Keynote speech by Alan Milburn
‘From sick care to health care: meeting the challenge of chronic disease’ – speech given by the Rt Hon Alan Milburn MP, Speech to Oxford Vision 2020 Conference 2003, Magdalen College, Oxford
It is a great honour to be invited to speak at your conference. It is not my normal practice to make speeches on health nowadays. Indeed, this is the first such speech I have made since leaving the Government in the summer. I wanted to do so, however, because I believe the issues you are discussing today have such fundamental significance for the future.
Health care worldwide is on the frontline of sweeping change and great challenge. Demographic shifts and medical advances bring new possibilities but cause new problems. In the developed world, expectations rise but costs never fall. In the developing world millions die from preventable disease, making the gap between where we are and where we could be so frustratingly small. And in a world of open borders and easy travel, problems in one part of the world quickly land on the doorsteps of others. In this interdependent world common problems call for common solutions.
These waves of change are redefining health care – not just in any one country but in all. Reform has never been more needed – or more pressing.
Today I want to talk about how we in England have gone about the process of responding to these challenges. In particular I want to set out the lessons I believe can be learned from our reforms of the NHS to give it a clearer focus on prevention, not just treatment.
For most of the past death, illness and disability was down to the major infections of the day. Even today malaria, TB, HIV/AIDs and childhood infections kill millions. And much remains to be done to tackle this plague of preventable illness. But as Derek Yach and others have argued the major killers today are already chronic diseases, coronary heart disease, stroke and cancer in particular. That is as true for developing nations as it is for developed ones. There is also significant co-morbidity between mental illness and physical disease. And non-communicable disease will probably mushroom in decades to come. Diabetes prevalence among adults alone will rise by 50% in the next twenty-five years. Of the 300 million sufferers 228 million are expected to be from developing countries.
Chronic disease is the health challenge of the future. It is the new epidemic sweeping our world. We can see it here in Britain where obesity has trebled since 1980 – increasing the risk of heart disease, diabetes, stroke and some cancers. Our rates of coronary heart disease are amongst the highest in the world. Our cancer survival rates are too low. Already 9 million people live with a limiting long term illness like asthma or arthritis. And these numbers will grow as the elderly population and greater ethnic diversity grows.
The tide of chronic disease can sometimes feel overwhelming. Although the challenge is real, progress is possible. Here, since 1997 premature deaths from cancer have fallen by 10%, from heart disease by 20%. Waiting times for treatment are falling. Services are improving. More lives are being saved. The payback from the Government’s commitment to more staff, new drugs, better equipment is now coming through.
Progress has been achieved, first and foremost, by committing new resources to health. After decades when investment in health care fell behind, today Britain has the fastest growing health care system of any major country in Europe. When I became secretary of state for health late in 1999 I argued that the NHS would not be sustainable without major new resources. The Budget the following Spring represented a turning point. It provided 7.4% growth in real terms a year for five years.
These long-term resources have been matched by reforms. For all its great strengths – its one million staff, its ethos of public service, the great advances it has brought in public health – the NHS has profound weaknesses. In the fifty years since it was formed the health gap between rich and poor has widened. Too often the poorest services are in the poorest communities. Its centralised top down structure too often stifles local innovation. Staff too often feel disempowered. Local communities feel disengaged. Patients have little say and precious little choice.
The reform programme I introduced in the 10-year NHS Plan – and which my friend and successor John Reid is taking forward with such gusto -aims to remedy these weaknesses so we can build on the NHS great strengths.
We started by putting new national standards and systems of independent inspection in place. I identified certain services as priorities – cancer, CHD, elderly care, mental health and then diabetes. Each priority was given a plan for improvement (a national service framework) backed by clear targets, earmarked resources and clinical directors to provide national leadership for the staff and patients working in local collaborative programmes.
With a national framework of standards then in place the next phase of reform was to empower these local efforts by devolving decision-making. We soon learned that a million strong NHS could not be run from Whitehall. Our reforms are helping move health care in Britain from a 1940s model – top down and centralised – to a 21st-century model where there are national standards but where control is local.
