Website of the Department of Health

Even with the new, more stringent criteria applied by the Commission for Health Improvement, the story is one of improvement.

Yes, there are still problems and challenges in the NHS. But more hospitals are today meeting the tougher standards applied by the Commission for Health Improvement.

Yes, there are individuals cases where more needs to be done. In an organisation which treats 1 million people every 36 hours this is inevitable. But the national picture is one of progress with 80% of hospitals improving or maintaining their performance on last year.

This information is important for the public as well as the managers and staff of the NHS.  If we are to transform the NHS into a truly patient-centred health care system, information such as this is the basis on which patients can begin to make decisions about their hospitals and their care.

That is our ambition.  In 2001 we pledged that we would provide patients with real choices inside the National Health Service.

Today I want to outline the direction of that journey and why it is so important. And I also want to place it in the context of the great debate which I believe is now opening up in Britain. A debate which, for the first time in sixty years, seriously threatens the fundamental principle underlying the NHS - that all of us are entitled to health care, free at the point of need.

More recently that principle has come under question, especially from those on the right of politics. Earlier this week the Daily Telegraph, for instance, used a single opinion poll to encourage others to continue their policy of dismantling the NHS. They seem to believe that the majority of people will want to take the NHS to pieces and to pay for their own health care with tax rebates. The Telegraph calls for a great debate on the future of health services and accuses the Government of wanting to shut down this debate.

I welcome the opportunity of any debate which poses our policy of investing in improvement in the NHS against those who want to dismantle the NHS.  There is and ought to be a major public interest in the different methods of providing and financing health care in this country.  Because, for the first time in decades a dividing line - some would say a yawning chasm - has opened up.

The great debate which is starting to take place centres around three important questions.

Are we still committed to a National Health Service, based on the founding principle that health care should be provided on the basis of need, and free at the point of need?

If we are, how should we allocate the resources provided by the taxpayer in order to best serve the interests of the whole country to that end?

And finally how best can we place real power - the power of making real choices about health treatment and exerting real influence over those choices - in the hands of the many in this country, rather than, as hitherto only in the hands of the few?

I believe that the answer to these questions will shape our health care for generations to come.

I also believe that all of these questions are interlinked. Because you cannot be in favour of a prosperous, thriving NHS if at the same time you would deny it the resources it needs, or deny to its users the sort of choices which the privileged few can obtain in the private sector.

I bring to these questions three basic assumptions.

Firstly, that that the prevention of preventable pain for everyone is a fundamental obligation on any progressive government, and the hallmark of any civilised society. It is a right for all, which should never be transformed into or tolerated as a privilege for the few.  It is a rational and moral position which is increasingly reinforced by scientific discoveries, in particular by genetics, with the prospect of the increasing predictability of one's health, which could price some, perhaps many, out of the private insurance market.

  Secondly, I believe that with every generation, as people's expectations rise and their income follows suit, they will demand more power and flexibility over the manner in which they and their families are treated. In short, people will want choice for themselves and their families. We should be as ambitious for them and their families as they are for themselves.  The main question, therefore, is not whether they can and should exercise choice, but whether we can ensure that choice can be exercised within the NHS, rather than only outside the NHS.

Thirdly, I believe in equity of access to health services, both in service delivery and in choice over the manner of that delivery. We have always argued that the introduction of money into the patient-doctor transaction will decrease fairness. But it is also true that within the NHS there is evidence of unfair access to planned operations. At the moment some people can find their way through this system and others cannot. If the Government really believes in equity of access, and it does, then we need to equalise the access to knowledge about hospitals and consultants and ensure that everyone has the same rights to use that knowledge. That is what we plan to do.

So we can, indeed we have to improve upon what we have. But always on the basis of the fundamental principle underlying the foundation of the National Health Service - that simple but fundamental principle that every one of us is entitled to the care we need, free when we need it.

That is the great dividing line between those who want to support the NHS and those who want to usurp it, as it has been the dividing line since the NHS was founded.

Then, in the aftermath of World War II, this country was physically exhausted and financially bankrupt.  But it felt morally justified like never before in its history. We had just achieved the defeat of fascism - the greatest single threat to come out of the European continent. The British people decided, at this difficult time, that the only way the health service could be fully and fairly provided for everyone was if we all decided to work together to pay for its provision.

