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For some people there appears to be a real problem about conferences such as this. They seem to be opposed to learning. For some, the problem appears to be learning from the US. One Labour colleague commented on my trip to America - when I had said that Kaiser were worth looking at - that 'usually Labour health ministers have gone to the US to say how good the NHS is, rather than how brilliant the American health care system is'.

For others the problem appears to be learning from anywhere at all. A leading spokesperson for the Trade Union Unison said 'it must be very demoralising for doctors, nurses and other health care professionals to be told that experts from outside can do better than the NHS".

In fact, nothing would be more demoralising for the NHS than to be led by people who thought we had nothing to learn from anyone.

These are arguments that demonstrate a lack of confidence in the NHS that I don't share. We are asked to be so frightened of 'abroad' that we must not learn from them. I stand in a different position. I believe that a preparedness to learn and improve is a sign of strength, not of weakness.

I think people know where this Government and I stand on the values of health care and the NHS.  But let me re-state it. The NHS basic value is that health care should be provided for everyone free at the point of delivery and that it should be funded through central taxation. We believe this is the way the British people want their health care provided. This will be maintained.

If personal money or wealth is introduced directly into the health service/patient relationship then it is inevitable that those who have more money will get a better service and those that have very little money may get no service at all. Money is unequally distributed in society and if health care follows that distribution, it will also become unequal.

We know that the NHS principles do not apply in the United States. For most Americans their private insurance meets some of their health care and for many of these there are strict limitations on that cover as insurance companies pick and chose what they will cover. And for over 43 million there is no cover at all. This system entrenches inequalities of health service and health service outcomes. It leads to over 40% of all personal bankruptcies being caused by the size of health bills.

So, I couldn't be clearer - the values and structure of the NHS are different and will remain different. But should that mean that we don't learn anything from a different way of working? Of course not. Markets do a number of things, some of which are worth learning from.

Among other things, they encourage people to illustrate a preference for one kind of activity, service or product over another. That in turn has an impact on the organisations they choose and the organisation they don't choose. People do this all the time - express preferences and through their individual preferences help to develop and shape organisations, including those providing services.

In the market the main way people express preferences is through the use of money in prices. If you have the money your preference gets noted and has an effect. That means, for example, my preference for a Maserati car that is coloured silver is never going to have any impact upon those who decide the colours of Maseratis, because I don't have the money to buy one.  That is why we reject that approach in health care - why we provide collectively the resources to give all a fair chance.

But preference can have an effect without money being involved. Where the public is empowered, choice can take place in public services where no money is used in the exchange. For example, with our plans to increase the amount of choice for patients.

This will not involve the patient passing over money at all. The choice will be within the framework of an NHS principle of providing health care free at the point of delivery. Of course there are some people who object to patient choice even though it is within the framework of our founding NHS values and even though it does not involve money - because they object to choice itself. But for most people the expression of preference by public service users is a good thing.

 We can in this case learn from the market, but without copying it. 

It is true that Kaiser works within an overall market system of health care but Kaiser is unusual in the US. It brings together three separate organisations - the Kaiser Foundation Health Plans, the Kaiser Foundation Hospitals, and the Permanente Medical Group - in a number of regions to deliver care to the insured membership. These organisations are bound together in mutually exclusive partnership and contractual relationships.  Kaiser is a not-for-profit organisation that operates for community benefit. So Kaiser operates in a market but is not a market-driven organisation - making assumptions about it from the old left in this country all the more odd.

A group from my Department and the NHS visited Kaiser in February to learn about the Kaiser model and to identify lessons for the NHS. The following five features stand out as being particularly noteworthy:

First, integration. There are two important aspects of integration in the Kaiser model. First, their integration of inpatient care and outpatient care enables patients to move easily between hospitals and the community. Under this arrangement, medical specialists are de-coupled from the hospital and focus on providing care in the most appropriate setting. There is no incentive to build up facilities and resources in the hospital at the expense of other settings.

Kaiser integrates prevention, diagnosis, treatment and care. Doctors who work for Kaiser also have fast access to diagnostic services in the outpatient setting, thereby avoiding stays in hospital, and they practice from relatively large (at least from an English perspective) medical centres that enable diagnostic and other equipment to be easily accessible.

