Joan Ruddock
A vision for the NHS
SPEECH to MSF HEALTH SECTOR CONFERENCE
HARROGATE 9 May 2000
“A health service of all the talents” was how Alan Milburn described his vision of the NHS when speaking to the RCN last month – he described a service which liberates nurses not limits them; an NHS which if patient centred must be nurse centred too. In his speech he outlined Labour's plans to put nurses at the centre of the modernisation of the NHS stating that "nursing values are health service values. Caring. Compassionate. Professional. Dedicated. The needs of the patient at the core of all we do". I share that view and equally value the role and the contribution of the nursing profession - but those are the values too of the other professions working in the health service, many represented here today, and we need to ensure that their role and contribution is not overlooked or taken for granted. And that means recognising their value and reflecting that in their pay and conditions.
If it is to be a health service of all the talents then this will require the involvement of all relevant staff not just in service delivery but in planning and policy formulation and in management. It means involving all the relevant professions on working groups and task forces and no exclusions.
MSF has two roles. Firstly it is a trade union defending its members' employment rights and negotiating pay and conditions and secondly it is an organisation representing professional groups within the health service. As a trade union it will sometimes come into conflict with the employer but a dispute over pay provides no excuse for the Department of Health to exclude the union from representation on planning groups, working parties or task forces.
I want to deal with some of the very positive changes in the NHS which have occurred under Labour.
In the past a nurse had narrow career options and in order to advance, the only paths were to enter nurse education or the realms of management.
There is no problem with those choices. We want able nurses in management roles. I welcome the increasing numbers of nurses who are making it as chief executives in the NHS. Equally nurse education needs some of the best nurses to ensure that the next generation of nurses is adequately skilled. But it has been frustrating for good clinical practitioners who want to remain with patients.
Since the Halsbury report in 1974 the profession has been wanting genuine opportunities for a clinical career grade. With the establishment of the nurse consultant, the government has now provided the profession with a real chance to break new ground in building solid options for a clinical career.
This is not - and must not be allowed to become the grading debacle we saw under the Tories. These trailblazing nurses will spend up to half their time in direct contact with patients and we must ensure that this remains the case. What we must avoid is the situation under the Tories when the higher grades at H and I were often used to reward nurses in management roles rather than clinical excellence. These new posts give nursing a real chance to ditch the baggage of the past and to move ahead.
These posts avoid the creation of yet more hierarchy. By their very nature, nurse consultants will stand or fall by earning clinical credibility. The word “consultant” has been chosen with care. These expert nurses will be available as a resource for patients, nursing colleagues and those in other disciplines. They will be consulted because of the value they add to care, not by dint of position in a hierarchy. We should wish the first nurse consultants well in their new task and I am confident that they will bring about real change not only for the profession, but more importantly for patients too.
The second exciting change lies in primary care groups. The government was adamant that there should be a voice on these boards for nurses in clinical practice. All PCG boards have two or more nurses serving on them. Again, those nurses were not put onto boards by any hierarchy, they got on to the boards because they carried the confidence of their colleagues in their local patch. And I wish to congratulate MSF, not only for encouraging its members to seek positions on PCG boards but on its outstanding success in getting MSF members appointed.
During the debates on primary care in Parliament last year I was somewhat concerned that all of the focus was on GPs and in an article which I wrote for the Nursing Standard in June of last year I said that “listening to some of the debate on the Health Bill as it proceeded through Parliament, one could be forgiven for hardly noticing the enormous contribution made by health visitors and community nurses to primary care services.”
Not only are there are far more qualified nurses, midwives and health visitors working in primary care than GPs, but health visitors, district nurses, community midwives, community mental health nurses and practice nurses are the first point of contact for vast numbers of patients and clients in the community.
The abolition of GP fundholding has been widely welcomed by community nurses. The commitment to public health, prevention of ill health, and genuine multi-disciplinary working across professional boundaries has been acclaimed by these key staff.
Different professions bring different skills enabling them to drive this agenda forward. District nurses can provide the key bridge between health care and social services. Health visitors are, by nature, practical public health specialists, ideally suited to the Government's new agenda. Community psychiatric nurses, by nature and training, are key workers in delivering the modernisation of mental health services. Increasingly, Practice nurses are undertaking skilled work delegated and previously carried out by GPs.
This is a crucial workforce. It is one that welcomed "The New NHS" as one that broke with years of cuts in services, an increasingly dysfunctional internal market and a complete failure to properly use and develop their skills.
