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Hague: Common Sense on Health

Today, I set out how the Conservative Party will transform a National Health Service that is now in a permanent state of crisis into a health service that is the envy of the world. And I am delighted to do so under the auspices of the Centre for Policy Studies, which has thrived with the determined leadership of Tessa Keswick and her team.

"The health service is in the news again. On Thursday, the Prime Minister will set out the latest in a stream of Government plans. It is called the Four Year NHS National Plan. It comes after the Ten Year Transport Plan and the Three Year Spending Plan announced by the Chancellor last week. It won't be long before we have the Five Year Economic Plan and the annual tractor production figures.

"Like the Plans produced by the Soviets, I suspect the NHS National Plan will be more about fantasy than fact. For when the Prime Minister announced back in March that he was drawing up the Plan he spoke of an NHS where there had been 'substantial improvement in recent years', where waiting lists are falling, where 'nurses are returning' and where patients are receiving 'better care'.

"This picture of the National Health Service today is not one recognised by the hundreds of thousands of health service professionals who work incredibly hard in it, or the ten of millions of patients who rely upon it. What they see is an NHS that is now in permanent crisis and which is badly letting patients down.

"Among the seven largest advanced industrial countries in the world, Britain has the highest mortality rates for respiratory system diseases, cancer and heart disease and the second highest mortality rate for circulatory diseases.

"In France, there are 36 heart disease deaths for every 100,000 population. In the UK, the equivalent number is 70. In other words, British people are twice as likely to die from heart disease as our neighbours across the Channel.

"If you live in England or Scotland, the chance of surviving lung cancer after diagnosis for more than five years is only six and a half per cent - in Germany it is 13 percent, double our rate.

"Then there are what one might call quality of patient life issues. Thousands of male and female patients still endure the indignity of mixed sex wards, and the lack of privacy that comes from shared accommodation, bathrooms and lavatories. In too many cases, food for hospital patients is still of an unacceptable standard.

"I am not going to pretend that the problems of high mortality rates or mixed sex wards or long waiting lists began on 1st May 1997. As I have said many times before, some of these problems have been endemic in the health service for years.

"But nor can the Prime Minister pretend that there has been a substantial improvement since 1st May 1997. For everyone can see that the problems in the NHS have got worse under this Labour Government.

"Thanks to recent newspaper reports, we know that even the Prime Minister's own chief adviser is aware that 'TB has not delivered. He said that he would improve the NHS and public services, he said he would change Britain, but instead things have got worse.'

"He is right. The waiting list to see a hospital consultant has risen by 154,000. Last week, 79 out of the 99 Health Authorities in England and Wales reported that they have more patients waiting over a year for treatment than at the time of the last election.

"Instead of tackling this problem, the Government's Waiting List Initiative has created a web of bureaucratic devices and perverse incentives that mean clinical need has taken a back seat to political priorities. We all remember from earlier this year the tragic case of Mavis Skeet, the grandmother with throat cancer whose operation was cancelled four times until it became inoperable and she died. The real scandal is that while the operations of Mrs Skeet and others were being cancelled, hospitals were continuing to carry out other minor operations.

"Let me read to you from a letter which our Shadow Health Secretary received earlier this year from a senior orthopaedic surgeon at Guy's Hospital, Dr David Nunn:

'Dear Dr Fox, I heard on the radio this morning that the Government is about to yet again announce vast amounts of money to attempt to hit their own political targets of reducing waiting lists. Setting targets of numbers is totally contrary to the practice of medicine based on clinical need. I am now in a situation where I have so many patients on my waiting list who have been waiting so long, that I have to admit patients for albeit painful conditions on the basis of how long they had been waiting not on the basis of clinical severity'

'The use of taxpayers' money in this way is both contrary to clinical priority and a blatant waste of money. The money will be much better spent on better resources within the National Health Service in terms of beds and nursing staff, which are the two main reasons which reduce our capacity to service waiting times.'

"Dr Nunn indicates that the current crisis in the health service is not down to the Waiting List Initiative alone. Hospital bed shortage, once a feature of the winter, is now an all year round occurrence. The nursing profession is facing its worse recruitment problems for 25 years, with 14,000 fewer nurses now than there were three years ago.

