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JOHN HUMPHRYS: Alan Milburn, let's pick
up first with this great consultation exercise that you launched, twelve
million what consensus forms that were sent out. How many have you had
back?
ALAN MILBURN: We've had a reasonable response
but they were still being counted last time I asked last week. I think
we will get a reasonable response to it because my sense is that most people
in this country care about the NHS and they've got a stake in it, that's
true for the staff and for the patients and what's interesting about your
film, and I think this is a reflection of what is happening in the country,
is that for the first time I can remember, probably in a generation or
more, there is a debate now, not about resources going into the NHS because
we are doing that, putting the money in, the question is how we can radically
reform the NHS to make sure that it can do its job for patients, not just
in some parts of the country but everywhere.
HUMPHRYS: Which is exactly what
I'd like to talk about in this interview. But let's just deal first with
the consultation exercise. You said reasonable, what's a reasonable number
to come back in?
MILBURN: Well we've have to wait
and see..
HUMPHRYS: You must have an idea
at this stage..
MILBURN: Well the industry standards
say that if we get around sixty-five thousand that will be a good response.
But we'll wait and see what we get but the important thing in my view about
this consultation is that frankly it would be quite bizarre if we didn't
ask the people who provide services in the NHS, the staff and the people
who use the services in the NHS, the patients, for their views. The NHS
doesn't belong to me, it belongs to them and what we've got an opportunity
to do now, with these big resources going into the service and remember
the NHS budget is going to grow by around one third in real terms over
these few years, so it's quite unprecedented, what we've got an opportunity
to do now is to tackle some of these big systems weaknesses, which your
film highlighted, which we need to put right, if patients are going to
get the faster, better care that they deserve.
HUMPHRYS: But it's been a terrible
cock-up this consultation exercise hasn't it. I mean you send out the forms
at the end of May, they've got to be back by June the 9th, you say well
we'll extend the deadline a bit and the whole thing is bonkers isn't it.
The idea that you don't know what people think about how the NHS should
be reformed is frankly risible.
MILBURN: Well I've already said
that the leaflet could have been better worded. Of course it should have
been better worded but there we are...
HUMPHRYS: ..the whole thing...the
timetable. I mean you send it out at the end of May and say let's have
it back in three days or something, it's crazy.
MILBURN: I think people want to
get on with the job. I think where Ian Bogle was actually wrong, I agreed
with some of the things that Ian Bogle from the British Medical Association
said about the National Health Service, but where I think he was wrong
was to say that people in this country want to slow down improvement of
the National Health Service. A lot of people want faster improvement in
the NHS, there are a lot of things that are right about the NHS, its principles
are right, its staff are right but the fact is there are too many things
that are wrong and what we've got an opportunity to do now is to put them
right.
HUMPHRYS: Did you know that they
didn't send out any forms other than in English - Welsh in Wales I'm sure
- but you know if you happen to speak some other language or if you were
blind and read Braille, no forms in there.
MILBURN: Well actually I think
there were translation services available. Remember this is an English
consultation remember, I'm responsible for the English National Health
Service, someone else is responsible for Wales and for Scotland..
HUMPHRYS: ...lots of people who
speak Punjabi or whatever it happens to be and lots of people who are blind
and they didn't have Braille forms and they should have shouldn't they.
MILBURN: Well it's very important
to remember that the consultation exercise isn't just built around one
consensus form, it isn't. People have been writing in to me, I've been
doing radio phone-ins until I'm blue in the face. We've had lots and lots
of letters, lots of e-mails, there's a dedicated website and so on and
so forth and people can continue to send their views, their forms, their
letters, their e-mails, their telephone calls - of course they can.
HUMPHRYS: You should have sent
Braille forms out shouldn't you.
MILBURN: Well look there are translations...
HUMPHRYS: Go on admit that much
at least, I mean if you were a blind person you'd feel a bit short changed
wouldn't you.
