Lack of accountability was another problem. Who judged the performance of your local force? To whom was the chief of police in each area accountable? The answer was Police Authorities, but most people – including many politicians – had barely heard of them or knew who sat on them. An idea we developed in opposition was police and crime commissioners. They would be elected every four years to bring visibility and answerability to policing.
The first election for forty-one ‘PCCs’ took place on 15 November 2012. Turnout was depressingly low at just 15 per cent. But, seven years on, I believe that the idea of named individuals elected by the public to hold the police accountable is beginning to become well established.
And there were real results. The budget may have been cut, but crime actually fell by a quarter. Again we had crushed the old orthodoxy that equated levels of success with levels of spending. And we had made our streets safer while improving policing and repairing public finances.
Nigel Lawson was right when he said the National Health Service is the closest thing we have to a national religion. Its premise – universal healthcare, free at the point of use – is seen as sacred, its hard-working staff as saints, and the public is constantly on the lookout for any attempt to undermine it, which would be seen as sacrilege.
I share that devotion. I’ve been there, rushing into A&E at three in the morning with a gravely ill boy. I’ve spent the night sleeping at his bedside on a hospital floor. My family and I owe the NHS more than I can ever say.
So when I became leader I was determined to show that the modern, compassionate Conservative Party would be the party of the NHS.
Standing on the stage in Bournemouth at our party conference in 2006 I signalled the change. ‘Tony Blair explained his priorities in three words: education, education, education. I can do it in three letters: N. H. S. We will always support the NHS with the funding it needs.’
Immediately, I scrapped Michael Howard’s policy of Patient Passports, which would subsidise those who chose to go private. Like the Assisted Places scheme, it took people and public money out of the NHS, rather than trying to improve it for everybody.
These words and actions would, I hoped, do something to repair our unfounded reputation as cutters of the NHS (as I’ve said, the only cuts to the NHS in the last fifty years were in 1977, after reducing public spending was a condition of the IMF bailout – under a Labour government).
But our inheritance was mixed. The boost to NHS funding had raised standards, but a whole set of problems remained – and some had got worse. Cancer survival rates in the UK were among the worst in Europe. Mixed-sex wards were still a reality for many people. Infection rates and MRSA dominated the headlines. And the excessive target culture had serious consequences.
Stafford hospital, in the constituency where I had been a parliamentary candidate, was a small district hospital run by the Mid Staffs Trust. Just before we came to office, the shocking neglect there came to light. As families and staff who blew the whistle were ignored, possibly hundreds of people died between 2005 and 2009 as a result of poor care.
Health secretary Andrew Lansley announced a public inquiry during our first month in office. It would eventually confirm our suspicions about what had been going wrong: the priority in the hospital had been targets over patient care, not care itself; and with so many layers of bureaucracy, everything was assumed to be someone else’s problem.
That was true of the health service more widely. This vast organisation – the world’s fifth-largest employer – had suffered under Labour’s top-down, centralising approach and constant reorganisations. Bureaucracy was rampant. Patient care was taking second place to meeting targets and Whitehall diktats.
The situation was only set to get worse. The population was growing, and life expectancy had risen – that meant more people to care for, and for longer. There were more people suffering from lifestyle-related diseases and chronic long-term conditions such as diabetes. Our most precious national institution was at a perilous moment – but so were our public finances. We simply weren’t in a position to match the sort of increases Labour had made in the good years.
We said that we would ring-fence the NHS budget, and we did. In fact, we increased funding by £10 billion in real terms, leaving it almost 10 per cent higher.
Yet we knew we needed structural reforms to make the system work better. These would prove to be highly controversial. While I believe much of the controversy wasn’t justified (a lot of it was fuelled by Labour and union claims of ‘Tory privatisation’, which it manifestly wasn’t), I accept that mistakes were made, time and energy were wasted and a better approach could have been taken.
The reforms were logical: we were putting power in the hands of professionals, just as we had done in other public services. We gave control of budgets to the people who knew what patients need, generating greater choice and competition. Allowing clinicians and patients to choose from a variety of providers shifted the philosophy from ‘get what you’re given’ to everyone getting the best treatment possible.
And they were evolutionary – following on from what had gone before. Margaret Thatcher had given some GPs the funds to commission services and had created the concept of Trust Hospitals, with greater freedom to manage (although, a bit like grant-maintained schools, the changes were too piecemeal). There was continuity with Tony Blair, who introduced semi-independent ‘Foundation’ Hospitals, and said that the NHS should pay for patients wherever the care was best, whether that was an NHS, private or third-sector provider.
But we were still battling against the preconception that Conservatives had sinister motives towards the NHS. People were told about ‘coalition reforms’, and all they heard was ‘Tory cuts’ and ‘privatisation by the back door’. At a time when we were having to make savings, this assumption had particular potency. It didn’t matter that we were increasing funding. Or that when we did encourage private or charitable providers, it was because they – people like Macmillan nurses – were excellent. Or that, in reality, under Labour 5 per cent of NHS services had been delivered by outside providers and under us that figure was just 6 per cent. Our reputation was set. Therefore we did not have the political space or the public permission to undertake such fundamental reform.
