The Future of the NHS - Ed Miliband's speech to the RSA
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Full copy of speech given by Ed Miliband, Leader of the Labour Party, to the RSA:
Can I start by thanking the RSA for their contribution to public life in Britain and Matthew Taylor in particular.
Matthew, I’ve known you for nearly twenty years now and you have always been a passionate advocate, a force of energy and at the IPPR, the RSA and in your work in government, an inspiring leader of people.
Over the next few months I’m going to be talking about education and other public services.
But today I am here to talk about the National Health Service.
This is unusual. The role of Leaders is often to give panoramic ‘public service reform’ speeches and indeed the Prime Minister gave one here three months ago.
But I think getting the NHS right is so important, it should demand the full attention of leaders — and preferably before, not after, they realise their policy is half-baked.
The NHS is vital to the well-being of our nation.
It is a genuinely world-leading healthcare system based on principles of fairness.
One of the proudest institutions of our country.
If it was proposed today, we would be told it could not be done.
And yet the NHS was built at a time of serious financial deficit as Britain rose to the task of rebuilding itself after the war.
The NHS is an institution which each generation has a responsibility to pass on to the next in better condition than they found it. This is part of what I call “The Promise of Britain”.
And in my view, it is under threat from this Conservative-led government’s reorganisation.
Today I want to set out what the Government’s priorities should be.
Let me say at the outset that this is a debate I come to as a reformer.
A reformer of the state as well as the market.
It is particularly incumbent on those who believe in the role of public services in our society to be always seeking to make them better.
My conviction stems from my own experiences and those of my constituents. I have seen first-hand the ability of the state to protect and empower, to extend opportunity and to transform lives.
And yet I have also seen the sense of powerlessness and frustration that comes when people have to deal with services which are unresponsive or which let them down.
An accountable public sector, just like an accountable private sector, is integral to creating a fairer Britain.
My argument today is that to do that, to create an ever better health service, change will be essential.
The new pressures on the NHS are too great, the new challenges too large for us to think that preserving the status quo will be enough.
The choice for the NHS is not as the Prime Minister suggests, between change or no change. It’s a choice about what that change should be.
My cas e is that we need change which upholds the values of the NHS and makes it work in the era in which we live.
I believe the Government’s changes will undermine the values of the NHS and make it harder to meet the challenges of the future.
I want to base my account of the future for the NHS on three critical lessons from our record which I think point to the right path for future change.
First, change is successful where it is driven by the current and future challenges faced by the NHS.
Second, change in the NHS works best where it strengthens accountability and makes the NHS answerable to patients.
And third, whilst reform requires difficult and sometimes unpopular choices, it is only successful if it protects the sense of national mission and the values of cohesion and collaboration that underpin the work of our health service.
I want to show why these lessons are the right ones to learn from our time in office, question whether the government is applying them in their reforms, and then look to what priorities our NHS should be pursuing in the future.
In 1997, Labour inherited an NHS in dire straits. It was an institution that was profoundly valued, but it was also seen as being in steady – and, according to some, irreversible decline.
Yet investment and reform transformed the service.
Two facts stand out beyond all others:
The verdict of the public: at a time when people talk about cynicism in our public life, the NHS is now benefiting from the highest satisfaction ratings it has ever achieved, 72%.
Against the lowest ever in the 1990s.
And then there is the verdict of experts: the Commonwealth Fund have recently shown that the NHS to be one of the world’s leading healthcare systems for quality and the very best on value for money.
What are the lessons which we should take from this success?
The first I draw is that change worked because it came from a clear-eyed focus on the reality of the situation that was inherited.
In the late 1990s waiting times were unacceptably high and stubbornly rising.
Standards were low and there was little sense they could be turned around.
Patients too often felt like they were an inconvenience, not the reason services were there.
John Major’s government had looked long and hard at the idea of setting a maximum wait for treatment of 18 months.
They decided this was too difficult.
Even some on the left were arguing that charging might be unavoidable.
Labour’s response was to meet this challenge head on.
The Wanless review led to the refinancing of healthcare through the increase in National Insurance and substantial increases in investment.
The NHS plan in 2000 took decisive action to challenge the legacy of long waiting times and improve the focus on patients.
All were aimed at the central challenges of getting patients acces s to treatment they had previously struggled to get.
Second, changes worked best where they strengthened accountability.
In the 1990s, the government was embarrassed about the state of the NHS.
But the citizen had no set of standards to call upon.
