacity in the NHS is not remotely comparable to the increase in resources, yet it is vitally necessary to create new capacity if we are to achieve our objectives, and
· Thirdly, we have to understand why it isn't simply a matter of more money. Increases in resources are a necessary but not a sufficient condition; we need to combine investment with reform. These are worrying words for an NHS audience to hear, after 18 major upheavals in the last 20 years, and with bureaucratic initiatives swamping the service's capacity to grow, innovate and respond. The last thing you want to hear is that we would throw every past change out and start again. You want, and we want, to deliver reform which works and which is therefore driven by the needs of the service not the demands of politicians; and reform which builds on changes happening in the NHS, keeps what works and rejects change for its own sake.
It is an important moment for me to be able to set out how we are approaching the next Election and the prospect of Government. Important, because I can do so with the benefit of two very significant contributions.
Two weeks ago, Michael Howard made a speech in which he set out his personal vision. He said then that the reason he came back into front-line politics was because of the needs of his constituents and how local NHS services were not meeting their needs. He was determined to promote reform in the NHS so that his constituents would be able to rely on the NHS to be there for them.
Earlier this week, Oliver Letwin set out the framework of public expenditure for the next Conservative government. Within a framework designed to avoid the tax rises that independent commentators say will be necessary under Labour, Oliver recognised that substantial growth in health and schools spending should continue beyond 2006 and, even for the longer term, that they should grow as fast as the economy as a whole. He made an important commitment in recognising that there would be costs associated with our reform proposals which would need to be provided for.
Those two speeches mean that I can speak today against the background of our Party's explicit commitments - to investment in the NHS; to investment with reform and, as Michael Howard also made clear, to reform which will not undermine the NHS principle of treatment free at the point of use, regardless of ability to pay.
For me and, I hope for those who care about the NHS, this is an exciting prospect. We can plan to meet challenging and ambitious objectives: to enable the NHS to meet the clinical needs of the public; to do so to a high and consistent standard; and to do so increasingly in response to the choices and interests of patients.
Over the coming weeks and months, key elements of our policy proposals will be published for further consultation and debate prior to the Election and to our Manifesto. Today, building on the valuable ideas set out in consultation documents published by Liam Fox last year, I can set out the structure of our policy and invite some more immediate specific responses to certain key issues.
Our health policy will rest on four pillars.
The first pillar will be to deliver a sustained positive public health programme. At every level in the NHS, staff and organisations know that long-term health outcomes depend more upon the response of the public to public health issues than they depend upon specific NHS interventions. Equally, they all experience the frustration of seeing public health objectives pushed to the margin of activity and resources, as they have to meet the immediate needs of patients.
In the public debate, initiatives and reports tumble over one another, leapfrogging one another in their effort to warn of apocalyptic outcomes or the need for legislation to ban this or prohibit that, or of new taxes to try to control our behaviour.
Labour's approach to public health has been incoherent and haphazard. In the space of two weeks, we have seen the Department of Health announce a consultation on public health with a White Paper in the Summer; the Treasury have commissioned a another report from Derek Wanless which is due to be published imminently, focussing on matters specifically on public health; and yesterday the Prime Minister's Strategy Unit announced plans for a tax on junk food.
A senior figure in the food industry said to me - they are 'sponsored' by the DCMS, regulated by the Food Standards Agency which is answerable to the Department of Health. Sport is in DCMS, but sport in schools is in DfES. Treasury set up Wanless, but Department of Health are doing the diet and health action plan, and Number 10 intervene at several points. How can they work out what to do?
Labour have made woeful progress since the Health Select Committee criticised the Government's lack of co-ordination over public health initiatives three years ago. These announcements highlight Labour's continued fragmented approach.
Meanwhile, obesity rates rise sharply, sexually-transmitted diseases and binge drinking worsen, smoking among young people remains disturbingly high, drug abuse continues, even TB and HIV/AIDS are more prevalent. Inequalities in health persist as not only are many living in relative poverty, but they are failing to respond to the public health messages which could offset the effects of economic disadvantage.
There is no magic formula, but we know that the pronouncements of Public Health Ministers are not the answer. If the public trust doctors the most and politicians scarcely more than journalists and estate agents, then clearly the Public Health Strategy must be owned, and communicated, by the medical profession.
The effort has to be communicated individually, but also on a population basis. As responsibilities and power within the NHS are devolved, there is therefore a case for creating a separate, focused, resourced, strategy for public health. The principles are clear: for a coherent strategy, accountable to Parliament but based on evidence not political whim. The strategy must be population-based, seeking to achieve major shifts in behaviour and policy shifts in provision to lift those suffering from disadvantage and health poverty.
Also, the strategy must be based on incentives and innovation whenever possible, but prohibition only in extremis.
