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David Cameron: How the NHS can deliver rising standards of healthcare

In America today, there is a real debate going on about healthcare. But here in Britain, the recent political exchanges over the NHS have neither been real, nor a debate.

Not real, because they have focused on a question that is now settled: the Conservative Party's commitment to the NHS.

And not a debate, because the back and forth of the past week or so seems to have been more about political point-scoring than a serious discussion of an extremely serious subject:

How, in a world of rapidly rising healthcare cost and demand...

...should we deliver the rising standards of healthcare people expect in the 21st-century within a taxpayer-funded, free-at-the-point-of-use system, in which treatment is provided to all on the basis of need not ability to pay?

That is the question I will try and answer today, but first I just want to say a word about the values of the NHS, and the Conservative Party's belief in them.


I know perfectly well that some of the changes we have made in this Party over the past few years have not been easy for the Party to accept.

But there is one change we've made where frankly, it has felt like pushing on an open door - and that is making crystal clear our wholehearted commitment to the NHS.

Conservatives rely on the NHS, work in the NHS, volunteer to help the NHS...this Party wants to improve the NHS for everyone.


It's not to do with ideology, or philosophy, or any abstract political theory.

It is the simple, practical, common sense, human understanding of a fantastic and precious fact of British life:

That the moment you're injured or fall ill...

...the moment something happens to someone you love...

...you know that whoever you are, wherever you're from, whatever's wrong, however much you've got in the bank...

...there's a place you can go where people will look after you and do their best to make things right again.

That's why we're committed to the NHS, and to the principle of a healthcare system that is free at the point of use, based on need and not the ability to pay.

But that's just the starting point.

The real debate we should be having in this country is how we improve the NHS, given the enormous pressures we face.

The debt crisis means we need a new approach to public spending, to make sure we get more for less. 

But in the NHS, even that won't do. 

The pressures on healthcare spending - from an ageing population, from medical advances, and from rising expectations - are simply too great.


The biggest pressure is of course our ageing population.

The fastest growing age group in Britain today is those aged 80 years and over.

For the first time ever there are more pensioners in this country than there are children under 16.

As people live longer they're more likely to live for more of their life with at least one long-term condition like Diabetes, Parkinson's disease or Alzheimer's.

It's estimated that by 2025 over six million older people will be suffering from a debilitating long-term illness. 

The number of people with dementia will have increased to around one million; with osteoporosis to over four million; with hearing loss to around ten million. 

These are increases of up to fifty per cent from today. 

And paradoxically, while we're living longer we're also becoming less healthy in many ways.  

Obesity, drug and alcohol abuse and sexual health problems are all on the rise, putting massive pressure on NHS resources...

...with alcohol misuse costing the NHS £2.7 billion a year and obesity estimated to cost it a staggering £4 billion a year. 

As well as these pressures there are still big infectious diseases to fight - and not just the sporadic scares like swine flu. 

Tuberculosis is an ever-growing pressure on our health service. 

We used to think TB was a disease of the 19th century, not a threat to the twenty-first...

...but the number of cases has increased by 25 per cent since the turn of the millennium. 

HIV is the fastest-growing serious health problem in the UK, with an estimated 80,000 people living with it.

And perhaps the most shocking rise in modern disease has been Hepatitis C - since 1997 the number of cases reported each year has almost trebled.

While the latest official figures show that 60,000 people in England have been infected, the Department of Health estimates that the real figure is more like 200,000.

But the Hepatitis C Trust believes that you can double that number - with nearer 400,000 people in England being infected.


But while the number of patients is rising, so too is the range of treatment. 

Today, medical advances, driven by the hi-tech revolution, are increasing at an exponential rate. 

Genetics, nanotechnology and robotics are being integrated into the work of the NHS. 

Da vinci robots, costing millions, are routinely used for pelvic surgery.

Those at risk of inherited disease may be referred for genetic diagnosis by their GP, at a cost of £5,000 a time. 

