Wednesday, 20th July 2005

Health Secretary Patricia Hewitt's Fabian health lecture, argued that Labour values demand a deepening, widening and democratising of choice in health-care as essential to maintaining public support and protect the core principles of the NHS.

Introduction

Thank you for inviting me here today. I joined the Fabians over 20 years ago. Then as now, the Fabian Society is the home of progressive political discussion and debate. The Fabians have a proud history of setting the agenda on health policy – often ahead of its time. In 1911, a Fabian pamphlet made the case for 'A National Medical Service'. The work of Richard Titmuss and Brian Abel-Smith in the 1950s and 60s exposed how the NHS was too often providing 'poor services for poor people'. More recently, the Fabians powerfully argued in their Tax Commission for increased taxes to fund the NHS after years of Conservative neglect and under-funding.

So it is highly appropriate that the Fabians are hosting this lecture, in which I aim to set out the values and philosophy that drive the Government's reforms of the NHS.

The legacy

Those values of social justice and public service were given their greatest expression with the creation of the National Health Service in 1948.

We think of it, rightly, as Labour's proudest achievement … and that pride is shared by millions of people who may not know its history, but who will name the NHS when they are asked what makes them most proud to be British.

Our values bind together one of the largest, most complex and best-loved organisations in the world. And those values of equality, social justice and public service that the foundation of our transformation of the NHS for modern needs.

A few weeks ago, I bumped into someone I've known on and off for many years – campaigning for equal rights for women, when I ran the National Council for Civil Liberties, and then later when I worked for Neil Kinnock.

She said: "Well, you've come a long way. How does it feel to go from feminist campaigner to champion of the private sector in the NHS?"

This speech is, in part, my response to that question.

Labour's response

Over the past eight years, Labour has started to rescue the NHS from years of Tory neglect.

We can see the improvements.

Waiting times for an operation down, from the 18 months we inherited, to six months by the end of this year.

A&E departments dealing with 98% of patients within four hours.

Deaths from breast cancer for women and lung cancer for men falling faster in Britain than anywhere else in the world.

Improvements in health and in healthcare that are the result of three things:

Firstly, the commitment of our staff – now properly valued with higher pay, more opportunities to train and more support to take on new roles.

Secondly, increased investment - doubled since 1997, nearly trebled by 2008 to reach £92 billion a year, around the European average.

And thirdly reform – that has enabled us to get results, and get them faster, than many people ever thought possible.

A world-class health service needs all three: superb staff, sustained investment and reform. But it is the reform that is most controversial and most complex: and that is what I will concentrate on today.

The need for reform

I want to start by linking the case for reform directly to the political challenge that we face.

We cannot rely on the luxury of an opposition in disarray for ever. Sooner or later, the Conservatives will get their act together. They will start to challenge us again on the central issues facing modern politics: the inter-relationship between the individual, the market and the state.

By 1997, people were as disillusioned with the new right answers to those questions as they had been with the old left position.

With the creation of new Labour, we offered a different view of the role of the state: an enabling state, enlarging opportunities for individuals, balancing rights with responsibilities, restoring social solidarity, playing its part in supporting a modern, dynamic economy.

Over the last eight years, we have begun to rebuild faith in public services and in the role of government.

We have persuaded people to pay more – through their national insurance contributions – to fund the investment the NHS desperately needed.

But we still have a great deal more to do if we are to put beyond doubt, for at least another generation, the proposition that a universal service, paid for by general taxation and free at the point of need, is not only the fairest health system, but can provide the best healthcare – and provide it to all.

We know where the Tories want to be.

They want to persuade people the extra money is being squandered.

They want to promise tax cuts.

They want to provide incentives for private health, and private education – incentives that will benefit the few at the expense of the many.

We should not under-estimate the challenge that a revived Conservative party could make to public services.

Our challenge is to ensure that the NHS becomes part of the revolution of rising expectations, providing not just a greater quantity of healthcare but a greater quality as well, providing services that are truly fair for all, and personal to each.

And because the patients and users of the NHS are also its taxpayers and contributors, we must ensure that we are seen to provide value for money.

That is what we mean by a patient-led NHS.

I referred earlier to the extraordinary improvements that we have already achieved.

But they are nowhere near enough.

So whilst ensuring that no-one has to wait more than six months for their operation is a huge improvement on what we inherited in 1997, when over 280,000 people had been waiting more than six months, it is still too long - especially when the time it takes just to get onto the list isn't included in that six months.

That is why we've promised to get the maximum waiting time down to just 18 weeks - from GP referral to hospital treatment - by 2008.