People were abandoned for hours on hospital trolleys, while others sat for an entire night in A&E, and some were asked to wait for weeks for a GP appointment.
This was partly about investment but not only about it.
The NHS today is more accountable to patients at every level.
That was the goal of reforms like targets and later waiting time guarantees, which created clear rights for patients.
It was the goal behind the introduction of greater choice of hospital and appointment, as well as personal budgets for those with chronic diseases which gave patients greater flexibility in how they received their care.
Although we shouldn’t pretend choice is the only thing people c are about in their NHS, it can make a real difference for those frustrated with the system or those looking to have some flexibility in their own arrangements for care.
And greater accountability was the goal behind Foundation Trusts and Payment by Results, making NHS management responsible for its performance.
So, accountability was strengthened.
But that doesn’t mean every reform worked.
Some reforms were badly executed.
The GP contract changes, for example, failed precisely because they reduced, rather than enhanced, the accountability of GPs to their patients for evening and weekend opening - although later reforms made up much of the ground.
Other reforms under estimated the disruption they would create.
The frequent reorganisation of the size and shape of primary care trusts frankly did not take sufficient account of the costs and problems they caused.
David Cameron rightly decried top-down re-organisations before th e election.
It is both surprising and disappointing that he has since decided to impose just such a top-down re-organisation now in direct contravention of his promises.
Overall, there can be no question that on the last decade of reforms, the picture was one of success.
And this insight, that accountability is key, should be central to any strategy for change in the future.
The third lesson I take is that whilst reform requires tough choices it will be successful only if it protects the sense of national mission:
The values of cohesion and collaboration, that underpin the NHS and the efforts of those who work in it.
The founding of the NHS by Labour after World War Two didn’t just change the method of payment.
It also transformed both the culture in which healthcare was delivered and doctors’ relationship with their patients.
Abolishing the requirement to pay for care made a huge difference to patients, but we must al so recognize that it made a huge difference to clinicians, and their relationships with each other.
It encouraged collaboration.
A lot has been made of Julian Le Grand’s analysis of the Knights and Knaves of the public sector.
He is right that we must not be naïve about the public realm. The state, if not accountable, can sometimes stand in the way of the interests those who depend on it.
But if it is a mistake to be glib about our public servants, it is an even bigger mistake to be cynical about their motives to serve.
One of the great assets of the NHS over some other healthcare systems is that this is an institution which fosters a sense of common endeavour and nobility of purpose.
On a train recently, four medical students came up to me expressing deep distress about what they feared would happen to the health service.
Their concern wasn’t about money.
It wasn’t about whether they would get a job.
It was a bout the values and sense of mission in the NHS.
So I believe our reforms worked best when they strengthened the ability of those who work in the NHS, including those young people I met on the train, to serve people in need.
Any effective reform must ensure collaboration continues alongside the right kind of competition.
And it must strengthen the NHS ethos, not destroy it.
This idea, of binding the NHS together in a framework of values focused on the patient, was behind the establishment by the last Labour government of an NHS constitution.
And it is why, as we look forward to the future, we must be mindful of the impact which changes can have on the culture and ways of working which we have always taken for granted.
So, it is on the basis of these three lessons from our past that I want to judge the proposals of David Cameron.
There is considerable confusion, not least within the government itself, about why Mr Cameron has embarked on this costly reorganisation of the NHS at a time when funding is so tight.
What is clear is that the overall intention is to shift significantly the NHS towards what can only be described as a free-market model of healthcare provision, albeit one without an extension of charging.
That is the underlying ideological driving force behind their choices:
The fragmentation of commissioning into hundreds of small GP consortia.
The removal of the financial protections on Foundation trusts.
The abolition of private patient caps.
A regulator to promote competition at every level in the NHS where UK and EU competition law will be – for the first time - applied right across the Health Service.
I believe this plan does not represent a serious response to the lessons of the last 13 years, nor a credible response to the challenges of the future.
Instead, it is a year-zero approach to reorganising the NHS.
Ideological and reckless.
Why do I say that David Cameron’s plan has failed to learn the lessons of the past?
First, the shift towards free-market healthcare will not in any sense help the NHS prepare for the challenges it will face in the future.
An ageing population and rising chronic disease both demand an NHS which can prevent and intervene earlier.
Given these challenges the big task for the NHS is to get family doctors and hospitals working more closely together.
But the government’s plans risk setting GP against hospitals in the battle for profits and patients.
