1 A modern and dependable NHS

there when you need it Key themes £1 billion from red tape into patient care NHS Direct - 24-hour nurse helpline NHS information superhighway guaranteed fast-track cancer services The new NHS 1.1 The Government is committed to giving the people of this country the best system of health care in the world. At its best the National Health Service is the envy of the world. But often it takes too long for patients to get treated. Quality is variable. And NHS staff feel too much of their time and effort is diverted from treating patients into pushing paper. This White Paper explains how the Government, working with those one million staff, will build a modern and dependable health service fit for the twenty first century. A national health service which offers people prompt high quality treatment and care when and where they need it. An NHS that does not just treat people when they are ill but works with others to improve health and reduce health inequalities. 1.2 Achieving this vision means we have to change our approach to tackling ill-health and inequality. The Government will ensure the NHS works locally with those who provide social care, housing, education and employment, just as the Government itself will work nationally across Whitehall to bring about lasting improvements in the public's health. The forthcoming Green Paper Our Healthier Nation will outline this strategy in more detail. 1.3 But we also have to change the way that the NHS itself is run. The introduction of the internal market by the previous Government prevented the health service from properly focusing on the needs of patients. It wasted resources administering competition between hospitals. This White Paper sets out how the internal market will be replaced by a system we have called 'integrated care', based on partnership and driven by performance. It forms the basis for a ten year programme to renew and improve the NHS through evolutionary change rather than organisational upheaval. These changes will build on what has worked, but discard what has failed. 1.4 The needs of patients will be central to the new system. Abolishing the internal market will enable health professionals to focus on patients, making the NHS better every year. Individual patients, who too often have been passed from pillar to post between competing agencies, will get access to an integrated system of care that is quick and reliable. Local doctors and nurses, who best understand patients' needs, will shape local services. Patients will be guaranteed national standards of excellence so that they can have confidence in the quality of the services they receive. There will be new incentives and new sanctions to improve quality and efficiency. Frontline patient services will be backed by more investment and better technology. These changes will bring a more responsive and dependable service to every community in England. 1.5 The Government has committed itself anew to the historic principle of the NHS: that if you are ill or injured there will be a national health service there to help; and access to it will be based on need and need alone - not on your ability to pay, or on who your GP happens to be or on where you live. The NHS has stood the test of time for fifty years. But the Government was elected with a mandate to change the NHS for the better. This White Paper will modernise the NHS so that it is prepared for the next fifty years. The Goverment's Commitment If you are ill or injured there will be a national health service there to help: and access to it will be based on need and need alone - not on your ability to pay, or on who your GP happens to be or on where you live. 1.6 The speed of change in science and medicine and the potential of modern information and communication systems require the NHS to embrace change. A modern and dependable national health service will capture developments in modern medicine and information technology. It will be built around the needs of people, not of institutions and it will provide prompt reliable care. It will learn from those at the leading edge of good practice and will make the best available to all. 1.7 Realising this vision of a modern and dependable NHS means providing: at home: easier and faster advice and information for people about health, illness and the NHS so that they are better able to care for themselves and their families in the community: swift advice and treatment in local surgeries and health centres with family doctors and community nurses working alongside other health and social care staff to provide a wide range of services on the spot in hospital: prompt access to specialist services linked to local surgeries and health centres so that entry, treatment and care are seamless and quick. 1.8 Some of these developments are already available to some patients, but not everywhere. The Government wants to see them available to all as part and parcel of the new NHS. 1.9 This is an ambitious programme which cannot happen overnight. It will be achieved over ten years with demonstrable improvements each year. We have already made a start. The process of modernisation began on May 2nd, the day after the election. Since then the worst excesses of the internal market have been tackled and extra resources devoted to patient care. 1.10 The changes in this White Paper will take forward the modernisation of the NHS. The Government has pledged to cut waiting lists for hospital treatment. By the end of this Parliament we will have done so. But more needs to be done at all levels if the vision is to be made real. Three developments will symbolise our new approach. 1.11 At home: we will provide easier and faster advice and information through NHS Direct, a new 24 hour telephone advice line staffed by nurses. We will pilot this through three care and advice helplines to begin in March 1998. The whole country will be covered by 2000. 1.12 In the community: patients will benefit from quicker test results, up-to-date specialist advice in the doctor's surgery and on-line booking of out-patient appointments, when we connect every GP surgery and hospital to NHSnet, the NHS's own information superhighway. It could also mean less waiting for prescriptions in the pharmacy because of electronic links between GPs and pharmacists. As a first step, by the end of 1998 demonstration sites will be established in every Region to pilot how the NHSnet can be used to bring direct benefits to patients. As a second step, by the end of 1999 all computerised GP surgeries will be able to receive some hospital test results over NHSnet. By 2002, these services will be available across the country. 1.13 In hospital: we will improve prompt access to specialist services so that everyone with suspected cancer will be able to see a specialist within two weeks of their GP deciding they need to be seen urgently and requesting an appointment. We will guarantee these arrangements for everyone with suspected breast cancer by April 1999 and for all other cases of suspected cancer by 2000. 1.14 These developments, along with the pledge to cut waiting lists, will chart progress to a quicker and more responsive NHS. They will demonstrate that services to patients are getting better every year.