If we did that, then it was felt we could - all of us - collectively pool all the risks that would defeat us all individually. This was a grand social aim. Something that the public loved then and still hold in their affection. The White Paper on health put this very clearly at the time:

'The government want to ensure that in future every man woman and child can rely on getting all the advice and treatment and care they may need in matters of personal health; that what they shall get shall be the best medical and other facilities available; that their getting these shall not depend on whether they can pay for them or any other factor irrelevant to the real need'.

[A National Health Service CMND 6502]

These are important values. And even in our cynical age are worth recognising for what they are - the best aspirations of our society. The values of equity, of fairness, of the whole community looking after each other, and providing care on the basis of need not the ability to pay.

But, of course, values are meaningless unless they can be applied in practice. And that requires, above all, financial and human resources. No theoretical commitment to the underlying principles of the NHS is meaningful unless the person or persons making the commitment is prepared to make those resources available, or - to put it more idiomatically - to put their money where their mouth is.

It's clear that the NHS has been starved of the necessary investment to build capacity for decades.  We are beginning to put that right. That is why we have made the case for the sustained and biggest ever increase in investment in the history of the NHS.  It's why we have worked with you in the NHS to drive down waiting times and waiting lists, improve cancer and heart services, and rejuvenate primary care.

But we can only do that because we have put in the resources commensurate with the task. The 2002 Budget provided the largest ever sustained increase in NHS funding - an average annual increase in real terms of 7.4% between 2002/03 and 2007/08 taking total net NHS expenditure from £55.8 billion in 2002/03 to £90.2 billion in 2007/08.  Our NHS today is no longer starved of cash.  We may have a long way to go.  But we have turned a corner.

This investment is buying the biggest ever capacity growth in the history of the NHS.  There are 50,000 more nurses than there were in 1997, 14,000 more doctors, 68 major new hospitals that have been completed, or are underway or approved.  These extra staff and buildings have had an impact. Waiting lists are now 155,000 lower than in March 1997, and the number of patients waiting over 3 months, 6 months, 9 months and 12 months are now all lower than those inherited in March 1997.

So those who argue that nothing has changed are already being proved wrong.  Last year planned operations in hospitals increased by 4.5%, that is around a quarter of a million extra admissions. Outpatient activity increased by 2.8% - which is around 330,000 more consultations.

So tell those half a million people that the NHS failed to do any extra activity last year. Tell the 6 million extra people who can now find a doctor's appointment within 48 hours, or the 120,000 extra women receiving breast cancer screening, or the 6000 lives saved by a 30% increase in the prescription of statins.

So why is it, that some people should be so consistently misrepresenting the reality of what is happening in our health service?

Of course, we all know that in a service which treats one million patients every 36 hours, mistakes will be made.  But why are some so intent on always highlighting the single mistake and ignoring the thousands of benefits brought? 

Of course, in a service employing 1.3 million, some people will break the rules.  But why are there those who imply that the sins of the small minority should be visited upon the vast majority of hardworking staff?  Why is it that real and substantial advances should be so often dismissed as cheating or fiddling rather than attributed to the acknowledged efforts and achievements of over a million dedicated, committed and professional personnel?  Why is it that when targets are met, and benefits delivered, they claim that things are actually getting worse?

The answer is simple.  There are those who do not want to see the extra financial resources being put into the NHS. Who, most of all, do not want to see visible improvement in the NHS. Why?  Because they want to divert the money away from the NHS.

In short, they have to run down the NHS achievements, because they want to run down the NHS.  There is an agenda that starts from the prejudice that the NHS cannot deliver, so they have to keep repeating that the NHS is not delivering. They have to say that the extra investment is being wasted, because they want it diverted elsewhere.

Let's be clear that without this capacity growth - not in one year, not in two years, but for six years running - it is not possible to provide the health service that the public want and deserve. If there was a cut in resources it would be impossible to deliver any serious growth in capacity inside the National Health Service.

And there would be direct results.  Under those circumstances waiting times would increase and people would look for alternatives to the NHS. So cuts in capacity growth in the NHS automatically push people towards private practice. We know that over 60% of people give as a reason for seeking private health care avoiding NHS waiting lists. Reduce those waiting lists by increasing NHS capacity and you reduce that pressure. Conversely increase those lists and you increase that move to private insurance.

So why would you interrupt the growth in NHS capacity unless you wanted to increase private practice? Why would you want to cut by, say 20%, the level of additional resources?

Quite simply, because there are those who want to take another disastrous road.  That is to pump money into the private sector through subsidy from the public purse.

