"I think the biggest frustration by far in getting across a balanced picture of the NHS today is the gap between people's personal experience of it, which is usually excellent, and their perception of it as a whole, which is often negative.

"And the fact is that on any objective basis, for all the challenges and largely thanks to people like yourselves working in the NHS, the NHS is improving often quite dramatically in its treatment of patients.

If we're going to keep the NHS vibrant then there has to be change

"But it will only carry on doing so if, like any other institution or business in the modern world, it continues to meet the challenge of changing times.

"I think the thing that is very obvious but is worth saying, is that everybody knows that the services they receive and the services that they work for are undergoing processes of change; changes in the expectations of their customers, changes in technology, changes in working practice.

"It would be bizarre if the NHS alone of all institutions in this modern world did not also face those challenges of change.

"And the important thing really for us together, is to try and explain why this change is happening - why it's necessary, why in the end it will be to the benefit of patients.

Collaboration

"I've learnt something from almost ten years as Prime Minister, which is that if the politicians do this on their own it is not nearly as effective or persuasive frankly as if we do it together; the people working in the service and the people responsible for overall policy.

The most difficult thing in any walk of life is to make change

"And there's probably no area of domestic policy changing more quickly than healthcare - the demands and requirements of patients are rising.

"I'm constantly struck by this when I talk to patients.

"For example, someone the other day was telling me that over the past 10 or 15 years they have had pacemakers fitted.

"The first time they had it fitted they were staying several days in hospital, they were under general anaesthetic.

"The last time they had the pacemaker fitted it was done under local anaesthetic as a day-case surgery.

"So these changes are perfectly natural and they're happening all the time.

Technological advances

"The other thing, of course, that is happening increasingly is that technology is empowering us to deliver that change in a different way.

We're trying to put greater choice in the hands of patients

"And I think the issue today really is not: is there a change-free option? - because there isn't.

"In the end, whatever we decide to do, if we're going to keep the NHS vibrant then there has to be change, the question is what sort of change.

"And I think the choice is this either we shape the change to ensure that the principles of the NHS are preserved for another generation or we let the change, as it were, shape the NHS but in a haphazard and random way.

"If we recall the NHS of 10 years ago; waiting lists were well over a million on the in-patient waiting list, and 250,000 people or more at any one time waited over six months.

"Many patients I know - I used to receive letters when I first came into office from their relatives - used to die waiting for cardiac care.

"The length of time waiting for a cataract operation, if you remember that, was often over a year, sometimes two years.

"On the out-patient list there were some 160,000 people waited over six months and over 300,000 over three months.

"Cancer patients regularly failed to get to see consultants for weeks after being told by their GP that they might have cancer and accident and emergency department - all of us remember using it in those days - was often a disgrace and people could wait hours and hours for even the simplest treatment.

No longer flawed

"So I think people a decade ago were kind of asking, not will the NHS work but could it work - was it an inherently flawed concept almost that meant that it had to be dismantled?

Managing this system of change is incredibly difficult

"And I think now that is not the question. Now people accept that it can be improved, the question is how.

"Waiting lists are at their lowest level since records have been kept; the maximum wait on the in-patient list is down from 18 months to six months; cancer deaths have been cut; cardiac deaths have been cut and there are whole new services - NHS Direct walk-in centres and so on.

"A lot of this is about the extra money that has gone in, there is no doubt about that, the investment has helped.

"But actually alongside the money, the single most important other dimension to this progress has been the fact that the system itself is undergoing change.

"Now managing this system of change is incredibly difficult; there are different elements to it.

"We're trying to put greater choice in the hands of patients, we've got new suppliers - whether it's independent treatment centres, the foundation trust as a different way of running hospitals.

"There are the new service frameworks, there's NICE and then there are the changes we're making now in the primary care trusts in practice-based commissioning and in the changes that we're trying to make at a local level to bring care closer to people.

Difficult decisions

"I think the most difficult aspect of all of this is not simply trying to introduce these different systems, but trying to see how everything fits together and how we incentivize people, particularly you who at the sharp end of this and have to take the most difficult decisions to innovate and be creative in how you are giving patients care in a different way for today's world.

"So practice-based commissioning should reduce unnecessary referrals but that won't happen just as a matter of course, it has to be managed.

"Chronic disease can often these days be managed in primary care but again that won't happen just naturally, it's got to be a system of change that is put in place for it to be done.

"The elderly can be looked after at home, diagnostic tests and minor surgery can be carried out nearer to home where patients want it to take place. All of that is true.

"And earlier today, as you know, Patricia (Hewitt, the Health Secretary) received two reports from two of her national clinical directors, that's George Alberti and Roger Boyle.

"And what they offer is a compelling and vivid account of change and why it is necessary but also why it is difficult.

"If we take accident and emergency; 18.5 million people go to accident and emergency every year, very few have life-threatening conditions.

"Major emergencies only affect about 10% of people. Most people would actually be better served by care that was closer to home.

"At the moment, if you have a pressing medical need you end up almost inevitably in accident and emergency.