Today three-quarters of the total NHS budget is controlled by 300 locally run primary care trusts purchasing care from public, private, voluntary or not-for-profit providers. An explicit reform objective is to encourage greater plurality in service provision so that capacity grows and responsiveness to patients improves. PCTs now hold three year budgets allowing them to reshape local services around local needs. There is a greater emphasis on prevention. More intermediate care alongside hospital care. Greater integration between health, housing and social services so that patients – older people especially – can be treated and cared for in the community.
As the WHO and others have rightly argued, meeting the challenge of chronic disease requires a paradigm shift away from episodic treatment – often in hospitals – towards earlier, preventative action and continuity in treatment within the community. The growing burden of chronic disease is driving the crucial relationships in health care to become ever more local. That’s why the new NHS Foundation Hospitals will be run by local people not national politicians.
Modern health care means embracing the public as partners not as passive recipients. It is not just that there is a more inquisitive and demanding public less willing to accept that politicians or professionals always know best. The evidence suggests that the informed and involved patient is a better patient. In arthritis care for example educating patients and increasing their role in self-management has been shown to produce better outcomes. Patients with chronic conditions have to live with their condition every hour of every day. They need to have a greater role and a bigger say in their own care.
The implications for relationships between patients and health care professionals are profound. Professionals need to take patients into their confidence. Communicate better. Acknowledge risks as well as benefits. Actively seek consent. Own up to mistakes not cover them up. Earn trust, not assume it. Be accountable. This recasting of the relationship between professionals and patients is perhaps the most difficult cultural challenge facing health care reform but it is amongst the most important.
Public services do not belong to professionals, still less to politicians – they belong to the public who use them and fund them. Services – private or public – only succeed if they respond to modern expectations. In today’s consumer age they have to be tailor made to the needs of the user, not mass produced to the convenience of the producer.
That required a lengthy and sometimes contentious process to reform NHS pay systems. It required traditional professional demarcations to be broken down. It required the NHS to be opened up to public scrutiny and league tables on local service performance. It required the NHS to become a purveyor of information and advice – through new services like NHS Direct – as well as a provider of treatment.
All of these reforms were resisted but all were required. All are now in place. As John Reid puts it they are about creating a modern service, fair to all personal to each.
A modern health service is one in which patients can exercise more power. And that means more choice. In Britain we are moving to a system where, for the first time, within the NHS, patients can choose the hospital and the time of treatment best for them. And because resources will follow the choices patients make it will provide real incentives for improvements in performance. The next challenge is to make choice available not just over hospitals but over individual consultants, over GPs and over other NHS services. It will take time to get there of course. But these reforms are putting patients in the driving seat.
And giving patients more rights makes it easier to require more responsibilities. To use services appropriately. To treat health care professionals respectfully. To help others through blood donation or organ donation. To acknowledge that there are limits to what any health care system can provide. To contribute to their own health and wellbeing. To give as well as to take.
I believe this will be the next great challenge. The next key area of reform. How to move the health debate in our country which for too long has been focussed on the state of the nation’s health service onto the state of the nation’s health. The challenge posed by chronic disease calls for renewed emphasis on prevention as well as treatment. Our ambition today must be to fashion for our country health services and not just sickness services.
In the last six years we have started to rise to that challenge, drawing on our great strength in public health, especially in primary care. A new GP contract now provides incentives for family doctors to raise quality and prevent illness. Directors of public health have been appointed in all local PCT areas. Public health teams now work alongside officials responsible for regeneration, housing and planning in each government regional office. The unparalleled leadership provided by Prof Sir Liam Donaldson, the Chief Medical Officer, has been augmented by the creation of a specialist Health Development Agency and a Food Standards Agency. Progress has also been driven by extra resources for deprived areas, new screening and preventative programmes and the first ever targets to reduce health inequality.
