Introduction
I want to speak today about the future of our National Health Service. There is no place more fitting to do so than here at the Royal Free.
More than one hundred years before the NHS was conceived, the surgeon William Marsden discovered a young girl dying on the steps of St Andrew’s Church in Holborn but could not find a hospital prepared to take her in. He was determined this should not happen again.
So he set up the Royal Free to provide healthcare for anyone who needed it, free at the point of use, regardless of background or income.
A century later this principle of fairness became the defining creed of our National Health Service.
From life-saving treatment to managing a life-changing condition – whoever we are, whatever our means, we know the NHS is there for us when we need it.
It was there for me when I was diagnosed with Type 1 diabetes. I will never forget the support – not just of my GP and consultants – but also the clinical nurse specialists attached to my local hospital. Their advice was critical: enabling me to adjust to the new treatment regime, to manage my condition, and minimise the impact it has on my life.
I would not be doing the job I am doing today without that support.
But as Prime Minister, I don’t just get to see how the NHS helps me. I see how it helps other people when they need it most.
I will never forget visiting the Royal Manchester Children’s Hospital in the aftermath of the Manchester Arena attack.
There, in the face of the very worst that humanity can do, I witnessed first-hand, the very best.
Doctors and nurses working 24 hour shifts to treat the injured.
And surgeons who were off-shift, dropping everything to come in and perform life-saving operations.
In every instance, I was struck not only by the medical expertise of the staff, but the compassion with which people were treated.
Alongside the horror and anger over what had happened, I felt once again that deep sense of pride we all share in our National Health Service — and a humbling gratitude for the incredible people who work within it.
This is our National Health Service.
This is the model of healthcare that reflects our values as a people.
Our shared belief that no-one should face illness or injury alone.
That no-one should be denied medical treatment because they cannot afford to pay for it.
And that this great national institution that is there for us from cradle to grave should remain in public hands…not just now, not just for the next seventy years, but forever.
So today, as it approaches its 70th birthday, I want to talk about how we preserve those values of fairness on which our NHS was founded whilst building the NHS of the future; ensuring that it will be there for our children and grandchildren and beyond, just as it has been there for us in the past.
Our record
The NHS was the crowning achievement of the post-war Labour Government. It is why, in the Members’ Lobby of the House of Commons, Attlee stands alongside Lloyd George, Churchill and Thatcher as one of the four great 20th Century Prime Ministers.
But the NHS does not belong to a single political party.
The coalition government that led the country through the Second World War proposed the idea.
It was born of a national determination that the country we would build after the ravages of war should be a fairer and more civilised nation.
A nation where the giant evils of squalor, ignorance, want, idleness and disease should be tackled by collective effort.
There was a cross-party consensus on the core principles that underwrite our NHS.
In its 70 years it has been under the stewardship of Conservatives for 43 years – and Labour for 27 years.
And throughout that time its core values have endured.
When we took office in 2010, we recognised its unique importance.
At a time when we had to make difficult decisions on government spending in order to deal with the deficit left by to us, we protected and prioritised the NHS with real terms increases in spending each and every year.
That investment has delivered significant improvements for patients.
Clinical outcomes are better for almost every condition, with for example 7,000 more people alive today due to improved cancer survival.
The number of staff recommending the care of their own organisation in the ‘friends and family test’ has never been higher.
We are leading one of the largest expansions of mental health services anywhere in Europe.
And last year independent experts rated our NHS as the best and safest health system in the world for the second time running.
But it is also true that because of the difficult decisions we had to take to fix our public finances, the increases in NHS spending in recent years have been lower than the NHS has seen in the past.
And over the same period the demands on our health service have grown.
Much of this growth is a consequence of other welcome developments.
As we grow wealthier as a nation it is natural that we would want to spend more of our national income on being a healthier nation too.
Medical research and scientific discoveries mean there are more and better treatments available.
And we are living longer than ever before, but that often means people living with multiple complex conditions.
Other causes of the increase in demand are more concerning.
Malnutrition has given way to obesity as the great threat to our children’s healthy development.