"The truth the Prime Minister cannot escape from is that it is his chronic mismanagement, his waste of resources, his distortion of clinical priorities, his political interference, his crony appointments, his gimmicks and targets and taskforces and plans that have created the permanent crisis in the National Health Service.

"The NHS National Plan is a blunt and shocking acknowledgement by Labour, three years after the election, that it has failed on health. But how can we rely on a Government that has so far got so much wrong, to get it right in the future?

"We will wait to see all the details of the Government's National Plan before we deliver a final verdict on it. However, there is one part of it which we unambiguously welcome, and that is the new money for the NHS.

"There should be nothing surprising in that. Conservative Governments always delivered year on year real increases in spending. Now the Chancellor of the Exchequer is doing the same by increasing the NHS budget from £54 billion now to £68 billion by 2004.

"We have pledged to match Labour's spending because we believe that the NHS is badly under-funded. By doing so I hope we can end the sterile party political game of 'I'll spend more than you' and move the debate away from the overall size of the health budget to the equally important issue of how that money is spent.

"Judging by what the Government has already leaked to the newspapers, it looks like Labour has not learnt its lesson.

"We are told that the Plan will have four themes - information, intervention, inspection and incentives - what are being called the four 'i's. We are told that 'Patient Power' is going to be the new buzzword, although there is precious little evidence to suggest that the Plan will deliver anything other than a cosmetic improvement in the ability of patients to make choices about their health care. In other words, like everything else this Government does, their NHS National Plan will be more about presentation than substance.

"When are Labour going to learn that you cannot solve the crisis in the NHS with new slogans, and that what we need is more doctors not more spindoctors?

"We are also told that the Plan will involve the Secretary of State for Health using a host of targets, initiatives, incentives and Whitehall-set bureaucratic controls in the doomed belief, in the face of all experience to the contrary, that more and not less central control can solve the problem of unequal performance by different health authorities and trusts across Britain.

"Of course we should be concerned that breast cancer survival rates are twenty percent higher in Surrey than in Staffordshire, or that 30 per cent more patients in North Derbyshire see a consultant within 13 weeks than in Portsmouth. These are serious disparities and show what substantial room for improvement there is within the system itself.

"But when are Labour going to learn that what the health service needs is not more interference from Whitehall, not more political initiatives and abstract targets, but less interference and fewer eye-catching political gimmicks?

"Dr Hamish Meldrum, the Deputy Chairman of the General Practitioners Committee who negotiates directly with the Government on behalf of GPs, spoke for many health professionals this week when he said: 'all we seem to be getting is lots of daily leaks about a little scheme here or a little scheme there which is not actually going to make a fundamental difference to the overall NHS. It seems again that we are falling into the trap of what I thought this exercise was meant to avoid.' ( Pulse, 22 July 2000)

"My fear is that Labour has learnt no lessons from their absolute failure on health of the last three years, and that this National Plan is just another gimmick that will condemn the NHS to more years of bureaucracy, failure and crisis, and condemn the British people to more years of second class health care.

"We need to get more money in the NHS; but we also need to spend that money far better if we are to create the first class health service that Britain deserves. So let me set out what we Conservatives believe should be in the NHS National Plan this week.

"First, the National Plan should provide for a wholly new approach to the treatment of patients that puts clinical priorities before political priorities. In other words, treating people with the most serious illnesses first.

"That means scrapping the Waiting List Initiative introduced by Labour Ministers who, in the words of the Chairman of the BMA Consultative Committee, have tested 'the tolerance of patients who are waiting even longer for treatment, and the goodwill of health service staff by persisting with an initiative that distorts clinical priorities and denies care to people in more acute medical need'.

"It also means introducing a Patient's Guarantee that gives NHS patients, starting in defined clinical areas, a maximum waiting time based exclusively on their medical need. To guarantee the waiting time given to a patient, the health authority should be required either to treat the patient itself within that waiting time, or to arrange for the patient to be treated in another health authority, or to pay for treatment in the private sector.

"The patient's waiting time will be determined by their consultant on the basis of their own medical needs, rather than on the arbitrary judgment of politicians. Good medicine is about seeing patients as individuals not as averages.

