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Burnham For Mayor

Tuesday, 27 January 2015

Andy Burnham speech on Labour’s 10-year plan for health and care

Good morning and thank you for being with us at such an important moment.

The Party which created the NHS in the 20th century today resets it for the 21st.

Ed Miliband has this morning launched Labour’s pledge to create a national health and care service, backed by new investment in investment in the nurses, doctors, midwives and homecare workers that will ensure the NHS has time to care.

I am setting out a 10-year plan explaining how we will build it.

It is based on the simple notion that, if we start in the home and make care personal to each family, it is more likely to work for them and cost less for everyone.

A service where families no longer have to battle for help, telling the same story to everyone who comes through the door, but have just one person to call.

Where people can find mental health support, such as counselling or therapy, as readily as medication.
Where care is no longer cut up into crude 15-minute slots but where staff have the time to care.

And where people with dementia and autism are supported as well as those with cancer.

This is the scale of our ambition: an NHS for the whole person; affordable and sustainable for the country.

The challenge is so great that it can’t be achieved with more of the same: another imposed re-organisation without consent.

Instead, the journey to a national health and care service must be one that everyone is invited to join and everyone has a part to play; where change is not dropped on people from a great height but worked at and built by people in every community.

But one thing is clear: change can’t wait.

At the start of 2015, the NHS finds itself in a dangerous place.

If A&E is the barometer of the whole health and care system, then we must look at what it is telling us.

Hospitals have not met this Government’s lowered A&E target for 79 weeks running – and things are getting worse.

The barometer is warning of severe storms ahead.

If we don’t change course, the crisis we are seeing now in A&E and the ambulance service will become entrenched in the NHS.

At the start of this Parliament, I warned of the impact that cuts to social care could have on the NHS.

That warning has been borne out by what is unfolding now: the collapse of social care is dragging down the NHS with it.

As 2015 began, there were record numbers of frail, elderly people in hospital beds – trapped there because the hospital is the last resort in a system where other services can’t meet their needs.

Last year, an elderly lady from Lincoln spent an entire calendar year in a hospital bed; a sad sign of a system that simply isn’t working for anyone.

Hospitals are operating at their limits and, with the wards full, pressure is backing up through A&E.

People are waiting longer for ambulances to arrive and to be seen in A&E.

But there is a knock-on effect felt by other patients, having operations cancelled at the last-minute or waiting longer for cancer treatment to start.

This situation is affecting patients in the community too. As hospitals treat record numbers, so they draw in more resources. This Parliament has seen cuts to GP services, community services and mental health.

People struggling to get GP appointments are turning to A&E, as are people with mental health problems who can’t access the crisis support they need.

Unsurprisingly, our hospitals are close to being overwhelmed.
This is the vicious circle in which the NHS is now trapped.

And it could get much worse.

On the current Government’s spending plans, social care will be further stripped out, pushing hospitals to breaking point.

And, with the Health & Social Care Act still in force, the next Parliament could see the NHS sunk by a toxic mix of cuts, crisis and privatisation.

The NHS desperately needs a change of course and the plan we are launching today provides it.

It will lift the NHS out of its downward spiral and provide a long-term solution to the A&E crisis.

But it is much more than that.

It offers a positive vision of what the NHS can aspire to be in a century when people’s needs have changed; that answers the question of how it can be afforded; and that, after the divisive change of the past, is something for people to believe in and unite around; that offers something in short supply in the NHS right now: hope. Hope that the NHS is not on a slow path out but that it can be rebuilt as a 21st century service.

It is two years since I came here to propose full integration – a single health and care service.
Since then, we have been round the country and consulted professionals, patients and public.

We have taken expert advice from Sir John Oldham and the Commission on Whole Person Care. Their work has been invaluable to Ed Miliband and I and the plan we are publishing today draws heavily on it, together with that by Stephen O’Brien on mental health in society and Denise Kingsmill on the social care workforce. We thank them all.

Other important reports have been published since my 2013 speech: the RCP Future Hospital report; the NHS Confederation’s 2015 Challenge Manifesto; reports by the Fabian Society and the IPPR on Whole Person Care; the Barker Commission and the Five-Year Forward View.

All have helped shape our thinking and I see them as entirely complementary to our plan.
It is also a substantive and considered response to the Francis Report and the failings at Mid-Staffs.

