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POLLY BILLINGTON: Alan Milburn is a man with
a mission. He's searching out the obstacles to change that lurk in the
corridors, wards and operating theatres of the health service. He says
vested interests are getting in the way of his determination to slash waiting
lists, reform the medical profession, and to raise performance in the NHS.
His aim is to sweep through the hospitals and surgeries of the land, rooting
out conservatism at every turn. That at least is the government's diagnosis.
With billions of pounds being spent on new surgical centres like this one,
ministers are determined that patients see results, and that the taxpayer
gets value for money. Radical action will be needed to achieve some of
the suggested targets like cutting waiting times down to three months for
surgery. Will Alan Milburn have the courage to overcome to overcome opposition
from managers, consultants, and even Labour MPs? He's keen to get his
message across to anyone who'll listen even if it means preaching to the
converted, like the New Health Network meeting in London this week; a group
of health service managers and employees ready to share ideas about how
they've managed to speed up the delivery of services.
CLAIRE PERRY: I think that they're going
to have to not rule out anything. I think that they're going to have to
make sure that there is a bond between the people who are working within
the service and the change that's needed rather than a conflict.
BILLINGTON: Consultants are among those
up for scrutiny by the Health Secretary. He thinks there may be a perverse
incentive in their contract that encourages some of them to restrict their
NHS work to keep their part time private work coming in. He has an opportunity
to change that as the contract is being renegotiated. Restricting or even
barring NHS consultants from taking on private work won't make him popular
with many in the medical profession but his own party would love it.
DAVID HINCHLIFFE MP I think it's right that the
whole basis of the contract is looked at and I hope that there will be
a possibility of ensuring that NHS consultants are full-time in the NHS
and not enabled to spend time in the private sector and generate waiting
lists to create demand for that private sector.
DR IAN BOGLE Perverse incentives for consultants
to sort of create that demand I do not believe are there, I don't believe
that this happens. I believe what does happen is that the resources in
the National Health Service are often insufficient for the consultant to
be able to do all the jobs they should be doing in the Health Service and
therefore they do work elsewhere but it is a resource problem, once we
get the resources right so consultants can work, I mean they can't work,
surgeons can't work if there is no operating theatre time which is a good
example.
BILLINGTON: Alan Milburn will be considering
whether to buy the consultants out, give them a big hike in pay to persuade
them to work solely for the NHS, and he could decide to link pay increases
to achieving NHS targets like reducing waiting lists.
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STEPHEN THORNTON: We need to make sure that the
way in which consultants are paid relates to the priorities of the National
Health Service so there are incentives built into the way consultants are
remunerated that deliver NHS objectives.
BOGLE: I think it is too simplistic
to look at an NHS target and say that it is right to picture something
like a merit award or any other incentive payment at targets, I mean target
imply counting something and achieving it. I think there are better ways
of measuring quality, I think now we've got better ways of measuring quality.
BILLINGTON: It's not just consultants that
the government has in its sights. NHS managers are keen for change as long
as it's on their terms. Many are innovating in the NHS but the government
wants to bring the worst up to the same level of the best. That could
mean national targets, extra money for those that succeed, and hit squads
for those that don't. But managers would prefer to solve their own problems
in their own way. Some people wait minutes - others wait hours in casualty.
Alan Milburn wants to eradicate such differences by managers learning from
the best performers such as those running pilot projects that have slashed
waiting times to half an hour.
SUE PAGE: No longer are patients
having to wait in waiting rooms, waiting to see a doctor that they didn't
really need to see in the first place. As soon as they come in, they're
seen by the nurse and they're sorted out and so therefore they can get
everything done and they're back out through the door within about thirty
six minutes. It's not rocket science, it's ever so simple. It's just
that traditionally in A and E departments doctors used to see everybody
coming through the door and there's no need to do that any more now.
BILLINGTON: The Health Secretary is determined
to set targets to force hospitals to match the standards of the best. But
as any doctor will tell you, the same treatment doesn't suit everyone,
and central control doesn't go down well with people used to running thing
their way.
JULIA NEUBERGER: What I think people do resent
if being told that necessarily they have to do it now like this with lots
of central directives coming in like this and then they feel that they're
almost being de-skilled and I think one has to be very, very careful about
that.
