Psst...wanna buy some health? Herewith Tony
Blair's great vision: health = consumer choice
(didn't Meg Stacey comprehensively demolish that
one back in, er, 1978?) A brief taster from this
week's Fabian speech (which follows in full
below):
'The public, like us, want education and health
services free at the point of use - but they
don't want services uniform and undifferentiated
at the point of use, unable to respond to their
individual needs and aspirations. They want the
consumer power of the private sector, but the
values of the public service.'
Could this be a rare sighting of poliy based
evidence making in action?
The full text of the prime minister's speech to
the Fabian Society.
"I'd like to start with a quote from a New
Statesman profile of Clement Attlee in 1954.
The profile is striking for the absence of a
single reference to the creation of the National
Health Service. It is also striking for its
verdict on the 1945 government:
"it was the only event of its kind in history
which contributed almost nothing new or
imaginative to the pool of ideas with which men
seek to illuminate human nature and its
environment."
Today we see that great 1945 government as coming
closest to building a new Jerusalem. Yet,
immediately afterwards, it was routinely attacked
on the left for not trying hard enough to form a
Socialist state as a bulwark against capitalism.
On August 2nd this year we will have been in
power for longer than that Attlee government.
And once more, midterm in our second term, the
same feeling is in the air again. Have we done
enough? Are we radical enough? Once more the
left's laudable restlessness is mingling with
what seems to be the equally strong impulse to
decry.
For much of the 20th century, left of centre
governments, have agonised over a series of false
choices.
To be principled and unelectable or electable but
unprincipled?
To honour our past or shape the future?
To champion the state or accept the market?
To tackle poverty, or support aspiration?
To proclaim our convictions or respond to the
anxieties of voters?
There are some who seem to think that power for
the left is a luxury item -worth indulging in
once in a while but not for too long in case we
get a taste for it. For it comes with too much
unwanted baggage - compromise, pragmatism,
patience, resolve, messiness, setbacks.
In short that power involves the contamination of
principled thinking. In too many countries whilst
the Right acts as if it has a divine right
to power, the Left sometimes acts as if it has a
love-affair with opposition.
New Labour, and other parties like it round the
world, are attempting to break out of this bind.
Trying to lead as well as listen, letting
our traditional values shape the future,
reforming the state as well as regulating the
market.
The point of our politics is to exercise power
for the good of the people - not to protest from
the sidelines: "compromise" with the electorate
in a good cause. New Labour has shown it is
possible to be principled and win elections -
even with big majorities and big tents - but yes
it does require some pragmatism too.
New Labour is attempting to do things differently,
to take traditional Labour values - equality,
liberty, solidarity, democracy, justice - but
find modern means to give them expression
to reclaim territory wrongly conceded to the
right like law and order or the family and
redefine it for progressive ends
to reach back into our history and develop our
social liberal tradition so that our belief in
social justice is enriched by our commitment
to individual freedom
to stress we are a party of production as well as
redistribution - that we need strategies for
higher growth as well as greater equality
to rebuild civil society around a new contract
between citizen and state based on
responsibilities as well as rights
to reassert the belief in the theory and practice
of international solidarity.
Britain's Progressive deficit
Flowing from this repositioning was a programme
for government.
A programme that addressed what we might call
Britain's Progressive Deficit. What I mean by
that is that by 1997 Britain was a long way from
being a modern social democratic country.
Our constitution was failing, with Scotland and
Wales denied proper government, and hereditary
privilege still the foundation of a second
chamber where people made laws simply because of
their birth.
Decades of under-investment meant that public
goods, the things that most European countries
took for granted: quality childcare, universal
nursery provision, modern public buildings,
schools and hospitals with proper equipment and
enough well paid staff - were all run down in
Britain.
It was a country where we spent billions of
pounds keeping able-bodied people idle because of
boom and bust, with unemployment at times over
3 million, and where millions were denied a
living wage. Social division ripped apart
communities with one in three children growing up
in poverty, one in five families with no one in
work; many communities crippled by crime and
anti-social behaviour. Meanwhile the turmoil in
the Conservative Party over Europe had reduced
Britain to its margins, without effective
influence within the key strategic and political
alliance on our doorstep. This was Britain's
Progressive Deficit.