That is why the question of resources and capacity is inextricably linked to the question of choice. Without an increase in capacity in the NHS, we cannot expand real choice for the majority of people in this country. Conversely, unless we give the patients the power to make real choices, we will not maximise the effect of the increased capacity we are creating.

Those who want to undermine the NHS will work in simple stages. First, they have to deny that increases in capacity and resources are having any effect - talk down the NHS in order to run down the NHS. Then, they have to deprive the NHS of that capacity by diverting those resources away from the NHS, thus reducing the prospect for improvements and for choice inside the NHS. Then they will inject these extra resources into private health insurance and private health care, partially subsidising the costs of private health care for those who are sufficiently well off to afford it or fortunate enough to have it provided by their employer.

They want the many of the NHS to subsidise the few who are on private insurance in two ways.

First, a direct subsidy from the taxpayer for all private insurance by applying tax relief. This moves funding from the NHS that covers all of us to those people that can afford insurance.  About 40% of the richest 10% of the population have private medical insurance while under 4% of the population in the lowest 40% of income brackets have it. Therefore if you are in the richest 10% of the country you are over 10 times more likely to benefit from the choices this provides you with, than if you are in the lowest 40% of socio-economic groups of the population. Assisting private medical insurance with money from the NHS shifts resources and choice from the poor to the rich. It does not provide choice for all.

Secondly, they are planning that the NHS should provide a direct subsidy to all of those who have an operation in the private sector.  But that would be a bad deal for the NHS and a disaster for many individuals facing illness.

The plan is that individuals would have part of the cost of an NHS operation, (and, therefore an even smaller part of the total private cost) if they would be willing to go private.  If the NHS was to pay for 60% - the suggested figure - of every existing private operation each year then the deadweight costs of paying this NHS subsidy for existing private operations would cost the NHS between £800 million and £1 billion.  This would not grow capacity at all.

But it would also leave the patient with potentially huge costs. For example if you have a hip replacement within the NHS it costs you nothing at all. But the cost to the NHS is £4,356. If you were to receive a subsidy of 60% of the NHS cost, you would therefore receive £2614.  But the cost of a private operation is higher than in the NHS. At the present going rate - even after the so-called subsidy - the prospective patient could still look forward to a bill of over £5,000 under the suggested scheme. The cost to an individual for a cataract would be almost £2000 and for a knee replacement nearly £7000 after the subsidy has been given.

Those that argue for this public subsidy from the NHS for private health claim that this increases choice. They are practising a cruel deception.

Theoretically, of course, we could all choose anything we wanted - including paying the extra £5,386 for a hip operation under this scheme. Theoretically we could all choose to own a Rolls Royce. It's only the lack of money that prevents most of us from doing it. 

But let's move back to the real world. The truth is that only if you had these sums of money would you be able to take advantage of the choice being offered to have your operation in the private sector.   And let's remember the experience of the United States, where 40% of personal bankruptcies are attributed to the failure to find the money for medical bills.  So there's a very limited and deceptive notion of choice here. What is being offered does not increase capacity by a single operation. It only increases choice for the better off. Put simply, it increases choice for a few by decreasing choice for the many.

But there is an alternative - one which links the major investment we are making in the health service with a real extension of choice for the many - possible only because of the increased capacity we have provided.

The overall aim of all our reforms is to turn the NHS from a top down monolith into a responsive service that gives the patient the best possible experience. We need to develop an NHS that is both fair to all, and personal to everyone.

One of the key ways of doing so will be to give patients more power - both collectively and individually.

So where individual choice is difficult, for example in emergency services, we will empower patients collectively by increasing the accountability of local health services to local communities. That lies at the heart of our proposals for elected boards of NHS Foundation Trusts.

But wherever possible we will empower patients by giving them genuine individual choices - about where, when, how, and by whom they are treated.

I have explained that we can only achieve this if we increase the capacity. For us, increasing capacity for NHS patients and choice go together. As the Chancellor said on July 1st:

'I can tell you that our aim is that by 2005 no one will wait for their operation for more than six months. By 2005 every patient will not have just to take what's available but be able to choose from a much wider range of options and book their treatment in advance at a time and place convenient to them.'

This of course was developing our commitment from 2001, which said:

'By the end of 2005 every hospital appointment will be booked for the convenience of the patient making it easier for patients and their GPs to choose the hospital and the consultant that best suits their needs'  [p22 2001 Labour Manifesto]

Capacity for all; choice for all.  A National Health Service that is fair to all of us and personal to each one of us.

