Secretary of State for Health and Social Care's speech Health Reform in the 2020s

Part A: Context 

Introduction 

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 20^th Century. We must make it so for the 21^st 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 everythingfrom 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 improved outcomes in a modern and personalised way is just as important for people as how much it spends. We can’t sit back and just hope for the best. Reform is absolutely essential. 

The NHS Long Term Plan we set out in 2019 made great strides forward. The Plan significantly increases investment in primary, community and mental health services. Together with the Health and Care Bill, currently before Parliament, it sets a course for more integrated care. But it was designed in a pre-pandemic world: it won’t be sufficient to meet the challenges we face after the pandemic. We are now starting on the road to recovery after Covid. 

I’m often asked if reform is worth the risks. But Covid has raised the stakes. The risks of doing nothing have dramatically increased. It’s not that we would simply stand still: we’d actually go backwards: taxes AND waiting lists would rise. That’s not going to help anyone. That’s not going to help people get their operations in good time. That’s not going to help staff recover from the collective trauma of Covid. That’s not going to help managers hold onto talented and dedicated colleagues. 

The second question people often ask me is “Why now?” – now, when we face the tail-end of the greatest public health emergency in a generation? But that’s even more reason to get going. Not only is the need greater now, but the way the NHS responded to the pandemic gives us a wealth of innovation and learning to draw on. In truth, I’d rather have made this speech before Christmas – but then the Omicron wave struck. And yes, we might face another more dangerous variant. There will be other bumps in the road. But I believe there’s not a day to waste. As Markus Brunnermeier recently argued in his book ‘The Resilient Society’: “Resilience is not the same as ‘robustness’. It’s about being able to weather a storm and recover”. We don’t just need to be robust, we need to be resilient. 

Business as usual won’t fix winter pressures or the Covid backlog. Doing nothing risks locking us into a decade of decline. Reform is an essential pre-requisite for recovery. So as the Talmud says, ‘If not now, when?’ 

I might not be here in 2032, but my successors – and, far more importantly, the British people – would never forgive me if we didn’t get started now. Of course, it won’t be easy. In the NHS we have one of the largest workforces in the world - there are hundreds of organisations within it. It’s not just those three letters: it’s a whole ecosystem. Working with so many people on reform is never going to be straightforward. But it doesn’t have to be fraught, because so many of the changes we need to make are changes people working in the NHS have wanted for a long time. In many ways, reform has really been going on for some time – far away from my office in Victoria Street. As we’ve all seen through the pandemic, it’s people within the system itself who are the greatest drivers of change. It’s now up to us to reach their level of ambition. 

Reform to me is about hundreds of thousands of innovators being freed to make tens of millions of innovations. It is an ever growing and more intricate mosaic of change with the entire health and care workforce as its co-creators. My model of reform is the one that backs the thousands of models being developed in wards, offices and surgeries across the land. “Free at the point of use and freedom at the point of delivery”, you might say. 

Part B: Our reform agenda 

Now to do this, we’ll need one of the most comprehensive reform plans that this country has ever seen – and we’ve already been getting started. In December, we published “People at the Heart of Care”, to kickstart a comprehensive programme of reform of Adult Social Care. Last month, we published the Integration White Paper and the Elective Recovery Delivery Plan to tackle the Covid backlogs. And this April, subject to the will of parliament, our new Health and Care Bill will come into effect – ensuring our system and structures are set up for success. 

The next steps of my reform agenda will build on these foundations. These are radical but logical next steps. They flow from the increasingly patient-centred and systems-based working through the Integrated Care Systems. I’m going to set out our plans in three areas. 

First, in Prevention – how we build, not just a ‘national hospital service’ but a true ‘National Health Service’. 

Second, in Personalisation – how we deliver more personalised care, empower patients and fulfil the promise of the technological leaps we’ve seen throughout the pandemic. 

And third, in Performance – how we make sure the NHS can deliver the British people the very best healthcare in the world. 

#1 Prevention 

Why prevention? 

First, turning to prevention.  

In years gone by, this country has been at the cutting edge in prevention and health improvement: Think of Edward Jenner; John Snow; the 1875 Public Health Act. But in recent years, while we’ve talked a good game on prevention and health improvement, the truth is, we’ve not always delivered. We can see the results today. 

