7 January 2008

Prime Minister's speech:

It is a pleasure to be here today to congratulate all of you here at Kings College London and the Florence Nightingale School of Nursing for the contribution you make to the health of our country. Almost one hundred and fifty years old, yours is one of the oldest colleges of nursing and midwifery in Britain with a modern reputation for outstanding professionalism, excellence in research and world leadership in the training of nurses --- and there is nowhere more appropriate for me to talk about how we can work together to renew Britain's NHS for the future.  This July we celebrate the 60th anniversary of the National Health Service which is not just a great institution but a great, unique and very British expression of an ideal --- that healthcare is not a privilege to be purchased but a moral right secured for all.

Over the last six decades, the NHS has cared for tens of millions of people and saved many hundreds of thousands of lives;
It has been at the forefront of innovation in healthcare too, pioneering advances:

And with its unique offer of healthcare free for all at the point of need, it has liberated all of us from the fears of unaffordable treatment and untreated illness. But as we begin to celebrate the achievements of the NHS over the last 60 years, it is also right that - as new technologies emerge, as expectations rise, and as healthcare needs change - we look ahead and continue to reform and renew the NHS for the future. Ten years ago people questioned whether the British NHS could survive. And it is a testimony to the extraordinary work done by nurses, doctors and all NHS staff - backed up by the extra investment which has seen the health budget treble to almost £100 billion pounds a year - that ten years on the NHS is now more firmly than ever part of the fabric of British national life ----- an achievement that in itself should give us the confidence to look forward with ambition to an even greater future for the NHS. It is because the NHS has been a central priority since June that we have made immediate changes to improve safety and cleanliness in every hospital - beginning the deep cleaning of our wards, making provision for MRSA screening for all patients entering hospital, and giving matrons new powers to report safety concerns direct to the Care Quality Commission.  And we have also taken practical steps to give patients access to treatment and advice at times that are more convenient to them with our plans for greater access to GP services in the evenings and at weekends in every area of the country. It may be controversial, but we will see it through -- as part of our modernisation of public services to meet the rising expectations of the British people.

But these immediate actions are just a start --- our ambitions for the future of the NHS can and should go much further. We can build on its strengths -- and make it stronger.  The NHS of the future will do more than just provide the best technologies to cure: it will also - as our population ages and long-term conditions become more prevalent - be an NHS that emphasises care too. The NHS of the future will do more than just treat patients who are ill - it will be an NHS offering prevention as well. The NHS of the future will be more than a universal service - it will be a personal service too. It will not be the NHS of the passive patient - the NHS of the future will be one of patient power, patients engaged and taking greater control over their own health and their healthcare too. And so if the NHS is to change like this - to meet the challenges of 21st century healthcare and our 21st century lives - we will have to embrace even deeper and wider reform.  For the fact is that the health service of the next decades will need to recognise - and respond to - very different challenges than those that faced the NHS 60 years ago.

As advances in medical knowledge and technology have made it possible for us to do more than ever before.

As rising aspirations and expectations challenge the traditional ways of delivering NHS care.

And as demographic change and changing lifestyles create new healthcare needs.

Changing the NHS to address these 21st century challenges is precisely why we have asked the eminent surgeon Professor Ara Darzi to conduct a fundamental review of how the NHS must continue to reform - talking to patients and staff across the country about what should be done.  And during the course of 2008 the Secretary for Health, Alan Johnson, will set out the steps we can take to begin to make this transformation a reality:

This is the third stage in our reform of the NHS since 1997.

Stage one of reform was to set minimum standards - a success story in ensuring improved access to key treatments and renewing the physical infrastructure through hospital building.

Stage two was to widen diversity of supply to create new incentives for better local performance and more choice for patients - a success story in achieving the shortest ever waiting times including meeting our commitment to less than eighteen weeks from doctor's appointment to hospital treatment, and improving the management of NHS resources through foundation hospitals and the use of the private sector.

Stage three will see us continuing the work of stage two and matching increased diversity of supply with an ability to respond to the new diversity of demand in preventive and curative medicine - tackling the underlying causes of health inequalities as well as providing the best care. And it is about taking new and decisive action against failing services:

And the changes are necessary because of the new challenges facing the health service today.

First, the NHS has to respond to technological change.