The strategy must be national yet have influence over local decisions, through Directors of Public Health - who have to work on a population basis, across all the boundaries of the public and private sector, applying leverage through a specific budget. This has to be co-ordinated with and linked to a national Public Health Strategy, which is not short-term, not political, not subject to weekly initiative-itis from Ministers, but backed by a clear public consensus and strong peer pressure. It needs to mobilise not only medical responses, but media and consumer industries, especially food and drink. They, and the hospitality industry, know their customers best. They spend a fortune on marketing. They control product characteristics. Politicians could try and force them and the public to comply, but I think it is far more likely to succeed through self or co-regulatory solutions.
The second pillar is the Patient's Passport.
This is a comprehensive programme designed to give patients more control over their healthcare. Putting patients first is the instinct of health professionals; it must be our policy as well. We are here to serve patients, not the interests of any system or any vested interests.
The objectives are clear: patients who control their health care are more likely to do well and the service is more likely to allocate resources effectively in meeting patients' needs.
The practical issues in rolling-out the Patient's Passport are of course, similar in some respects to the patient choice issues considered in the 'Building on the Best' published in December. Specifically, we can plan for the implementation of the Patient's Passport in relation to choice of elective surgery from December 2005 based on the electronic booking service and the NHS national tariff. If the opportunity comes earlier, this will be implemented as soon as possible, so we do not expect, as Labour would do, that patients should wait six months before exercising choice or be required to choose from a limited range of hospitals - the choice should be at point of referral and from amongst all relevant providers. So far as the tariff is concerned, there are issues still covering its composition, but we see the need for and value of this. However, we do not regard it as appropriate to be a uniform tariff; rather it should be a maximum tariff. Hospitals should be able to offer capacity below the tariff price, subject to meeting quality standards. Otherwise, after a transition period, the tariff will no longer act as a spur to efficiency through challenging comparisons on cost. Even now, you can see Trusts converging on average reference costs rather than being led by the most efficient providers.
The opportunity to choose one's elective care is important, but we wish to go very much further.
The Patient's Passport should allow those with long-term medical conditions to exercise control over their care too. Clearly, this may extend to secondary and tertiary care, but be essentially rooted in the decisions made in primary care.
The structure of the Patient's Passport will need to reflect the character of the case and the choices relevant to any specific disease. For the great majority of patients, they will exercise choice in consultation with and through their GP. We need also to consider how patients can have control over their care within the community, choosing between therapists and therapies, perhaps having access to specific budgets or direct payments, even in some cases being able to exercise control over the whole care pathway. We wish to develop these concepts fully; to be clear about how far and how fast we can implement them, consistent with the available resources - but recognising that meeting patients' needs more directly can also be more efficient and deliver major health gains. It also needs to be consistent with GP's contract responsibilities to deliver the primary care needs of patients and of the PCT to carry budgets; and with the provision of a structure of information and advice that ensures choices made are fully informed and clinically safe.
Liam Fox made clear our wish to extend the Patient's Passport to chronic diseases. I wish to reiterate today that intention. We are clear that we need now to establish with patient groups, and those representing them, more precisely how they may wish to benefit from the structure of the Patient's Passport. We have no doubt that many will wish to do so, for the empowerment it will give them, for the confidence it gives in being able to access therapies of ones' choice and in the engagement it brings which can deliver wide advantages in public health terms.
Many of the relevant bodies will already be aware of this, but I want specifically to invite bodies with an interest to join with us over the next six months in defining the terms on which they wish to have access to the Patient's Passport.
We do recognise that this major extension of patient empowerment will in many cases give quicker access to therapists or treatment which are, in effect, rationed by long waits in the NHS today. There will be costs incurred in giving guaranteed standards of care. That is why Oliver Letwin has pledged substantial funds to enable us to make progress in this direction. He has also made clear that if we can identify savings in the NHS from waste, or excess bureaucracy, we can direct those resources to front-line services, including the faster roll-out of those aspects of the Patient's Passport.
That is an extremely positive opportunity for everyone working in health care and one which we are determined to grasp, working together with David James' team.
There is one further aspect to the Patient's Passport. It will offer choice and, in doing so, not treat those who choose to receive treatment outside NHS provision as if they were not the responsibility of the NHS. Those who are accepted for NHS treatment will therefore be able to benefit from the Patient's Passport whether they choose an NHS or independent provider. We do not intend that this should run the risk of prejudicing the NHS's ability to utilise its capacity to the full, so the value of the Patient's Passport for independent treatment will amount to only a proportion of the cost of the treatment, thus leaving a significant slice remaining for the NHS to cover costs such as the capital, fixed and overheads costs. While we deal with the large inherited waiting lists for treatment, anyone accepted for NHS treatment but choosing to use an independent provider will be replaced by someone from the waiting list, so there is a transitional cost there too, in increasing the number of treatments overall - an our expenditure plans have made provision for this.