"As I made clear to the Royal College of Nursing's Congress in April, we will begin by applying the Patients Guarantee to patients with the most serious conditions. The clinical areas which we have already identified are cardiology and cancer care, areas where the record of this Government has been particularly poor.

"The Society of Cardio-Thoracic Surgeons recently announced that the number of cardiac by-pass operations fell by 500 last year, the first such fall in 25 years. The result was graphically spelt out by the Bristol heart consultant Peter Wilde when he confronted Tony Blair on television with the fact that in his hospital 'twenty five people have died waiting for cardiac surgery in the past six months'. He said that 'we are doing our utmost to treat people as quickly as possible but we have to acknowledge that they are waiting much longer than we would like'.

"The situation with cancer treatment is equally shocking. One fifth of people diagnosed with curable lung cancer are inoperable by the time the treatment begins.

"How can it be that we have the World's fourth largest economy and an outstanding record in medical research, but that we are unable to take proper care of those suffering from cancer or cardiac problems?

"Conservative policy would revolutionise treatment for cancer and cardiac patients. Our Patients Guarantee would ensure that the NHS treats these very sick people first, instead of being preoccupied with the Government's election slogans on waiting lists. It would give desperately anxious patients the reassurance of a certain date for treatment.

"When we set out our Patient's Guarantee, the then Health Secretary called it: 'a guarantee of private profiteering at the NHS`s expense'. Now, surprise surprise, we read in our newspaper that the National Plan will include a 'guarantee' for patients. When an operation is cancelled on the day, hospitals will either have to offer another date within 28 days or - wait for it - pay for the operation to take place in a private hospital.

"I have always said the Conservative Party would support the Government when it does the right thing. So if the newspaper reports are correct that the Government will work with the private sector to carry out cancelled NHS operations, I welcome this little outbreak of common sense.

"But now they have conceded the principle, why not go the whole hog and embrace our Patient's Guarantee in its entirety? Why not give NHS patients a guarantee that not only protects them against administrative failures and surgery cancellations, but also gives those with the most serious illnesses the commitment that they will be treated first on the basis of clinical need - and that their waiting time will be backed up by the guarantee that if the NHS cannot treat them, then it will pay the private sector?

"The Patient's Guarantee should be the first part of any National Plan for the NHS, and if this Labour Government refuses to introduce it then the next Conservative Government will.

"The Second part of any National Plan should be to give NHS patients real choice.

"We live in a country in which people expect to choose what car they buy, what holiday they go on, and what food they eat. They do not expect to go into a travel agent and be told that there is only one place they can go on holiday, and that there is an eighteen-month queue for next available flight.

"Yet that is exactly the equivalent of what happens in today's NHS, and it is unacceptable. Tony Blair and Alan Milburn now talk of Patient Power, but it was this Government's abolition last year of extra-contractual referrals, that means that you and your GP can no longer choose which hospital to send you to. The choice is made for you by the local health bureaucracy. So you cannot choose to go to a hospital with a shorter waiting time than the one that the health bureaucrats have selected. You cannot choose a hospital with a better success rate in performing the treatment you need, or even a hospital that is more convenient for your family to visit. As the Director of the College of Health said: 'patients have less choice than ever in the NHS's history' (Health Service Journal, February 1999).

"The consequences for patients of this lack of choice can be devastating. Take the case of a brave young woman called Helen Smith, who wrote to Peter Lilley explaining why 'choice is absolutely necessary' when he was preparing his recent and very impressive Demos pamphlet on this subject.

"As a result of a terrible illness called meningococcal septicaemia, Helen needed four artificial limbs. The limbs provided by her local hospital led to horrible blistering, damage and infection. She found an orthopaedic unit in Dorset that could fit her with the better artificial limbs that would stop this, but the East Anglia health authority refused to transfer the funds to Dorset.

"Such a tale is a scandalous indictment of the way the NHS is now run. It must change; there must be real choice for patients. For, in the words of Helen herself, 'the only way to improve the health service is to allow patients to choose where they want to be treated'.