To start with, while the general trend is that we’re living longer – life expectancy has begun to stagnate. On top of that, we spend a fifth of our lives in poor health – and the poorer you are, the greater the proportion of your life spent in poor health. Next, we lack resilience. This became starkly and painfully clear during the pandemic: Covid-19 didn’t strike randomly. There’ll be risks and shocks in the future, but based on the underlying health of our population, we can’t honestly say that we’re well prepared to face them. Finally: poor health is economically destructive and socially unjust. 

Of course, there are some things we simply can’t prevent: like some types of cancer. But there are many things we can. Each year, the burden of just one preventable disease – cardiovascular disease – costs society over £18 billion. The NHS spends vast sums treating people whose conditions are avoidable - and by some estimates 40 percent of its costs go on treating preventable conditions.  

So I want us to shift to a new mode of operating – one that’s about helping the whole population to stay healthy, not just treating those who show up asking for help. A mode that gives us the resilience to meet both the challenges we know the rest of the century will bring – and those we don’t yet know are coming. 

I am a small-state conservative. If we continue to spend too much time trying to address the symptoms and not enough on the causes, we will end up with an ever-expanding state and even worse health. There is no small state which isn’t a ‘pre-emptive state’. The NHS is significantly bigger than it would be if we had done a better job at preventing avoidable disease. 

I talked about freedom earlier: freedom from pain and disease is one of the greatest freedoms there is. We need to get to a place where we’re healthier for longer. 

Not only do I want to see life expectancy go up again, I want to close the gap between life expectancy and Healthy Life Expectancy – the measure of how long a person lives without health problems. More than that, we must close another gap: the almost 20-year difference in healthy life expectancy between the richest and the poorest amongst us. That is completely unacceptable. 

Public service reform under this government, and the health reforms I am leading, should have social justice right at their core. I will be tireless and unyielding in this mission to close these gaps and I know you will all join me in this. 

How? 

The question then, is how? 

Part of the reason we’ve not always delivered on prevention is that we’ve spent too long arguing about who is responsible for prevention and not enough time doing it. Of course, we know who’s responsible. It’s everyone. Every part of national government – not just my department. Local government. Social care providers. Industry. Employers. And people themselves. 

Our new Office for Health Improvement and Disparities, or OHID for short, marks a new era in preventive healthcare. The new ‘Health Promotion Taskforce’ is joining up work with every part of government and I will launch a Health Disparities White Paper later this year to help prevent disease and reduce deep-seated inequalities. 

NHS for prevention 

‘Everyone’ also includes the NHS, of course. 

Clearly, the NHS has a vital role to play in stopping people becoming patients in the first place. It has a huge reach. It has a huge budget. It has real levers and influence. But we’ve consistently under-prioritised and underutilised what the NHS can do in prevention. That must change. We must hardwire prevention into the NHS. 

Our ‘Road to Recovery’ begins with tackling the Covid backlog, because we want to prevent worse outcomes for people waiting the longest. Our plan is to recover elective services over the coming years, so that by March 2024, 99 percent of people are waiting less than a year. 

But it’s just as important we prevent new people from joining waiting lists, by putting as much effort as we can in keeping people well, before they get ill. The irrefutable logic is to act now, to stop risks and costs building up in the future. 

The NHS Long Term Plan heralded new programmes to help prevent and manage diabetes and other long term health conditions, and greater action to tackle smoking and obesity, for example. But we still have an enormous way to go. 

We must now put the full power of the NHS behind prevention. Every part of the NHS has to play its role, and every part of the NHS stands to benefit. 

So as we look at every part of the NHS, naturally we must look at Primary Care where the bulk of prevention already happens. Primary care and all our GPs, pharmacists and dentists must be at the heart of this new agenda on prevention.  

I know there is a sense that primary care is far too stretched to be proactive on prevention – even though it wants to. Claire Fuller is currently conducting a stocktake on how primary care networks can be supported in ICSs – and I’m looking forward to hearing her views on how we can best help primary care deliver for the communities they serve. 

We need a reform that works for populations and the profession alike – because primary care represents one of the very best ways of preventing and managing illness in the community. We need to make patients a 21st Century offer – and give frontline innovators the tools to deliver it. 

Community Diagnostics Centres 

That’s also the spirit behind our Community Diagnostics Centres, which are already helping millions of patients benefit from earlier diagnostics closer to home, without ever having to set foot in a hospital. 

As well as preventing disease from occurring, long-term action to improve the health of the population means identifying risks as early as possible and intervening to stop them from getting any worse – and that’s what our 100 new Community Diagnostic Centres opening across England will help achieve. 

