Even in the historic surroundings of the Dorchester Library, I know that for many of us, our hearts and minds will be with Ukraine. We’re now seeing the beginnings of a humanitarian and medical disaster, just a short flight from London. In recent days I’ve been in close contact with my counterparts to offer not just solidarity, but support.
I’m pleased that yesterday, the sixth shipment of vital medicines and medical equipment from the UK touched down in Poland – now on its way into Ukraine. The Prime Minister and every part of government will be working closely with the Ukrainian government to establish what they need and we stand ready to help them in every way that we can. I am so proud of these efforts — and of all the people who’ve rallied around the many Ukrainians we’re lucky to have working in the NHS and social care – a reminder of the incredible diversity of our workforce.
This half term, I hit the road and travelled over 1,000 miles on my ‘Road to Recovery’ tour. I was visiting hospitals, laboratories, vaccination centres and care homes, all around the country. No matter where I was – rural or urban – I saw the very best of modern Britain. Nurses, doctors, GPs, vaccinators, porters and so many others have put everything on the line to care for people through this pandemic – and I wanted to thank them personally. I saw their incredible teamwork, resilience, and compassion. I also heard about challenges, both old and new, and some of the innovative things we’re already doing to face them. It showed how recovery and reform must go hand in hand.
In September, we set out our plans to put Adult Social Care on a sustainable footing. Today, I want to set out the reforms we need to make in health – and I’m honoured to talk about it with such a distinguished group.
It’s not something I can do in a short amount of time. When I was putting this speech together, one of my team asked I’ve I’d deliberately made this speech so long because I never got to deliver a budget!
William Gladstone’s 1853 budget lasted nearly 5 hours – I promise I won’t go on for that long! But I hope you’ll forgive me if I avoid the usual soundbites and use this address to get into some depth on those challenges and changes.
My case for the NHS
I’m mindful I’m not the first Health Secretary to stand in front of an audience and propose reforms in health. Governments of all stripes have believed in the NHS and sought to strengthen it for their times. It was a Conservative Health Secretary who first proposed the idea of a National Health Service – then a Labour Health Secretary who brought it to life. For 73-years the NHS has had bipartisan support and – together with the monarchy – is one of this country’s most important and beloved institutions.
That spirit was at its best in the pandemic, as people of all political persuasions made incredible sacrifices – yes, to protect their friends and family, but also to protect the NHS’ critical services. And the support of every political party for our national vaccination programme built the confidence that gave us one of the highest vaccine uptake rates in the world.
We must keep this spirit on our road to recovery. We all have faith in the NHS, not just because of what it can do for us, but also what it stands for: the ideal that we each have a responsibility for the health of our fellow citizen.
It’s an ideal I’ve always believed in, and that shouldn’t surprise to anyone who really knows me. My political philosophy wasn’t just shaped on the trading floors of London, Singapore and New York. It was shaped in Dr Gandhi’s surgery on Bristol’s Stapleton Road, where I translated for my Mum. It was shaped when the NHS cared for my Dad in his final days. And it was shaped as my children tumbled forth into this world, born — like so many of us — into the NHS.
Nye Bevan believed we needed the NHS: a world-class health service, free at the point of use. So do I. Edmund Burke believed in the preservation of vital institutions. So do I. Blair and Thatcher believed we needed to reform vital institutions to preserve them. So do I.
It takes the Burkean reverence of the institution AND the reforming zeal of Blair and Thatcher to sustain the Bevanite dream of world class healthcare free at the point of use for all our people.
Public health and economic freedom are mutually reinforcing. Richer communities get healthier – and healthier communities get richer. Healthy people work more, learn more and earn more. Here in the UK, we go about our daily lives with the freedom of knowing that the NHS is there for us.
Yet when I look across the pond to the United States – the land of the free – healthcare costs nearly twice as much. Well, that’s not freedom for the millions of people who can’t afford it.
The conservative mission to enhance freedom must encompass both of Isaiah Berlin’s concepts of liberty: the freedom from constraints and coercion and an overbearing State, and the freedom to strive, to learn and to grow. Freedom isn’t paying a fee to hold your new-born baby. Freedom isn’t declaring bankruptcy because you had to pay vast medical bills after being hospitalised with Coronavirus. Do you feel free if you are in constant ill-health and pain and face catastrophic financial costs? Freedom and health are eternally intertwined.
I believe in the NHS and I believe in its founding principles: and it’s for that reason I want it to thrive and be sustainable. As the custodian of the NHS, it’s my responsibility to make sure it’s fit for the times we live in and the future we face.
So, even as we embrace the innovations of our modern age and we learn the lessons of Covid, my faith in the founding principles of the NHS has never been stronger. It’s my choice – and I believe the choice of the vast majority of the British people – to stick with our approach of world-class healthcare, free at the point of use, paid for out of general taxation.
Long-term challenges
That’s my case for the NHS. But if we’re going to keep doing it – and doing it well – we face some long-term challenges: how to keep the NHS focused on delivery while futureproofing it for changing demographics and disease; how to meet rising patient expectations and address the injustices of widespread disparities; and how to deal with an unsustainable financial trajectory while backing the brilliant people who work in health and care. I want to turn to each of those for a moment.
#1 Demographics and diseases are changing
First, let’s look at demographics and disease. There are some parallels between the situation we find ourselves in today and the one the NHS was born into. Just as the Second World War set the foundations for the creation of the NHS in 1948, coming out of this pandemic is a once in a generation chance to reimagine how we do health.
But that parallel ends when we look at the state of our health: it’s so profoundly different to 1948. The health challenges that the NHS must meet are radically different to those it was originally set up to address. The NHS was set up in a world where the main killers were infectious diseases. Polio, diphtheria and high child mortality: these are largely problems of the past. Today’s challenges are more around cancer, cardiovascular disease, degenerative diseases and mental ill health.