MILBURN: I will look into that
John, but the fact is this is the biggest consultation exercise we have
ever seen in the history of the National Health Service. There's been nothing
quite like it and I think that frankly there are some things that are wrong,
of course there are, and you learn from it but the fact that we haven't
had a consultation exercise of this sort in fifty years is something that
should have happened in the past, it hasn't happened and I would have thought
that actually most people would regard being asked about their views for
the National Health Service as a good thing and not a bad.
HUMPHRYS: Except they will know
that you're publishing the national plan next month, in July, that you've
had three years to think about it, that you've got very clear ideas, of
course you've now got extra money and that has to be taken into account,
naturally. But you have got very clear ideas of what is going to be in
your national plan and I suspect a lot of people will say, I wonder if
we are just being used here. I mean you may get, I don't know ten thousand,
a hundred thousand, maybe a million responses in, who knows and then you
are going to sit down and collate all of these things and say oh my goodness
people want shorter waiting lists or they want something we didn't think
of, so now we'll tear up the national plan and we'll substitute something
else in its place. I mean it doesn't stand up to careful scrutiny or a
moment's scrutiny that concept does it.
MILBURN: Just think if the reverse
had happened. Just think if we hadn't gone out and asked staff and patients
for their views, there would have been a huge hue and cry and quite rightly.
Look, a lot of things that are happening in the National Health Service
and some of the changes that you've just seen in your film there are actually
being taken forward by the doctors, nurses and the managers in the NHS.
These people are leading the process of change and in particular I think
it would have been an affront frankly to the staff of the National Health
Service as well as to the patients, if we hadn't asked them for their views.
HUMPHRYS: Ok, let's look at the
staff and let's look at the radical changes that you want to introduce.
Consultants, you believe that private work, you appear to believe this
because you raised the questions, consultants doing private work acts -
and let me quote something you said - 'as a perverse incentive which helps
sustain long waits for surgery' that's the questions that you raised. In
other words, it's in the interests of a consultant who does private work
that the waiting lists be longer because if the waiting lists were shorter,
everything was wonderful, nobody would need to go private. So that acts
as a perverse incentive. You believe that, what are you going to do about
it. How are you going to change that.
MILBURN: Well I think it
is a very very important question, of course it is and indeed the OECD
report that was published last week raised some of these issues as well.
But look, let's just be clear about one or two things, the first thing
to say is that the overwhelming majority of consultants who work in the
National Health Service do a damned good job and work extremely hard. Indeed
there is evidence to suggest that they over-fulfil their contractual obligations.
In other words, they are working more than they are strictly being paid
for. The real problem that I think we have got in the NHS as far as consultants
are concerned is that although by international standards consultant productively
is actually quite high, over the last what ten or fifteen years, there
hasn't been a big increase in consultant productivity to mirror the increase
in the number of consultants that we see. And certainly there are real
variations in performance as far as productivity is concerned.
HUMPHRYS: So what are you going
to do about it?
MILBURN: Well I think the answer
there is to do two or three things. First of all for the first time we
are going to make sure that there is annual appraisal of consultants -
indeed of every doctor working in the National Health Service. We can't
have a system where you simply believe that once a consultant or a doctor
has qualified that that should be the be all and end all. I have a responsibility
if you like as the employer to make sure that we are getting the best from
all of our consultants everywhere. As I say overwhelmingly they do a good
job...
HUMPHRYS: And if they don't come
up to scratch as a result of that annual appraisal then they might be suspended
or sent off to do more training or...
MILBURN: As you know there is a
wide variety of proposals that we have got on the stocks, the General Medical
Council's made some proposals around re-validation, I think that is a
sensible thing. In other words, rather than just assuming that you qualify
and then for the rest of your life you are going to be automatically up
to scratch, you have got to prove that that is the case. Periodically
every five years or so.
HUMPHRYS: And you shouldn't then
automatically - which is what happens now effectively because the consultants
vote for it don't they - you shouldn't automatically get an upgrade in
your pay.
MILBURN: I think that is an entirely
different issue with respect....
HUMPHRYS: ..but it would relate
to competence surely..
