Alan Milburn – 2002 Speech to the Royal College of Nursing Congress

Below is the text of the speech made by Alan Milburn, the then Secretary of State of Health, on on 24 April 2002.

It is a pleasure to be here today – especially on a day when you are focussing on the needs of student nurses. It is right today that as we plan for the future generation of nurses we can plan with confidence the future of the NHS.

It is two years since I was last at your Congress. Since then, quite a lot has changed, for the RCN and for the NHS. You have a new General Secretary. Beverley is a powerful advocate for nurses and for patients. I am grateful for the role she plays and I believe you have every reason to be proud of the leadership she shows.

I said two years ago I shared an ambition with you: to get more members for the RCN because I wanted to see more nurses in the NHS. Two years later, there are 16,000 more members of the RCN because there are 20,000 more nurses in the NHS.

After years when nurse numbers fell and when training numbers fell too, nurse numbers in the NHS are now rising and are set to go on rising for many years to come.

There are of course huge problems still in the NHS. Decades of under-investment still take their daily toll on frontline services and frontline staff. Nurses work under huge pressure. I know that because I hear it and see it wherever I go. I know too the pressures and frustrations brought by staff shortages or by equipment failures or by lack of IT support.

I know the pressures are real – and today I want to set out how we can address them together. In the last few years we’ve made a start. Waiting times are still too long – but they are falling. Cancer equipment is still too old – but it is improving. Hospital buildings are still in disrepair- but the biggest programme of new building is underway. Staff shortages are still there for all to see – but the NHS Plan target for 20,000 more nurses has been delivered – and delivered two years early.

The NHS Plan we prepared and published with your help is a programme for ten years not for two. The truth is we are at first base in what will be a long haul to improve services for patients. But step-by-step we are making progress. And we can now build on the foundations that you have helped to lay.

Whether you work in the health service or the independent sector, in mental health or in the community, whether you are a student or a sister, a matron or a midwife, up and down the country nurses at every level are making a difference for patients every hour of every day.

It is tough out there and the problems that are real have to be tackled. But we also have to have some balance, particularly in the media debate on the NHS.

Nothing makes me more angry than when stories in some of the papers give the impression that no patient ever gets good treatment. Or when the false charge is made that nurses treat patients worse than dogs. Or that the NHS is full of bad nurses, or bad doctors, when it is in fact full of good people doing their best for patients.

In a service treating millions of people every week, there will always be cases where things go wrong but, thanks to your efforts, for most patients most of the time things go right. Most staff do a good job. And I’ve got a simple maxim: if you are on the side of the people who use the NHS you’ve got to be on the side of the people who work in the NHS.

So today I want to set out what the future holds for the health service – for staff and for patients. And because nursing values are health service values, I will set out the leading role I want nurses to play in changing the health service – and changing it for good.

Today we can look to the future with confidence. Last week’s Budget gives the NHS the best chance it has ever had – perhaps the last chance it will have – to transform health care in our country. For decades we have lagged behind the rest in Europe. Now we have the chance to be up with the best.

Funding for the NHS – already growing faster than in any other major European country – is now set to grow by over £40 billion. It is the biggest increase in NHS resources the country has ever seen. Where there used to be funding for just one year there will now be funding for sustained increases for the next five.

And the same is true of social care. For too long nurses know social services have been the poor relation of health services. Health and social care are two sides of the same coin. They both rely on each other. Older people rely on both. So I can confirm today that funding for social care, which just five years ago was rising by less than 1% above inflation a year, is now set to rise by 6% a year for the next three years.

The Budget is a profound moment of choice for our country. It puts behind us the decades of pretence that Britain could get world class health care on the cheap. That was our nation’s impossible dream.

But it was just that: a dream. If we want world class health care it has got to be paid for. And I believe the best and fairest way of providing health care for country is a tax-funded, well-funded NHS.

The NHS is an insurance policy that comes with no ifs and no buts, no small print, no get-out clauses. It is based on the scale of your need not the size of your wallet. So we should support the NHS with our heads as well as our hearts.

Some say that what we did in the Budget is a gamble. Well maybe it is. But I believe it is now right to ask the British people to pay a little more for the health service so that we can get a lot more for patients.

And when the British people are being asked to put more in, they have every right to expect more out.

So the Government has an ‘acid test’ for health investment. It is this: the extra investment has to secure an expansion in capacity or an increase in productivity or an improvement in performance.

Against this ‘acid test’ we expect to be judged. Against this test the NHS can expect to be judged.

Raising the money required discipline – sorting out the public finances, putting the economy on an even keel. Spending the money requires discipline, too.