THORNTON: It is important that
we do have clear objectives from the top of the NHS to say this is what
we're about. But at the same time you also have to give people working
at the shop floor level a sufficient degree of freedom and professional
autonomy to be able to make their own judgements about what is best and
there's if you like a need to kind of marry those two together
BILLINGTON: If Mr Milburn finds
some managers are succeeding by reaching his targets, their hospitals could
get more money - performance related payments. That could mean under-performing
ones having less money to treat patients.
PAGE: I would very much
welcome performance related pay for hospitals or for clinical teams or
for any parts of the health service that work together. And certainly
over the past few years if my teams that I worked with had been rewarded
they would have had a lot more money in the system instead of you know
trundling along at the bottom of the resource table.
THORNTON: We need to be careful
that we don't punish the patients twice: that on the one hand they have
a poor service and secondly then the hospital that's provided that poor
service gets money taken away from it so it can't improve. So you know
we need just to be very careful about that.
BILLINGTON: But the forces of conservatism
don't only lie in the NHS. The Labour Party's own identity is so tied up
with the establishment of the health service, Alan Milburn may find his
most radical ideas are resisted by his own party. Any suggestion for example
of the use of rationing or the private sector as managers to tackle poor
performance or to cut waiting lists is anathema to many Labour back benchers.
HINCHLIFFE: I am not keen on bringing people
in from outside unless they've got some relevance to the direction the
service is taking and also some sympathy with the broad objectives of the
National Health Service and certainly many of the people brought in by
the previous government from a commercial background, from private enterprise
background, I don't think had the least idea of what the National Health
Service was all about.
PERRY: I think that there are elements
of the health service which are not, if you like, the specialisms of the
NHS and in some areas of support services in some of the diagnostic and
radiological services evidence of other countries has shown that private
sector providers could take on a much broader range of services than currently
exist.
BILLINGTON: Alan Milburn might even find
a solution to the perennial problem of waiting lists in the private sector.
Some say there's enough spare capacity in private hospitals to tackle the
NHS shortages, especially for routine surgery. And in the future the private
sector could expand to provide more services for the NHS.
PERRY: I don't think we should
get so hung up about whether it's the public or the private sector that
provides, the fundamental principles for me about the health service are
that we are taxation funded and we should look at universal coverage and
still be free at the point of delivery.
HINCHLIFFE: I think within the Labour Party
there are sufficient people who will understand that it's not just about
ideology, it's about the practical concerns over what expansion of the
private sector actually means and it means that we will actually reduce
the capacity of the National Health Service to offer decent service to
people when they need it and that's a fundamental argument against expanding
private care.
BILLINGTON: And even more fundamentally
some suggest Alan Milburn should be explicit about what medical services
the NHS just can't afford to provide. Decisions should be transparent to
the public on what is available for free and what treatments should only
be available only in the private sector.
NEUBERGER: We believe that the government
is failing in its duty to get people to face the fact that however much
money is in the service, however much resource they put in, we will have
to make tough choices. You can never provide absolutely everything for
everybody that they might want. And we believe that the government has
to face that and has to get the public to face that.
BOGLE: The British Medical Association
has actually launched its own review which should take most of this year
to see really what we can afford from the Health Service and whether we
can afford a full range of comprehensive service so I think we are going
further than the government in having a look at what the choices are and
whether there should be alternative methods of funding. I don't think the
government is going to be quite that brave.
BILLINGTON: The government itself could
be a restraint on truly radical changes to the NHS. But the vision is clear:
Something must be done especially since public expectations of improvement
have risen since Labour came to power. But in his determination to carry
his national plan through Alan Milburn may find some of those people he
has to take with him put obstacles in his way.
BOGLE: The fact is that we like
to see change take place that has been evaluated that would be shown to
produce some benefit and so a lot of the changes we would like to see just
a little bit slower than what has been done and certainly to be consulted.
NEUBERGER: I think he may have to be much
more conciliatory and make far more compromises than perhaps he thinks
at the moment. Because I think part of carrying everybody with you is
making all sorts of compromises that make them feel their interests have
been taken into account.
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BILLINGTON: Alan Milburn is ready to operate
to save the NHS from terminal decline. Everyone else is ready to help -
even if they'd prefer less radical intervention. If he wants to keep them
on board he may have to scale back his ambitions for wholesale change.
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