Across government there is a shared determination to narrow Britain’s health gap. When Labour first came to office in 1997 we established an inquiry, led by Sir Donald Acheson, the former CMO, into health chances. His conclusion was stark and simple. Poorer people get sick more often and die earlier. For over fifty years the health gap between the better off and the worst off had widened, not narrowed. Even today a boy born in Manchester will live on average a decade less than a boy born in Dorset. Chronic disease contributes to this yawning health gap because it often has such a strong social class gradient. Unskilled men, for example, are three times more likely to die from heart disease than professional men.
Social inequality breeds health inequality. Poverty cascades down the generations. Up to a quarter of all children are persistently in low income families. Babies born to fathers in social class five are more likely to be low birth weight. Low birth weight is a key factor in a child’s subsequent development and opportunity. Poor children are less likely to get qualifications and to stay on at school. Poor health then is linked to low educational attainment, which is not only bad for the individual but also bad for the nation. In a globalised economy success depends on harnessing the skills and potential of all our people. Ill health is an economic drain on the country’s resources. The health gap is an impediment to the sort of society we wish to create: one based on fairness and justice, in which each citizen gets the opportunity to fulfill the potential of all their talents.
A healthier nation calls for a fairer society. It was this recognition which lay behind the Government’s action plan to address health inequalities. The job of improving health became one for the whole of government rather than a part of it – just as it is a job for business, local communities and individuals too. So the Treasury introduced new tax credits to raise living standards of millions of poorer families. Unemployment has been reduced. There are a record number of people in work. The education department is investing in early years provision linking health and education through the Surestart programme. The transport department is improving public transport in deprived communities. With local government the housing stock is being improved. There is a long way to go but progress is now underway, not least first in reducing child poverty, then abolishing it by the year 2020.
Now is the time to go further faster in our determination to make Britain fairer by focusing harder on tackling health inequalities. The paralysing debate of the past about whether anything could be done to tackle health inequalities is now being won. Some argued they were the product of such deep-rooted social and economic factors that action by the NHS or other agencies would merely scratch the surface. Others argued – even when they were in government – that it is individuals rather than society to blame. Both analyses became recipes for hopelessness and inaction.
Today there is a new outlook. There are wider determinants of ill health – and a broad programme of action is necessary to deal with them. But the NHS can make a specific contribution to improving health prospects by working with the communities it serves: making the task of tackling health inequality something done with local people not just done to them.
This approach recognises that diets are often less healthy and smoking rates are higher in poorer communities. It acknowledges that while people have the right to make a choice about what they eat or whether they smoke, they should have the opportunity of a healthier diet or to give up smoking if they so choose. Many are denied that opportunity because healthy food has not been available locally or because help to give up smoking has not been available freely. Providing new opportunities allows us to then ask people to take greater responsibility for their own health.
Elsewhere I have argued that the modern job of progressive governments is to redistribute opportunities in society. More affordable childcare, more chances for people to own their own homes, more choice over hospitals and schools. These are new routes to social justice. So too is the opportunity for better health. Achieving it needs a better balance between prevention and treatment. Last year Sir Richard Peto said current medical expertise could potentially halve the rate of premature death worldwide. Healthy eating could reduce by one-fifth deaths from cancer, stroke and heart disease. Fruit and vegetable consumption in our country is among the lowest in Europe and still less in lower income groups. The introduction of local five-a-day initiatives and free fruit in schools shows that those trends can be reversed.
I believe we should go further still. Within the next year Government should organise a national summit involving the NHS, consumer groups, retailers and the food industry to decide what action can now be taken to improve diet in our country. Specifically an ultimatum needs to be placed before the industry that unless it voluntarily cuts fat, sugar and salt in food within a specified time frame then tough regulatory action will be taken to ensure that it does so. The summit could also discuss how to make greater choice over healthier food available in local communities and local schools. In the meantime I hope Ministers will take swifter action to remove fast food, soft drink and confectionery machines from all schools.
Together with the work being done to encourage greater exercise, these opportunities to improve diet can help stem the rising incidence of obesity. More exercise on prescription and new incentives for people to join gyms could also make a difference.
Already the Government’s efforts to help the 7 in 10 smokers who say they want to quit are paying dividends. As our 1998 White Paper starkly put it: smoking kills. It kills about 120,000 people each year in Britain. It is the main avoidable cause of death. It is the principal cause of the inequalities in death rates between rich and poor. Smoking is a public health disaster.