MILBURN: It will relate to competence
and certainly the annual appraisal will assess how you as the consultant,
are doing in NHS time and I want to make sure, obviously I do, that when
you are working in NHS time, that I am getting the best from you, that's
what needs to happen. But the big problem I think, that we've got as far
as waiting lists and waiting times is concerned, isn't so much the commitment
from consultants, it's the fact that we need more of them in the first
place, but secondly, we need to re-organise the whole way in which waiting
work is done, so that we know that we are an un-doctored system. That we
need more doctors and we need more nurses in the NHS. We've been doing
some of that, we've got more nurses in than we had now a year ago, we've
got more doctors too, but we need a lot more.
So we need to, if
you like, plug that capacity gap, we certainly need to do that, but as
Sue Page, was suggesting from the Northumbria Health Care Trust, what we
also need to do is to fundamentally change the way in which consultants
and other staff work. So for example, we've got to breakdown these big
demarcations between staff and the question from my point of view for the
NHS is this, look if in some places, in some parts of the country we've
got nurses doing endoscopy clinics, why isn't that happening everywhere.
If we've got physiotherapists running orthopaedic clinics in Manchester
why isn't that happening everywhere and the reason for that John is very
straight forward, that if we get the nurses and the therapists taking on
some of these tasks that used to be regarded as medical, but are in fact
clinical, that frees up the consultants time and its means then that they
can concentrate on the patient with the most severe condition and we can
get the waiting time down.
HUMPHRYS: Exactly, but you didn't
answer, perhaps deliberately, the question about private work. Are you
prepared to consider buying them out, which what some people believe.
I mean David Hinchliffe says you've got to stop them doing private work,
and that's that.
MILBURN: Well, I don't think frankly
that is a sensible solution to it...
HUMPHRYS: Why, because it's too
expensive, or.....?
MILBURN: Well, it would be enormously
expensive of course it would, and it would mean the NHS paying a premium
market rate over the top of what we pay in the National Health Service
to get consultants back in. What I....
HUMPHRYS: So this perverse incentive
will continue?
MILBURN: What I don't rule out
is in the future as we have been doing over the last year or so, as we've
been getting the waiting lists down, buying extra consultant time for work
in the National Health Service. I don't think there's a problem with that
frankly, and indeed as you report was suggesting one of the things that
we're looking at as part of this national plan is to see how we can take
advantage of any spare capacity that exists.....
HUMPHRYS: ... on that. I mean you'd
be sort of competing with the private sector then. You'd be going to Doctor
so and so, or Mister so and so, and saying you know, we want to buy a bit
more of your time, and he might say, well actually I can flog it to some
rich foreigner and do a kidney operation on him or something at a much
better rate. I mean why can you not - you have trained them, the NHS -
we the taxpayers have paid for these people to be trained - why cannot
we say: you're working for the NHS, full stop.?
MILBURN: Well, in most walks of
life employees have got a choice haven't they, about whether they work
part time or whether they work full time.
HUMPHRYS: Sure, but these......
MILBURN: But we're not going to
deny that to consultants surely, why should we. You know it would be a
pretty odd state of affairs if we said to consultants, some of the most
highly trained expert people, professionals that we have in the National
Health Service, you're going to be denied a set of rights that everybody
else on the NHS has.
HUMPHRYS: But you've just said
yourself that there is a perverse incentive to ....
MILBURN: But John, there's more
than one way to skin a cat, so for example we can look at whether it's
feasible to buy extra consultant time to work in the NHS rather than to
work in the private sector. We've got to look at the incentives and the
rewards. We've got to look at the incentives and the rewards that are
available to consultants. So let me give you an example of that. For
example at the moment we pay out what - I guess it's around a quarter of
a billion pounds a year, around two-hundred, two-hundred-and-fifty million
pounds a year in the form of bonus payments to consultants. The distinction
awards, you know to reward meritorious service in the NHS and the discretionary
points which if you like are a local variation of the national distinction
award, yet by and large there isn't a clear linkage between those payments
and what the recipients are doing in the National Health Service. Now,
as part of the National plan we will need to look at that to ensure that
we're better rewarding people for their NHS endeavour and if you like providing
a better incentive to work in the National Health Service.