"I absolutely agree. Patient's choice should be at the heart of the National Plan. The right of GPs to refer patients to the hospital of their choice should be restored in practice and not just in theory. This was in effect abolished by the Labour Government last year, a decision which the President of the Royal College of Surgeons described as 'not right for the highest standards of patient care'. To ensure GPs and patients can make an informed choice, they should have free access to information on things like waiting times and treatment success rates in different hospitals. And, crucially, hospitals would then be paid for the operations they carry out. For that is the way that patients choice will drive up standards across the National Health Service. Good hospitals will then attract more patients and more funding, while bad hospitals will have a real incentive to improve their services. Extending choice will be good for patients and good for the NHS, and that is why, alongside the Patient's Guarantee, it should be the second part of the Government's National Plan.

"The Third part of the Plan should be the creation of special dedicated surgical units to treat patients with more routine conditions.

"Patients who need relatively routine operations such as a hip replacement or a cataract removal may not be in danger of losing their life - but they are often in pain and their quality of life can be greatly diminished. They must not be ignored. As part of the National Plan, we should set up special stand alone surgical units that would only deal with routine operations like hip replacements. There is no reason why these stand-alone surgeries should not be operated by the private sector, within the umbrella of the NHS. For us, what matters is not where patients are treated, but when they are treated and the quality of treatment they receive. We should also look at whether routine procedures currently carried out by surgeons might not be performed by trained GPs.

"We cannot promise that this would lead to dramatically shorter waiting times, as the Patient's Guarantee means that resources would still be focused where they were needed most - on the sickest patients. But special surgical units would give patients requiring operations like hip replacements much greater certainty about waiting times. And they would go some way to tackling the distress which is caused to patients and their families when operations are endlessly cancelled, many of them on the day itself - as 57,000 operations were last year alone.

"Special surgical units are a classic example of how the next Conservative Government would spend the same money currently going into the NHS better. Scrapping the Government's ludicrous National Handover Plan to prepare the NHS for joining the euro is another. The Government refuse to say how much this is costing the NHS. But one average sized health trust told us recently that they were spending £200,000 a year preparing to join the euro. "Given there are 375 trusts and 99 health authorities, it is reasonable to assume that Labour is forcing the NHS to spend £200 million on the euro preparations. That would pay for 20,000 hip operations, and that is how we would spend the money - at the frontline, on operations like hips and heart bypasses, not on pet political projects that no one supports.

"The Fourth part of any National Plan should be an Exceptional Medicines Fund so that we end the scandal of post code rationing. It cannot be right in a truly national health service that the treatment a patient receives for certain life-threatening conditions is determined by where they happen to live rather than whether it might actually help cure them. But it happens all the time now in the NHS.

"For example, there was the case I read about of a woman in Avon who was refused the Docetaxol she needed to treat her breast cancer but was told that if she lived two miles down the road in Somerset, she would receive it.

"Wiltshire refuses to fund the paclitaxel drug for ovarian cancer, even though there are on average 55 cases of ovarian cancer in Wiltshire every year.

"Beta interferon is not available to multiple sclerosis sufferers who happen to live in Cambridgeshire, Nottinghamshire, Buckinghamshire and Oxfordshire.

"Our proposed Exceptional Medicines Fund would end this post code lottery.

"Health Authorities would no longer need to provide the money to fund these exceptional treatments. Instead, they will be financed directly from the central Health budget, through the ExceptionalMedicinesFund.

"The Secretary of State would determine the size of the Fund's budget each year.

"The Fund's Committee, made up of independent senior clinicians and academics, would then be responsible for deciding on which medicines the fund will be spent and on what clinical criteria would have to be met before a doctor could prescribe them.

"The job of the Government's National Institute for Clinical Excellence (NICE) would be to assess the cost-effectiveness and clinical effectiveness of medicines and procedures, and inform the Committee of its findings. Its job would not be to provide a shield for politicians by trying to make judgments about the affordability of treatments, as the Government now requires it to do. Because we do not believe NICE should be making judgments about affordability, the next Conservative Government will review its decisions.

"If the NHS can no longer afford to give beta interferon to anybody, as may now be proposed, then that should be a decision taken by politicians whose job it is to manage overall budget levels and who are answerable to the electorate for their decisions, instead of forcing NICE to do Ministers' dirty work for them.

"The Fifth part of any National Plan should involve taking the party politics out of management of NHS trusts and health authorities.