When the NHS was created in 1948, much of what could be offered was a standard - and in practice rather modest - service ---- and the scientific and technological limitations of medicine were such that high-cost interventions were rare or very rare.  But over the last half-century technology has opened up vast new areas of diagnosis and treatment and the potential of further scientific advance is colossal.  With cutting-edge techniques from genetics to stem cell therapy - and life-saving drugs to prevent, alleviate or cure conditions like Alzheimer's - likely to be developed in the years ahead, what seem medical miracles today will be medically routine tomorrow.  So if we are to prevent as much suffering and save as many lives as possible, it is clear that utilising these new technologies must continue to be at the heart of any progressive health policy. And I am delighted to support Europe's largest medical science centre here in London - developed under Nobel Prize winner Sir Paul Nurse: public and private sectors working together to pioneer new technologies and new treatments.  At the same time, new technologies are giving clinicians the ability to diagnose and intervene earlier than ever before.  With new tests to identify women who are at heightened risk of breast cancer, new drugs aimed at preventing allergies, and the discovery of new genes that are key to the progression of conditions like Alzheimer's - to give just three examples - we are at the dawn of a whole new era:

And already the effectiveness of early intervention - as soon as symptoms develop - has been demonstrated.  Many people suffering heart attacks now receive life saving drugs on the doorstep and in some areas of the country are being delivered directly to specialist units for treatment. If - as the NHS is working to do - we extend this nationwide, we could save another 500 lives a year. Some stroke patients are also now getting immediate treatment with the latest clot-busting drugs in specialist centres. Extending that across the country could allow 1000 more stroke survivors every year to avoid disability and lead independent lives. And where the evidence and advice from local clinicians and the independent clinicians on the National Review Panel shows that specialist units can offer life saving access to the latest treatments we must not be afraid to support them. To be true to its principles, the NHS must continue to change. So we will reject the views of those who say the NHS must put a moratorium on change and reject those who oppose further reform. This would be a massive failure of leadership. If, for example, reconfigurations of services into specialist units proposed by the consultants were postponed or abandoned, this would lead to lives lost as nurses and doctors are denied the use of new technologies, treatments and cures. And we must be prepared to listen to the clinicians and the public and take the tough decisions which will save lives.  Indeed, now more than ever, the NHS must adapt to take advantage of our world class medical research -- and support the genius of British scientists and doctors by making reforms to support their endeavours to combat disease.  

There is also a second challenge for the 21st century NHS which goes beyond technology -- a rise in expectations about the care people want to receive. Growing expectations about choice, access, and convenience in healthcare are a fact of modern life. Our increasing freedom to make individual choices as consumers we rightly take for granted. And people want healthcare services which meet their needs and busy lifestyles. People tell me of the truly excellent experiences of care when they get into the NHS, of the nurses and doctors dedicated to their care -- but at the same time of their frustrations with access to services, with a service too often centred on the needs of the providers rather than those of patients.  That is why giving patients choices through reforms to encourage plurality of provision, create a genuine level playing field between competing local providers and allow money to follow the patient are so important in building a more responsive and more accessible healthcare system.

The third challenge facing the NHS is a transformation in the patterns of need the NHS must provide for. In the last century the main concerns were infectious diseases, acute medical and surgical illness, and the long struggle against cancer. Much of what the NHS delivered consisted of brief episodes of increasingly successful acute care. But today, with the ageing population and a rise in so-called 'lifestyle diseases', the NHS finds itself with new challenges in supporting and caring for patients with long-term conditions. In 1948, when the NHS was founded, 11 per cent of the UK population was 65 or over; in 2008 that figure is 16 per cent. In 2028 it will be over 20 per cent. More and more of us can now expect to survive into our eighth, ninth and tenth decades - our 70s, 80s and 90s.  And because much of ill-health is age-related, healthcare costs rise with age, with the average annual cost to the NHS of a person aged over 85 approximately six times the cost for those aged between 16 and 44.

At the same time, advances in medical science are enabling people with debilitating conditions to live longer and more active lives.  There are now more than 15 million people in England with a chronic or long-term disease ranging from asthma to heart-failure to the 900,000 living with the after-effects of a stroke. This could mean even greater costs for all health systems as they adjust to providing on-going care, particularly for older people. So one of the main challenges that the NHS faces in the coming decades is that of providing high quality, cost-effective care for increasing numbers of older people. And it won't just be the NHS that has to respond to this challenge but our social care system as well. That is why, through personal budgets, we are pursuing the reform of our care services; we will be consulting on a green paper on the long-term funding issues for care and for carers; and in the coming months I will say more about the reforms needed in both the NHS and our social care system in order to meet this challenge. Alongside these demographic trends, increasing numbers of people suffer from what are often called 'lifestyle diseases' ---- with smoking and drinking, but most of all obesity, increasingly the main threats to the health of ourselves and our children.