Given the challenge of an ageing society a central task is to get GPs and social care for the elderly working together.
But the government’s plan risks fragmenting services into hundreds of GP consortia each with an uncertain financial future.
Everything we know from around the world suggests free markets don’t work in planning efficient healthcare systems. Demand for services is less well managed and cost pressures rise.
The Prime Minister likes to say we need better cancer survival rates. Who could disagree? But he’s given us no clue as to why his reorganisation will help achieve that goal.
When judged as a plan to prepare the NHS for the next decade, Mr Cameron’s proposals are, at best irrelevant, and at worst deeply unhelpful to the kind of integrated and preventative care we need.
Second rather than strengthening patient focus and accountability, these plans will weaken them.
The abandonment of many of the waiting time guarantees takes power away from patients.
The Bill offers only the vaguest answers to the question of what happens if your GP consortium wants to restrict your choice or standard of care as a patient.
The decision to make adoption of NICE recommendations optional for GPs means guarantees about the type of treatment, as well as speed, are further undermined.
Equally o f concern is the uncertainty about the accountability of how NHS money is spent.
It is right to involve GPs more in the commissioning of services.
But this was being done within the current system and could have been enhanced.
There is little reason to believe that the wholesale transfer of £80 billion of public money to GPs will enhance accountability and some reasons to believe it will be reduced.
Labour did use the private sector to deliver services for NHS patients.
But these proposals take us into a whole different arena, with the prospect of private sector companies being used to carry out commissioning on behalf of GPs.
Decisions about which services are available, when and to whom, may slip swiftly into the hands of private companies.
Thirdly, I fear that rather than strengthening the values that underpin our NHS, the proposed changes risk squeezing out collaboration and common endeavour.
I suspect that, if implemente d, this Bill will do enduring damage to the culture in which our NHS operates.
When I asked David Cameron about the clauses of the bill dealing with competition at Prime Minister’s Questions a few weeks ago, he seemed ignorant about them.
I still believe that not enough people understand the potential implications of them.
The government’s bill envisages the same regulatory and competition regime for the NHS as for the energy, telecoms or water companies.
But do we really want healthcare to be run on the same basis as the privatised utilities?
It is right that the big energy companies do not collude.
Is that really our view about Britain’s best hospitals? our NHS?
Not in my view.
I absolutely do want hospitals like UCH and Imperial to co-ordinate, collaborate and work in partnership in offering NHS patients world-class specialist health services.
But this isn’t what this plan achieves.
As the Kings Fund said: “This Bill signals a significant shift towards a more competitive market for healthcare. While we support increased competition in areas where it demonstrates benefits to patients, the Bill appears to move towards promoting competition at the expense of collaboration and integration.”
The defenders of David Cameron’s reorganisation plans will say that if NHS hospitals can prove that collaboration is in the interests of the patients, they will be allowed to do it.
But frankly that is not a sensible way to run the NHS—an organisation of 1.3 million people.
The value of collaboration is too important to our NHS for it to be reduced to something you have to prove is sensible to a bureaucrat in the regulatory authority.
I worry that little thought has been given to the environment in which our doctors, nurses and clinicians will be asked to work, once the NHS has a duty to promote competition at every level and competition law is pre-eminent.
So on grounds that it doesn’t meet the challenges of the future, that it weakens rather than strengthens accountability and that it threatens the ethos of the health service, these changes are simply wrong.
What’s more, this is a proposal that nobody voted for. None of us should forget how, before the election, David Cameron explicitly and repeatedly promised there would be no top-down reorganisation of the NHS.
Now we read in the newspapers that horse trading is taking place between the Conservatives and Liberal Democrats.
Almost daily, we have contradictory briefings to the newspapers from Tory sources, from Treasury sources, from Health department sources and from the Liberal Democrats. Blame is being cast around.
But each passing day is adding to the sense of utter confusion and chaos about a Bill that has already completed its committee stage in the House of Commons.
This is bad government. This is not how the future of the health service should be determined.
It is an insult to the people who work in the health service.
It is an insult to the people who use the health service.
And the Prime Minister should be ashamed of the way he is running the NHS.
It is too important for its future to be determined in a back room deal which would then be bounced on MPs with precious little scope for proper debate let alone public consultation.
Today we hear the government thinks the answer is delay, but going slower isn’t the answer to a bad policy.
That's why I say this: Mr Cameron, go away and think again.