I set out when I became leader in 1994 a modern
agenda for addressing this shortfall.
Employment opportunity for all in a stable
economy protected from boom and bust.
Modern public services where quality and
excellence depended on need not ability to pay.
A modern welfare state with people at work not on
benefits; and where rights were matched by
responsibilities.
Tough on crime, tough on the causes of crime.
A modern constitution which devolved power and
entrenched human rights.
It was a programme described by John Prescott as
traditional values in a modern setting.
Catching up
Our first six years have essentially been about
making up for the Progressive Deficit.
On the economy macro-economic policy was
revolutionised with Bank of England independence
and new fiscal rules: giving Britain the strength
to enjoy stability and the lowest inflation,
interest rates and unemployment for decades.
On the constitution we developed Britain as a
modern pluralist democracy - devolution for
Scotland and Wales, mayors for London and others
cities, House of Lords reform, freedom of
information and the Human Rights Act.
In the wider world the retreat into isolation
ended: stronger with the US if we are stronger in
Europe, stronger in Europe if we are stronger
with the US. And a government leading the way on
3rd world debt and development. For working
people we delivered the progressive rights that
other countries took for granted - minimum wage,
four weeks paid holiday, better maternity
and paternity rights, the basic right to join a
trade union.
For those without a job or skills we began to
create an active, not a passive Welfare State
putting partnership in place of paternalism - the
New Deal, the new tax credits, the extra
childcare, the IT training in an economy where 90
per cent of jobs will need skills with computers.
And it meant a million and a half new jobs.
For communities and families torn apart by crime,
anti-social behaviour, racial intolerance, and
drugs, destroying the very respect for others
on which society is founded, we are putting in
place major programmes of inner city
regeneration, excellence in cities for schools,
Sure Start, and additional investment in youth
and sport facilities; but also passing measures
toughening up the criminal justice system.
The reform of public services
But let me focus on the area where the
progressive deficit was greatest: public services.
The public services we inherited suffered three
big problems:
First, years of under-investment. The legacy of
decades of under-spending culminating in 18 years
of Tory ideological opposition.
Second, an unequal system. The 1945 model, for
all its great strengths, was not the answer to
inequality.
Third, lack of responsiveness. Public services
were just not moving rapidly enough with the
times to meet rising expectations in a modern
consumer society.
Let me focus on the equality argument in some
detail because it is important for us on the left.
Those who defend the status quo on public
services defend a model that is one of entrenched
inequality. I repeat: the system we inherited was
not equitable. It was a two-tier system.
Our supposedly uniform public services were
deeply unequal as league and performance tables
in the NHS and schools have graphically exposed.
The best schools were either private or in
affluent areas; access to the best healthcare
could be bought; the highest crime areas were in
the lowest income neighbourhoods; and public
transport was most deficient in serving the most
deprived housing estates. The affluent and
well-educated meanwhile had the choice to buy
their way out of failing or inadequate provision
- a situation the Tories 'opting out' reforms of
the 1980s encouraged. It was choice for the few,
not the many.
But these inequities were in evidence before
Thatcherism exacerbated the two-tier system. We
now know from work by Julian Le Grand, Brian Abel
Smith and others that this situation
overwhelmingly benefited the middle-class
in Britain, so that by the late 1970s for example:
Households in the richest fifth of the income
distribution received nearly one and a half times
as much public expenditure on education as the
average, and three times as much as the poorest
fifth. The top received 50% more spending than
the bottom.
On universities, the top professional social
group received five times the expenditure of the
poorest group, as working class families failed to
benefit from the expansion of HE in the 1960s,
and too few stayed on at school.
Le Grand also established that the top social
group received up to 40% more NHS expenditure per
ill person than the bottom unskilled manual
group. This figure would be higher if it were
possible to factor in the fact that richer groups
tend to receive longer consultations and
treatments in the NHS.
On public services, our ambitions as
progressives, our ambitions for Britain, and the
ambitions of the public all intersect.
For those on the left strong public services
drive equality and extend opportunities. They
bind society together in collective action,
citizens as well as consumers.
That is why the reform programme matters. It is
only a means to an end: to create greater
opportunity and social justice. And of course, it
will be hard to do.