What the Francis Report laid bare was the danger of trying to rise to the challenge of the ageing society with a hospital-based, production-line model of care that is not sufficiently person-centred and where social and mental needs are frequently neglected.

Robert Francis invited us to rethink from first principles how we care for older people and this is what we have done.

But our solution is equally applicable to the care of anyone who needs on-going support: from the child with complex needs to the adult with learning or physical disabilities.

When we talk of the ageing society, we tend to think of people in their 80s and 90s in homes or hospital. But the truth is that ageing is changing society more profoundly than we might realise.

For instance, children with severe disabilities are now living into their 20s and 30s - beyond the point of transition from children’s to adult services – while more adults with learning disabilities are living long enough to develop dementia too.

This is the complexity of care in the 21stcentury and the truth is we don’t yet have services that can provide an adequate response.

Our aspiration should be to have services that can meet all of one person’s needs – physical, mental and social – wherever they may be; from home to hospital and everywhere in between.

That is what Whole Person Care should mean in practice; services that don’t just see the immediate problem but the whole person behind it.

That is the vision I put to you two years ago and, in the discussions we have had since, I have taken great encouragement from the endorsement you have given to it.

But you made a number of important calls - and I have listened.

First, you asked for clarity.

The Oldham Commission sets out succinctly what we are trying to achieve: one person, one team, one service; a service that aspires to achieve in all of us a state of complete physical, mental and social well-being, rather than just treat disease or infirmity.

Second, you asked for stability.

Our response is to set the path to full integration and a single service as a 10-year journey.

The plan reaffirms our intention to work through the bodies we inherit, with no new structural re-organisation, but adding ambition and impetus to existing plans for integration.

Third, you asked for flexibility.

We agree that integration can’t be mandated from on high. Instead it will need to be worked at, a journey driven at local level, where people work to build relationships and change culture.

So we won’t impose one way of doing things – one model of care - but let different places find their own way to solutions that are right for their area.

And, fourth, you asked for consensus.

I know that the NHS is in such a fragile position, and morale so low, that a new round of contested reform might finish it off.

But, that said, the Health & Social Care Act put a political agenda at the heart of the NHS that goes against its grain.

So I also know that things can’t stay as they are.

That has been the dilemma I have faced and this plan is designed to square that circle: putting the right values back at the heart of the NHS without a re-organisation; and moving beyond the polarising debates of the past about tariffs, targets and structures and towards a new goal – Whole Person Care – true to people’s professional vocation.

If people get behind it, this plan can provide the new national consensus that the NHS so badly needs.

A big claim, I know. And people will ask – how?

It means going back to the things that truly matter - values, power, money, organisations and people – and getting those fundamentals right.

So let me take you through what we propose on each.

Our journey towards a national health and care service starts with values.

Today Labour calls time on the Tory market experiment in the NHS.

I am clear: the market is not the answer to 21st century health and care.

If we allow market forces to continue to take hold, they will eventually break the NHS apart.

Our destination is integration. Markets deliver fragmentation. They bring more providers onto the pitch, increasing the cost and complexity of care.

But they also clash with the NHS values, undermining collaboration with competition and patient care with the profit motive.

I believe the reason why the public continue to trust the NHS in the way that they do is because it remains at heart a service that is based on people and not profits.

That is why so many NHS staff give more of themselves to it than their contracted hours.

If today’s politicians do not understand that, they will never understand the value of what our predecessors created.
That is why the Health & Social Care Act 2012 created such a rift.

It remains a contested piece of legislation, with no democratic legitimacy.

Securing a national consensus on the NHS will simply not be possible as long as it remains in place.

So, if elected, Labour will introduce a Bill to repeal the Health and Social Care Act 2012 in our first Queen’s Speech.

But we do this not because Labour is turning its back on reform. We do it to enable the radical reform of services that is now urgent.

The NHS needs the freedom to collaborate, to integrate, to merge, to break down organisational boundaries without having to run wasteful tenders that integration harder to achieve in practice or having the competition authorities blocking its plans.

Over the next decade, services will have to change more than they have in the history of the NHS. To embrace that, the NHS will need to be secure in its position.

So we will cement the public NHS as our preferred provider at the heart of every community. Our new Bill will legislate for that, claiming a full exemption for the NHS from EU procurement and competition law - as we are entitled to do under the Lisbon Treaty - and from international trade treaties such as TTIP.