Don’t come back with piecemeal changes. It’s a bad bill, built on bad assumptions and dangerous ideology.
If this plan to reorganise the NHS is going to be significantly changed - and it must be - let any new plan be the subject of a new White Paper and a new national consultation.
Because the NHS is so important, I will make this offer:
If there is a genuine attempt to address the weaknesses of the Tory reorganisation proposal then my party will enter into a debate about a new plan with an open mind, accepting that any NHS plan must be delivered within a tight spending settlement.
Whilst satisfaction is the highest ever, the huge challenges that the NHS faces, must be addressed.
I want Labour’s plans to be written not in some secret negotiation and then presented without a mandate, but in dialogue with patients and professionals.
Today I want to move that debate forward and talk about what I see as the priorities.
I do so, clear that whichever party was currently in power, the NHS would need to be driving greater efficiency through the system.
That is in fact, an argument against the current multi-billion re-organisation, which is likely to end up costing more, not less.
First, the biggest challenge s the NHS faces in the future.
The biggest is how it responds to an increasingly elderly population with far higher levels of chronic disease.
Our response to this must be a decisive shift to a more preventative service.
This is essential not just for better outcomes but for the better use of public money.
And it is essential to tackling the gross health inequalities we still face in Britain.
Family doctors should be expanding their role in helping people understand their risks, manage diseases and live healthier lives as we grow older.
Some of the best examples of this kind of care come out of patient-led groups or patient-to-patient mentoring
Public trust in our NHS makes it extraordinarily well placed to drive such a shift in care.
An NHS which prevents as well as treats should looks outward to schools, workplaces and homes.
Let me give you just one example of what I mean.
Cancer survival can be dramatically improved with early diagnosis.
That requires better screening and faster testing, but also getting those who need to be tested into a clinic.
The change to transform our cancer survival rates is as much outside the NHS as inside its walls – and that is the challenge of the future.
But I don’t believe the distraction of a massive bureaucratic re-organisation will help it happen.
The second big challenge is mental health.
Improving services for these patients would have a profound impact on the wellbeing of tens of thousands, many of who never currently come into contact with the NHS or only come into contact very late in their illness.
As well as being devastating for individuals and families affected, mental ill health can be a cause of people falling out of work and losing their homes.
Again, this is also about how we prevent the costs of illness from cascading into other areas.
When I look at what the last Labour Government achieved in transforming hospital care, I think the next Labour government will need to complete a similar transformation of mental health care.
The third challenge is how we deal with social care for the elderly.
As currently constituted, provision will struggle to meet need in the future.
If unreformed, this wil l pile immense pressures on our NHS and further erode our aspiration to be a fairer country.
All of us should look forward to a secure old-age with the certainty of knowing care will be there we need it.
This is why the Dilnot commission is so critical and why its recommendations and the debate it fosters is so important.
In addressing these challenges we must secondly seek to strengthen accountability and meet rising expectations of the NHS.
We can do much more to put patients at the centre of the health service.
This is about how patients exercise more control over their own care.
We need to think about how we can get more of the 15 million people with chronic diseases in front of a GP, discussing their care and whether an individual budget would help them.
Accountability also comes from patients being clear what they are entitled to.
Rather than being eroded, we should look at how we can strengthen national guarantees and entitlements.
In 1997 the NHS couldn’t offer enforceable national standards because the service was too poor.
Today, because of what Labour did in office, we are closer to that possibility.
And stronger patient entitlements could sit alongside strengthened local accountability.
Too often necessary change in the NHS is held back by the sense that local people fear losing out to the decisions of an unaccountable system.
The right response is not to back off difficult decisions but to share them with patients and the public.
The British people know how to make tough choices. And I know the NHS would be better and stronger if such decisions were made with local communities through real accountability.
As we meet future challenges we must always protect the ethos of the NHS.
It is not good enough to pretend that because reform is unpopular it must be right, as this government is doing.
Difficult decisions are necessa ry, but the thrust of reform must maintain what people value in the NHS.
Let me end by saying this.
All of us have our own personal experiences of the NHS.
It is a great British institution and one we need to preserve and renew for the next generation.
I want my sons to be as proud of the NHS as I am.
The question we face now as a country is not “change or no change”.
To protect the NHS is to change it.
Labour governments have never stopped doing that. It is my ambition to lead a government which takes the next steps in that process of change.
As we debate this government’s proposals for the NHS, we must learn the lessons of the past and properly address the challenges of the future.
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