On current trends nearly 60 per cent of the UK population will be obese by 2050 - that is two out of three in the population defined as severely overweight. If we do not reverse this, millions of adults and children will inevitably face deteriorating health and a lower quality of life; Hundreds of thousands more will suffer diabetes and hypertension; Thousands more will die from cardiovascular disease, strokes and cancers. It has been estimated that 42,000 lives could be lost each year because we do not eat enough fruit and vegetables, 20,000 because of eating too much salt. And that, overall by 2050, the direct healthcare costs of obesity will have risen seven-fold, with the wider costs to society and business reaching almost £50 billion pounds a year.  So these lifestyle diseases now pose as great a threat to the future of a world class NHS as under investment posed ten years ago. And our response and the response of our NHS to these changes will be one of the defining elements in our lives over the next twenty years -- one of the most powerful influences on the kind of society in which we live. Already more and more of us are taking our own health seriously -- but I believe we could go further in finding new ways of expressing the idealism of the NHS: to do more to help patients feel engaged and empowered by:

And as more of us live longer we need to put support in place to help us all stay active into old age, and thus to stay healthy - adding life to years...not just years to life.

So all the changes that I have outlined this morning -

...are putting pressure on the NHS.

But I also believe that these challenges themselves mean that the NHS - with its central commitment to healthcare free for all at the point of need - is today even more relevant, more essential, than ever. Let me explain why. In too many countries around the world new technological breakthroughs become available only to a select few with the ability to pay. Even those systems which offer protections to disadvantaged groups very rarely offer them the same quality of care as the well-off. But because we provide a universal service not a minimum service - and by prioritising the adoption of medical advances across the NHS - we can make sure that the very best care is offered to all British people, based on the need they have not the money they have.  And whereas in many other countries this scientific revolution could become a profound social injustice as those with a with a predisposition to specific conditions face exorbitant private insurance costs or even exclusion from cover altogether, in Britain healthcare will be provided to everyone free of charge, regardless of medical conditions. Indeed, as the cost of ever more effective technology intervention rises and there is little advance knowledge of upon whom those costs will fall, it is more important than ever to pool the risk and share the cost of those interventions fairly across our whole population. In today's world, families more than ever need a system of funding like the NHS that insures everyone as comprehensively as possible against the risks of huge medical bills. And this is true for the most comfortably off members of our society as it is for the poorest because charges for treating illnesses such as cancer or living with the long-term effects of heart disease or strokes could otherwise impoverish individuals, households, and families far up the income scale.

As individuals in Britain we know that - should serious illness strike - we will be cared for, and the cost of that care will be absorbed not by us as individuals, but by all of us together - in a comprehensive healthcare system publicly funded by taxation. And we know that our doctors will never ask us "who's paying for this?". We leave hospital and are not followed by a bill, or by complex negotiations with an insurance company - even when we have had care the costs of which might run to thousands - indeed many thousands - of pounds.  Such a system is also efficient, because it is comprehensive, and for the same reason it is cost-effective too. And the care we get is the care we need - not just the care we can afford, or the care our own insurance coverage will allow. And that - to put it bluntly -- may make the difference not just between solvency and bankruptcy but between life and death. So I believe the NHS is the best insurance system for the long-term - and even more relevant to Britain's needs today than it was in 1948.  But for too long in this country the pressures on the hospital system meant funding for prevention and a personal service took second place. But the record levels of investment since 1997 have opened up the potential for us both to provide an excellent hospital and GP service and to fund new preventative programmes and care more tailored to need.

This means an NHS which is personal to the patient not just because it's available at a time to suit you, with the clinician of your choice, in the setting and environment which meets your needs, but also because it works directly for your needs and wishes. It identifies your clinical needs earlier than before, is targeted to keeping you healthy and fit, and puts you far more in control of your own health and your own life. And in the long run a preventive service personal to your needs is beneficial not just to individuals but to all of us as we reduce the costs of disease. Choice between providers has been among the forces for changes that have meant hospitals, GPs and others have been thinking about how they offer the kind of personal service we all expect. But real empowerment of patients will come from going further ---- the driving force: higher patient aspirations, more patient expertise, more trust between clinicians and patient, patients becoming fuller participants and partners in health and healthcare. In this way the nature of NHS provision will and must change - to be based not just on what it can do for you but what, empowered with new advice, support and information, you can do for yourself and your family.  So if in the last generation the big medical advance was the doctor administering antibiotics, in the coming generation it will be patients working with doctors and NHS staff to improve our own health and manage our own conditions.