Giving patients the choice of at least four hospitals by the end of this year is a huge improvement. But it's not enough – not when patients want and expect more choice and information over all aspects of their health and healthcare. That's why we've promised that by the end of 2008, patients will be able to choose from any hospital that can provide treatment to NHS standards for NHS prices. By 2009, every woman will be able to choose where and how she has her baby and what pain relief to use. And it's why we'll expand choice in primary care and palliative services too.

But our definition of choice is far broader and deeper than simply giving patients choice over when and where they receive their healthcare – vital though this is.

When we ask patients what they want from their health service, they tells us they want to be given a greater say over their treatment and they want to be treated with dignity and respect. In short, they want choice and they want voice – not just over their operations but every aspect of their health and healthcare.

Even when we've achieved the goals set out in our manifesto, we won't be able to say 'the job is done'. Because the revolution in medical technology won't stop. Rising public expectations won't stop. And new challenges to health and healthcare won't stop.

If the NHS is to continue retaining the support of patients and the public, it has to continue changing and improving.

So far, we've achieved our improvements by heavily relying on centralised targets and tough performance management.

But no organisation can cope with this top down, command and control approach for ever. We have to move from reforms that depend upon centralised performance management, to embedded reforms that create a powerful, in-built dynamic for continuous improvement.

What do I mean by embedding reforms?

Creating more choice for patients – so that everyone who uses the NHS has a greater say and control over their health and healthcare, at both the individual and collective level.

Creating more capacity in the system – so that patients can choose where and how they are treated.

And enabling greater diversity of provision – to underpin choice, encourage innovation and deliver greater value for money.

Let me go through each of these in turn:

More choice

The left has always been uneasy about choice in public services. Progressives have feared that choice would entrench middle-class privilege, create a two-tier service, compromise equality.

So let me spell out the four reasons why I believe it is essential that a Labour government should create greater choice in health and healthcare.

First, quite simply, it is what people want and increasingly expect.

People are more informed and less deferential than ever before. They want, and demand, as much choice and control as possible over most aspects of their lives – and that includes their health.

Of course, people want their own local hospital to be able to offer good, safe, fast care. But when we piloted choice for London patients who had been waiting six months for an operation, two-thirds of patients offered a choice of hospitals used it. And those who said 'no' still liked being made the offer.

And of course, choice isn't always appropriate – particularly for emergency care or highly specialised treatment. And some patients will continue to want their doctor to take the final decision.

But hospitals aren't only about A&E – and healthcare isn't only about hospitals.

So when it comes to elective treatments, like hip replacements and cataracts; when it comes to maternity services; when it comes to the management of long-term conditions and the care of the elderly – the biggest challenge to health services all over the developed world and one where patients themselves have a crucial role to play – then the more we can offer people a choice, the better.

Our critics say choice will inevitably create a two-tier system. But they conveniently ignore the fact there is already a two-tier system in the NHS.

Some hospitals, and some GPs' surgeries, are far more effective than others.

Some communities – generally the better-off – are far better served than others.

And some people – generally the best-educated, most confident and articulate – are already exercising choice and control over the services they get.

We all know middle class professionals – whether they're politicians, journalists, or even doctors - who use their contacts and inside knowledge of the system to make sure they get the right doctor and the right treatment.

And if more information, more choice and more control over their lives is good enough for middle class professionals, then it is certainly good enough for my working class constituents.

So the second reason why choice is important is because – far from entrenching inequality – it will help us create a more equal society.

We are a progressive party – and our goal should be to democratise choice. We want to spread individual choice and build collective voice in the NHS.

This means giving all patients the information, support and confidence they need to make genuinely informed choices – not just the privileged few.

And it means giving all communities a greater say over their local services. Like the breast cancer unit I recently visited at Barts Hospital which had involved their patients and users to design the refurbished building and services provided there.

It would be a major mistake – a mistake the Conservatives are just waiting for us to make – to deny people choices over their health and health care, leaving us out of step with irreversible changes in society and out of touch with the people we seek to serve.

I remember very clearly our disastrous opposition to the sale of council houses. We thought we were opposing the sale of a public asset: council tenants realised we were denying them the chance – the only chance many of them would have - to buy their own home.

I was on the wrong side of that argument, as most of us in the Labour Party were at the time. So let us not make the mistake on choice and personalisation in public services in the 21st century that we made over council house sales in the last.

The third reason for greater choice is that it is a means to an end – better quality healthcare.

I frequently hear colleagues say: 'people don't want choice, they just want a really good local hospital.'

Of course, people want a really good local hospital: but more choice means more chance of having a good local hospital.