There will be many pressures from many quarters for many good causes. But we will not be forgiven – and the NHS will not be forgiven – if having raised the resources we fail to use them to get the results that both nurses and patients want to see. Shorter waiting times. Higher clinical standards. Better health outcomes.

So we will focus the extra resources where they will count most for patients. Expanded capacity means more nurses and doctors, scientists and therapists, more beds and buildings.

We need more investment in more modern hospitals and health centres, better equipment and, of course, IT systems that might just actually work.

Investment will help to reduce the waiting times for treatment and investment needs to be focussed not just on treatment but in prevention.

Our job in government is to provide opportunities for all and not just some in our society. So improvements in cancer, heart disease, mental health and care of the elderly will remain our key priorities.

Investment here will help to improve health outcomes and tackle the health inequalities that are such a scar on the face of our nation.

So investment will be focussed not just in hospital services but in primary and community services too. To create the modern health service we need we have to shift the balance of services in the NHS. The problems of hospitals can not be solved solely in hospitals.

Tackling waiting in the A&E and in the outpatients department of course requires more staff and new equipment. But it requires better help and more support in the community, in primary care and in social services.

Social services will be able to extend by a third the number of older people with access to rehabilitation. There will be extra resources to stabilise the care home market and to buy more care home beds. And we can now set ourselves the objective, not just of giving older people a choice of care in a care home but of increasing the number of people who can be cared for in their own home.

The point is this. Everywhere I go, virtually every nurse I speak to says: things can not just go on as they are. And you’re right.

The new money cannot be just for more of the same. It has to buy a different sort of health service. It has to meet the ‘acid test’ of expanded capacity, increased productivity and improved performance.

That’s why the reforms we implement are as important as the resources we invest. Only if we now have the courage to match reforms with resources will we get the best results for patients.

So as we expand capacity for patients we must expand choices for patients. So that for the first time in fifty years NHS patients are able to make an informed choice about where they are treated and when they are treated.

So that we pay hospitals by results – with more resources for treating more patients, more quickly and to higher standards.

So that social services are paid by results too – for ending the misery of bed blocking, using their extra resources to expand community support to the elderly patient in need.

So that the services that are struggling – rather than being left to sink or swim, as they were under the old internal market – are helped and supported and yes, where necessary are taken over by management with a track record of success.

So that we get the public, private and voluntary sectors working for a common cause – improved services for NHS patients.

None of these changes can happen through Government action alone. We can secure the resources. We can help set the standards. We can hold the system to account. But in the end I do not treat a single patient. You do that. So I need your help, not for political reasons (still less for party political ones). But because nurses make the difference for patients.

Nurses above all others are the frontline in the NHS. Alongside your colleagues in medicine and the other professions, you are uniquely placed to help translate the extra resources into results for patients.

Make no mistake about it there is a bruising battle ahead. The cynics and the critics say that to choose the NHS is the wrong choice for Britain. That the health service is not working and that it can never work.

The Government is on test – of course we are. And we are happy to be judged against the improvements we have promised. But there is a bigger test than the political one. It is whether the NHS itself can deliver. The public want to know that if they put more resources in we can get more results out. That the NHS can meet this ‘acid test’.

I am one hundred per cent confident that the NHS will deliver. Why? Because I know NHS staff are one hundred per cent committed to delivering improvements for patients.

And it is nurses who are leading this process of reform. Reform is happening out there because you are making it happen.

Nurses who are now running clinics, triaging patients, discharging patients, prescribing medicines, running walk-in centres. Nurses the first point of call already for 10 million patients through NHS Direct. Nursing doing jobs previously only done by doctors. And now, through PMS, for the first time, nurses in charge of doctors.

And this meets our ‘acid test’: liberating the talents of nurses helps to expand the overall capacity of the NHS, increases the productivity of the NHS and improves the performance of the NHS.

Liberating the talents of nurses quite simply means better care for patients. And in the last few years, nurses have carried the torch for change.

We share between us – the profession and the government – a common aim: to get the best from nurses so that we can get the best for patients. Now we look to strengthen our partnership so that we can go further still. To make sure that we liberate the potential not just of some nurses but of every nurse.

There are five further steps I believe we should now take to realise our shared ambition:

First, to get the best from every nurse we need to get more nurses working in the NHS.

A start has been made. And I want to thank you for the help you have given us so far in our recruitment campaign. Since 1997, over 11,000 nurses who left the NHS have been encouraged to return. 2,000 more are on their way back. In total the number of nurses working in the health service has risen by 31,000. That is good progress. But there is more to do.