The CDCs are a one-stop-shop for checks, scans and tests right in the heart of our communities. I visited on my tour, in Poole, where people no longer need to travel miles and miles for a test: they only need to pop into Beales Department Store, right on the high street. Convenience matters, because we know easy access often means early diagnosis. 

CDCs have already delivered more than half a million extra tests in their first full year of operation, and we expect them to provide at least one and a half million tests in their second year. 

It shows that phenomenal health services don’t have to be hospital services. In fact, a lot of people don’t like visiting hospitals – especially for routine tests and scans. In the future, most of us will be more familiar with our local CDC than our local hospital. The NHS will look, feel and operate very differently in the years to come. 

A new approach to vaccination 

I think we already started getting that sense through the pandemic, when we turned up in places like mosques and museums to get our jabs. That was a whole new approach. Those efforts delivered over 140 million vaccines against Covid-19 in little over a year – all while we delivered millions of other routine and flu vaccinations. 

It’s not just numbers, it’s new ways of working: like our National Booking System, which helped millions of people get their jabs, and the NHS app which now allows people to show their vaccination and Covid status. 

I want us to apply this level of ambition onto other routine vaccinations, with a new approach to vaccination. We can do it by taking forward the lessons we’ve learned and the technology we’ve built to deliver a sustainable vaccination service that doesn’t displace other health and care services. This can be a better experience for the public but will also help the NHS drive the prevention agenda forward, providing improved data that helps plan services. 

This approach has merits for childhood vaccinations too. By harnessing data across programmes, we have tools to halt the decline in uptake of life-saving vaccines like MMR and become a global leader in the elimination of other preventable diseases. 

I’m also excited by what the future holds for vaccination. Last month I was in Cambridge, Massachusetts to hear about some of the pioneering work in mRNA technology – something that was previously regarded as too experimental, but came to save tens of thousands of lives in the pandemic. Such technology offers hope on everything from HIV to malaria and will be a key part of our prevention agenda in the years to come. 

Commitments on Prevention 

That prevention agenda will take shape through every part of the NHS, including Primary Care, CDCs, our vaccination service and much more. There's no going back. And so today I want to make four further commitments on prevention: 

The first is to baseline, report on, and assess how much is being invested into prevention. 

Not only do we need to put the power of every part of the NHS behind prevention – we also need to put the power of the NHS budget behind it too. It’s self-evident we need to increase spending on prevention, yet we don't accurately know how much we spend. A baselining exercise is a vital first step towards agreeing how much our investment in prevention will increase year-on-year. My department and NHS will also work together to look at where barriers can be removed and incentives improved to focus on prevention. 

Building on our Integration White Paper, my second commitment is to put prevention at the heart of how we hold our ICSs to account in the future. We will expect NHSE and individual ICSs to commit to joint delivery plans to reduce the biggest preventable diseases – starting with cardiovascular disease, but in time, expanding to include diabetes, cancer, and poor mental health. 

The third commitment I want to make today is to push the entire health and care system harder on the prevention of cardiovascular disease. It’s clear we cannot build a sustainable NHS without making a step-change in how we prevent and manage the biggest risks to health, yet over 100,000 people die from cardiovascular disease each year. More than that, premature deaths from cardiovascular disease are four-times higher – four-times higher – in the most deprived communities compared to the least. We must end that disparity – especially because we know it’s possible with some simple interventions. 

My fourth commitment is to 21st Century Digital Prevention. The NHS App has shown just how receptive people are to having healthcare literally in their hands. We’re going to build on this incredible momentum. We’re putting prevention at the heart of the NHS App, making it the front-door for preventive tools and services – like a new digital health check. And we’re going to further develop the apps and websites that give people direct access to the diagnostics and therapies. That’s the future. 

#2 Personalisation 

Why personalisation?  

I’ve talked about prevention. Now I want to focus on the second of the ‘three P’s’: personalisation. 

The ideas behind personalisation go all the way back to Hippocrates, but in recent years, personalisation has taken on a new life: from making use of our new ‘family hub’ service, to taking a test at home for Covid-19 and then uploading the result. We know that when healthcare is personalised – built around the person and their family – it works better. It’s not just more efficient, it’s more effective too: with more diseases prevented and better medical interventions. 

Let me share with you a short story from my own life. When I was around five, my Dad was a smoker – a lot more people were back then. I remember standing at the top of the staircase overhearing my Mum confront him, saying: “If you die, your boys won’t have a Dad”. He never smoked again. That kind of intervention is more powerful than most of us can imagine. Although he still died many years later of colon cancer, I do wonder if, by stopping smoking in his early 30’s, it gave us many more time together as a family. 