An effective team of community nurses and GPs as a partnership of equals can combine the commitment of GPs to their practice population with the public health perspective of health visitors and the community care perspective of district nurses It can build real partnership between these staff and community midwives and mental health nurses.
But again, it is not only nurses who we need to see in key roles on PCG boards and Primary Care Trusts. There is a vital role for representatives of other professions allied to medicine – the physios, OTs, the speech and language and other therapists, psychologists, pharmacists – all working together in partnership with GPs and social service staff as equals, supporting and complementing each other.
I believe we really are moving away from sterile old models of leadership in seeking to build new ways of working, developing nurses and others for clinical leadership roles.
On the eve of the HVA Annual Conference in 1995, Denise Hagel, then chair of the HVA expressed concerns that, under the Tory NHS model, the public health role of health visiting and the holistic approach to practice was seen by government as unfocused, ill-defined and difficult to measure and ran the risk of being side-lined. She argued for a greater public health focus with a role for nurses and health visitors in raising the awareness of GPs and purchasers that health promotion and primary prevention were valuable investments for health.
Today, nearly 1000 nurses are undertaking this role on PCG boards. I recognise that the pace of change is difficult and that balancing clinical work with a leadership role is tough, but evidence shows that these brilliant nurses are undertaking these new roles with relish. They deserve our support and encouragement - and yes praise and I am confident that they will make a real difference to the NHS and provide a real benefit to patients.
Another innovation has been NHS Direct. I know that NHS Direct has not been universally popular but within community and primary care, new challenges and new roles are emerging in NHS Direct It is senior experienced nurses who are actually delivering what the public want, easily accessible, credible advice on a whole range of health care and it is right that the government is looking to augment the current repertoire of NHS Direct by including the skills of mental health nurses. Given the overwhelming evidence that most mental health need is spotted in primary care settings, it must make sense to offer the skills of these specialist nurses via NHS Direct.
In the new pilot NHS walk in centres, again it is nurses, midwives and health visitors who are taking on new roles to meet the needs of some of our most disadvantaged communities in different ways. It is early days for this concept, but the Prime Minister has indicated that every major town will have an NHS walk in centre within five years, complementing traditional GP services.
In affluent areas like Harrogate, it is likely that almost all of the population will be registered or will have no difficulty in registering with a GP but what of poorer inner city areas or a rural community with little choice? What happens to people with no permanent roof over their head? What happens with transient populations, with travellers or young people moving from place to place and not staying in a given area for long? What happens to the increasing number of people fleeing conflict or persecution coming to our country?
For many of these people, the traditional pattern of general practice is not easily accessible. These are the groups who are often marginalised from easy access to good quality primary health care. NHS walk in centres, led by experienced nurses and other health professionals, have the real potential to transform the health status of some of these vulnerable groups of people in entirely new ways.
The argument advanced by some critics of NHS walk in centres suggests that the public are somehow potentially shortchanged by such a service. But that begs the question “why does the private sector set up such services on the concourses of major railway stations?”, usually run by experienced nurses with GPs moonlighting. Why should the NHS patient not enjoy something similar? If it is OK for the district nurse, the practice nurse or the health visitor to extend his or her role in the GP practice, why is it so wrong for these very same staff to extend their role more autonomously in an NHS walk in centre?
Another area of change is in prescribing. When in opposition, I shared a platform with Julia Cumberlidge, then Tory Health Minister, at the Community Nurse Conference on Nurse Prescribing held in London in November 1995. Just to show how even-handed I can be, I would like to pay tribute to the contribution which she made, despite her government, to enhancing the role of nurses. The Cumberlidge Report was published in 1986 but it took 8 years before its recommendations were implemented. I welcomed the nurse prescribing pilot project which she initiated - but we have taken that forward. I had an ear bashing from some of my local community pharmacists at the PSNC Annual Dinner recently, so I know that some community pharmacists are a bit peeved and feel that their skills are undervalued or not recognised - but rather than taking a negative attitude to the extension of the role of the nurse they need to be making the case much more energetically for a further extension of their own role in primary care and, in doing so, they would have my full support.
We are about to witness a revolution in prescribing. Some district nurses and health visitors have had limited prescribing powers for a few years and this has proved successful. What is now proposed will unlock an enormous potential, particularly amongst CPHVA members.
Recent recommendations by Dr Crown will lead to radical change in prescribing powers for many more nurses midwives and health visitors, and for other key professions, such as the PAMs and community pharmacists.