This does not mean there is no longer any role for the voluntary and private sector. There is a role. But we will clarify what that role should be: a supporting – not replacement - role.

To help them become stronger partners, non-NHS organsiations need more stability too. So we will move away from an approach based on short-term contracts towards long-term alliance contracts as proposed by the Oldham Commission.

But a distinction will be drawn between not-for-profit and for-profit providers.

Given that voluntary organisations build volunteering capacity – which in turn builds the health of people and communities – we should give them the benefit of much longer and more stable arrangements, for instance for five or even ten years.

Private sector organisations, working as long-term partners, will have to accept NHS standards.  So we will extend the Freedom of Information provisions to any provider of NHS services and consult on a new training levy so that all providers contribute to the costs of training clinical staff.

This approach returns the right values to the heart of the NHS. But is also cements its financial strength as a national service, rather than a market-based system.

All the evidence from around the world says that national systems like ours cost less than market-based health systems.

The NHS delivers comprehensive cover of a good standard to every single citizen for less than 10 per cent of GDP. No other country in the world comes close to that.

In a century when rising demand and costs is the greatest challenge, we should build on that foundation not chip it away.

A national system allows us to set out in a fair way what people are entitled to and thereby to control those costs.

People don’t want postcode lotteries in health care. Nor do we want an NHS that sits in judgment on people’s lifestyle, with arbitrary restrictions on operations, or saying that people with two cataracts can only have clear sight in one eye.

So we will stop that growing practice and re-establish the authority of NICE. If a service or medication is judged clinically necessary, effective and affordable, everyone should get it.

And we will ask NICE to help us set out a new entitlement to Whole Person Care, given that it will make sense to provide more services on a universal basis in an integrated NHS.

For instance, we will ask for advice on establishing a universal re-ablement scheme to help the most vulnerable people return home from hospital.

And to make sure the focus is always on prevention, we will ask NICE to take an expanded view of all public spending when making their decisions.

It makes no sense to restrict treatments to save money for the NHS if that only adds costs to other government departments. For instance, restrictions on mental health care for young people may add huge costs to the criminal justice system.

But as we strengthen the N in NHS – and restore democratic responsibility to the Secretary of State - where does that leave the local role?

This brings me to stage two on our journey which is about putting power in the right hands.

I don’t think we have ever got the balance right between the national and local roles.

The current Government’s reforms have weakened the national function.

But the last Government was accused of being too prescriptive: deciding not just ‘what’ should be done but ‘how’ people should do it.

If our journey to Whole Person Care is to set off on the right foot, we need to get the national and local roles in better balance.

Here’s what I think that should be: if the national role is to spell out the ‘what’, then the local should be to decide the ‘how’.

How best can Whole Person Care be delivered in our community? How can we make the range of services, buildings and providers we have work better for everyone?

Integration can’t be imposed by top-down edict and timetables.

But this doesn’t mean the pressure is off.

The quicker that people embrace full integration – and everything it entails – the sooner they will place local services on a path towards clinical and financial sustainability.

By legislating for commissioning with this budget – as a partnership between the NHS and councils through the Health and Well-being Board - we will finally vest people at local level with real power.

Local authorities will have a bigger canvas on which to create much more imaginative solutions to improve population health and well-being.

They will be able to link health with housing, education, planning, transport and leisure – achieving Professor Michael Marmot’s ‘health in all policies’ goal – and develop new solutions that are simply not achievable from within the confines of the current public sector silos.

Local areas will have more ability to invest in prevention – for instance, expanding exercise on prescription to make maximum use of local leisure facilities – while having more ability to protect children from the proliferation of outlets selling fast-food and cheap alcohol.

This is how our new approach to public health is consistent with the plan published today.

We know that intervening in the first 1001 days of life makes all the difference to life chances for children with the biggest challenges.

So why doesn’t it happen and why do families still have to battle every day?

It is because of those silos in commissioning, where people argue about who should pay for the speech and language therapy while all the while the child slips behind.

And it is because those same silos create services that don’t relate to each other and can’t see the whole child.

I heard about a recent meeting attended by a paediatrician to discuss the care of one child with 36 people in the room.

Another family reports a child having over 150 appointments in a year but couldn’t get help with a simple problem out of hours.

This is no longer affordable nor morally justifiable.

Nor is a situation where child and adolescent mental health services are the poorest relation of all, getting just six per cent of the mental health budget.