We were also battling against our own promises. I had repeatedly pledged ‘no more pointless reorganisations of the NHS’. And the Coalition Programme for Government said, ‘We will stop the top-down reorganisations of the NHS.’
We weren’t lying; our reorganisation was never meant to be top-down. The local organisation of the NHS was based around bodies called ‘Primary Care Trusts’ (PCTs), which were bureaucratic organisations responsible for ‘purchasing’ care for their localities from the ‘providers’ of care, principally the district general and other large hospitals. Our view was that, as GP practices took on the purchaser role, PCTs would wither on the vine.
Yet when combining Lib Dem policy with ours, the Lib Dems insisted on abolishing the PCTs. It was neater – and we assented. This was a rare occasion when something turned from an evolution to a revolution because of the coalition. Not only was it now a top-down reorganisation, it became one of the biggest in the history of the NHS – so big you could see it from space, as NHS chief executive David Nicholson put it. More significantly, abolishing PCTs required legislation. And so the saga of the Health and Social Care Act began.
We were also hindered by the personalities involved. Andrew Lansley had shadowed the health portfolio since 2004 and would, I thought, make a sterling job of it in government. But he was too submerged in the detail. The jargon he’d use was baffling. I remember sitting in cabinet when he shared his reform white paper. It was like an artist unveiling a piece he’d spent years on, and everyone wondering what on earth it was.
The people who should have been supporting us, whose members we were giving more powers – the royal colleges and
others – began falling away. While our school reforms had caused a ruckus with the old education establishment, which he had nicknamed ‘the Blob’, Michael Gove did manage to build a new coalition of support. The same could not be said of the health service. When Ken Clarke was health secretary he said that the BMA was the worst union he’d ever had to deal with, and it was now demonstrating its militancy once again by holding votes of no confidence in the government. One of the problems with the BMA is that you know it will oppose absolutely anything, whether it is a good idea or not. Back in 1948 it had opposed the creation of the NHS, for instance.
Looking back, I see the health reforms not as a triumph, nor as quite the disaster our critics predicted; but as something that took up a lot of energy and missed the biggest targets we should have been aiming for, which was the costs of an ageing population and reforming social care.
The controversial legislation all came to a head when the Lib Dem grassroots rediscovered their inner protest party on 13 March 2011 and voted against the reform bill at their annual conference. It was ironic, given the central role they had played on PCTs.
It seemed then that we wouldn’t be able to get the Bill through Parliament. I feared – for the first time – that this might really be the moment the coalition would unravel, as many people were expecting it to. But on 20 March 2012 the much-amended Bill made it through both Houses – just.
But that wasn’t the whole story. Look beyond the legislative behemoth and you can see that we achieved strides in healthcare I’d dreamed of since opposition. Waiting times for consultant-led treatment fell in our first two years. The number of people waiting more than a year for operations halved. Hospital infections halved. Mixed-sex wards were all but abolished. There were almost 10,000 more doctors, over a thousand more midwives, and fewer managers. Patients finally had a choice in which GP they registered with. The NHS was ranked the best in the world by the Commonwealth Fund in 2014 and again in 2017.
On a few key issues, the picture on health changed markedly during my time in office. In these I was exceptionally well advised by my health spads, Paul Bate and then Nick Seddon, who told me to pick a small number of really big issues – perhaps those that others had failed at, or not even attempted – and try to effect change. I had four focuses – what I called my preoccupations: cancer, dementia, genomics and anti-microbial resistance.
It was before I was even party leader that my constituent Clive Stone brought the lottery of cancer drugs to my attention. People were dying, he said, because the treatments they needed were not being approved fast enough by the regulator, NICE.
Finally, in 2011, I could address this, introducing the Cancer Drugs Fund, which pays for treatments that NICE hasn’t yet reviewed or has not deemed cost-effective. Sadly, Clive passed away in 2016, but because of his determination thousands of people who might not have survived are alive today. The fund’s continuation is crucial.
My obsession with dementia was formed by that special vantage point you get being an MP and a PM.
As an MP I visited many care homes as part of my Friday constituency rounds. I noticed more and more new floors being built for dementia patients, and met many of those affected, including a sixty-year-old daughter and her eighty-year-old father. He had no idea who she was, or who he was. It was heartbreaking to witness.
As PM I surveyed the bigger picture too. I saw that, with an ageing population, many more people were slipping into this world of darkness. And I learned from experts that we could do little about the diseases, like Alzheimer’s, that caused it. All the advances we’d made in cancer, heart disease and stroke – and there was, shockingly, nothing for dementia.