Patients undergoing operations might have stents - tubes like internal medical scaffolding - put into their airways and blood vessels, with a hand-made stent for the aortic arch costing £60,000 alone.  

And these are just the technologies already in operation.  

Right now scientists are working on artificial limbs that are controlled by thought alone. 

Breathalyzers that can diagnose disease with one puff. 

Microscopic robots that can be injected into veins to perform minor procedures from the inside.

Of course, timely interventions with effective new drugs and technologies have the potential to deliver cost savings.

But overall, the cost implication of all this growth - both in the supply of and the demand for healthcare - is clear. 

Spending on the NHS cannot stand still, because standing still would be taking a step backwards. 

That is why we have pledged real-terms increases in NHS spending...

That is a pledge Labour have not made - a fact which, to put it mildly, takes the wind out of their point-scoring sails. 


But even so, we have to recognise something. 

Given the huge pressures faced by the NHS over the coming decades, that increase in spending alone is not enough. 

The gap between what we will have to do and what we can afford to do presents an urgent need for reform.

We need reform on both sides of the cost equation.

We have to make the supply of healthcare more efficient...

... and we must also do something about the increase in demand for healthcare. 

The first set of reforms is all about choice, competition, and a focus on outcomes not targets...

...while the second is about public health.

But I believe we in this Party have shown that we now have the credentials to achieve both.


 Now I know that reform has become a dirty word in the NHS.

That is a real shame, because as in education, after a number of wasted years, the Labour Government started moving in the right direction.

So I think it would be quite wrong for me to stand here and pledge that we will undo everything Labour have done and start afresh.

Where Labour are going in the right direction, I want us to go further and faster.

But where they've got things wrong, we will call a halt and try to undo their mistakes.

So let me first make clear what our reforms won't look like.

We will not persist with the top-down re-structures and reorganisations that have dominated the last decade in the NHS.

They have caused terrible disruption, demoralisation and waste, and the people who work in the NHS have just had enough of it.

We believe we can make a big improvement in NHS performance - both in terms of quality and efficiency - within the structures that already exist.

First, by extending the competition and patient choice that Labour have started - not least by equipping patients with the information they need to inform their choice and exercise more control over their healthcare.
And second, by focusing on real health outcomes rather than political process targets.


The argument for more competition in the NHS seemed to have been won a long time ago.

Blairites like Alan Milburn were evangelists for market mechanisms to drive up standards and drive down costs.

But the implementation of competition within the NHS has been damagingly unclear and inconsistent.

The NHS and independent sector hospitals were never competing on equal terms.

When extra capacity was needed, private providers were waved in - but then pushed out again later on.

Such an unpredictable approach is never going to build the long-term variety of provision - or bring forward the investment - we need.

Only a stable, transparent and pro-competitive framework will attract the independent sector to invest in and expand the capacity of the NHS.

That means clear payment and commissioning structures - a clarity that's been sorely lacking from the Government.

The proposals we have set out will give the NHS the clear legislative framework it needs to create a stable environment.

By reducing political risk, we will open up the opportunity for any willing provider to supply care to NHS patients...

...accepting commercial risk, at NHS prices or less and at the right quality standards. 

That means appropriate weight should be given in contracts to quality as well as value for money.

And it means a proper partnership with the independent sector and voluntary sector...

...not a push-over like the Government's experience, where block contracts are awarded to independent sector treatment centres at greater expense than the equivalent cost in the NHS. 

The charity Whizz Kidz is a good example of how a genuine partnership approach can work. 

They collaborated with the PCT in Tower Hamlets to identify local children and young people who were on the waiting list for wheelchairs.

The PCT then offered them a property to use as a base.

Within two years every child in Tower Hamlets who needed a wheelchair had one.

This shows that bringing in different organisations isn't just about competition, it can spark collaboration, too.


Greater competition is vital to make a reality of the next crucial step in NHS reform: more choice.

Labour have rightly moved down this road.