Our plan for integrated local budgets for children will change this.

It finally creates an incentive to do the right thing at the earliest possible stage in a child’s life, because all the long-term savings will return to the same pot.

That is the way we will build a fairer society, get best value for taxpayers and make services sustainable.

But it isn’t the only financial reform we need to make and this brings me to stage three on our journey: money.

The pressures on public spending are now so great that the journey towards integration will need real momentum.

And that will not happen until we change the way the money flows.

The NHS is today trapped in a financial framework that rewards the treatment of illness and infirmity.

The financial tide drags to the most expensive end of the system – the acute hospital bed.

Community services have no incentive to invest in prevention and hospitals get paid by everyone who comes through the door.

This is bad for patients and bad for taxpayers.

For the want of spending a few pounds in people’s homes on decent care, we are spending tens of thousands keeping people for months, even up to a year, in hospital beds.

If we were to put new investment into the NHS without fundamental financial reform, the reality is that much of it would end up being sucked into hospitals.

So we must turn that financial tide around.

We need a new financial system that makes the home the default setting for care, not the hospital, and prioritises prevention as well as treatment.

Social care is prevention and the key to making that change. It is by integrating it with the NHS that we create the conditions for major efficiency and productivity savings.
For people at greatest risk of hospitalisation, we will implement a ‘Year of Care’ payment system covering all of their care needs to replace the activity tariff.

At a stroke, this will switch the incentive from treating in a hospital to preventative support at home.

It will mean giving people quality time rather than flying 15-minute visits.

And it will mean a big shift towards more personalisation.

If we take time to ask people what will work for them and their family, then it will be more likely to work and not exceed the ‘Year of Care’.

When the NHS is paid for in this way, it will finally bring the change that is urgently needed to the way services are provided.

NHS organisations will have an incentive to start in the home and evolve into integrated care organisations, moving on from the 20th hospital-dominated treatment model.

This takes me to stage 4: organisations.

Whole Person Care will only succeed if all NHS bodies rethink how they work and begin their own journey towards integration.

For ‘Year of Care’ to work, it will need an accountable organisation to hold the ring and co-ordinate the care.

All health economies will need to develop integrated care organisations, providing services directly or working through trusted partnerships.

And if we are to encourage this evolutionary change, we must now rethink the principles that have governed provider reform and create a new role for Monitor.

The Foundation Trust reform, and the focus it brought on financial grip, helped improve efficiency and productivity.

But it no longer makes sense to focus solely on the viability of individual institutions, particularly where efforts to securing the finances of one could end up destabilising all around it.

The public spending outlook for the next 10 years brings a new reality: the competing silos are a luxury we can no longer afford.

The stark truth is there are too many separate organisations with separate administrations. There are savings to be made from reducing administrations in every health economy in England.

We need to break down the silos and end those divides that hold us back: primary versus secondary care; physical versus mental health; NHS versus council.

As the Future Hospital report recommended, people must leave loyalties to parts of the system behind and embrace a new shared loyalty to the local population.

To help this process along, and unlock the savings it will bring, we will abolish Monitor’s duty to promote competition and ask it to focus on promoting integration.

Rather than assessing the viability of individual organisations, we will ask it to rate all local health economies annually on the overall financial viability of their provider arrangements.

CQC will need to undergo a similar change as organisations begin to work across traditional boundaries, assessing overall care quality by locality as well as individual organisations.

The fact is that care failures in one local organisation can be the root cause of problems in another.

For instance, there are too many care homes in England failing to give adequate training to their staff who often feel they have no option but to call 999 in a challenging situation.

While we have been clear for some time about what integration will mean for local NHS organisations, there has been a missing piece in the jigsaw: out-of-hours care and the ambulance service.

To take a major step towards integrated, seven-day working in the NHS, it is right that we look at a new future for the ambulance service.

I see that as an integrated provider of emergency and out-of-hours care, able to treat people where they find them rather than carry them to hospital.

This is a substantial answer to relieving the growing pressure on A&E.

It is the lack of integration in out-of-hours care that often results in carrying to hospital as the default option.

Just as we call for a single team approach in local care, so the same principle should apply in out-of-hours arrangements.

This is how we do it.

As NHS 111 contracts expire, we will look at ambulance services taking them on so that, in time, they could handle all 111 and 999 calls from the same call centres.

This will mean more experienced staff on the phones, and better classification of calls.