That is why we targeted special help on lower income and on pregnant women. Promoting and advertising tobacco was banned by law. Resources were invested in public information and education campaigns. And today the NHS provides a genuinely world leading smoking cessation service, helping hundreds of thousands of smokers to quit. Smoking rates have fallen and the largest falls have been in manual occupations. Progress could be enhanced still further by allowing local authorities to conduct local referenda and to enforce local bans on smoking in public places.
There is little doubt future trends will accelerate the drive towards this renewed focus on prevention. Technological advance will take monitoring and treatment out of the hospital into the community and eventually into the home. Electronic records will give patients greater control. And in time, the genetics revolution should move health care from a model based on diagnosis and treatment towards one that predicts and prevents disease. We have tried to anticipate tomorrow’s developments by making investments today – in IT and in genetics in particular.
I do not pretend for a moment that we in England have got all the answers. Or that despite the progress that has been achieved there is anything other than a long way to go. But I do believe there are important lessons that can be learned from our experiences in this country in trying to meet the challenge of chronic disease worldwide.
The first lesson is simple. Anticipate the future rather than simply letting it happen. The writing is already on the wall. Chronic disease is big and it is growing. What has happened in the developed world is now happening in the developing world. Globalisation brings many benefits but it brings costs too. In China obesity among young children has increased eight-fold in just ten years. Worldwide, mass marketing of foods and drink high in calories, fat and sugar is replacing traditional diets rich in fruit and vegetables. The same is true for tobacco consumption. Lung cancer is rising in countries as diverse as Korea and Jordan as smoking rates increase. Unless these trends are halted the cycle of poverty and ill-health will be intensified and developing health care systems will be stretched to breaking point. Action taken today can make a difference tomorrow.
Secondly, then, chronic disease needs to receive new priority internationally. Of course the fight against AIDS and malaria and TB must be deepened. But the front on which the battle against ill health is fought must now be broadened. And the developed world must do more to help the developing world. The WHO’s Framework Convention on Tobacco Control is the best instance to date of the global community standing together to promote good health. Similar internationally agreed action – between the WHO, G8, WTO, EU and others – is needed on food and drink products.
Thirdly, new resources are needed to fight chronic disease. Health care should be seen as a credit not a debit. An activity that makes an immense contribution both to well-being and economic progress. Improving health is a long term business. It needs patience. And it needs long term investment. The success of the Global Fund in providing dedicated resources to fight AIDS, TB & malaria points the way. In my view a new global fund is needed to begin to win the battle against chronic disease.
Fourthly, improving health is not just a job for health ministries. It can only be achieved by tackling both the causes and consequences of ill health and inequality. Of course that requires cross government action. It also requires the involvement of business, local communities and individuals themselves.
Fifthly, since so much chronic disease is preventable, a new deal between governments and citizens is needed. The job of government is to provide opportunities for better health, particularly for those who would otherwise be condemned to a life of poor health and premature death, so that citizens themselves can take greater responsibility for their own well-being.
Sixthly, health care systems need to be reformed to reorientate them to the challenge posed by chronic disease. The old re-active model of the last century needs to give way to a more proactive model in this. Where the new deal between state and citizenry gives patients more control and greater choice. Where there is a new focus on prevention with investment in primary care infrastructure and a leading role for primary care in commissioning. It is not less reform that is needed. It is more.
A century or more ago the foundations were laid in the developed world for a future of better health and longer lives. The communicable diseases that had claimed millions of lives in the 19th century were beaten in the 20th century by clean water and safe sewage, the discovery of new vaccinations and the start of mass immunisation programmes. Today new foundations need to be laid if we are to beat the threat posed by chronic diseases. Just as those health care pioneers 100 years ago came to realize that prevention is better than cure, faced with new challenges we need to come to the same insight today.
The challenge is real. Progress is possible. Resources and reforms are both needed. Your conference is an important step towards a better future and a healthier world.