If a hospital fails to provide the service that people want and expect, some patients will choose to go elsewhere. And under payment by results – which we've started to introduce this year - money will follow the patient.

All this creates a very sharp incentive for hospitals to improve the quality of care they provide – and an equally sharp challenge to the medical profession to change old vested interests and protective practices if they are holding back patient care.

The final reason for extending choice in public services is because choice can, in itself, be good for health

There is now ample evidence, from scholars like Professor Sir Michael Marmot, to demonstrate that people who have more choice and more control over their lives tend to be healthier and to live longer.

By Christmas, we will be offering NHS patients the choice of at least four hospitals for elective care – all of it free, all of it on the NHS.

But if we are truly to improve the health of people in our country, choice must extend far beyond hospitals.

We need to empower people to make healthier choices for themselves and their family. Achieving this means recognising that it is much harder to make healthy choices if you and most of your neighbours are living on low incomes, in poor housing, in a high-stress, high-crime neighbourhood.

So we need to do more to build the capacity of people living in our most disadvantaged communities to make healthier decisions.

This means giving low income families the practical support they need to give up smoking, for example through smoking cessation clinics and nicotine patches on prescription.

It means giving patients with long-term conditions like heart disease, diabetes and depression greater control over the drugs, treatment and care they receive - through more information and support from self help groups and patient advocates - so they can better manage their condition.

And it means involving residents in the development of local services and the regeneration of their own neighbourhoods – all helping to create a virtuous circle of healthier people in safer communities supported by responsive public services.

The Wanless report powerfully set out how high levels of public engagement in health would not only lead to better health for patients - it could also save taxpayers £30 billion a year by 2022, nearly half of the current annual NHS budget.

So my appeal to progressives and supporters of the NHS is: don't oppose greater choice and control for individuals and communities; don't just grudgingly go along with it; but embrace it as part of the way in which we renew the values of the NHS for modern times.

More capacity and diversity

I have dealt with the issue of choice in detail, both because it excites such passions and because it is central to the creation of a patient-led NHS.

Let me turn now to the other two central elements of our reform: greater capacity in our health service, and greater diversity amongst providers.

At its creation, the NHS ended the injustice of a healthcare system based on social class and charity.

In many ways, the NHS was ahead of its time.

But over the years, it started to fall behind the changes in the society, and people, it sought to serve.

Almost from the start, public needs and expectations and advances in medical technologies grew faster than investment in the system.

Demand began to outstrip supply. Long waiting times became a permanent feature of the system - the means of rationing access to care. The interests of the providers of services came to take precedence over the interests of the users of services.

The NHS's monopoly over the provision of services compounded these problems.

The creation of the NHS required the nationalisation of hospitals, which had previously been the responsibility of charitable and mutual organisations.

That was vital to establishing a truly national health service that provided free care to everyone, no matter what they earned or where they lived.

But as time moved on and as people's demands and expectations changed, the NHS monopoly meant that the system lacked both alternative sources of capacity, and the inbuilt challenge and spur to innovation and efficiency that a plurality of providers can bring.

Our commitment to greater diversity of supply – through new structures like Foundation Hospitals within the NHS and increasing use of the independent sector for the NHS - is helping us to tackle these problems.

The first wave of Independent Sector Treatment Centres has already brought down the waiting times for cataract operations to a maximum of three months, a target achieved four years earlier than promised.

Now we have to tackle the wholly unacceptable waiting times for MRI scans and other diagnostic tests. There, too, we will need a massive increase in capacity in both the NHS and the independent sector, all of it free at the point of need. We will simply not meet the 18-week target by 2008 otherwise.

But the independent sector is adding to the innovation capacity, as well as the operating capacity, of the NHS. The dramatic change in cataract treatment times was the result of mobile operating theatres, introduced by independent providers to the NHS. Similar mobile units, again from the independent sector, are now cutting waiting times for MRI scans in some of our most deprived communities from 20 weeks to five.

The NHS has always innovated. Everywhere you go in the NHS, you will find some example of world-class practice. But all too often, best practice remains a project, a few examples, not the general rule. By increasing patient choice and mobilising the independent sector for NHS patients, we are challenging every part of the NHS to work in new ways – 'contestability' in the jargon.

As many hospital chief executives have told me, it is striking how NHS waiting lists miraculously shrink when consultants are faced with the prospect of an independent treatment centre down the road or patients being sent to empty beds in a private hospital.