In my party conference speech back in October, I talked about how we’ve got to recognise the power of families to make the difference when it comes to healthcare. Whether it’s stopping drug addiction or dealing with depression, there’s no more powerful motivating force than family. And again, there's no small state without strong families. 

I’ve talked about prevention and what government can do - but we as citizens need more power to determine our own health. We need a decisive shift from the state to individuals, families and communities. I want to expand on that today – and set out some of the ways I want to transform the quality of healthcare and put power in the hands of patients and their loved ones. 

Personalised care & personal budgets 

I am especially ambitious about personalised care and personal budgets. 

People with long-term conditions, which can be managed but not cured, account for half of all GP appointments, two-thirds of outpatient appointments and inpatient bed days, and two-thirds of all health and care spend in England. This presents a real challenge. And not just here. It’s literally pushing health services around the world to breaking point. 

Preventing long-term conditions is an essential part of our health agenda. But equally important is improving the quality of life and care for the millions of people who are already affected by their multiple long-term conditions. 

For people with multiple chronic diseases, healthcare is too often focused on individual diseases rather than the person as whole. It is often fragmented across a range of providers, specialists and sectors rather than being part of a longer-term plan for their overall health and their quality of life. I know this causes frustration to patients, their loved ones - and clinicians too. 

Among people with multiple conditions, there are over 60,000 unique disease combinations. It’s clear so many of these people can benefit from personalised care. 

And we know people value it too. It’s why we’ve worked hard to expand it - and the NHS has exceeded its target of 2.5 million people having benefitted from personalised care, a whole two years early. 

Today I’m setting out a new ambition on personalised care: that as many as 4 million people to benefit from personalised care by March 2024, covering everything from social prescribing to support plans. 

Personal health budgets are another way to put power back in people’s hands. It puts people and their families in control of budgets and helps them to tailor these resources to their needs and wishes. 

Our current target is for 200,000 people to have a personal health budget by 2024, but I want to see a significant expansion in the coming years. We will start by exploring the extension of legal rights to enable significantly more people to benefit. I also want more people to have integrated health and social care budgets to better join up care for individuals. 

The NHS is already becoming a more personalised service with personalised budgets, personalised technology, personalised medicine and treatment. I want to see a radical acceleration of that process. 

By 2030, I intend for personalisation to become the norm and personal health budgets to be an increasing part of that. Taken together, I intend for this to be one of the biggest transfers of power and funding in decades: from the state, to the individual and their family. 

Shared lives 

We know that people can really benefit from receiving care at home. It can help to be in familiar surroundings around people who care about you. 

Many of you will not have heard about it, but one of the most exciting schemes to help with that care at home is called ‘Shared Lives’, where people in need of care go to live with carers and become like any other member of the family – think of it like fostering but for adults. I’ve heard some wonderful stories of people living together for decades. Not all of them live together full time – sometimes it’s respite care. 

At the moment nearly 9,000 people in England are supported in this way. Not all of them live together full-time; for some people Shared Lives provides short breaks or respite care. I think it’s a great example of personalised and life-changing support. 

I want to be ambitious about how we grow the Shared Lives model. We will work with Local Authorities to expand the model, making sure it is available for more people across the country. Above all, we’re going to raise awareness among the public and inspiring more people to come forward to be Shared Lives carers. Shared Lives is just one example of an innovative model that reimagines how we provide care and support. There are many more. 

Improving patient voice 

Another way I want to put power back into the hands of people and their families is to improve their voice within the system. We’ve taken bold steps in response to scandals, like the Francis Inquiry and the Cumberlege Review. But these kinds of scandals happened because people weren’t listened to earlier. Their voices weren’t heard. 

And what about those smaller everyday injustices? How are we responding and learning from them? That’s where I believe we need to do much more – we need to get better. 

Before becoming Health Secretary, the main way I interacted with patients using the NHS was in my constituency surgeries: I’d often hear about things that had gone wrong. MPs will continue to play an important role, but we must get better at capturing that voice within the system. 

We need a new approach that’s about more than individual experiences and complaints – it must be about continually listening to patients, users and their families. It’s an approach we’re already embedding across the board – from the Adult Social Care Reform White Paper to the new Health and Care Bill – and I want us keep thinking about how we can be more than the sum of our parts when it comes to the voice of patients and care users.  

