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Speech by the Rt Hon Alan Johnson MP, Secretary of State for Health, 18th June 2008: NHS Confederation Annual Conference, Manchester

I’m delighted to be able to address NHS Confederation’s Annual Conference, particularly here, in Manchester, where on 5 July, 1948, just a few miles from here, Nye Bevan opened the very first NHS hospital.

It marked the beginning of the remarkable adventure that we are still engaged in.

It’s an adventure I am honoured to be part of, particularly in the NHS’s 60th year.

Just under a year ago, when I was appointed Secretary of State for Health, I was asked what the NHS meant to me. The answer I gave was serenity –  although the NHS was created in living memory, we can no longer imagine a time where you had to worry about whether you’d be able to afford treatment if you became ill. A world without the peace of mind provided by universal healthcare is inconceivable to people today.

I am passionate about tackling health inequalities because the disparities undermine the concept upon which the service was created. This has nothing to do with class warfare. At education, the cause was to improve our schools to a standard of investment, attainment and extra-curricular activity that matched public schools and encouraged parents who were wealthy enough to access private education to send their children to a state school.

In health, the goal is similar. We have no interest in creating a system that simply concentrates on improving health of the poor. The great doyen of social policy Professor Richard Titmuss was right to point out that poor public services become public services for the poor. So improving the health of people from all social classes, whilst seeking to improve the health of the poorest the fastest, makes the gap harder to close, but ensures that people from all backgrounds use the NHS because it’s as good or better than anything on offer in the private sector.

Our great achievement in tackling health inequalities is that the health of the poorest, whether measured by the life expectancy or by infant mortality, is now at the level that the rest of the population enjoyed when we first came into government. It demonstrates what can be done when you make tackling health inequalities a political priority.

I can offer more personal reflection as I approach my first anniversary as Health Secretary. I have a huge respect for the good ship NHS and all who sail in her, but it’s not born out of any kind of sloppy sentimentality and I do recognise that the role of politicians is not to pretend they’ve become an instant experts on the complex and diverse nature of healthcare and medical science. Neither is my role to protect the vested interests of various professional bodies who, from time to time, dress their self interest in the clothes of patient concern.

My role is to use the power vested in me sensitively, collegiately and effectively, to ensure that people of this country, to whom I am indirectly accountable, get the properly resourced, high quality healthcare that they are entitled to expect.

I don’t claim that we’ve reached Nirvana yet, but I think it’s fair to say that when the service was approaching its golden anniversary in 1997, it was a very sick patient.

People didn’t wait weeks for life-saving operations, they waited months, even years, many dying on waiting lists. They didn’t wait days for an appointment with a GP, they waited weeks. They didn’t wait just four hours to be seen in A&E, they sometimes waited 24 hours or more.

The health inequalities gap actually got progressively wider. The mortality rate among men of working age in the early 1970s was almost twice as high in unskilled groups as for those in professional groups. But by the early 90s, the gap was three times higher.

Eleven years ago, the NHS was not so much in need of repair as resuscitation. Increased investment has obviously been a major element in the treatment. The transfusion of money heralded by the NHS Plan in 2000 has seen spending on health rise to within touching distance of the European average.

Today, 99 per cent of patients with suspected cancer are seen by a specialist within two weeks, compared to less than two thirds in 1997.

Mortality rates for cancer have fallen by 17 per cent, saving 60,000 lives and for cardiovascular disease, by 40 per cent, saving 178,000 lives.

More people with long-term mental health problems are being supported at home and in the community, with the addition of 760 new community mental health teams providing home treatment, early intervention or intensive support for people who might otherwise have been admitted to hospital

Major investment in facilities means that from the beginning of this year, one new building has been opened every week for primary and social care, and there will be 122 new hospitals open by the end of 2010.

The structural changes of the last eleven years have been difficult but essential reforms to improve how the NHS works and support good leadership.

Whilst health has unquestionably been the overwhelming priority for this government, its transformation has nothing to do with political fervour. All we have done is enable, encourage and support those who work in the NHS to do what they have always wanted to do – improve patient care.