 Integrating care makes sense outside of markets For the NHS we can learn by building on the establishment of primary care trusts (PCTs) and using these to develop stronger links between prevention, diagnosis and treatment. For example, primary care trusts could start employing medical specialists in areas like diabetes and asthma care in order to move away from a hospital focused system. This in turn would move us away from the sterile debate about the balance between primary and secondary care to think much more about integrated care.

Secondly, keeping patients out of hospital. Kaiser uses around one quarter of the number of bed days as the NHS for leading causes of admission like asthma, bronchitis, and stroke for the over-65 population. Kaiser's philosophy is that 'hospitals are an indicator of system failure' because patients are admitted to hospital only when prevention and treatment in the community do not succeed. Early discharge is facilitated by the availability of intermediate care. Nurses and therapists playing a major part in the delivery of intermediate care.

 Keeping people out of hospital makes sense outside of markets. For the NHS the availability of intermediate care in the form of skilled nursing facilities and home health care is essential if acute hospital beds are to be used differently. As intermediate care is developed, the NHS can also learn from the role of nurses and therapists in the Kaiser model.

Thirdly, the active management of patients. When patients are admitted to hospital, there is a strong emphasis on minimising stays and maintaining the flow of patients through the hospital. A good example is orthopaedics where care pathways have been developed for patients undergoing hip replacements and knee replacements specifying what should happen on each day of hospital treatment. Lengths of stay for these conditions are typically around 4 days in Kaiser compared with 12 days in the NHS. Discharge is planned either on or before admission with the emphasis placed on early rehabilitation. Kaiser employs specialist discharge staff to manage this process and to ensure that patients are not kept in hospital unnecessarily. The aim is to keep patients moving through the system and to review readiness for discharge on a daily basis.

Actively managing patients works outside of markets. For the NHS the increasing focus in the NHS on chronic disease management and discharge planning demonstrates our recognition of the active management of patients. In the case of chronic conditions, this includes identifying patients who are most at risk and intensively case managing them, as well as ensuring patient compliance with standards set out in clinical guidelines. For patients who are acutely ill, active management entails the development and use of care pathways, and the adoption of roles such as discharge planners whose functions include avoiding unnecessary stays.

 Fourthly, self care and shared care. Patients are enabled to return home by being supported to do as much as possible for themselves. Self-care is at the heart of Kaiser's philosophy and practice to the extent that patients, carers and families are seen as co-providers in health care. Orthopaedic patients are therefore taught how to dress themselves, the exercises they need to undertake and how to administer medication such as anticoagulation in the home. Kaiser staff offer advice and support either in person or by phone and manage the expectations of patients and families to enable hospitals to be used only when necessary. Self care and shared care are particularly important in relation to chronic diseases where Kaiser makes a substantial investment in patient education and the provision of information to help people with conditions like diabetes and asthma remain independent and healthy. Group consultations involving several patients and a health care professional are used to support self-care

Self care, as we know works outside of markets. The NHS has started to promote self-care through the expert patient programme and by giving patients access to health information, for example through NHS Direct Online. The experience of Kaiser suggests that higher priority needs to be attached to these and similar initiatives to enable the most expensive resource, hospital beds, to be used more appropriately.

And finally, the use of information. Kaiser's IT system is being developed and replaced and this involves a substantial commitment of resources. The existing system enables easy access from different sites to patients' records and information on tests that need to be done on patients in line with clinical guidelines. It also enables the development and use of disease registries for chronic conditions. These registries are then used to review compliance with the standards set out in guidelines and to identify doctors and patients whose practice or care may be departing from the guidelines. The data captured on the information system is used in part as a tool for quality improvement/peer review and in part to inform how Permanente physicians are paid.

As our own national IT programmes shows, information can be better used outside of markets. We know in the NHS that there is a large amount of data about our patients that fails to become useful information. Disjointed bits of the health services takes down information and fails to use it in tandem with other bits of the service. Our new IT programme is aimed at gathering all the useful information in one system so that it can be used for the patient wherever they appear in the system.

In conclusion - to refuse to learn at all is to commit an institution to steady decline. The NHS is not a fragile institution afraid of paying attention to the successes of others because we are uncertain of our future. The NHS is a strong powerful social force in British society. It has the capacity and the strength to learn from the market just as it has the capacity and strength not to copy it.

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