So I can confirm today that we plan over these next five years to increase again the total number of nurses working in the NHS by a further 35,000.

Applications for nurse diploma courses have doubled. Nursing degrees are now the second most popular university course in the country. And I can confirm that these increases in training mean by 2008 there will be 60% more nurses qualifying each year than there are today.

And we will continue to bring back nurses who have left the NHS and to recruit some nurses from abroad. And I can give this assurance today, where we do we will not actively recruit from developing countries. Those countries need their nurses more than we do.

Like many of you I have been appalled by reports of nurses being dishonestly recruited abroad, for a fee, by private agencies, coming to this country and then finding themselves exploited.

So I can announce today that to tackle this exploitation we will establish a national helpline for these overseas nurses so we can get them out of dead-end jobs, match their skills to NHS jobs, make them an NHS employee and end their exploitation.

But getting more nurses into the NHS is just one part of the story. We may have turned the corner on nurse recruitment but what we cannot have is nurses coming in through the front door only to find more nurses leaving by the back door. The emphasis now has to shift to retaining nurses as well as recruiting them.

So second, as the RCN constantly reminds us, we can only expand the number of nurses in the NHS if we improve the working lives of nurses already in the NHS. A start has been made but much, much more needs to be done.

The NHS won’t get better treatment for patients unless it offers better treatment for staff. And the truth is some NHS employers are better at it than others. You can see that in vacancy rates where in one trust the nurse vacancy rate is 8% whilst in the next door trust it is less than half of one per cent.

Nurses often have two jobs – one at home and one at work. The NHS has got to do more to help nurses balance their family and their working lives. Some employers are already doing that offering more flexible hours and better childcare. But some are not.

When I met with a group of nurse returners earlier this year their message to me was that improving working lives should be a priority for every chief executive in every trust in every part of the country.

So today I can confirm that in future the star ratings system for NHS employers will include an assessment of how well the staff are treated and how well they are involved.

Beverly, you asked on Monday for a guarantee that every NHS employee would have access to a child care co-ordinator.

Now, I can’t promise you’ll always get everything you ask for – you know that – but I can promise that by April next year every nurse will get the child care help you called for.

And today I can go further still to extend nurses’ access to practical childcare support. As you know we plan to invest an extra £100 million in childcare for NHS staff. So far, the intention has been for this to be targeted only at qualified nurses. Today I can announce that it is our intention, within two years, to make subsidised childcare available not only to qualified nurses but to student nurses as well.

This is investment in nursing. In the future of nursing. In the future of the NHS. And to those who say that there is a choice between investing in staff or investing in services, I say in the NHS unless we invest in staff we will not get better services for patients.

Third, then that brings me to the question of pay.

Every nurse deserves fair pay.

In the past nurses pay was staged. Now it is being paid in full.

Three years ago we increased the starting pay of newly qualified nurses by 12%.

Two years ago staff nurses had increases of almost 8%.

Last year ward sisters and charge nurses got over 5%.

Since 1997, nurse pay has risen faster than average earnings.

And nurses deserve a fair deal over the years to come.

Investment in pay, just like every other area of future NHS spending has to pass our ‘acid test’ – it must contribute to expansion in NHS capacity, it must bring about increases in NHS productivity and it must deliver improved NHS performance.

As the Chancellor said in his Budget Statement last week, “sustained commitment to better public services demands responsibility in setting public sector pay.”

As you know, we have been negotiating a new pay system for nurses and for other staff. The Agenda for Change discussions have been long and hard.

I am grateful both for your participation and for your patience. I know there have been concerns about our commitment to Agenda for Change.

So I can confirm today, that we are fully committed to Agenda For Change; we want now to move to conclude the negotiations; and providing we can reach agreement we will start to implement Agenda For Change by the end of this year.

But let me just say this: this will not be a something for nothing arrangement. Agenda for Change is all about paying people according to what they do. The more they do the more they can get. As nurses take on new roles and responsibilities they have a right to expect a fair reward. In return the NHS has a responsibility to gain improvements in flexibility and productivity. This must be a something for something arrangement.

It will take time and effort to fully implement the new pay system but, providing we can reach agreement, we can deliver a better deal for Britain’s nurses.

Fourthly, we know that if we are to get improvements in flexibility and productivity, the NHS has to change traditional working practices to help more nurses smash through the glass ceiling that has held them back for too long. There simply have to be better career prospects for all NHS nurses.

There are already 700 nurse consultants, 2000 modern matrons. They are showing that nurses can break through that glass ceiling. If it can be done in some parts of the health service it can be done in all parts of the health service.