Those steps are in contrast, I might add, to engaging in 'spot' purchases in the private sector at 143% of the NHS tariff to meet waiting list targets, as the present Government has done. It will include independent sector provision to meet NHS capacity needs, but this must be transparent and on all fours with the financial flows and framework offered to NHS providers. Under a Conservative government, the independent sector will not be discriminated against in contracting to provide capacity for the NHS but they will not be able to profit from distress purchases from the NHS. If patients choose to go to an independent provider, we intend that it should not be because of any deficiency in the standard of care offered by the NHS.
Our proposals are designed to promote supply-side reforms and responses across our health care system, by reforming and empowering demand through extending choice. That will energise both NHS and independent provision.
The third pillar is of standards. The Patient's Passport cannot succeed if there is no clear framework of standards within which patients can make informed choices. Choice in medical care is not entirely subjective. There cannot be an opportunity to choose treatment which is not safe, not efficacious or of clearly poor clinical effectiveness and quality.
We will, therefore, look to build on evidence-based elements of standards already set out in National Service Frameworks, NICE guidelines and guidance from Royal Colleges and Societies. This will need to be practical and immediate in its effect, even if there are also aspirational future objectives. It cannot be politically-directed. Nor can it be about affordability as distinct from relative clinical and cost-effectiveness. We need to establish a framework of standards which effectively sets the parameters of provision and choice and in which clinicians put their trust.
The fourth pillar is of freedom for the NHS. In my own constituency, I know how much excellent work is being done at Addenbrooke's and Papworth Hospitals and in primary care. I know how much many NHS staff resent that first-rate medicine is constrained by bureaucracy and red tape. They need to be set free from this Government's range of star ratings, targets, performance indicators, plans, information requirements and interventions. We cannot get the supply-side response we need if we continue to seek to manage every hospital and GP practice from Whitehall.
We should not underestimate how much time, energy and money is taken up responding to these centrally-driven requirements, nor the opportunity cost of the energy and time devoted to it. By extension, we can look to major benefits arising from setting people in the NHS free to manage themselves in the interests of patients. Successful hospitals are those where clinicians, nurses and managers have a shared vision. How difficult it can be to achieve that when managers, often contrary to their own wishes, have to impose a structure of targets and reports on consultants and senior nurses which is, at best, clinically irrelevant, at worst runs directly counter to clinical best practice. [NHS Confederation: Smarter Reporting]
Is this an NHS without managers? No. Management is essential - good management, just as we need accountants, so we know what it costs to carry out treatment, so we need to know where systems and resources are failing to deliver. What we don't need is centrally-imposed performance management. Performance management should derive from those responsible for an institution. Managers should agree those internally with their Boards. They and their clinical colleagues should be accountable locally to their Boards for their performance management, accountable to patients through the exercise of choice and accountable within the NHS through CHAI in four specific senses:
· for the quality of services offered measured against the framework of evidence-based standards;
· for a standardised set of data on outcomes and patient satisfaction, and certain other factors like HAI, which are needed to inform patient choices.
· through audit, for the propriety of expenditure;
· for value for money, through comparisons with best practice and benchmarked studies;
We believe this is a deal that the NHS would buy tomorrow - freedom to manage in return for genuine and relevant accountability. We should not underestimate the potential this could have in motivating NHS staff, especially doctors and nurses, and encouraging them to remain in, or return to, NHS practices. Increasing the supply of doctors and nurses is not just about expanding training numbers, it is also about deploying staff more effectively and motivating them to remain in, or re-enter, the workforce. We will be consulting in coming weeks on these aspects of accountability as well, including the relative priority of making NHS Hospital Trusts accountable through local ownership as compared to the structure of PCTs, whose geographic basis and priority-setting role offers a clearer basis for local ownership to be engaged.
These then are the pillars on which our policy rests: improved public health, the Patient's Passport, empowering patients, evidence-based Standards and setting the NHS free to deliver. There are, of course, many other issues on which we will be offering a Conservative view and seeking to encourage the views of the NHS and public between now and the Election. My purpose today has been to take this early opportunity, when we have set out our commitment to the future funding of the NHS, to follow it up by describing the structure within which we hope to see the NHS grow and to be able to offer to the people of Britain a high quality health care service, responsive to the needs of the patients, active in improving public health and reducing health inequalities, by setting the NHS free.
It is our intention to ensure that no longer do we have first-class medicine trapped in a second-class system, or to see NHS staff working hard to limited effect. We want the skills and effort of the NHS to deliver for the best interests of patients."