Managers in the NHS are as important in this transformation as anyone else. Better services for patients and greater financial stability require excellent leadership. The commitment and dedication of managers and leaders to deliver change has played a significant role in these achievements.

Rudolph Klein, the great historian of the NHS pointed out that in the 1970s, that waiting lists had remained stubbornly at around 600,000 and every successive Minister pledged to reduce them. In his words, “The captain shouted his orders from the bridge and the crew carried on as before.”

Ten years ago, reducing waiting times looked like Mission Impossible. Five years ago, it seemed we’d never be able to stop the rise in hospital acquired infections. Eighteen months ago, the idea that we could turn a deficit into a surplus seemed unrealistic. Managers, leaders and staff have achieved what many believed was impossible and I’d like to thank you for that today.

The fundamental principles of the NHS are as valid today as they were 60 years ago, but the world has changed.  

The NHS was conceived, in a time of austerity, when rationing was getting tighter – in 1948, when London hosted the Olympics, British athletes were dependent for their nutrition upon food parcels from Australia and other commonwealth countries.

It was an age of acute and infectious disease, where as today, we battle with lifestyle and chronic disease. Even Nye Bevan could not predict that the first generation of children to grow up with universal healthcare would be the longest lived in this country’s history – something we should celebrate, but that also presents new challenges.


Binge drinking among the young was unknown. The only people who did drugs were aristocrats and debutants. Sedentary lifestyles were confined to the elderly.  
Televisions were becoming increasingly common in people’s homes, but no one would have imagined a device that avoided the exertion of having to get up to switch it off.

Today, we lead lives that are more hectic but less active. New technology has not only brought us unimagined medical advances, it has also changed the way we work, and communicate and make choices. We are consumers of information about health in general and our own health in particular, in a way that was inconceivable 60 years ago.  

The NHS is fitter and stronger than it has been at any stage in its history.  Yet it still struggles to keep pace with rising expectations and with growing threats such as obesity. Bevan himself drew attention to the inevitability of these developments, saying in the week before the NHS was launched that: “This service must always be changing, growing and improving; it must always appear to be inadequate.”
  
The reforms of the last eleven years have been in every sense a prelude to the Next Stage Review. I can’t lift the veil on the final report today but I can show a bit of leg, so to speak and say what it won’t contain. As I said a year ago, it will not introduce structural change. There will be no more top-down reorganisations of primary care trusts or strategic health authorities. There will be no new national targets.

I’m not usually in to management consultant speak books, but I recommend Jim Collins’s “Good to Great,” which examines how good companies can improve their performance. The Next Stage Review is about how we move the NHS from good to great. From world class in many aspects to world class in every aspect.

As Jim Collins says, you can mandate “good” but greatness can only be unleashed, which is why the  content of this report will be determined by the local visions published in each Strategic Health Authority, which set the direction of health services in every region of the country. They have been developed locally because local clinicians, patients and managers are best acquainted with the specifics of improving patient care and the knowledge and ideas necessary to shape Ara’s national enabling framework.

Existing national targets on tackling infection, reducing waiting times and reducing health inequalities will remain essential drivers of performance. Investing in primary care, particularly in areas where provision is scant, will remain a national priority and despite noises off stage we will continue to advocate nationally in the interests of patients for improved access and higher quality.

Integration is the great strength of the NHS. It needs to be enhanced, not diminished, so it is right that there are national standards determining good quality care and ensuring that it is available to all.  But the system relies fundamentally on strong local leadership that enables clinicians to deliver the best possible care to patients.

Ninety per cent of all contacts with the health service happen in primary care. The Primary Care Strategy we publish with the Next Stage Review will present a vision that puts primary and community care centre stage, with a relentless emphasis on promoting good health and wellbeing.

Our understanding of how disease develops and how to detect and treat illness has vastly improved since 1948. We can screen for more conditions, we can vaccinate against more deadly diseases, and advances in genetics mean we can predict and prevent to a far greater degree. The NHS was created several years before scientists confirmed the connection between smoking and lung cancer. We now have a profound and unprecedented understanding of how diet, exercise and smoking can affect people’s health.    