CPHVA members know that many experienced practitioners, particularly in areas of chronic disease management, will often have more knowledge of the patients needs regarding medication than a GP or a junior doctor.
It must make sense to allow the CPN, the district nurse, the school nurse, the practice nurse or the health visitor to have a greater ability to sensibly manage decisions around medication where it makes sense to a nursing orientated care plan and offers greater convenience to the patient.
It is surely a bit daft for the district nurse visiting the elderly diabetic patient over a long period of time to have to take time out to get a GP prescription for a medicine which the nurse is quite capable of prescribing. For proper implementation these proposals will of course need proper investment in training and support for staff but they will, in my view, offer better and more focussed use of key NHS staff and offer better and more flexible options for patients. I, for one, am pleased that the Secretary of State has recently accepted in full the second report of Dr. Crown and I hope you are too.
I also want to consider the role of CPHVA members in a wider context. At last we have a government which recognises the links between poverty and ill health. These issues were buried for eighteen years under the Tories. Recognition of this link between poverty and health status is crucial in considering policy options.
The government has made a start in changing the way in which we manage the health needs of some of our most disadvantaged citizens. All nurses - district nurses, health visitors, school nurses, CPNs, practice nurses and midwives have a role to play. Our health action zones are beginning to target some of the areas of greatest need in both rural and inner city communities and the nursing contribution to such initiatives is crucial for success.
In the Sure Start programme, there are countless examples where the health visitor has been a crucial link in helping some of the most deprived children and families in accessing better opportunities. In Education Action Zones there is some brilliant work being done by school nurses, who have been able to bring the health agenda to meet the education agenda in practical ways, offering children a better chance in getting the best of their educational opportunities.
This government realises that the contemporary challenges to our NHS will not be met in hospitals and other institutional settings. In whole areas of health, including an increasingly old population, in HIV/AIDS, in substance misuse, in chronic mental ill health, and in supporting people with a variety of longer term complaints, traditional medical concepts of diagnosis, treatment and cure have little meaning. It is in primary and community care that potential solutions will be found, offering support and care to people going on often uncertain journeys, based on a partnership between the patient or client and enlightened health professionals who work on the basis of empowering, not controlling individuals or communities.
I am confident that MSF and its members well understand this agenda and are well equipped to make it real and better. There will be occasions where you will have to challenge this government and question its actions - as some of us on the back benches do from time to time - but as our party slogan says, much has been done, but there is much to do. As politicians we need people like you, at the front line of our NHS who are well placed to keep us in touch with what more needs doing. And if it is to be an NHS of all the talents, the Department of Health needs you too not just in service delivery but on its task forces and working parties.
We inherited an NHS fragmented by the internal market – GP fund-holding, a two tier service and post code rationing; privatisation creeping in on the back of PFI and lip-service only to a public health framework linking health to poverty, housing, transport, employment and the environment and a climate of fear in the NHS about speaking out and the work-force treated as a cost and a burden and not an asset.
There may be many criticisms of what we have not done but we have ended GP fund-holding and secrecy between Trusts. We are beginning a serious attempt at planning through health improvement programmes. systems of clinical governance are being improved – an end to gagging clauses and a more vigorous approach to malpractice; and whilst it never is enough – very large extra resources have gone into and continue to go into the NHS with additional funding earmarked for key areas like heart disease, breast cancer and mental health.
There is still some controversy about PFI. Personally I and many members of the Health Select Committee have serious reservations about whether PFI is such a good idea in the long-term. It has delivered a massive hospital building programme but I wonder if this is not as a result of some clever creative accounting to satisfy the Treasury which may cost us more in the long run. But that is an argument for another day.
The government is making a genuine attempt to link health to its social and economic context – Surestart is an example of that and the appointment of a Public Health Minister – much has been done but yes more needs to be done.
And there is now a serious attempt to address issues of discrimination in the work-force. MSF has been at the forefront in this campaign – exposing for example the discriminatory way in which discretionary wards were used both in terms of race and gender.
And I believe we have made a start in tackling pay inequalities through an end to local pay bargaining and a new pay system – but I regret to say we seem to have made a mess of it so far as the treatment of staff outside the Pay Review Body is concerned. MLSOs for example, many of them performing services unseen by the patient, but many in intimate contact with various parts of our bodies. Scientific staff are a crucial part of the workforce, crucial for diagnosis, for treatment and in prevention – a highly skilled and grossly undervalued profession. The union has won a great victory as far as speech and language therapists are concerned now we need a similar victory with laboratory staff. This is one of the areas where the union needs to apply even more pressure on individual Members of Parliament.