Their speeches show that they understand the public's demand for greater control over the healthcare they receive.

But their actions reveal a party that finds it hard to let go of the levers of state control...

...with patients in the NHS, after twelve years of Labour government...

...still experiencing far too much of the old-fashioned, 'get-what-you're given and be grateful-for-it' treatment.

By contrast, we in the Conservative Party are unambiguously clear that giving people greater control over their lives is a good thing.

We want to give people more power to choose their child's school, to hold politicians to account, to start their own business, to generate their own energy - more power over every aspect of life.

That should apply to healthcare too.

Of course we're not expecting people to choose complicated operations from some medical menu.

But we can create a more user-friendly NHS, where patients have a choice over the doctor they see, and the hospital they're treated in.

They'll be able to check their own health records online in the same way they would their bank accounts, and decide which doctor sees those records.

In all these choices they'll be guided by a GP they have a real relationship with - because it will be a GP they have chosen, rather than one they're stuck with.

Labour undermined the GP relationship with their catastrophic negotiation of the GP contract, which took the responsibility for organising out-of-hours care away from GPs.

We're going to restore the link that was lost by giving GPs the responsibility to manage the entire relationship that a patient has with the NHS.

So either they provide the care that person needs, or they commission it from another provider - or along with the patient they decide on a combination of the two.

With this power GPs will control the budgets for the care of each of their patients.

Instead of far-off bureaucracies soaking up funding, local doctors will be able to ensure that money follows the patient, and is spent on frontline care.

And the human benefits are clear too.

The family doctor service ensures that - even though through the course of your treatment you may see many specialists...

...there is always one person in charge that you know by name and trust completely.

With their help people will be empowered and informed to make the right choices about their treatment.

This will make a big difference to the way people feel about healthcare.


Of course the thing that matters most to people when they become injured or ill is what will happen to them...

...whether their pain will be relieved, whether they'll be able to live a normal life - in some cases whether they will live or die.


That is what patients focus on, and that's what the NHS should focus on.

It sounds blindingly obvious but it's something the Government seems to have lost sight of.

The imposition of political targets has skewed the focus of the NHS away from what really matters and on to the minutiae of its processes and procedures.

The consequences of this approach range from the harmless to the downright appalling.

Three quarters of nurses say patients are regularly admitted to the wrong wards, just in order to meet a target.

The Healthcare Commission has linked the pressure to meet targets with a rise in hospital infections.

Ambulances in hospital car parks are regularly used as 'waiting rooms', putting them out of action, purely so A&E patients don't enter a ward and start the clock running on the four-hour maximum wait target.

Tragically, a 16-year-old cancer patient died after waiting over an hour for an ambulance to transfer him.

Three ambulances could have reached him but they were tied up waiting to hand over patients to A&E.

Health targets have, in many cases, made people more unwell instead of making them better.

And their impact  has been significant.

By endlessly specifying how the NHS should respond to every situation, the Government has assaulted the professional responsibility and sense of vocation of everyone who works in our health service.

How can that be good for quality, or efficiency, or patient care?

So the third component of our reform plan - and the area where instead of building on the changes Labour have made, we want to go in the opposite direction...

...will be to replace Labour's process targets with actual health outcome measures.

Conservatives understand that there is no one-size-fits-all model that can be drawn up in Whitehall.

This is true in health as it is in other areas.

A Whitehall plan wouldn't fit the patient causing trouble on the ward...

...or the pensioner who needs company more than they need medicine...

...or the child in A&E who's covered in strange bruises.

The target and the rulebook can't help you with these things.

The millions of human dramas that pour through the doors of the NHS need different responses, on-the-spot decisions, professional initiative, judgment, discretion.


But replacing targets with outcome measures doesn't mean 'caving in' to the professionals and removing accountability, as some have argued.

We don't have some naïve view that you can put taxpayers' money into the health service and just hope for the best.

Our reform plan will improve accountability, not diminish it...