In the Eighties when Mrs Thatcher embarked on
reforms to the public sector - like privatisation
- it may have been hard to do politically, but it
didn't require massive re-engineering of vast
organisations with millions of public servants
employed in them.
What we are trying to do, the core of our second
term programme in rebuilding the public realm,
re-energising public services, and the scope and
reach of what they can achieve - is big, radical,
very difficult to achieve and long term. It will
define what kind of country we live in not just
this year or next year, but for this decade and
long after. It is about whether we manage not
just to eradicate the progressive deficit but
build a lasting progressive settlement. And I
know, from comparing notes with many foreign
heads of government battling the same issues, how
ambitious it is.
To put it at its simplest we are putting in place
reforms that will:
improve 24,000 schools
turn round an NHS of one million employees which
sees one million people every 36 hours
remodel the criminal justice system
get an outdated railway system to function
properly
put integrity back into a failed and random
asylum system
And in doing so create first class A and E
departments, short waiting times, better cancer
and heart disease services, less crime and anti
social behaviour. These are the tangibles
benefits people want to see.
So the scale of challenge is absolutely clear.
The choice is how we go about it.
The Right has had its go - and wants another go;
cuts in spending, less collective provision. Been
there, done that, let's not return to it.
For the left two options are open - one littered
with the false choices I referred to at the
beginning. This option asks us to defend the
1945 settlement in all its forms, throw money at
problems, and champion public servants against
change.
It has its attractions. Money matters which is
why spending is rising sharply.
Britain is the only major European economy where
this year, next year, and the year after public
spending as a proportion of national income is
rising; and where spending on health and
education continues to grow in real terms.
Motivating staff matters which is why starting
salaries for nurses are up by 16 per cent in real
terms since 1997; up 19 per cent for GPs; and
newly qualified teacher's pay is up 15 per cent.
For those experienced teachers who pass the
performance threshold pay is up 22 per cent since
1997 (and 32 per cent for secondary teachers in
inner London). One of the key reasons why school
funding this year is tight is the huge increase
in pay and pension provision for teaching staff.
Already we can see major progress.
The number of heart operations each year has
risen by a third since 1997 - no patient is now
waiting more than nine months for heart surgery.
Over 98 per cent of patients referred by their GP
with suspected cancer are now seen within two
weeks, while 96 per cent of patients receive their
treatment within a months diagnosis of breast
cancer.
Waiting lists are down to a million for the first
time in a decade. Waits to see a consultant in
outpatients are falling too - with waits longer
than 21 weeks virtually eliminated and a 50 per
cent reduction in people waiting more than three
months compared with 1997. Every A and E
department that needs it is being or has been
modernised and the largest ever hospital building
programme is underway.
In schools we have the best primary tests and
GCSE results ever. There is no more basic symbol
of equality than a child being able to read and
write. Without it too many start life without the
basic tools to succeed. There are more staff:
25,000 more teachers, with 80,000 more support
staff. We have cut the teacher vacancy rate to
below 1%. Almost no infants are now in class
sizes of over 30, and 11,000 schools have new
classrooms and facilities. Over 1400 failing
schools have been removed from special measures
and turned around.
Crime is down since 1997 - the first government
since World War II to achieve a lower crime rate
than it inherited and there are now record
numbers of police officers. All of this
represents significant progress. But it is short
of transformation. To do that we don't need just
to spend more money in a system whose structure
remains the same. We need fundamental, systemic
change.
In respect of public service reform, the first
term was about introducing proper means of
inspection and accountability for public services
and about intervention where there was failure.
Inevitably, it was driven from the centre.
For the first time, we were publishing
information on the performance of hospitals and
healthcare; a proper method of evaluating the
effectiveness of drugs; inspecting police
authorities in detail; changing the management
of LEAs that were failing. As an urgent strategy
to improve literacy and numeracy in primary
schools, an externally driven programme was
essential; it worked.
To turn waiting lists around - which had risen by
over 400,000 under the Tories - to get the issue
of access to GPs or to A and E departments
taken seriously, we needed targets, again
centrally set.