Long waits & right to choose 

As well as voice must come choice. Choice is written into the constitution of the NHS, where it says: “You have the right to make choices about your NHS care and to information to support these choices”. That’s what the constitution says. But I know it doesn’t always feel that way – sometimes it feels more like that famous Henry Ford quote: “You can have a car painted any colour you like, as long as it’s black”. This feels especially true when you’re stuck on a long NHS waiting list. 

So today I’m announcing a new ‘Right to Choose’. 

It starts with more choice at the front door, including more active discussions between professionals and patients. But that ‘Right to Choose’ can’t just end at the front door. 

Today I’m announcing a better offer to long-waiters: we will move to a model where long-waiters will be offered the ‘right to choose’, proactively contacted to discuss an offer of alternative provisions. 

That could be the Trust next door. It could also be a Trust that’s further away – and if it is, your transport and accommodation would be covered. It could be the independent sector. 

This is something the very best systems are already doing – but I want it to become standard. I know it won’t be easy, and that we must begin by making this offer to the very longest waiters. So by the end of December, people who are at risk of waiting 78 weeks will be contacted first. 

For the trusts with the highest number of long waiters, and those who have been waiting more than two years, they will be contacted by the end of this month. 

In future, I want to make this improved offer to all patients in the NHS – working from the longest waiters down. It’s right, because it can bring the waiting lists down over time. But it’s also right because choice is an intrinsic good. 

And it must be available to everyone. Disparities in health are exacerbated by the fact that it’s middle-class people in leafy suburbs that are better able to push the system to work for them. I want choice for all, not just the privileged few. 

Soon, the NHS and the My Planned Care Service will be the gateways to all kinds of information. From the choices you have to the waiting times you might expect – backed by the latest tech matching demand and capacity. It’s an example of how we’re embracing technology and data to drive up performance. 

App-first 

Because in years to come, the primary way people will interact with health services will be online. The pandemic has accelerated this process – bringing us to a point where over 25 million people are carrying the NHS App around in their pockets. We must keep up that momentum – because, as I said earlier, I want that app to be the new front door to the NHS. You could say: the NHS App is for life, not just for Covid. 

Health needs to embrace the revolutions that have already come to banking and shopping – it needs to be as easy for doctors and patients to order a blood test as it is to order a burger – or a salad - on your phone. 

This Spring, we’ll publish our first ever comprehensive Digital Health and Care Plan: which is also the very first to span social care too. People are already starting to see what that looks like, with the choice of remote GP appointments and consultations. We want a digital future for the NHS that works for everyone, not just digital natives. 

It’s also beginning to feature in acute care too. Watford General Hospital was one of the first places to trial virtual wards. Patients with Covid were able to safely stay at home, preventing the spread of infection, all while having their heart rates, oxygen levels and temperatures remotely monitored. If there was any sign of deterioration, clinicians were alerted right away. 

Clearly, there’s so much more we can be doing from home. And we should be doing it too, because it’s often a more dignified form of care, away from hospitals and closer to your family and friends. Long-term conditions like diabetes, asthma and depression are some the best examples of where we can do more to support people to manage their own health. 

#3 Performance 

Why performance? 

I've talked about prevention and personalisation. I want to close by talking about our third 'P': performance. 

As I said in my opening: people's expectations have been raised - and rightly so. Part of my current mission is to bring waiting times down. Still, even as we push to go faster, the push to get better must never stop. 

In some areas such as affordable drugs and accessible care, we deliver with the best in the world. In others, like cancer survival, CVD and maternal health outcomes, we all know the NHS must do better. We’re not the kind of country to sit back and accept middling performance. Neither are we the kind of country that should tolerate unacceptable variations in performance from place to place. We will take the next steps to improve performance on cancer with the 10-Year Cancer Plan I will set out later this year to help make our cancer care system amongst the best in the world. 

Digital Revolution 

Embracing the digital revolution doesn’t just have the potential to transform the patient experience – it can improve the daily experience of colleagues working in the NHS. I want us to pull every digital lever we have: it’s why I brought together all the digital leadership across NHSE, NHSX and NHS Digital. 

The NHS is already one of the more efficient health services in the world, spending 2p in every pound on administration, compared to 5p in Germany and 6p in France. But there’s so much more we can do.  

At Heartlands Hospital in Birmingham a few weeks ago, clinicians told me how the switch to Electronic Patient Records has been transformational. Now, as patients come in: rather than drowning in a sea of paperwork and trying to piece together that patients’ history, staff immediately know which doctors they’ve already seen, which medication they’re on, and which previous conditions they have. All at the touch of a button. 