Our mental health is under growing pressure in modern society.
Research shows that loneliness is as damaging to our physical health as smoking 15 cigarettes a day.
The internet has brought countless opportunities, but we are only beginning to understand the risks it might also pose to our mental wellbeing.
So for reasons good and bad, the NHS is facing rising demands for more treatment, for more people, for longer and for ever more complex care.
This has meant that despite more funding, more doctors and more nurses, and great progress on treatments, our NHS is under strain.
Our NHS staff are rightly proud of what they do, but they worry that their current workloads are not sustainable.
But it is not just a question of money.
Patients admire the NHS, especially when it responds to an emergency like a heart attack. But when they try to book an appointment with a busy GP, or get some help for a relative with multiple conditions, too often they can be frustrated by a complex, hard to navigate system.
We have hospitals that are world leading for patient care, but others that lie too far behind the best.
As the NHS approaches its 70th birthday, it is the right moment to look again at how we secure the future of the NHS: now and for generations to come.
Long-term funding
Let me start with funding.
It is clear that more money is needed to keep pace with the growing pressures on the NHS.
But it is not just a question of more money this year or next. To meet these pressures and deliver the world-class care that we all want and expect, the NHS needs to able to plan for the future with ambition and confidence.
Over the last seventy years increases in health funding have often been inconsistent and short-term – creating uncertainty over what the funding position will be in as little as two years’ time.
This has led to a system of planning from one year to the next, preventing much needed investments in technology, buildings and workforce.
We cannot continue to put a sticking plaster on the NHS budget each year.
So we will do more than simply give the NHS a one-off injection of cash.
Under our plan, NHS funding will grow on average by 3.4 per cent in real terms each year from 2019/20 to 2023/24. We will also provide an additional £1.25 billion each year to cover a specific pensions pressure.
By 2023/24 the NHS England budget will increase by £20.5 billion in real terms compared with today. That means it will be £394 million a week higher in real terms.
So the NHS will be growing significantly faster than the economy as a whole, reflecting the fact that the NHS is this government’s number one spending priority.
This money will be provided specifically for the NHS. And it will be funded in a responsible way.
Some of the extra funding I am promising today will come from using the money we will no longer spend on our annual membership subscription to the European Union after we have left.
But the commitment I am making goes beyond that Brexit dividend because the scale of our ambition for our NHS is greater still.
So, across the nation, taxpayers will have to contribute a bit more in a fair and balanced way to support the NHS we all use.
We will listen to views about how we do this and the Chancellor will set out the detail in due course.
We should be clear that we are only able to make this funding offer because we have managed the public finances responsibly.
It is because of our balanced approach: to reduce debt as a share of GDP, to keep taxes as low as possible – and to invest in our public services.
So we will stick to our fiscal rules, reduce our debt but prioritise our NHS within public spending.
We also know we need to improve social care and continue to support prevention and public health, both for the benefits they bring in themselves and to relieve pressure on NHS care.
So we will come forward with proposals to put social care on a more sustainable footing. And we will set out budgets for both social care and public health as part of the forthcoming Spending Review.
But equipping our NHS for the future is about more than what we put in. It also depends critically on what we all get out.
In 2002, the then Labour Government significantly increased NHS funding, but much of this did not go on directly improving patient care.
That cannot happen again.
So in return for this increase in funding, the government will agree with the NHS later this year – a ten year plan for its future.
This must be a plan that ensures every penny is well spent.
It must be a plan that tackles wastes, reduces bureaucracy, and eliminates unacceptable variation, with all these efficiency savings reinvested back into patient care.
It must be a plan that makes better use of capital investment to modernise its buildings and invest in technology to drive productivity improvements.
It must be a plan that enjoys the support of NHS staff across the country – not something dreamt up in Whitehall and centrally imposed.
But NHS leaders at national and local level must then be held to account for delivering this plan.
This includes ensuring that over the medium term no NHS organisation is in financial deficit.
And it includes getting every part of the health service back on the path to delivering core performance standards so patients are never left waiting when they most depend on the NHS, whether that’s for life-saving emergency care or treatment for cancer.