Both men and women can expect to live more than a decade longer than they did in 1948. Back then, less than 1 percent of the population lived past the age 80. Today, we have 3 million people over 80 – predicted to rise to 4.4 million by the end of this decade. As the Resolution Foundation has pointed out, this decade is likely to see the fastest pace of ageing in any decade from the 1960s to the 2060s. As the IFS has shown, treating an 80-year-old is on average four times more expensive as treating a 50-year-old.
Improved life expectancy over the last century — the product of economic growth, medical breakthroughs and vastly improved health and care services — is one of the great triumphs of the 20th Century. We must make it so for the 21st Century too.
We will have more time on this earth to see our children and grandchildren grow up; more people blowing out the candles on their 100th birthday cake. I want these extra years to be spent in good health. But sadly, for too many people, that’s not the case.
As our population gets older, more and more people are living with increasingly complex long-term conditions. The National Institute for Health Research predicts that, on current trends, two in every three adults over 65 will live with multiple health conditions by 2035. 17 percent would be living with four or more diseases – double the number in 2015, and one-third of these would have a mental illness like dementia and depression.
And these burdens are not spread evenly. Last year in Blackpool, I spoke about my mission to end the “disease of disparity” that has led to unacceptable health inequalities for some people, in places and communities across our country. We can’t hope to level up unless we level up in health.
It’s said that ‘demography is destiny’. And while politicians must have some humility in the face of this long impersonal arc, we are not powerless to bend it towards health and prosperity.
#2 People’s expectations have been raised
The second challenge is, again, a positive one: not only are we living longer, but our expectations of healthcare have been raised.
Much of this is a result of some incredible scientific and technological advances. Whether it’s life-saving antivirals or game-changing genomic capabilities, the NHS is so often at the cutting edge.
A couple of weeks ago, the first sickle cell patients in England started receiving a revolutionary treatment on the NHS: a treatment that’s going to give so many people, who have been left behind for too long, a better life.
The UK is a global superpower in life sciences: people then rightly expect to see the latest treatments on the NHS – even when the cutting edge doesn’t come cheap. Technological change accounts for a significant proportion of the increase in healthcare spending growth in recent decades.
But there are areas where the cutting edge is getting cheaper. For instance, the cost of sequencing a whole human genome has decreased by 98 percent since 2010. Genomics is the future of post-pandemic healthcare.
In the not-too-distant future, medicine will be personalised in ways that were previously unimaginable. Detailed understanding about how genes affect different people’s physiology will make gene therapies ubiquitous, and dramatically improve our ability to prevent, detect and treat ill health.
And aside from the scientific advances, we also have high expectations of what the NHS can do for us. On a typical day, nearly 45,000 people attend A&E. More than 250,000 people have an outpatient appointment. And more than a million people speak with their GP. In the meantime, we’ve seen consumer markets from banking to book buying completely disrupted over the last decade with transformations in choice and convenience.
#3 Financial sustainability
All of this together – our demographics, our diseases and technological advances – leads to a third challenge: funding.
The first NHS pamphlet that landed on people’s doorsteps back in July 1948 said of the new health service: “It’s not a charity. You’re paying for it, mainly as taxpayers”. Well, we certainly are paying for it. This year, the NHS will spend its original 1948 budget, adjusted for inflation, once every month. Our health budget is now bigger than the GDP of Greece.
At the start of this century, in 2000, health spending represented 27 percent of day-to-day public service spending. By 2024, it is set to account for 44 percent. This has been an acceleration of the trend in which the composition of the State has shifted towards health and care over the last 70 years.
I’ve now led six government departments, including one where I was responsible for the nation’s finances, and this one – the highest spending department. I’ve seen first-hand how – when healthcare takes up an ever-greater share of national income, you have to make some serious trade-offs on everything from education to infrastructure.
From April we will have a new UK-wide Health and Social Care Levy on earned income – it’s being debated in parliament as I speak. It will go directly to health and social care services across the whole of our United Kingdom, raising almost £36 billion over the next three years. With that additional money comes an even greater sense of responsibility to get it right – which includes putting Adult Social Care on a sustainable footing.
Yet we know that investment on its own is not enough. Economists amongst you will be familiar with William Baumol’s theory of ‘cost disease’, which is particularly acute in the NHS. You can build a computer that’s ten thousand times more powerful, but you can’t make a doctor treat ten thousand times more patients.
Why now?
So, those are the long-term challenges that healthcare must adapt to: changing demographics and disease; changing technology and expectations; and unsustainable finances.
Taken together, it’s clear that we were always going to come to a crossroads: a point where we must choose between endlessly putting in more and more money, or reforming how we do healthcare.
There were major challenges before the pandemic. Pressures in social care were rising substantially too. But without the pandemic, the Covid backlogs, an even more stretched workforce and other new pressures, that choice might have been a few years down the road. The shock of Covid-19 and the urgent need for recovery has brought us to this crossroads right now.
I choose reform.
It’s impossible to identify an exact size of the State that maximises growth, freedom and health. My vision of the State is one that is small but strong; empowering not constraining. But if the trajectory of the State continues unchecked, I don’t believe it will be compatible with that vision.
And even if you don’t agree with me about my vision of the State, there are three very clear reasons why none of us should be comfortable with the current path. First, we will have a proportionately much smaller working age population over the coming decade to pay for more and more spending. I don’t want government to have to keep going back for more tax hikes on a smaller workforce. As someone once said: ‘There is no such thing as public money, there is only taxpayers’ money.’ Second, there are far fewer elements of public spending which can be traded off against health and care spending compared to previous decades. And third, how the State delivers services — and whether it can deliver i
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