And again, whatever the problems, the trend is
now down for in-patient and out-patient waiting
and GP and A and E access have significantly
improved. In 1997, for example at any one time
there were 70,000 people waiting more than 26
weeks for an outpatient appointment. Today it is
less than 500.
But it only takes us so far. Now there is a
sustained programme of investment, with public
spending rising as a percentage of GDP every year,
we need to use the opportunity of investment to
engineer real and lasting systemic reform.
I want to focus on health and education. Here,
reform means putting power in the hands of the
parent or patient so that the system works for
them not for itself.
Our aim is to open up the system - to end the
one-size-fits-all model of public service, which
too often meant one supplier fits all, with little
diversity, irrespective of how good new suppliers
- from elsewhere in the public sector, and from
the voluntary and private sectors - might be.
The public, like us, want education and health
services free at the point of use - but they
don't want services uniform and undifferentiated
at the point of use, unable to respond to their
individual needs and aspirations.
They want the consumer power of the private
sector, but the values of the public service.
Over the next two years more than half of all
secondary schools will become specialist schools,
with centres of excellence in areas such as
science, sport, or languages. When the last Tory
government first allowed schools to take on
specialist status, it did so on an exclusive
basis - restricting it only to those schools that
had already gone grant-maintained, and
limiting funding so that the opportunity to gain
specialist status was tightly constrained. In
1997 there were just 260 specialist schools,
concentrated in affluent areas.
We have changed all that. The programme has been
rapidly accelerated. There are now over 1000
specialist schools spread across advantaged
and disadvantaged areas alike. Sir John Cass
School in Tower Hamlets with over two thirds of
its pupils entitled to Free School Meals is the
fastest improving specialist school in the
country.
The critics said that our programme would only
create a new form of two-tier schooling. But this
has not been the case.
Specialist schools recruit on a par with
non-specialist schools at the age of 11, as shown
in the Key Stage 2 tests and the deprivation
statistics. Yet GCSE performance in specialist
schools was this year eight percentage
points higher than in non-specialist schools - 54
per cent to 46 per cent in terms of those gaining
five or more good passes.
Among specialist schools with deprived intakes
the out-performance is equally marked, and so too
is the rate of improvement over time.
These schools are actively breaking the cycle of
poverty and low achievement.
And they are also increasing choice. By
developing strengths in particular areas,
specialist schools increase choice for parents
and pupils - depending of course on the range of
schools and the availability of places where
you live.
Under the new Education Act, all schools will now
have the freedom to vary the school day, the
freedom to hire staff, pay more flexibly, to use
the national curriculum in an innovative fashion,
and to develop the school in the ways they want.
We have also radically changed the framework for
starting new schools, allowing the expansion of
successful and popular schools, irrespective
of surplus places in other less popular schools.
In the inner cities, there will be a further step
change.
Sponsors of new City Academies - with a track
record of success in the voluntary and private
sectors, are able to build and run
first-rate schools - and are now taking over
failing schools and opening new schools in some
of our most challenging localities.
City Academies are non-selective schools, free at
the point of use. They teach the full national
curriculum. All this is guaranteed in their
founding charters. What marks them out? That
their sponsors have a powerful mission to
succeed, a track record of success and the status
of independent schools to enable them to develop
as they wish. And they bring this to the provision
of state education, where previously the system
was closed to new entrants able to manage
state-funded schools in this way.
Over the next five years we are setting up at
least 30 new Academies in inner London alone.
In addition, we are examining urgently how to
avoid future problems over school funding, so
that every school has a secure funding base
sharing in the sustained increase in national
funding we are providing for education.
So too with the health service. What is our most
urgent priority? To expand capacity of the right
quality, to deliver the 1m extra operations we
need by 2005.
It is entirely sensible, therefore, to open up
the system to allow new suppliers - including
overseas operators and the private sector - to
provide the new diagnostic and treatment centres
for the major elective conditions. New suppliers,
injecting new ideas, greater choice, extra
capacity and best practice from outside into the
NHS. But still free at the point-of-use -
and available at the point of need, where
previously there was simply a waiting list and a
period of anguish and disappointment at the lack
of service.