Vision
The founding of the NHS was remarkable because it changed the nature of healthcare as we knew it.
We now have the opportunity for a similarly profound transformation.
At its heart it is about building an NHS around the needs of the patient. Taking the principle that the NHS provides care no matter who you are or what your means and transforming it into the principle that everyone deserves the right care, in the right setting, at the right time.
To do this we need to break down the barriers between providers so that staff and patients are empowered to work together across organisations – so that we have a health and social care system that addresses your physical, mental and social care needs together, not as separate problems to be dealt with in isolation.
We will need a workforce that is empowered to deliver the best possible outcomes, flexible enough to adapt to new models of care and valued for their commitment to our NHS.
We have the opportunity to lead the world in the use of data and technology to prevent illness, not just treat it; to diagnose conditions before symptoms occur, and to deliver personalised treatment informed not just by general understanding of disease but by your own data including your genetic make-up.
If we want not just to cope with an ageing population, but thrive too, we will need a renewed focus on prevention.
And finally we will not have succeeded in building the NHS of the future unless we recognise the importance of looking after our mental health, just as much as our physical health, and we put the resources in to mental healthcare to make that a reality.
So these are my five priorities: Putting the patient at the heart of how we organise care; a workforce empowered to deliver the NHS of the future; harnessing the power of innovation; a focus on prevention, not just cure; and true parity of care between mental and physical health.
I know that all of this is possible because much of it is already happening in parts of our NHS right now.
Sharing best practice across the NHS
Indeed, the NHS we want to build for tomorrow can already be found in the very best of the NHS today.
We see it in the Royal Marsden Hospital and its academic partner, the Institute of Cancer Research, ranked as one of the top four centres in the world for cancer treatment.
We see it in innovative examples of integrated care – like in mid-Nottinghamshire where teams of different professions and staff from the NHS and Local Authority have worked together to reduce hospital admission by 6 per cent and care home admission by 20 per cent.
We see it in new models of social prescribing – like in Somerset where over 400 local care providers and volunteers are working together to support those whose health is being affected by loneliness.
We see it in outstanding NHS leaders who are using their expertise to improve other organisations – just as David Sloman and the team here at the Royal Free have been doing with Barnet and Chase Farm; and now with North Middlesex.
At its best the NHS is world class. But for decades it has been a challenge to spread that best practice.
When I brought together some of the most outstanding NHS leaders, they told me why.
Those who were innovating felt they were going against the grain. They described the competing incentives that lead to negotiations between different organisations at every step, and business cases and templates that seem to put process ahead of patients.
Those who were taking on struggling trusts said their organisations were not compensated for their effort and wasted too much time on reporting.
As one Chief Executive put it – sometimes you can spend so long reporting and providing assurance about the organisation you are trying to help, that you don’t actually have time to do the work that’s needed.
So a critical part of the long-term plan for our NHS must be to change this.
As Nye Bevan said at the Second Reading of the NHS Bill – our intention is that “…we should universalise the best, that we shall promise every citizen in this country the same standard of service.”
Our long-term plan must empower NHS leaders to spread the very best of the NHS to every part of the country.
It must properly recognise and reward those who do so and hold those responsible for poor performance to account.
It must also make it easier to break down the barriers between different organisations to deliver integrated patient-focused care.
So people don’t feel like a pinball in a machine, bounced from one part of the system to the next, re-explaining to the next healthcare professional what they had just said to the previous one.
And so they don’t end up stuck in hospital when they could be better cared for in the community or at home; or waiting to see a GP when they could be at a pharmacy or getting help over the phone or online.
For example, as many as one third of people in hospital stay longer than they need to medically because they can’t get the care they need in the community in time.
Yet for people aged over 80, 10 days of bed rest in hospital leads to the equivalent of ten years of muscle ageing.
Ensuring people get the right care in the right place at the right time is not just about what is most efficient for the NHS. It is fundamental to the quality of care.
Building the workforce we need for the future
To deliver such a transformation right across the NHS, we must invest in the workforce to deliver it.