But on the general issue of pay, go back and look at what was being said – and what you were saying in 1995 –when the Editor of the Community Nurse said that the “UK's 18,000 practice nurses could be forgiven for feeling ignored as the 9 month-old pay dispute grinds to a close” where many practice nurses received far less than had been provided for pay increases and many received none at all.
I am sure you welcome the discussions which Alan Milburn is having with the BMA to ensure that all practice nurses benefit from the Pay Review Body's recommendations.
But of course, if Labour's plans are to work we have to recognise that the staff of health and social care organisations are the most valuable asset those organisations have. I don't need to tell this audience that staff members are often not valued, not developed and not paid well.
We need to create enhanced career paths and roles, particularly in the “Cinderella professions” notably PAMs with the kind of proper work-force planning recommended two years ago by the Health Select Committee.
We do know that there is a large gap in some areas between what local NHS employers are supposed to be doing to improve the treatment of staff and what is happening in many Trusts.
We know that the NHS workforce remains an exhausted one with continuing recruitment and retention problems. These may be amongst scientists and technicians where we know that in London for example things are very serious. They may be amongst community nurses and health visitors where commitment to boosting prevention and primary care is not yet reflected in new recruitment to expand an ageing work-force.
Expecting staff to wait for a new pay system to arrive whilst living on poverty wages is hard to understand which is why we do need to build up the pressure to deal with those staff outside the Pay Review Body.
But real changes have been made and more will come and the role of health service trade unions such as MSF and the MSF MPs is to ensure that this process is properly funded
But the fundamental question that worried so many people under the past administration as to whether the NHS was safe in their hands has been answered by a positive commitment to the principles upon which the NHS was founded – one financed out of taxation, provided on the basis of need and free at the point of delivery. There are still some problem areas such as Long Term Care, where the Health Select Committee – even with a Tory majority in the last Parliament – called for all nursing to be provided without charge irrespective of the setting in which it was provided – a recommendation endorsed by the Royal Commission – or at least a majority of the Royal Commission – I can only hope that the government will take the courageous and correct decision to implement that recommendation when it announces its response this summer.
But at a time when there is so much talk about the private sector and public/private partnerships, I take heart from the very clear and positive statements from both the Prime Minister and the Secretary of State about the future funding of the NHS. In March the Secretary of State addressed the London School of Economics he drew attention to the close relationship between the health of the economy and the health of the people. In his opening remarks Alan Milburn said “he conventional orthodoxy is that health spending is a debit, not a credit – a drain on the economy and a burden on the taxpayer. ….……. it is time to turn that thought on its head……………. health care should be regarded not just as current consumption but as social investment”
And he added that it must be “organised efficiently to deliver the maximum health gain” and “organised so that it delivers preventative services and not just sickness services, intervening upstream as well as downstream.”
Despite all the cosying up to business, even the newest of New Labour has recognised that the tax-funded principle of a free health service is the most cost efficient way of meeting health needs and providing health care. Recently, in the United States, President Clinton had to go to Congress for 0 billion funding so that just 5 million uninsured Americans can get only the most basic and minimum health care cover.
And now the structural inefficiencies intrinsic, for example, to the French and German social insurance health care financing systems are becoming all too apparent.
How astonishing then is the Tory agenda of moving away from a tax-based system when the funding system that we have in the UK is the most efficient way of financing health services. We can now see the real cost of social insurance schemes which is why French employers are up in arms.. The Institute of Directors in the UK may wish to take note. Social insurance turns healthcare into a tax on jobs.
It's worth noting too that a tax-based NHS has other advantages. It is better at containing healthcare inflation. It has low transaction costs, which means resources reach the frontline. And it provides clinically managed care, based upon needs. Ironically, at the very time that Mr Hague is urging us to abandon our model in favour of the continental health care model, France and Germany are looking to import the very best features of the UK's health care system. The Tories see the solution in terms of the expansion of the private sector. How far they have moved from Stephen Dorrell, the last Tory Health Secretary who said “My commitment as Health Secretary is to ensure that the service provided by the NHS is sufficiently good to render that private safety net unnecessary” . But for today's Conservatives the answer to the challenges facing our health care system is not to expand the NHS or to modernise services but rather to constrict and privatise it. Whether through point-of-treatment charges or top-up private insurance the New Right approach means patients taking their chance in the private sector. This argument does not stack up as a viable, let alone as a desirable policy. Compared with a tax-funded expanding NHS The private alternatives fail the three crucial tests: that they should match care to need; match contributions to ability to pay; and raise contributions efficiently. Would extra private charging or insurance somehow ‘help out' the NHS. It wouldn't. This argument fails to recognise that the extra clinical staff that would be sucked in to an expanded private sector are from a scarce pool of skilled professionals that the NHS itself needs.