The Challenge 1.15 Some say that this vision is not just ambitious, but unachievable; that tailoring the NHS to meet the needs of individual patients is simply beyond its capacity. They believe that the NHS is being overwhelmed by three big pressures: growing public expectations, medical advances and demographic changes. 1.16 It is certainly true that people do expect more, especially in speed of service and range of treatment. The pace of medical advance does create demands for new techniques to be assimilated and spread. And rising numbers of elderly people are looking to the NHS for a level of active treatment which would have been unimaginable in the past. 1.17 Those who argue that the NHS cannot accommodate these pressures say that it will need huge increases in taxation, a move to a charge-based service, or radical restrictions in patient care. 1.18 The Government rejects this analysis. So do the public. The recent British Social Attitudes Survey showed that three-quarters of people want the NHS to remain a universal health service. Two-thirds believe that health care should be available to all on the basis of need, not ability to pay. Nor are the arguments in favour of rationing or charging convincing. 1.19 First, the pressures on the NHS are exaggerated. Indeed they have always been exaggerated. It was Nye Bevan who noted some 50 years ago that "expectations will always exceed capacity". Rising public expectations should be channelled into shaping services to make them more responsive to the needs and preferences of the people who use them. Many women, for example, have welcomed the opportunity to plan the arrangements for the birth of their child with midwives as well as doctors. Our new NHS Charter will balance the patient's rights of access to NHS services with their responsibility to use services wisely. 1.20 The health service is a strong and resilient organisation. It has risen to daunting challenges over the past ten years, such as AIDS, more operations for coronary artery bypass grafts, and new drugs for stomach ulcers. Of course many new problems lie ahead but not all will increase the health care bill. As technology advances, allowing less invasive and hence cheaper treatments, costs in certain areas will be reduced. Heart catheters, in some cases, could increasingly replace bypass grafts, for example, or more day surgery could reduce expensive inpatient care. Taking a longer term view, the Government's new emphasis on improving public health and tackling inequalities will also help. 1.21 Likewise demographic pressures can be overstated. Over the next decade the NHS expects to provide services for an extra 100,000 people aged 85 and over; but that is just one-third of the increase that it has coped with over the last decade. Demographic pressures 1.22 Second, the choice posed between unaffordable levels of funding or charges and rationing is a false dilemma. No-one denies that the NHS needs more money every year. With this Government the health service will get it. We are committed to increasing spending on the NHS in real terms every year. But there are three other changes that will ensure better value for money in the NHS: the NHS needs to make better use of its resources. The internal market has driven up administrative costs. The Government's changes will reduce costs by £1 billion over the lifetime of the current Parliament. Fragmentation in decision-making has lost the NHS the cost advantages that collaboration can bring. Cooperation and efficiency go hand in glove. The proposals in this White Paper will produce a new drive on efficiency, quality and performance in the NHS the NHS should harness new developments rather than be driven by them. There are already mechanisms in place to evaluate new technologies, and to measure the clinical and cost-effectiveness of treatments. NHS funded research has, for example, already shown that universal screening for prostate cancer would not be worthwhile and new approaches to prescribing in primary care are helping to deliver better care at lower cost. But the take-up of research findings on clinical and cost-effectiveness is uneven and unsystematic. For example there are big variations in day case rates. In order to sustain the NHS, while making it both modern and dependable, this White Paper proposes a new drive for quality. Two new national bodies will lead rigorous assessment of clinical and cost-effective treatments and will ensure good practice is adopted locally decisions about how best to use resources for patient care are best made by those who treat patients - and this principle is at the heart of the proposals in this White Paper. For the first time in the history of the NHS the Government will align clinical and financial responsibility to give all the professionals who make prescribing and referring decisions the opportunity to make financial decisions in the best interests of their patients. That will better attune local services to meet local needs. But the Government will set a framework of national standards and will monitor performance to ensure consistency and fairness. 1.23 There is another reason why it makes sense to sustain the NHS as a universal service. The health of the economy depends on the health of the NHS. It helps ensure a healthy workforce. But it does much more besides. The NHS funded through general taxation is the fairest and most efficient way of providing health care for the population at large. Systems in other countries cost more, are less fair, and deliver little overall extra benefit. The cost-effectiveness of the NHS helps to reduce the tax burden to well below the European Union average, encouraging investment and strengthening incentives to work and save. The alternatives - rationing or a 'charge-based' system - would dissipate these advantages. 1.24 But it is clear there are tough choices facing the NHS. It has to improve its performance if it is to deliver the sort of services patients need. There will have to be big gains in quality and big gains in efficiency across the whole NHS. The two go together. They will bring about marked improvements in services to patients over the next ten years. This White Paper spells out how the NHS will meet that challenge. There can be no standing still. The next two chapters outline the Government's approach. The subsequent chapters set out the arrangements in detail, showing how they will work in practice. They are the means to deliver a modern and dependable health care system that will once again lead the world. A new NHS for a new century.

© Crown Copyright 1997

Prepared 8 December 1997