And this means health professionals building on the plethora of good evidence-based practice that exists already - and becoming champions and advocates of more empowered patients:

Professor Darzi's report later this year will deepen and broaden this process of reform. But today I want to briefly describe some of the changes we will seek to make in this sixtieth year of the NHS to establish this new direction. First, a more personal and preventative service will be one that intervenes earlier, with more information and control put more quickly into the hands of patient and clinician. Over time everyone in England will have access to the right preventative health check-up. The next stage is offering men over 65 a simple ultrasound test to detect early abdominal aortic aneurysm, or Triple A - the weakening of the main artery from heart to abdomen which kills over 3000 men a year ---- eventually saving more than 1600 lives each year. And in the next few months Alan Johnson will also set out plans to go even further - to introduce on the NHS a series of tests to identify vulnerability to heart and circulation problems. So there will soon be check-ups on offer to monitor for heart disease, strokes, diabetes and kidney disease - conditions which affect the lives of 6.2 million people, cause 200,000 deaths each year and account for a fifth of all hospital admissions.  And we will extend the availability of diagnostic procedures in the GP surgery --- making blood tests, ECGs and in some cases ultrasounds available and on offer not only when you are acutely unwell or if you can pay, but when you want and need them, where you need them, at the local surgery.

Second, we will do more to extend screening, for example for colon cancer and for breast cancer.  The National Screening Committee, an independent clinical body, will look at the evidence and advise on what additional screening procedures would be genuinely useful in detecting other conditions.  And I can commit today that wherever they recommend a new form of screening on clinical grounds, we will make it available to everyone, not just - as happens too often now - just for those who can pay. Last month we made available the cervical cancer vaccine which will prevent over 1000 cases of cervical cancer each year. And we will go further: offering -- wherever they are needed and there is the clinical case for doing so -- new preventative vaccines currently being developed.

The third change necessary to create a more personal and preventative health service is to give people the choice of taking a more active role in managing their own care.
Patients benefit from being treated as informed users and choice will help deliver this - so we will continue to make it more widely available.  But this third stage of reform involves moving beyond people being seen as simply consumers and empowering them to become genuine partners in care ---- not just making choices but knowing more about their condition and taking more responsibility for their health and their lives.  This is not about shifting costs but about enhancing care. And in doing so making it more cost-effective too. So even when we are healthy we should have access to information about our risks -- and advice on how we can maintain our health. That is the kind of real control the NHS must give us all if we are to have a service fit to meet the challenges of the 21st century.

There are 15 million people in England with long-term conditions ranging from asthma to heart disease.  Many are already taking more active roles in their own care - for example, by using new technologies that allow remote monitoring of their condition via the internet or on the telephone. And earlier this year on a visit to Southampton hospital I met Robbie who was managing his treatment for a heart condition from home, monitoring his own blood pressure and weight, and feeding his results back to his doctor.  This gave him far greater freedom - with the security of knowing his condition was still being checked. And he spent far less time in hospital -- reducing the cost of his care to the NHS. What worked for Robbie could also work for more patients - many of whom rightly want a greater say over their care, including in later life. With the right kind of NHS care and support, an active, fulfilled life should be possible for far more of us in our later years. So over the next few years we will give 100,000 people with long-term conditions the opportunity to manage their care in this way as 'expert patients'. And during 2008 we will bring forward a patients' prospectus that sets out how we will extend to all 15 million patients with a chronic or long-term condition access to a choice of 'active patient' or 'care at home' options -- clinically appropriate to them and supported by the NHS.  Real control and power for patients - supported by clinicians and carers. More than today's new choice of where and when you are treated, a new choice tomorrow - in partnership with your clinician - about your treatment itself. Something made even more accessible by using NHS direct, the internet and digital TV as well as the telephone to improve support for patients who want an active part in their care.

And where it is appropriate - just as with personal care budgets for the 1.5 million social care users - it could include the offer of a personal health budget, giving patients spending power and thus a real choice of services.  Empowering patients also means giving them a greater say in their care in the later years of their lives.  Our ambition must be to give everyone a choice - and we can expect this will mean more and more people choosing to be cared for at home. This will depend on a new flexibility and responsiveness in primary care, and new partnerships with the voluntary and private sectors where they can contribute and innovate.  And it means a more seamless integration of services between acute and primary care, and between health and social care -- reflecting far better the needs and wishes of patients and of their carers, a subject I will return to in depth later.