Our NHS staff are the lifeblood of our NHS.
They care for a million new patients every 36 hours.
They are the doctors and nurses who look after us – not only with clinical expertise but with compassion.
They are the researchers and pioneers at the cutting edge, creating new NHS treatments.
They manage the GP surgeries, outpatient clinics and operating theatres that we all rely on.
And they will bring about change if they are empowered – and if we have enough of them with the right training and the right skills.
Today there are nearly 42,000 more clinical staff working in our NHS than there were in 2010.
But to those working tirelessly on the front line, too often it doesn’t feel like that.
Growing demand and increasing complexity have led to a shortfall in staff. So our ten year plan for the NHS must include a comprehensive plan for its workforce to ensure we have the right staff, in the right settings, and with the right skills to deliver world class care.
Recruitment takes time. Students entering medical school this autumn will not become consultants until the early 2030s. So we will consider proposals from the NHS for multi-year funding for training places.
We will also need to create a more flexible workforce: with new routes into medicine and healthcare – building on the work to create new apprenticeships and the Nursing Associate Programme – and more diverse roles with the right skills to enable the holistic care we want to see.
More immediately we will act to increase the number of trained healthcare professionals in those areas of the NHS that are experiencing the greatest pressures.
So we will look at how we can support those with clinical training who are no longer in frontline roles, to return to patient care in some way.
And we are taking doctors and nurses out of the Tier 2 Visa Cap with immediate effect.
But the long-term plan also needs to do something more fundamental to make sure we train enough of our own people to work in our NHS and ensure we do enough to keep them.
It cannot be right long-term to rely so heavily on highly qualified health professionals from parts of the world where they can be desperately needed.
To do that we need to make careers in the NHS more attractive.
We need to recognise that today working practices in the NHS have not caught up with modern lifestyles.
Think of the nurse working beyond his shift for the fifth day in a row who can’t pick up his children from school.
Think of the junior doctor with limited choice about where and when she works who has to alter her plans because rotas are changed at the last minute without her having any say.
Many people working in our NHS will look at the flexibilities their friends and families enjoy and see that their own jobs don’t offer anything like the same.
And the same is true of career development.
Too often this is based around an assumption that people will want to do the same type of job for most of their career. For some that might be right, but others would embrace opportunities to learn new skills, take on new roles with new types of responsibility.
To change this, the long-term plan must fundamentally reset the deal between the NHS and its staff.
It is right that we lifted the pay cap and made a significant pay increase a core part of the new offer to over a million NHS staff.
But we must also take better care of staff and offer greater flexibility over where they work, when they work and what they can do.
We must do more to support the development of staff and provide meaningful opportunities to move between different organisations and into new roles.
And above all we need to listen to what staff themselves say about the support they need as they continue to deliver world class care in ever more complex clinical environments.
These things are often just as important as pay.
In short, we need a workforce strategy to make the NHS not just one of the world’s largest employers but one of the very best.
Embracing the opportunities of technology
New technologies are making care safer, faster and more accurate, and enabling much earlier diagnosis.
They are enabling greater self-care with new devices that give more independence to those managing different health conditions.
And they are transforming how we engage with the NHS so we can get the advice we need, when we need it and in the way we want to receive it.
Just last week, I hosted over 180 tech entrepreneurs and investors in Downing Street to celebrate London Tech Week.
It was fantastic to see some of our leading artificial intelligence technology in action.
This included a programme called Xim’s Lifelight, which is trialling the use of a webcam to detect early warning of health problems.
I am determined to position the UK at the forefront of the revolution in Artificial Intelligence and other technologies that can transform care and create whole new industries in healthcare, providing good jobs across the country.
This is why we identified AI and responding to our ageing society as two of the Grand Challenges in our Industrial Strategy.
Our first two missions within those Grand Challenges are to use AI to diagnose at least 50,000 more people with cancer at an earlier stage within 15 years; and to give people five more years of healthy, independent, living by 2035.
And all of this underpinned by the additional £7 billion we have allocated to research and development.
There are already devices that combine with smartphones to enable sophisticated home self-care and remote monitoring.