>From this April, we are introducing a uniform
tariff for hospital treatment, which allows spare
capacity within the system to be accessed by GPs
and patients in whatever part of the country it
exists. We are expanding choice for patients. It
started with heart treatment. It has developed
from this April for all London waiters of over
six months.
By 2005, we aim to have a maximum wait anywhere
of six months; an average wait of seven weeks;
choice for all patients everywhere after December
2005. By 2008, it will be three months maximum
wait. Just to set this in context: in 1997, there
were almost 300,000 people at any one time
waiting over six months.
Before the summer break we will be setting out
our forward agenda on the rollout of patient
choice for surgery, and in the Autumn we will be
bringing forward further choice proposals for
primary care, maternity services and chronic
conditions.
Meanwhile, contracts for staff will be changed to
allow for greater flexibility of working and
incentives for good results. Foundation
Hospitals will have enhanced freedom, a concept
we want then to extend through the NHS.
Extending choice - for the many, not the few - is
a key aspect of opening up the system in the way
we need.
Not choice for a small minority, as under the
Tories. Not choice for the few thousand who could
get on the Assisted Places Scheme. Or choice for
those who could afford private medical insurance,
subsidised by tax breaks.
But choice for the many because it boosts equity.
It does so for three reasons. First, universal
choice gives poorer people the same choices
available only to the middle-classes. It
addresses the current inequity where the better
off can switch from poor providers. But we also
need pro-active choice (for example, patient care
advisers in the NHS) who can explain the range of
options available to each patient.
Second, choice sustains social solidarity by
keeping better off patients and parents within
the NHS and public services. This is a
prerequisite for continuing public support for
the tax increases required for funding equitable
public services. Otherwise, we will slide towards
safety net services that are more inequitable as
services exclusively for poor people tend to
become poorer services, as Richard Titmuss
famously argued.
Third, choice puts pressure on low quality
providers that poorer people currently rely on.
It is choice with equity we are advancing. Choice
and consumer power as the route to greater social
justice not social division.
And what is the public response to choice so far?
In the NHS, for example, since the choice has
been available for heart patients, half - half -
have exercised the choice to go elsewhere than
the waiting list they were currently on. In
London, where the pilot has been extended to
cataract treatment, more than 70 per cent have
exercised the choice to get faster treatment
elsewhere.
Coping with all this change has been hard. I pay
tribute once again to our superb public servants
who daily perform heroics in providing good
education and healthcare and in policing our
streets.
But all the change and modernisation is for this
purpose: to renew our public services, keep them
faithful to the ethos and values of public
service but make them responsive to the
individual needs of the consumer of them. We need
a patient-centred NHS; and a pupil-centred school
system. We need to move beyond a monolithic NHS;
and a uniform secondary school system. We need to
do this in order to extend opportunity and social
justice.
Putting the user first, giving them choice is not
a Tory concept. On the contrary, as the recent
Tory health plans show, they would offer choice
but only to those able to pay. The essence of our
reforms is to keep true to the principle of your
citizenship - not your wallet entitling you to
decent services.
The new contracts of employment and flexibility
of working; the new ways of financing the
buildings we need; the opening up of the system
to new and diverse suppliers; the measures to
give choice to the consumer: all of it is
designed to ensure our public services fulfil
their purpose: to extend opportunity and security
on the basis of need, not ability to pay.
We are also pioneering new forms of civic
engagement in our public services - foundation
hospitals truly accountable to their
local communities, schools with a stronger voice
for parents and local employers, local councils
more open and accountable including directly
elected mayors where local people vote for them.
We're attacked from the right by those who run
our public services down, from the left by those
who defend the status quo. Where we've made
changes, we've made improvements, and whatever
the cynics say, the signs of progress are
everywhere - Britain now third in the world for
literacy aged 10, our cancer and cardiac services
are improving as fast as any in Europe,
for example. But we need more change to make more
progress, and the purpose of change is to ensure
everyone, whatever their background, gets a decent
education and good healthcare in times of need.
Irreversibility -cultural change
Many of the changes we have made - on the
constitution, economic policy, Minimum Wage, the
public services - will last the test of time.
But the challenge for us now is to make our
progressive changes across the board
irreversible; changes that can't be rolled back
by a right-wing government that wants to
dismantle all that we have be achieved.