There is no reserve army of nurses or unemployed oncologists or cardiac surgeons simply waiting for the call to arms. An expanded private sector can only mean a contraction of the public sector as it is faced with higher costs and fewer staff.
What's more, the very concept of ‘lightening the load' on the NHS begins to posit the NHS as a residual safety net service., one which becomes– as Richard Titmuss observed thirty years ago - a service for the poor becoming a poor service. That truth can be verified by anyone who has visited a public hospital in a major US city.
Less visible but no less worrying is the evidence that people who take out insurance become less willing to see public spending on the NHS – thereby undermining support for tax-based services rather than supplementing them. Nor will more charges at point of treatment solve any funding problems. The NHS currently raises about 2 per cent of its £40 billion budget from patient charges. If the charges are set low and everyone has to pay, they raise very little cash. If they are set high but with many exemptions, again the administration becomes heavy and expensive and they raise little cash. And if they are both set high and have to be paid by all – as a kind of medical poll tax – the international evidence proves that they stop sick patients getting care. They would even cost the NHS more in the long run, because they would put people off preventive services and early diagnosis.
Those who advocate charges ignore the fact that healthcare is disproportionately used by the very young and the very old. Two thirds of acute hospital beds are rightly occupied by retired people. The very elderly - again quite rightly - receive four times more healthcare, pound for pound, than people of working age. Yet they are the group of people least economically active and least able to pick up the cost of extra health charges.
All of this then points to the need for extra health funding to be based on some sort of risk-pooling arrangement - both to spread costs between individuals and over individuals' own lives.
The truth is that the NHS, in the words of the OECD, is “a remarkably cost effective institution.” That is not to say that there is not variation in performance which needs to be tackled. There is more that we can get out for what we put in – but overall as the Prime Minister has rightly said, we need to invest more of our national income in the NHS.
As the Director of the World Health Organisation has said, health isn't everything – but without it you have got nothing. Good health is the route by which each and every one of us can properly fulfil our true potential. It unlocks life chances, and is a fundamental building block of wellbeing.
The other argument we hear from the right is that with an ageing population, we can no longer afford the NHS. No-one disputes that there are real challenges. The NHS will have to change profoundly to meet them. Some say an ageing population is the biggest ‘threat'. It is not. Of course, there will be a higher number of very elderly people increasing demand on health services. And incidentally that's a success story not a failure. But the truth is that the elderly population is set to grow in the next fifty years at just half the rate of the last fifty years. And the pressures in Britain will be much lower than in many other industrialised countries. For example, over the next two decades, the proportion of the population over 80 will go up by under a quarter in Britain, but will increase by nearly a half in France, threequarters in Germany, and it will double in Japan.
The Health Select Committee, in its Inquiry into Long Term Care concluded that there was not a demographic time-bomb waiting to explode and in the last parliament, even with a Tory majority, in the pre-Hague era, concluded that there was no crisis of affordability and that funding long-term care through taxation was a defensible option.
There are challenges ahead – for the government, for the staff and for users – but exciting challenges to build a better and improved NHS - The new structures we have put in place - Primary Care Groups, the Commission for Health Improvement and the National Institute of Clinical Excellence the drawing up of National Service Frameworks - are now almost universally accepted as the right way forward. There is no serious contender to the NHS blueprint that has now been developed.
We need to build services around patients and not the other way around. The process of redesign has already begun. It is being led by health care professionals on the ground. The traditional hard and fast demarcations between clinical professionals need to give way to more fluid and flexible team working. This is the right time then to look at the skills the NHS of the future will need. It is time to look at these issues in a new way - across professions, across sectors and across services too. Because if we are to be responsive to patients we need energised and motivated staff, and better employment practices, with more staff involvement in key decisions and more investment in training and development.
The NHS was always the pride of Britain. Some of the shine wore off in the Thatcher/Major years, it is beginning to shine again and yes, the NHS is safe in Labour's hands.
John Austin MP
9 May 2000