From blood pressure cuffs to smart inhalers and remote sensors that can detect changes in heart rhythm and track them on your phone.
Systematically implementing digital innovations with the strongest evidence base will have a transformative effect.
I have seen the beginnings of that myself.
As a Type 1 diabetic, I have recently changed the way I monitor my blood sugar so I don’t need to prick a finger for blood so often.
And when I attended the Juvenile Diabetes Research Foundation awards earlier this year, I heard about an artificial pancreas in development that could dispense altogether with the need for multiple daily insulin injections.
We also need to invest in technology to improve the way care is delivered.
This includes pioneering the further development of a vast array of apps which allow people to access health support online, by email, by phone or face to face depending on what they need, what they want, and what is convenient to them.
Put simply, our long-term plan for the NHS needs to view technology as more than supporting what the NHS is doing already.
It must expand the boundaries of what the NHS can do in the future, in the fastest, safest and most ambitious way possible.
A renewed focus on the prevention of ill-health
My next priority for the ten-year plan is to create a renewed focus on the prevention of ill-health.
Whether it is cancer, heart disease, diabetes or a range of mental illnesses, we increasingly know what can be done to prevent these conditions before they develop – or how to ameliorate them when they first occur.
This is not just better for our own health, a renewed focus on prevention will reduce pressures on the NHS too.
As a government, we are committed to national action where we believe this can help people to make healthier choices.
That is, for example, why we published our world leading childhood obesity plan in 2016 and why we will be taking this further in the coming weeks.
But I want our long-term plan for the NHS to help every individual at a more personal level.
For we can increasingly use world-leading expertise in genomics to understand the risks to our own individual health.
And we can draw on cutting edge technology to monitor a condition and identify the actions we can take to remain healthy.
For example, NHS England, Public Health England and Diabetes UK are creating apps and wristbands that will help those at risk of type 2 diabetes prevent or delay the onset of this disease.
This is just the beginning of what can be possible.
Over the next decade, I want the NHS and its partners to develop ways to deliver much more personalised health information and advice to each of us – delivered in the way we choose to receive it.
Improving access to good mental health services
The long-term plan must also address an issue which is a personal priority for me – mental health and its place at the heart of our NHS.
We all know someone that has been affected by mental health problems – a family member, a colleague, a friend.
But when the NHS was established seventy years ago mental health and mental illness were not well understood.
It was not something that people talked about.
And so as the NHS has grown mental health was not a service that was prioritised.
Yet it is estimated 1 in 4 of us has a common mental disorder at any one time.
The impact of mental illness is vast, from the devastating effects it can have on people’s lives, to the productivity of our national workforce.
And with young people spending more time online and on social media – there are severe strains on their mental resilience and rising rates of mental health diagnoses in children and adolescents – as I heard here today in this very hospital.
Thousands of professionals deliver vital mental health services every day in our NHS – but for too long we have accepted that if you have a mental illness too often you will not receive the same access to care as if you have a physical ailment.
And that must change.
To transform how we look after our mental health, we will need to look beyond the role of the NHS so everyone plays their part –
whether it is schools or the criminal justice system, private sector employers or social media companies.
And we need to change how we view mental illness – so improving our mental wellbeing is seen as just as natural and positive as improving our physical health.
Thanks to the efforts of so many across society, that change is beginning and the stigma and discrimination around mental health are now reducing.
But as more people are rightly coming forward to seek help, so NHS mental health services are struggling to cope with this additional demand.
The Five Year Forward View for Mental Health set a number of priorities – including perinatal and children’s services, crisis care and psychological therapies – and backed them with additional funding. And there has been encouraging progress: for example, over 7,000 additional women accessed the expanded specialist perinatal services last year.
But we still have a long way to go.
Too often we hear that, in spite of the best efforts of staff, people are unable to access the support they need.
So we must improve.
This means that rather than just trying to catch up with the rest of the NHS, the long-term plan must contain proposals for mental health that are even more innovative and more ambitious.