"Earlier this year, the Commissioner for Public Appointments, Dame Rennie Fritchie, uncovered systematic politicisation by this Government of appointments to trusts and health authorities.

"Her Report revealed that since 1997, 343 people with connections to political parties have been appointed to help run the NHS. 83 per cent of them were connected to the Labour Party. Prior to 1997, the Report says, there were fewer political appointments, and those that were made were far more equally balanced between the two major parties.

"According to Commissioner Fritchie, in the present management of the NHS 'candidates who declare political activity on behalf of the Labour Party have a better chance of being appointed than other candidates. Less successful candidates have been brought forward to replace those identified on merit'.

"That is worth repeating: 'less successful candidates have been brought forward to replace those identified on merit'. No wonder New Labour have so mismanaged the NHS; they have put their cronies in charge.

"It is time we took the politics out of NHS management. The National Plan should propose an urgent and independent review of all aspects of the appointments process to NHS boards, in line with the Commissioner's recommendations. And we should enshrine in that appointments process the principle that people are selected on the basis of merit and merit alone, and because of the skills and expertise they will bring to the NHS, and not on the basis of who they happen to know in their local Constituency Labour Party.

"The Sixth part of any National Plan for the National Health Service must be to trust the professionals who work on it, rather than directing their every action and second-guessing their every decision from Whitehall.

"The Prime Minister talks about a partnership with doctors and nurses and NHS managers, but then treats them as little more than clerks following the orders of the Secretary of State. His Statement on Thursday promises more micro-management from the top, more arbitrary targets, more political interference.

"Of course, we must have a system in place that identify and deal quickly with health service personnel who are abusing the trust that is placed in them and mistreating their patients. But proper accountability and culture of openness need not get in the way of devolving real power to frontline NHS staff.

"The National Plan should take Health Ministers out of the day to day management of the NHS.

"The job of the Secretary of State should be to set the overall strategic direction of health care, negotiate the budget settlement with the Treasury and allocate funding to different parts of the health care system, and then set and police minimum standards of care throughout the service.

"The job of the doctor should be to treat their patients and run their practice with the minimum of interference from Whitehall.

"The last thing the NHS needs is another wholesale re-organisation of primary care. With that in mind, we should not look for a one-size-fits-all system. We should work with the primary care groups we inherit from Labour, while giving doctors the choice of moving to Primary Care Trusts - if that is what is right for them and their patients.

"We should also encourage a much greater specialization in general practice, so that we break down artificial barriers between primary and secondary care.

"With the advances of modern medicine, no GP these days can be expected to know about everything. GPs within a Primary Care Trust should be able to specialise, so that patients without serious conditions could be referred to another GP who has the special knowledge required to deal with their complaint. This would help ease the pressure on consultants and outpatientwaitinglists.

"Any National Plan should also let nurses get on with their job of looking after their patients. That means tackling the chronic shortage of nurses that puts those working in the NHS under enormous pressure.

"We should ensure the maximum number of people are encouraged to enter nursing; vocational skills are at least as important as academic demands to a successful nursing career. We should also ensure that nurses feel sufficiently fulfilled in their work so that we stop 12,000 of them leaving the NHS every year. The NHS should be a much flexible employer, so that women can balance the demands of their career and their family, and we should give nurses much greater control of their working environment - so that they can do something about untidy wards or badly prepared patients' food. These may seem like small things in the context of a National Plan, but they can make all the difference to the quality of care patients receive in the NHS.

"The Seventh and final part of any National Plan must be to encourage a larger private and independent health sector, not as an alternative to the NHS but as an addition to it.

"There used to be an assumption in politics that no Government could risk talking about a larger independent sector for fear of arousing the wrath of the public and of the health professions. Politicians should think again.

"In an NOP poll conducted this month, 74 per cent of people supported the use of private investment to help pay for the cost of building new hospitals and 69 per cent agreed that the NHS should pay private hospitals to perform operations when there is a long wait in local NHS hospitals.

"It is not only the public whose attitudes have changed. The General Secretary of the Royal College of Nursing told her Congress this year: `any vision for health in this country which denies the contribution of the independent sector is seriously flawed … The NHS and independent sector must find positive ways of working together`.