And it is in primary care that we must put this understanding to good use. Primary Care Trusts will have a unique role to play as local leaders, working in partnership with local authorities, schools, employers and children’s centres to promote good health and wellbeing. Incidentally, a recent survey in London showed that over 50 per cent of the public don’t know what a PCT is or does.

Just as the North West Strategic Health Authority refers to itself as NHS North West, there is no reason why Trafford Primary Care Trust shouldn’t call itself NHS Trafford - it would certainly better reflect the wider role expected of them and the public would understand their work much better than if it continued to be described as a primary care trust.

Irrespective of titles, they will have to be champions of good health, not just providers of health services and to listen and respond to the needs of local people – as indeed the best primary care trusts already do.

Rising expectations, an ageing population, lifestyle epidemics, the focus on health promotion and the need to shape change locally to respond to patients concerns will place different demands on staff.

Sixty per cent of the NHS staff who will be delivering services in ten years’ time are already working in healthcare – many will have been working there for a decade or more. As advances in medicine come thick and fast, the need to improve and update clinical care is constant.

The Workforce Strategy that forms part of the Next Stage Review will set out how we can support nationally the excellent training and development and workforce planning we need at local level, to meet the priorities that each strategic health authority has identified.

The overwhelming emphasis of the Next Stage Review is on quality. Managers and leaders need to be the champions of quality in all aspects of care  - this is how success must be measured. It is important that we measure not only the effectiveness and safety of patient care but also how compassionately that care is given.

It is often said that the NHS is data-rich and information poor. One of the challenges of the next few years will be to find better ways of converting that data into intelligence that can improve patient care.

The Interim Report said there would be a quality framework  that would establish a clear framework and standard ways of measuring performance.

We have already started working with NHS staff and professional bodies to identify ways of measuring the quality of care that staff provide for patients. We are developing these measures – or metrics, as they are more usually referred to – in partnership with staff. They will primarily be used by clinicians themselves to benchmark their performance and lead improvement.

It is expected that they will encompass patient experience, safety and clinical and patient-reported outcomes. They will include, for example, measures of the effectiveness and safety of nursing care, and also, crucially, how compassionately that care is delivered.

Excellent clinical care and clean hospitals are what patients expect of the NHS. But they also have the right to be treated with dignity and respect – to be treated as people, not just as symptoms of disease. It should come as no surprise that patients and the public are dismayed when staff fail to get the little things right - not closing curtains properly during an examination, failing to help patients eat at mealtimes, leaving patients and family unaware of what’s happening to them.

The most clinically skilled doctors, nurses and surgeons in the world will inspire little confidence if patients feel ill-informed, if they are ignored, treated dispassionately or without sensitivity.  

This is something that most staff know instinctively. When over 700 nurses at this year’s RCN national congress were asked what single factor could best measure the quality of care, the most popular response was respect and dignity, closely followed by communication. Nurses involved in the clinical working groups for the Next Stage Review all said that how we measure the success of what nurses deliver needs to reflect whether patients were treated with compassion and sensitivity and how well their dignity was protected.

So the Workforce Strategy element of the Review will set out how we will work with the RCN, UNISON, and other leaders of the profession to better define and measure the quality of nursing care – not just its effectiveness and safety, but also taking into account the crucial area of patient experience.


Almost exactly sixty years ago, on 4th July, the eve of the birth of the NHS, speaking at a rally in this very city, Nye Bevan said that the eyes of the world were turning to Great Britain. It took another 20 years for the Swedes – world leaders in social progression – to copy our system.

Many aspects of the National Health Service are still admired across the globe. But the NHS has no divine right to be admired and respected. It’s not a constitutional necessity for citizens to treat it as the most cherished of British institutions.
Rudolph Klein remarked that the NHS provided the paradoxical spectacle of contented consumers and disgruntled producers. I want to ensure that the NHS continues to earn the public’s affection and for those who work in it to feel that they have a role in shaping the high quality services they provide.

With the Baby Boomer generation becoming more frequent users of the NHS, it will be subject to even greater scrutiny and more sophisticated and knowledgeable interrogation. The Next Stage Review will be the most important development in the history of the NHS and the successful implementation of its conclusions, with your support and advocacy, will further secure its future.