Diverse institutions

"But in the light of the changes in medicine we need to do better than that; we need a diverse set of institutions, GP out-of-hours services, pharmacies, social services, mental health teams, minor injury units, walk-in centres - to treat the range of different needs.

It makes sense, alongside local provision, to create specialist centres of excellence which have 24-hour consultant cover and access to state-of-the-art diagnostic equipment

"Lots of people, for example, who come straight to A&E, would, for a variety of reasons, be better treated elsewhere.

"For example, paramedics can administer life-saving drugs to heart attack and stroke victims on the doorstep.

"If you have a stroke at 0200 in the morning, you want to go to a centre with access to a CT scanner 24 hours a day.

"For the life-threatening emergencies, a specialist is needed at once.

"If you have the rupture of a major blood vessel, for example, you need an experienced vascular surgeon with access to 24-hour laboratory services and radiology.

"The right care for strokes is now to have a CT brain scan within three hours followed by aggressive rehabilitation with thrombolysis in appropriate cases.

Specialist centres

"But that level of expertise can't be offered everywhere.

"That's why it makes sense, alongside local provision, to create specialist centres of excellence which have 24-hour consultant cover and access to state-of-the-art diagnostic equipment.

The reason therefore for all of this change in the end is the best reason there can be: better treatment for the patient

"Therefore, alongside that specialist emergency care, we can then offer a quicker and more immediately appropriate service.

"The patient gets a more specialised service; in most cases closer to home.

"This can range from immediate telephone access to information assessment and advice on self-care or the best place to seek further help, through to home visits and access to centres of care.

"There will be many more paramedics and nurses trained to treat people at home and stabilise a patient's condition for longer journeys and people will then have a shorter stay in hospital because the initial care received will be more specialised.

"The reason therefore for all of this change in the end is the best reason there can be: better treatment for the patient.

"And of course this means at times the way capacity is provided may be changed and I don't minimise either the difficulty or the importance of that but we do need to make the case for these changes and in that task I hope clinicians themselves will become ambassadors for change and improvement.

Big challenge

"What this means in each locality frankly is that a lot of it will be up to you in the PCTs and working alongside local clinicians you will be the main organisation developing these new improved services in your locality.

"We the politicians have to back you when you've the courage to make those changes and we will. And you need to have the confidence to make the arguments for service improvements.

"Now I don't under-estimate for a moment the difficulty of all this.

"As I often say to people - and I was saying this to the head teachers and deputy heads that I was addressing at conference in Birmingham last week - the most difficult thing in any walk of life is to make change.

"There is a natural inbuilt resistance to it.

"On the other hand, I think what most people realise is that once you get through the process of change and out the other side, it's remarkable how what was going to be the greatest disaster and catastrophe ever to hit the world, suddenly becomes part of the normal way of doing things.

"And the real reason why I think now is the right moment to do it, is that for years and years - and certainly when we first came to office - there was a real problem with under-investment in the health service - there was no doubt about that.

"On the other hand, sometimes that became a kind of excuse for not facing up to the need to reconfigure and change the system itself.

"There has been substantial investment in the past few years.

"Now I'm the first to be aware that no amount of investment is ever enough, as it were, and there are always going to be financial difficulties and financial constraints.

"But the truth is, within any given resource there is always going to be the need to change the service in order to meet the challenge of the changing times in which we live.

"This is particularly true in healthcare which around the world at the moment is undergoing a big process of change.

"When I sit down with other leaders in Europe or outside of Europe and we get around to domestic politics, healthcare is one of the biggest issues in the United States; it's a major issue at the moment in Germany; it's a vast issue in France where their health service has been in severe deficit.

"There's not a single country around the world of a modern developed nature where this is not a major issue.

"It is perfectly obvious why; people are living longer, more diseases can be treated in better ways and people's expectations are infinitely higher.

Exacting demands

"When the NHS was first started people thought it was fantastic that you got free healthcare.

"Today people want free quality healthcare and what's more they want it - as someone once famously said - at the time they want it, in the place they want it, with the person they want it.

"So it's that changing expectation along with the changing nature of the service and the treatments that are available - it poses a huge challenge.

"And sometimes what we need to realise is that this is not something unique to this country or indeed unique to you as the people leading the PCTs - this is the world in which we live.

"But the great thing is, we do have, I think, the right components and framework for change now and what we've got to do, bit by bit and piece by piece as we work together is make sure that that change works for the benefit of patients.

Bright future

"And I genuinely believe the best is yet to come.

"More lives saved, stopping more pain and distress, treating patients better, making sure the National Health Service is as an institution the pride and envy of the world - as indeed it should be because of the standard of care we do provide for people and recognising that none of this will happen unless we have collectively the courage to remain steadfast, to see through the process of reform and change and to make the alterations in the way the service is provided in order to meet the challenge of the modern world.

"Let me just say, I fully know how difficult it is for all of you but I congratulate you on the work that you're doing.

"Sometimes, perhaps you don't hear it enough from us, we are very grateful for the work that you do.

"What you're doing at the moment in the National Health Service I think is one of the most exciting things happening in our country today.

"It couldn't happen without you and without your commitment - so I thank you for that and as I say together I'm sure we will manage to do it. Thank you."