To do that - to make the deeper changes - we have
to make the cultural changes necessary as well as
the policy changes.
We need to do more than have the right education
policies but make the case for learning
throughout society. More ladders for people to
develop their potential.
We need to make not just the case for the Minimum
Wage but change the way people deal with low pay
so that it is unacceptable to short change
millions of people, particularly women.
We need not just to raise incomes through
benefits, but entrench a new welfare culture, a
new something for something contract between
citizen and state.
We know that deprived communities cannot revive
themselves without public support, but there also
needs to be a deeper culture of respect
that rebuilds our civil society.
We need more than just the right policies on
Europe we need to forge a pro Europe consensus
and sweep away the prejudices that hold Britain
back.
And let no-one think these arguments will be easy
to win.
A weak opposition can breed complacency. But it
shouldn't. The Tories' reactionary ideas remain.
The next election will in many ways be a
very traditional battle of reactionary versus
progressive politics.
The reactionary vision has some superficial
attractions. In a world of insecurity and
complexity it offers some simple solutions.
A Britain that turns its back on Europe
Where action on asylum rapidly becomes
anti-immigration
Where law and order policy is just about locking
more people up not dealing with the causes of
crime.
Where people pay for healthcare
Tax cuts are put before investment
And hierarchy and class are thought to serve
Britain well.
They are driven by a culture of grievance, a
pessimism about change, a cynicism about progress.
Put together these reactionary impulses and we
know what we get - a fortress Britain, too scared
of Europe to make Britain more prosperous,
too doctrinaire to build a decent health service,
too elitist to let poor people go to university,
too backward looking to understand family life,
too defeatist to let Britain succeed.
Never underestimate how much the centre of
gravity of British politics shifted to the Right
in the Eighties. Never underestimate the
cultural change needed, the battles that must be
won, to shift it back to the centre left and to
prepare Britain for the future.
Confidence: Preparing for the future
The progressive left should be confident. Our
ideas are in tune with the times.
Growing insecurity and fear requires active
government - collective solutions - to protect
the public. And the left believes both in
active government and pulling together. Helping
people through change, not leaving people to fend
for themselves. Here a small state, sink or swim
ideology is not only unjust, but inefficient.
And parties of change defeat Tory parties in a
fast moving age where to conserve is not just to
stand still but to fall behind. Look around
the world today, at every institution or
community, and the chief characteristic is rapid
change. The force of change outside our country
drives the need for change within it. We are the
Party of change. But our historic mission is
to turn change into progress so that every
citizen has a stake in the future.
By rectifying what is wrong with Britain we
create the means to succeed economically and
socially in the new century. To prosper, we must
overcome the social divisions, the class
distinctions, the cultural barriers that have
prevented us from reaching our true potential.
But the warning for the left is ever present - if
we are conservative we will fail too. We know
that from the 60s where the Labour government
failed to see through In Place of Strife and
paved the way for the Thatcher revolution. If we
fail to reform public services then one day the
Right will come back and demolish the very ethos
on which they are built - with more charging,
less investment, good services just for the
well-off, sink services for the rest.
If interdependence and collective action is one
impulse then the other big impulse is
individualism. And too often in the past the left
has failed to understand the aspirational
impulses of millions of people. Yet it's
impulse is everywhere - from soaring consumer
demands including in public services, to the
ability of any child to read any book on the
Internet.
If we don't understand that to make collective
provision work we must tailor their offer to
individuals then we will fail.
Conclusion
Let me end by saying: Your ideas, your support,
your debate is crucial at this time. Projects
such as ours depend on change, new thinking,
and renewal.
I am today more not less optimistic about the
future. I am excited by Britain's potential and
excited by the left's potential to advance change.
But collectively, all those who see themselves as
progressives, need to remember who the real enemy
is- Tory reactionaries - the defeatists,
the pessimists, the cynics.
We should never collude with them in running
ourselves or Britain down. Britain is doing
better today than in 1997. We are a more
progressive country today than in 1997 - our
constitution our economy, our society,
our standing abroad, are all in better shape. If
you are old, or sick, or poor you have more help
and more support.
We have achieved much in the last six years - but
much remains to do. Together we can take the next
progressive steps for Britain."
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