But these improvements are not based just on the ambitions of politicians.  They are based on what real people in the real world want.

Over the last year, we have been carrying out a number of pilots for patient choice in elective surgery. These have been very instructive. From July 2002, all patients who had been waiting longer than six months for heart surgery have been offered a choice to go somewhere else if they want.  2,549 patients - some 50% of those offered the choice to move to another hospital - have chosen to do so.  For the first time in the National Health Service, we are piloting allowing patients to choose where they go.

Since October 2002, patients in London have been offered a similar choice in other specialities too. Initially cataract patients were offered this choice but the scheme is being extended from this summer so that all patients in London waiting more than six months for elective surgery in all the main specialities will be offered the choice of an alternative hospital. To date 4,675 London patients have chosen to have faster surgery in an alternative hospital - no fewer than 67% of those offered this choice have decided to exercise it.

So, we have radical plans, but I want to proceed cautiously and steadily.

Let's be clear what we have done to date. Everybody within a certain clinical category - at a certain time of waiting, and in a certain part of the country - gets this choice. Not those with money. Not those that have friends or influence. Everybody.  Everybody gets the same chance through this sort of choice - the same information and crucially the same support to help make these choices.

For nearly everyone who does so this is a new experience. And for nearly everyone it is an important part of their experience of a new NHS.

This choice for people has not only improved their experience of the NHS but it has also increased the use of capacity within the system. If a patient is 'stuck' on a single waiting list there might be a hospital somewhere else that can treat them a lot earlier. But they and the system don't know. By allowing patients to move to another hospital, you increase the utilisation of the whole system.

In London, in the past it was the case that some people waited for a cataract operation for 8 months and some waited for 8 weeks. By giving people the opportunity to move, you make much better use of the capacity and also encourage those hospitals that are operating well to do even more work.

Today I will set out three further steps on expanding patient choice.

First, from next year we will roll out this choice at six months across the country.  I am today issuing guidance to the NHS on how this policy will be implemented right across England covering all elective specialties.

Second, today I set out how we will extend choice for all at the point of referral. Through careful roll out and implementation we expect we will be able to expand choice at the point of referral so that by 2005, patients will be able to choose from at least 4 alternative providers.

As the Prime Minister said in his progressive governance speech last week our eventual aim is, using the new fixed NHS tariff, to allow NHS patients to exercise choice of provider from within the NHS - be it treatment at a public, private or voluntary supplier - free at the point of need.

But as the Prime Minister also said in his recent Fabian lecture, we want to extend choice in further directions within the NHS - and this is the third aspect of what I am announcing today - into services such as chronic diseases, primary care and maternity services. So today, I am inviting the nation's patient groups to work with us over the next three months and beyond to work up radical proposals on how best we can empower patients in these and other areas. I have in mind the same sort of process used to develop the NHS Plan in which we worked intensively with the public and key stakeholders.

This work will look at all aspects of the patient experience. Fast access, certainly.  But also good information about your illness. Real choice of when and where and how you are treated.  Attentive staff.  A clean, comfortable, friendly place to be.  Safe, high-quality, co-ordinated care.  And all done in a way that makes people say: 'they treated me as if I mattered', and 'they took time out to explain what was wrong'. This is what staff want to provide, this is what patients want from their NHS.

And in the coming months I want patients, patient organisations, and NHS staff to contribute to a debate on how we take the next steps forward. 'Trust me, I'm a patient' should be a guiding principle of this new agenda. 

This is an ambitious, but I believe a realisable aim. We realise the importance of this to patients and the NHS. We are moving forward step by step, testing all the time, to ensure it will work. Above all, the Government's proposals build upon and develop, rather than undermine, the principles on which the National Health Service was founded and has flourished.  They go with the grain of the British people and their instincts, rather than imposing notions foreign to those which we have successfully relied upon for sixty years.

These choices will be there for everybody. Not just for a few with money who can buy the privilege. Not just for a few who know their way around the system. Not just for those who know someone 'in the loop' - but for everybody for every referral.

That's why our approach to increasing choice and increasing equity go hand in hand. We can only improve equity by equalising as far as possible the information and the capacity to chose. And we can only provide those choices when we have increased the capacity of the NHS.  But it is now within our grasp to rebuild a National Health Service for today's generations and for the generations to come, and one which is truly fair to all of us and personal to each of us.