...by replacing bureaucratic accountability with democratic accountability.

Instead of being obsessed with processes, we will be obsessed with results: the health outcomes that really matter to people.

What are my chances of living independently if I have a stroke?

How long will my Dad survive if he gets cancer?
What are my chances of surviving from heart disease?

That's what patients care about and that's what the NHS should focus on.

So the end of top-down targets and the introduction of transparency - the collection and publication of health outcome information - will give people the power to hold the professionals to account.

The power of competition - the opening up of the NHS to new providers - will bring innovation and investment.

And the power of choice - the ability for people to control what service they get - will lead to better quality care.

These reforms will create a more user-friendly and efficient NHS that both meets patient expectations and restores professional responsibility.


These three reforms - more competition, more choice, a focus on outcomes - are all about making the supply of healthcare better and more efficient.

But we also need to work on the other side of the cost equation.

We need to do all we can to reduce the demand for healthcare - and that means a much more effective approach to public health.

On almost every public health indicator, Britain has gone backwards in recent years.

Obesity - up, alcohol abuse - up, drug abuse - up, sexually transmitted infections - up.

None of this is inevitable.

Other, comparable countries don't have our health problems.

We are the most obese nation in Europe.

Our teenage pregnancy rate is the highest in Western Europe - more than double the Western European average. 

Now our plans to reduce political interference in the day to day running of the NHS will enable us to change the Department for Health into the Department for Public

...with separate public health funding to focus on prevention of illness rather than cure.

That way, money for long-term change won't be siphoned off by short-term demands.

It'll be used wherever there is a need for spending on public health, across government departments, at national or local level.

That might mean working with the Department for Children, Schools and Families on getting more kids into after-school sport...

...or giving money to a local authority to deal with damp housing that is a direct threat to people's health.

With a ring-fenced budget to treat the causes of poor health we can start to defy that depressing trajectory of illness that this Government have resigned us to.

But I don't for one moment believe that this will be enough.

I think that one important explanation for Labour's frankly disastrous record on public health is their philosophical attachment to state control.

When it comes to public health today, you can't just reach for the levers of legislation.

That might have worked for the Clean Air Act of 1956 - but we can't bring in an "Elimination of Alcohol Abuse Act 2009."

Bureaucratic methods are increasingly ineffective today...

...because the public health problems of today are increasingly the consequence of perfectly legal personal decisions, made in private spaces.

People choosing to binge on junk food; sit on the internet instead of going out for a run; drink till they pass out.

I stuck my neck out on this before when I said that instead of blaming external factors for everything, it's time we recognised that there is a moral choice...

...that personal responsibility cannot be shirked.

I've also spoken about how difficult it can be to make responsible choices within a highly seductive commercial environment.

The truth is that many big businesses are making huge profits on the back of poor health choices.

So the party that can make sense of this problem is not the party that instinctively reaches for the bureaucratic solution...

...but the party which understands - and is committed to promoting - both personal responsibility and corporate responsibility...

...the party of social responsibility, not state control - and in Britain today, that is the Conservative Party.


I don't want to be unfair in my criticisms of Labour.

They have the best intentions, and they have done some good with the NHS.

But they and their reforms have come to the end of the line.

Our health service is crying out for the next stage of change.

I believe we have shown that we are the ones to bring about that change, and that we have earned the right to call ourselves the party of the NHS today.

We believe in the NHS.

We understand the pressures it faces.

And we have a plan to make the changes it needs.

So we are the party of the NHS today because we not only back the values of the NHS, we have a vision for the future of the NHS.

We are the only party committed to the resources the NHS needs, and we're the only party with a plan for the reform the NHS needs.

This is the real debate we should be having in this country...

...and I believe that the Conservative commitment to the NHS, combined with Conservative reform of the NHS...

...can give us the best of both worlds: the fairness of a National Health Service that is unique to our country...

...combined with the quality and personal service that people are used to in other countries.

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