Greater diversity of provision means, too, far greater opportunity for innovators and entrepreneurs within the NHS itself. Foundation Hospitals are eager to use their new freedoms to benefit the public. The Homerton Hospital, for instance, which I visited a few weeks ago, now able to make its own decision to create a new peri-natal unit to tackle the very high level of premature births in their part of East London – a decision they have been able to make far more quickly than under the old system of controls.

But greater diversity, more freedom for providers should not be confined to the hospital sector. In primary and community care, we should encourage entrepreneurial GPs, nurse practitioners and others to expand their services into neighbourhoods where people are not well-served today, to find new and better ways of integrating health and social care.

In all of this, the test is a simple one: the needs of patients, users and the public. My elderly constituent in Leicester whose life has been transformed by her cataract operation doesn't mind whether the treatment centre is run by an NHS provider or an independent organisation: all she wants is fast, safe treatment by caring professionals, provided free to her on the NHS.

Our critics

Many on the Left see these changes as threatening. People are concerned that we are creating an internal market in the NHS, just like the Tories, even that we are privatising the NHS.

We are doing neither.

No Labour government will ever privatise the NHS. We will always ensure that healthcare remains free at the point of use, based on need not ability to pay. Nor are we creating a Tory-style internal market, with its inequities, inefficiencies and high transaction costs.

Giving patients more choice and creating greater diversity of providers does not mean creating a private market in healthcare.

We know, as modern social democrats, that dynamic, open and competitive markets are the best way to produce most goods and services, to generate employment and create wealth.

But we also know that there are limits to markets – and that health and healthcare, like learning and education, are not best served by the private market.

So we are introducing choice to give more power to patients. But whereas in a free market, the power to choose what you want is based on your ability to pay - in our new NHS, ability to pay is irrelevant.

We are creating greater diversity in provision, so patients have the opportunity to exercise genuine choice. But whereas in a free market, collaboration between companies serving the same customers is a cartel, and strictly prohibited - in our new NHS, we have placed a duty on every provider to collaborate with all organisations in the local health community in order to deliver the best outcomes for patients.

We are introducing payment by results to incentivise providers to be more productive. But whereas in a free market, companies can compete on quality or price - in our new NHS the price is fixed so that providers can only compete on the quality of care they provide.

We are bringing greater risk into the system by challenging the NHS monopoly and creating incentives for providers to meet patients' needs. But whereas in a free market, consumers can be left without access to a service if a company fails - in our new NHS we are licensing providers to guarantee the services they offer to ensure a comprehensive, high quality service to all.

Finally, we are introducing financial discipline and greater transparency about the costs of treatment. But whereas in a free market, financial success is the sole objective of the private market – in our new NHS, it is only the means to an end, that of better patient care.

Conclusion

I know very well that change is difficult.

The targets that we have used to deliver radical improvements weren't popular or easy. But without them, we would never have achieved so much, so fast.

The next stage of reform won't be easy or popular either. People will say we're going too fast, we're taking too many risks, we should leave the NHS alone.

I understand those fears. It is much easier to go on doing things the way they've always been done. Much easier not to reconfigure services, much easier not to challenge professional demarcation, much easier not to face the challenge from new providers. Much easier – at least in the short term until the deficits build up, the waiting lists start to grow up, and people who can afford it go elsewhere and those who can't are left behind.

I believe that we have a once in a lifetime chance to create a truly patient-led healthcare service in our country.

I said at the beginning of my lecture that it was, at least in part, a response to the challenge from that sceptical Labour activist who questioned me about the Government's programme of reform.

Let me finish by telling you what I said to her.

I said that the values which drive our reforms of the NHS are the same values that brought me into politics 30 years ago, and the same values that continue to drive me today.

I believe now, as I did then, in the equal worth of every human being – no matter what their class, gender, race or creed. And that collective action is the only means of ensuring every individual achieves their full potential.

I said that, when I worked for Neil Kinnock and when I served, under John Smith's leadership, on the Commission for Social Justice, I argued for the modernisation of the Labour Party because I had come to realise that was the only way to put Labour's enduring values into practice in very different times.

And now, as your Health Secretary, I will argue and work for the modernisation of the NHS because I believe this is the only way to put the enduring values of the NHS into practice.

In doing we will win a far bigger argument – one that faces progressive political parties the world over.

That collectively funded public services can meet the needs of both individuals and wider society.

That the state can be a dynamic force for good.

That we can achieve more together than we do alone.

If we can achieve this goal, we will ensure that the NHS is seen not only as a monument to Labour's past success but as a living symbol of what we can achieve in the future.

Patricia Hewitt, Secretary of State for Health, was speaking to the Fabian Society on Wednesday 20th July 2005. The event was kindly supported by our partners Pfizer.