So you have a job to do to challenge the structures in your own NHS organisations. To argue for better use of nursing skills. To say that it is good for doctors and good for patients to unlock the talents of nurses. And I want to help, if I can.

So I can announce a major expansion in an area of clinical practice that matters both to nurses and to patients – and I know it matters to the RCN. Today there are 23,000 nurses who are able to prescribe drugs to patients. Within two years we expect there to be more than 30,000 independent nurse prescribers but we need to go further and we need to go faster.

I can tell you today I have asked the Chief Nursing Officer to draw up proposals to extend the range of drugs and medicines these nurses are able to independently prescribe.

I can also announce today that it is now our intention to ensure that every nurse who wants to, and is trained to, is able to prescribe appropriate drugs and medicines to patients.

Last week we issued a consultation document on supplementary prescribing. We await your response with interest.

We now propose that supplementary prescribing should have no formulary, no restricted list of drugs, no restriction on the location or the type of practitioner other than that they are registered and qualified and safe to prescribe. Prescribing will be limited only by the individual patient’s clinical plan. I expect the first supplementary nurse prescribers to be in training by the end of this year.

And I can also say today that we will embed these reforms for the long term. So I have asked the CNO to work with the Nursing and Midwifery Council and Higher Education to review and reform nurse pre-registration training so that in future nurse prescribing can be enshrined in the training of every single newly qualified nurse.

Let us be clear: these proposals represent a fundamental change in traditional working practices in the NHS. What once was the sole preserve of the doctor will now become a shared responsibility between nurses and doctors together. It will be good for nurses, good for doctors and above all else it will be good for patients.

So those who say nurses can not lead or should not lead should think again. Nurses are leading, others can lead and in the future many more will lead.

Fifth, then, to get more nurses leading requires better training. Nurses should not have to struggle alone against the odds to make the reforms the NHS needs. Every nurse who wants to lead change should be supported to do so.

When I last spoke at your Congress two years ago, I announced then the largest ever investment in leadership development for nurses. Since then over 20,000 nurses have completed leadership programmes such as the LEO or the RCN’s own clinical leadership programme.

By October this year over 30,000 will have done so. The nurses I have spoken to say these training opportunities have given them the skills and the confidence to change services for patients. Indeed one ward sister I spoke to last time I was visiting Harrogate told me how she was so inspired by what she had learned that she has now become a course tutor to pass on the benefits she had received to other nurses.

Today I want to build on that nurse’s experience – and I want to extend opportunities to many more nurses. I can announce that over the next two years, the current leadership programmes will be extended to 50,000 D&E grade nurses.

The RCN clinical leaders programme will also be extended to a further 100 trusts including primary care trusts.

In addition I have asked the NHS Leadership Centre to provide e-learning programmes to tens of thousands more nurses, opening up new opportunities, particularly for nurses with family commitments. And I can announce today that I have asked the Chief Executive of the new NHS University to make nurse training an early priority in its work programme.

These five changes – more nurses, better working lives, fairer pay, improved career prospects, enhanced training opportunities – big changes – all amount to one thing: more power for nurses to improve services for patients.

As Beverley rightly puts it – you are the glue that binds the NHS together. Day-in, day-out you are on the frontline of patient care. I want to help you create a patient-centred service.

That is why nurses are in leadership positions in PCTs. It is why ward sisters have been given greater control over ward budgets. Why modern matrons have been given the clout to get the fundamentals of care – good food and clean wards – right for patients.

All of this is about putting power in the hands of the NHS frontline. The NHS can not be run from Whitehall. We have got the national standards and shortly we’ll have a tougher inspection system in place. So it is now time for Whitehall to let go. It is time to let nurses take more control.

Last week we announced the biggest ever funding package for the health service. Today I have announced reforms to extend and expand the power of nurses. To change traditional working practices.

On their own they represent important new opportunities. Together, this investment and these reforms can deliver a better NHS.

I won’t stand here and promise something I can’t deliver. I told you we would get more resources for the NHS and we have. I have told you we will deliver a fair deal for nurses and we will.

I want you to know we will keep faith with Britain’s nurses as you kept faith with the NHS through all the difficult years of cutbacks and closures.

No one is promising you there won’t be pressures or problems. No one is saying every difficulty and every demand will be met.

No one is pretending everyone will be happy.

Real life simply isn’t like that.

But what I can say is that with this level of investment, with these reforms, with your help, the best days of the NHS can be ahead of us, not behind us.

Together I know we will deliver for patients.