But just as with other parts of the NHS, we need to ask the ambulance service to work from a default presumption of treatment at home, not hospital – if clinically safe and appropriate.

To do this, paramedics will need to be able to call directly on a wider range of health professionals – GPs, OTs, physios, care assistants – who can settle and support people at home in out-of-hours times before handing over to local teams.

Building a sense of a single team with GP out-of-hours services is essential, all with a financial incentive to keep people out of A&E.

So we will consult on better ways in which GP out-of-hours can be integrated with the ambulance service.

These changes will allow us to build a high-quality, highly co-ordinated response behind the NHS 111 number that commands better public confidence than it has today.

This new vision for a 21st century ambulance service is a classic example of how we can build better integrated services without new money when we move away from the mentality that every small service must be put out to tender.

But organisations won’t deliver Whole Person Care.

If the new NHS is to be what we want it to be, it will be built by people.

That is why Stage 5 is the most important of all: empowering not just those who give care but those who receive it too.

With moves towards fewer, more integrated providers – and the notion of an accountable provider under the ‘year of care’ system – we will ensure that no-one will be stuck with poor or unresponsive services.

We won’t let that happen.

The great thing about uniting physical, mental and social in one service is that it creates the conditions for true personalisation of care in a way our silo-based services could never manage.

So, to give people the power to get what they need to live the best life they can, we will amend the NHS Constitution to give them a series of powerful new rights. For example:

·         the right to a single point of contact for the coordination of all care for those with on-going needs.

·         the right to a personal care plan – covering health and social care - agreed between the individual, their family and services, including new preventative checks for vulnerable or frail older people to help spot risks and act before problems occur.

·         the right to counselling and therapy as well as medication, as part of a new emphasis on social prescribing

·         the right to support for family carers, such as respite care

·         the right to care where you want it, to give birth at home or to be in your own home at the end of your life with homecare provided on the NHS

These rights, alongside financial reforms, will encourage services to change – to become less patient-centred and more person-centred.

We will also give people a right to a GP appointment within 48 hours, cancer tests and results within one week.

Of course, they will not be able to be delivered overnight. Services will need time to adapt.

But, to ensure momentum on the journey to Whole Person Care, I can say today that I will require them to be deliverable in all parts of the country by the end of the next Parliament.

This is how people and their families will no longer be passive recipients but active participants in building the NHS of the future.

But these new rights will empower people who give care too.

Rather than a system based on targets, which too often empower managers, a system based on person-centred rights will create a different culture for staff to work in and one which is more true to their clinical vocation.

It won’t just be NHS staff who benefit from the changes I am announcing today.

They also lift the social care workforce - neglected and exploited for far too long, as Denise Kingsmill so rightly and persuasively said.

We all have some soul-searching to do.

How much longer are we prepared to say that an older person is only worth 15 minutes of support?

And how much longer as a society will we send out the message that caring for someone else’s mum, dad, brother, sister is the lowest form of work, lower than the minimum wage because it doesn’t way the travel time between the fifteen minutes?

For as long as we fail to change this, we will continue to have a care system that fails older people and those who care for them.

A service provided on a below-minimum-wage, zero-hours basis will never be able to provide the quality we would want for our own parents or aspire to for everyone’s parents.

It will mean those appalling scenes of abuse that we see on our TV screens will recur year after year.

This is a national scandal and, today, Labour vows to end it.

We need tougher penalties against individuals and institutions in which this abuse takes place. But we also need to begin to value the care workforce.

As part of the move to Whole Person Care, we will begin the process of unifying standards across the health and care workforce.

We will be able to do this through the introduction of the Year of Care approach. It will give NHS organisations an incentive to provide better home-based care that does a real job of keeping people out of hospital.
So we will ask the NHS to require proper training and support for social care staff, either those it employs or those with which it contracts.

And, as good care is based on continuity, we will tackle exploitation in the care sector by banning zero-hours contracts that exploit workers; firms will no longer be able to operate business models that rely on zero-hours contracts.

This will begin to change the culture of social care in England and value those who work in it.

By turning the financial incentives of the system around to provide better care and support in the home we can drive the change in quality of social care that is needed.

Previous NHS plans have invested more energy in rethinking structures rather than developing people.

Well I am not going to make that mistake.