I’m determined to take this further, so I’ve set the ambition for electronic records to be rolled out to 90 percent of trusts by December 2023, and 80 percent of social care providers by March 2024. These are modernisations we cannot afford to live without. 

Beyond this, I have also seen examples of the dramatic potential of advances in AI to transform services across the NHS. If we get this right, we can improve the day-to-day patient experience, free up more time for GPs, nurses and others to focus on patient care and reduce costs. Lord Darzi has estimated that the NHS could achieve cost savings of £12.5 billion a year by fully automating routine and administrative tasks. 

Partnerships for reform 

A vital part of levelling up performance is being open and honest about where we can do better. Listening to patients’ voices – which I talked about earlier – will be a crucial part of this, but equally we must listen to the innovators already doing incredible things within the system. 

We’ve seen that where this happens, the challenges that appear to be intractable in one place can be resolved in another. It’s essential that innovative solutions don’t just stay where they are – they must go far and wide. 

Like the South West London Elective Orthopaedic Centre, a formal partnership of four acute trusts which has become a leader in providing high quality orthopaedic surgery in the UK. Or the South London Health and Community Partnership, where they’ve brought three mental health trusts together to improve services and innovation in mental health. The result has been a reduction of more than a third in out-of-area patients, and a reduction in readmission of two thirds. 

I want to see more of these partnerships for reform, so those teams and organisations with a track record of solving long-standing service issues can share learning across systems to bring improvements. 

I want to explore what Trusts working in such partnerships could do with greater freedoms and see what else we can do to help them share so much of the brilliant work they’re already doing, so more patients can benefit from improved performance and access to services. This approach of partnerships for reform is rooted both in the Bill and in the most successful public service reforms of the last few decades. 

People 

So. Prevention. Personalisation. And Performance. The three big areas we need to focus on. But as I finish allow me to mention what’s probably the most crucial ‘P’ of all: our People. 

On my ‘Road to Recovery’ tour, the biggest honour of all was meeting our phenomenal health and care staff. I was blown away by their professionalism and their dedication. I know the pressure of the pandemic has taken its toll. Of course it has. It would be wrong to pretend that everything was perfect before the pandemic – just as it would be wrong to pretend that everything will be better once the pandemic becomes endemic. 

But having more colleagues will be essential: we have 41,000 more NHS workers than this time last year, including some 11,000 more nurses and over 4,000 more doctors. And yesterday we published our delivery update on our progress towards our manifesto commitment for 50,000 more nurses. Already, since September 2019 there are now over 27,000 more nurses working in the NHS. 

But we also need - and we will have - a proper long-term workforce plan, so we can build our workforce and skills, and take tougher action on things like racism, sexism and bullying. 

Leadership review 

Through that process we must also look at how – of the 1.3 million incredible people working in the NHS – great people from all backgrounds and specialisms are making it to the top – and performing well once they get there. Excellence comes when you have great teams working together and excellent examples to follow. 

This is what I had in mind when I asked General Sir Gordon Messenger and Dame Linda Pollard to review leadership in Health and Social Care. Their mission is to look at the cultures and behaviours of all leaders and managers at all levels of health and care organisations: it’s vital that all staff working in health and social care – including porters, social workers, cleaners, medics and many more – are respected and recognised. 

Some of their early findings already make for interesting reading. There is some phenomenal leadership in the NHS, but investment in it is often unstructured and unsupported. 

I want to create formal systems that can embed excellence and rigour into the NHS, so our country’s greatest institution has the leadership it deserves for decades to come. 

Close 

So those will be my priorities for health reform as long as I have the privilege to do this job: prevention, personalisation, performance – and people. 

Today I’ve set out a direction of travel – these are just the next steps for reform, not the sum total. This must be an era of both recovery and reform. 

My four principles underlying that agenda are these: First, that services are redesigned around the patient by prioritising prevention and personalisation. Second, is clear performance standards and accountability. Third, is more choice, power, tech and funding in the hands of patients. And finally, backing our people with more freedom and support for system leaders and front-line innovators to partner and to deliver. 

Taken together, this is how we can deliver a health service with a renewed prevention mission; one that empowers patients and fulfils the promise of the technological leaps we’ve made through this pandemic; and one that’s truly world-class – for the people who use it and the people who deliver it. 

The agenda we are building will amount to a revolution in the supply-side and demand side of healthcare and a huge transfer of power and funding from the State to the individual and the family. 

This is the best way to keep the dream of 1948 alive – and now is the moment to seize it. 

We are at a turning point in history. We must not fail to turn. 

Thank you all very much.