I saw the financial challenge very clearly, which is why I doubled funding for dementia research. But too many people thought dementia was a natural part of ageing, rather than a condition that is caused by diseases of the brain. As a result, breakthroughs had been held back. This was the communication challenge, and it was a huge barrier to advances. That is why I made sure my entire cabinet were trained as Dementia Friends, as part of a national initiative to help society better understand and accommodate the condition. And it’s why I became president of Alzheimer’s Research UK, putting the issue at the heart of my post-politics mission.
There is another focus I am continuing beyond politics, and it’s about as personal as it gets: genomics.
When Ivan was born in 2002, genetic testing was in its infancy. We watched in agony as he had repeated blood and spinal-fluid tests, scans to record electrical activity in the brain, and any number of other interventions to try to find out what was wrong. And the ‘genetic counselling’ – to discuss whether this could affect any other children we might have – was little more than guesswork.
The intervening years, however, had brought us to the brink of a breakthrough. We now had technology that could provide not just the examination of individual genes, but whole-genome sequencing. Rather than testing for one disease at a time, this process could simultaneously test for all rare diseases (and, increasingly, for all forms of cancer too). The market was bringing down the cost of testing dramatically – and this could transform healthcare.
If some rare diseases are diagnosed early enough, the right medication can be administered so quickly that neurological damage can be prevented, or radically reduced. It brings me great hope when I read about babies born with Ohtahara Syndrome who have grown up with far fewer signs of developmental harm.
Britain has a great heritage in this area, but to keep us at the forefront – and to get ahead of these horrendous rare diseases – I set up Genomics England to run the ‘100,000 Genomes Project’. Over the next five years, 100,000 genomes from NHS patients with a rare disease or cancer had their genomes sequenced. I was proud to keep a copy of the first sequenced genome in a memory stick on my desk in No. 10, and I am proud to see the project expanding today.
The suffering caused by cancer, dementia and rare diseases was plain to see. But ‘anti-microbial resistance’ I’d never heard of until the chief medical officer, Professor Dame Sally Davies, came to my office in 2014. Many antibiotics were no longer working, she explained. Too many had been prescribed, and no new ones had been discovered since the 1980s. Diseases were evolving and becoming resistant to drugs.
I grasped how catastrophic this could be. Without action, we could return to a time when 40 per cent of deaths were caused by infections we’d been able to prevent for the best part of a century. And I grasped that it was an economic problem as well as a medical one. It was the lack of incentives to produce new antibiotics that was at the heart of the issue.
So that’s why in July 2014 I launched the AMR review, led by the economist Jim O’Neill, and why I raised the issue at every global forum I could. As PM, you get lots of people coming to you saying, ‘This is the next Armageddon, Prime Minister.’ Your job is to decide and prioritise. And this absolutely should be a global priority.
The recommendations of the report, which was funded by the UK government and the Wellcome Trust, are being followed today. The issue is on the global agenda. I am pleased that I listened to Dame Sally, and proud that it was Britain that kick-started this important endeavour.
When compared with the success of higher education, schools and police reforms, there are many lessons to learn from the failure of the flagship health reforms.
In the public’s eyes, anything you do at a time of financial hardship will be seen as a cut. Especially if you’re a Conservative. While university and police funding were cut and schools funding remained the same, the health budget actually rose. A government that was vilified for the cuts we made was, ironically, mauled most over the department in which we didn’t cut at all.
We were never clear enough about the problem we were trying to fix. Compare it to schools. People knew there was dumbing down in education. They knew there was a lack of discipline. But they didn’t sufficiently know that
targets and bureaucracy were strangling our health service, or the benefits that would flow from a different approach.
In order to reform both standards and structures in schools we were doing tangible things, like banning calculators from exams, or building new, good schools. But we didn’t explain how a GP’s ability to commission services would help, say, cancer patients. Nor did we have an answer for the broader problems coming down the track, namely the social care crisis.
I had a relatively hands-off approach when it came to my cabinet. I trusted them to get on with it. But I trusted Andrew Lansley too much, and was blinded by his science. I could and should have stepped in earlier and got him to slow down, explain and modify his plans. Sadly, at the 2012 reshuffle I had to ask him to move to the job of leader of the House of Commons.
And finally, the holy grail: keep your word. We had pledged ‘no top-down reorganisations of the NHS’, and, albeit unintentionally, had done just that. When it came to Cameron’s law of broken promises, I didn’t follow my own advice.
But I didn’t regret the pace or the philosophy, or the speed at which we saw results from our wider reforms. With every policy, including health, we started to see improvement (though our economic reforms would take a little longer).
Around the world we were being noticed. The front page of the Economist mocked me up with a red, white and blue Mohican, with the headline ‘Radical Britain: The West’s Most Daring Government’. I had it on the wall in the Downing Street flat, and it remains at home today.
We had a clear run at reform because of the political picture during those early years in office. Against all predictions, the coalition was holding together. Labour were looking less of a threat after electing as leader the more left-wing of the two Miliband brothers, Ed, in September 2010. Neither UKIP nor the Scottish National Party seemed a blot on the horizon. Indeed, we were on a long honeymoon as a coalition government.
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