Whole Person Care will in the end by driven by people and their passion for what they do, who want to do it better and know they could if freed up to work differently.
One of my greatest criticisms of what has happened in this Parliament is that a major re-organisation was foisted on the NHS with no meaningful workforce plan.

And, now, morale is sinking fast as hospitals and GP surgeries are becoming overwhelmed and doctors and nurses retire or go overseas.

But, as people leave, the pipeline isn’t bringing new people through in the required numbers.

This Parliament has brought deep cuts to training places - a false economy on the grandest of scales.

It has left the NHS saddled with a bill for agency staff that is spiralling out of control and forced to recruit overseas.

The NHS needs to break out of this and bring through a new, home-grown generation of staff to build the new NHS.

The extra £2.5 billion we will put into the NHS – our Time to Care fund - will be focused on building the workforce of the future, trained to work differently.

People often ask me where the extra nurses and other staff will come from.

Today I want to answer that directly.

I don’t think there’s any shortage of young people who aspire to work in the NHS.

It’s just got harder to do it.

Courses are heavily over-subscribed and I meet many young people in my constituency who aspire to work for the NHS but struggle to see a route in.

The increase in tuition fees, combined with reductions in places, has left some feeling a nursing or midwifery course is too big a risk.

So they turn instead to care but find themselves stuck in dead-end, zero-hours jobs with little or no training or career prospects.

There are thousands of young people stuck doing these essential but difficult jobs left feeling forgotten and under-valued.

I want to make a very direct offer to them.

If you want to help build this new NHS and devote yourself to it, we will give you a ladder into it - not just to become a nurse or midwife but any of the disciplines that Whole Person Care will need in much greater supply: physios, OTs, speech and language therapists, mental health nurses, dieticians, therapists and counsellors.

So, for young people working as care assistants or healthcare assistants, we will create a specific new route, through an apprenticeship and technical degree to move into nursing or other clinical roles or into the 5,000 new NHS social care roles we will create to deliver our universal re-ablement service and improvements to end of life care.

Sometimes it might seem that the NHS - built by a generation long ago who came back from the war – doesn’t mean as much to today’s young people.

But I was struck by a recent poll which showed that young people today care just as passionately about the NHS as those who saw it come into being.

I think this might be because, in their world, so driven by markets and money, the NHS represents something different to them.

If the post-war generation was infused with the same defeatism about the future that defines our times, then one thing is clear: there would be no NHS.

So that’s our message to young people: come and help us build the NHS of the future. It is your NHS too and now your generation must rebuild it for your century.

So this is our plan to re-set the NHS and, through these five stage of reform, we hope to bring people behind it.

The contested reforms of recent times have frayed the fabric that has underpinned it.

The NHS urgently needs a new consensus if it is to have the public backing to reinvent itself as a 21st century service.

Ed Miliband and I believe the plan we are outlining today provides the basis for that.

Never again should the public’s most valued institution be changed without their consent, as happened after the last Election.

Going forward, people will need to be informed, consulted and involved at every stage.

That is why I have put forward our plans in such unprecedented detail before people vote.

And, if I am Health Secretary in May, I will write to everyone, just as Nye Bevan did, to explain what people can expect from the new NHS but also what will have to change.

But, as well setting out new rights, we need to be honest with people: the NHS won’t be able to do everything.

So we will ask people to accept new responsibilities to help the NHS survive in a more demanding century by, for instance: taking more responsibility for our own health and becoming more physically active; by doing more to look after our own families and neighbours; by not applying on-demand consumer expectations but taking out only what we need; and by accepting that hospitals will need to change if home-based care is to be a reality.

This will help re-set expectations and help NHS staff rise to the difficult challenge ahead.

We say this today to the other political parties: if you can’t sign up to our plan, produce your own in as much detail as ours. Give people a proper choice at this election.

That’s because the NHS is now at a crossroads and the country needs to have the debate about which path it should take.

Labour has made its choice: an NHS for the whole person, based on its enduring values: compassion over competition; collaboration over fragmentation; people before profits.

I am proud of the plan we are publishing today.

I have put everything I have got into it because nothing matters more to me and I know what it means to millions of others.

It is borne out of deep reflection, honest assessment of our mistakes but huge optimism for what the NHS can be in the future.

It can be what we want it to be, as good as we all want to make it.

I know you may not agree with everything I have said but, if you agree with the broad direction, get behind it.

The NHS can’t wait forever for a new consensus to emerge.

We must start building our national health and care service today.