"The only group of people who remain dogmatically opposed to the independent health sector, the only group of people still waging the class war in our health service, are the Labour Party. The Health Secretary himself has said that 'he would come down like a ton of bricks' on anyone who had anything to do with the private sector.

"But there are now signs that, in the face of growing public anger, he has had to change his mind. I have already referred to the newspaper reports that the National Plan will include working with the private sector through a very pale imitation of our Patient's Guarantee.

"If the reports are true, and the Government are going to take off the ideological blinkers and work with the private sector instead of against it, then we Conservatives unambiguously welcome that.

"Let us make it common ground between the political parties that a proper National Plan for a twenty first century NHS should encourage more personal provision on top of an expanded and comprehensive NHS - as a way of increasing still further the total resources available to health care in Britain.

"Let us make it common ground between the political parties that a proper National Plan for a twenty first century NHS would get the private and public sectors working together to increase the capacity of the National Health Service.

"These things are common sense. I hope that the Labour Government will make them happen. But if what we have read is just more spin, then it will be up to next Conservative Government to make them happen.

"We also need to take a close look at the way the tax system operates in relation to private medical care. The present Chancellor has positively discouraged personal provision when this April he imposed National Insurance Contributions on benefits in kind like private medical cover. This amounts to a £100 million stealth tax on employers who provide health insurance for their employees.

"It is a stupid, short-sighted act of spite that will put yet more pressure on the resources of the NHS. The next Conservative Government will work to end the punishment meted out by our taxation system to those individuals and companies who do seek to make their own health care provision for their families, their employees and themselves.

"In his first Budget, the Chancellor also removed the tax relief on private medical insurance for the over 60s. This was another shortsighted act of spite that hits pensioners who have saved all their lives and try to be independent of the state. We will have to look carefully at what we can do to help these people.

"However, let me clear up one pernicious myth. The Prime Minister says that the Tories will take a billion pounds out of the NHS to provide general tax relief on all private medical insurance. We have not announced our tax proposals for the next election, and we have made no commitment to introduce a general tax relief. Furthermore, even if we were to introduce such a general tax relief, then I can tell you now that it would not come at the expense of the National Health Service budget.

"Working with the private sector and encouraging more personal provision is not part of a secret agenda to privatise the NHS, as the Prime Minister has until now tried to claim.

"Anyone who knows me, who knows my family and my upbringing in South Yorkshire, knows that the idea that I want to privatise the NHS is complete and utter rubbish. The families I grew up with, the people who I went to school with, rely on the NHS; I have relied on the NHS, and I still use the NHS as Leader of the Opposition.

"I believe the NHS is an essential service to the great majority of the British people - and by the NHS I mean a comprehensive national health service providing a full range of treatments to everyone in the country, free at the point of delivery.

"But I also believe that the NHS should be a source of great British pride, once again the envy of the world.

"Sadly it is not so today. We have mortality rates for major diseases that are among the highest in the developed world; we have waiting lists for operations that are among the longest in Europe; we have drug rationing that amounts to a postcode lottery and denies treatment in a way which would be inconceivable to our European neighbours; we have political interference in management appointments that stinks of cronyism; we have doctors and nurses who are not free to do the things they have the talent and ability to do, and a Health Secretary micromanaging and mismanaging the largest employer in Europe; we have a Government that brought the NHS to its knees with gimmicks and spin and political priorities; and we have a Prime Minister who has put on the ideological blinkers and cannot see how the total sum of health care in this country can be improved.

"The crisis in our National Health Service will not be solved by more National Plans, more gimmicks, more spin and more interference. It will be solved by giving patients real choice and guaranteed waiting times; it will be solved by trusting health service professionals and taking the politicians out of the health service; it will be solved by working with the private sector and encouraging greater personal provision, as a supplement to an expanded and comprehensive National Health Service.

"Patient Choice. Trusting the NHS Professionals. Partnership with the Private Sector. Getting rid of political interference. That is what the National Plan should be all about. That is what the next Conservative Government will deliver.

"For we will deliver a standard of health care that people living in the fourth largest economy in the world have a right to expect. We will give our doctors and nurses the professional fulfillment and trust that they deserve. We will increase year after year the total resources available for the good health of our people.

"We will create the first class National Health Service that a twenty first century Britain deserves."

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