The fourth area I want to highlight is the importance of being clear what a focus on prevention means for our hospitals and primary care services and how they are run. The reforms of recent years have undoubtedly created a better managed, more flexible, more accountable and transparent NHS. They have reduced waiting times and they have led to crucial improvements in health outcomes.  But we must do far more to make sure that NHS organisations and incentives are truly responsive to patients while supporting clinicians in keeping people healthy. And that funding not only follows the patient through an illness, but prevents illness too. So we will strengthen commissioning, give more responsibility to primary care professionals and open up primary care: with more providers, new primary care services, and more weekend and evening access.  And we will continue to open up acute care with, from the spring, the choice of hospitals trusts across private and public sectors in England extending to over 300 - including more than 150 private sector hospitals working as part of the NHS and at NHS cost and standards of quality. We will use all mechanisms available to us to improve our NHS --- public, private and voluntary providers can all play their part and there will be no 'no-go areas' for reform as we seek to deliver the preventive and personal services which will renew and secure the health service for the future. And to drive up performance we will not just increase the freedoms and autonomy of our local NHS --- giving hospital clinicians and GPs stronger incentives to work together and allowing foundation trusts the freedom to provide primary care services where this is in the interests of patients --- but we will also increase accountability of local services to local people.

Patient involvement is vital to local accountability. I want to see 3 million foundation trust members by 2012 - up from 1 million today - and give them an even greater say in the workings of their trust. That's 2 million more staff, patients and members of the public playing a direct part in running their local NHS.  And as we seek to devolve more responsibilities to the local level, we will also explore the ways of improving the legitimacy and accountability of primary care trusts and of the commissioning decisions they make on behalf of their local communities. As part of this change in relationship between patient and clinician - between the NHS and us all - we also need a new articulation of the rights and responsibilities of a modern 21st century health service. So this year we will, for the first time, set out the 'NHS offer' to patients as part of an 'NHS constitution' - what you can expect to get from the NHS and what we expect to give you in return.  As patients we will know the guarantees of service we can expect --- for example the maximum time from GP referral to the commencement of treatment or the right to screening and advice at certain points in our lives. But we will also set out the responsibilities that come with this --- our responsibility to make good use of NHS resources by turning up for booked appointments. So patients who do not turn up for appointments, for example, should not have the same entitlement to waiting time guarantees.

And with these changes in the NHS, we also want a wider debate on how society as a whole should face up to the new healthcare challenge. There can be no doubt that the influences on all of us - from advertising to peer pressure - affect our decisions and choices, particularly so for our children. We cannot remove from individuals and families their responsibility for their own health and that of their children. But we can - and must - do more to be on people's side, helping them live a healthier life. In the coming months we will be looking at what more government should be doing to help tackle these problems - by information, education and through the very latest advice  rom clinicians.

As we look forward to London 2012, our ambition is to have all children offered at least 5 hours of sport each week. We will increase the availability of physical activity prescriptions on the NHS. We will improve the accessibility of gyms and other sporting facilities. And Alan Johnson will bring forward proposals to enhance the role of employers in helping their staff lead healthy lives - extending to many the kind of employment benefits currently only available to the few. We will also look again at the responsibility of food producers, caterers and retailers in helping tackle ill health, especially obesity.  Parents tell me of their frustrations with the different food labelling they find on shelves when trying to make decisions on what their family eats. We are reviewing the multiple labelling systems currently in use and I want to see consensus on a single labelling system, easily understood by consumers, which will deliver real improvements in the health of the country. And because we know parents are concerned about excessive food advertising online or via mobile phones, the Culture Secretary, James Purnell, will be working with the industry to make sure the codes of practice are as tough as parents want them to be. These are all measures in line with our vision of a renewed and reformed NHS -- handing power and control to individuals, and ensuring they have the information and support they need to make their own choices about their and their families health.

Reform means not a new unelected quango, which would be about ducking responsibility for the tough decisions, but greater operational independence for local NHS organisations and NHS clinicians and I want this to be established through the constitution. Reforming the system itself requires real leadership, real accountability, and the strength to see through real change. So my guarantee to you today is that our vision for change will be based on clinical evidence and the new drive for a more preventative health service.  It will be founded on greater local control and greater freedom for staff, within the context of the right incentives and minimum standards.

And above all it will seek a new relationship in which the patient and clinician are both active and responsible -- a vision for a healthier and more empowered population.

Amongst global healthcare systems, the NHS is almost uniquely well placed to deliver this transformation in the relationship between patients and clinicians: one of the most trusted organisations in British society, its doctors, nurses and staff recognised by everyone as a force for good in our country ---- and let me thank everyone who is working so hard to make these changes possible. The renewal of the NHS will be our highest priority.  Our goal: deeper and wider reform --- building on the values, principles and idealism of the NHS to create for the next decade an NHS that is:

This is a worthy mission for an institution as great and as significant in our lives as the National Health Service --- and it is a transformation I ask you all to be a part of.