This could include attracting more of the best graduates into the mental health professions; or finding new ways to provide joined-up care in the community, or helping people to manage their conditions so they do not reach a crisis point.
It must be supported by sustained investment that reaches the frontline of mental health services and staff.
And for too long we have had one expectation for minimum waits and eligibility for care when we have a physical condition; and another entirely in mental health.
So the long-term plan must move us towards new clinically defined access standards for mental health that are as ambitious as those in physical health.
Legislation
As the NHS steps up to develop this ten year plan – I will do everything possible to support it.
That means more than providing the multi-year funding I have offered.
It also means removing any barriers that hold back progress.
I believe that right now, parts of our regulatory framework might be doing just that.
The intentions behind the creation of the internal market in the early 1990s were right.
It is right that those commissioning health services should be close to the populations they serve. They understand the specific needs of the people in their area – and they can choose the providers and services that best meet those needs.
It is also right that the best providers should have greater autonomy than those that are struggling. This drives innovation in care that would otherwise not happen.
But I believe that, as our NHS evolves, and delivers more joined up care across different services, we should make sure the regulatory framework keeps in step and does not become a barrier to progress.
So I think it is a problem that a typical NHS Clinical Commissioning Group negotiates and monitors over 200 different legal contracts with other, different, parts of the NHS.
It is too bureaucratic, inhibits joined up care, and takes money and people away from the front line.
So where legislation is making it harder for professionals from different parts of the NHS and different Local Authorities to work together – we should be prepared to change it;
Where it is resulting in overly bureaucratic processes – we should be prepared to change it;
And where it is making it harder to hold NHS leaders accountable for delivering better outcomes for people – we should be prepared to change it.
However, as we do this, I believe that any legislative proposals ‘should be led by the health and care community’ as recommended by the Health and Social Care Select Committee.
We must learn the lessons of the past and not try to design or impose change from Whitehall.
So as the NHS develops the ten year plan we will consider any proposals from the NHS on where legislation or current regulation might be creating barriers. And where we feel that action is required we will look to build the broadest possible consensus in parliament – so we truly create an environment in which the NHS can get on with delivering the long-term plan.
Similarly, as the NHS develops the priorities and outcomes the long-term plan will deliver, we would like clinicians to confirm the NHS is focused on the right targets – for both physical and mental health – which incentivise the best care and outcomes for patients, and have the broad support of our health professionals.
Devolved administrations
Finally, I have focused today on the NHS in England because that is the responsibility of the UK government.
It is the devolved administrations in Scotland, Wales – and when sitting again, Northern Ireland – which have responsibility for the NHS in their parts of the UK.
But because the UK Government is increasing NHS spending in England, extra money will go to Scotland, Wales and Northern Ireland under the Barnett formula, which ensures every part of the UK gets a fair share of public spending.
While it is up to the devolved administrations to spend the money as they see fit, I believe everyone in the UK should benefit from this extra funding for the NHS.
So I urge the devolved administrations in Scotland and Wales to use this money to improve the NHS – and to develop their own long-term plans for NHS Scotland and NHS Wales.
This way the vision I have set out today can benefit the whole United Kingdom.
Conclusion
The National Health Service is not the property of any one party or government.
The clue is in the name – it belongs to the nation.
Over seventy years, it has been held in trust by each generation for the next.
But those seven decades have not been years of stasis.
They have been years of constant evolution and growth.
Each generation has had to play its part in helping the NHS to meet the changing needs of the people it serves.
The values and principles of 1948 remain indelible, but how we make a reality of them in the modern NHS of 2018 has changed beyond recognition from the starched caps and bedsteads of post-war Britain.
The NHS that celebrates its 100th birthday in 2048 will be able to achieve things which today we can scarcely imagine – but only if we, at this moment, take the action necessary to secure the NHS’s future.
That is what the long-term plan for the NHS will do.
It will ensure that our NHS does indeed remain –
There for everyone.
Free at the point of use.
With high quality care based on clinical need, never the ability to pay.
A National Health Service that is there for each one of us.
That is our mission.
Let us work together to deliver it.
So that together we can secure this great national inheritance for generations to come.
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