HUMPHRYS: But what we're saying
here then is the doctors in effect are having a veto on change aren't they?
MILBURN: No.
HUMPHRYS: On the radical changes
a lot of people say, like your own man Mr Hinchliffe, like Hinchliffe would
like to see.
MILBURN: Well I would have thought
a big change to the distinction awards or changes to discretionary points
would represent quite a radical change, and indeed I think when we finish
the consultant contract negotiations with the British Medical Association
- those discussions and negotiations are going well, but I think people
will conclude that what we have as a final product is a very, very radical
change indeed.
HUMPHRYS; Let's look at this early
warning system. You're worried as we all are about incompetent or worse
doctors, and you've announced that there is going be some sort of early
warning system, some sort of register set up. The comparison has been
made - I think you made it yourself in the newspaper this morning, with
near misses at airports. So we would have these cases, these aberrations
if you like being reported. The problem here surely is who is going to
do the reporting, who's going to blow the whistle in the first place?
MILBURN: Well, overwhelmingly doctors
do a brilliant job for the National Health Service, but what I'm determined
to do is to learn the lessons from when things go wrong. Now, in the past
all too often problems have been repeated and the consequence is the patients
have suffered. That's why the Chief Medical Officer has now made these
proposals to set up an early warning system so that the alarm bells ring
and we can nip these problems in the bud.
HUMPHRYS: But who makes the alarm
bells ring?
MILBURN: Well, it will be a variety
of people. For example it could be the manager in the NHS trust, in the
hospital .
HUMPHRYS: But he could do that
at the moment.
MILBURN: Well, that's the point.
We don't have a system for that you see. Amazingly enough we don't have
a system where, where there's been a near miss or worse still where there's
been an adverse incident, where a patient has been damaged or in some cases
sadly has died as a result of a problem, we don't have a national system
for reporting, recording that, or doing something about it, nor have we
learnt the lesson from for example, there are lots of things that go wrong
in the NHS, sometimes they end up in clinical negligence cases in court.
There are a lot of cases that have happened over recent years. We haven't
fully learnt the lessons from those or of all the complaints that sometimes
we get in the NHS. So what this is designed to do is to take all of that
data, to analyse it , to learn the lessons and to ensure that in the future
problems aren't repeated.
HUMPHRYS: Would you encourage people
perhaps a ward nurse, or a sister in the hospital in the surgery or wherever
it happens to be, in the operating theatre, to report things anonymously
if they knew they were going on?
MILBURN: Yes I would. And indeed
you know when I was doing my previous job in the Department of Health as
Minister for State we issued new guidance to NHS Trusts saying that there
should be proper protection for people who blow the whistle. Of course
there should be, and any doctor, any nurse, any member of staff who feels
that something is going wrong should feel that they have the right to report
it but also know that they have somewhere to report it to. You see, if
you look at some of these dreadful, dreadful cases, the terrible thing
about them apart from the harm that's been done to patients is that all
too often the problem is well known about, it was often gossiped about
in the hospital but nobody did a thing about it. Now, that isn't good
enough, and it is indeed one of the radical reforms and changes that we've
got to make, because what comes first in the NHS or what should come first
is the patients' interests, and I genuinely want to see an NHS where the
patient comes first. Now that will be a cultural change, a big change
for the NHS but it's got to happen. .
HUMPHRYS: Right, radical reforms,
let's look at the role of the private sector in the NHS - you've talked
about needing to lay decades of shibboleths. Is one of those shibboleths
the notion, and we heard it expressed in that film a moment ago, that the
private sector should not play a bigger role in the NHS? Do you believe
that there is scope for the private sector to play a bigger role in providing
NHS treatment? Of course it would still be paid for in the way we're now
paying but one of the suppliers would be, maybe an NHS private hospital
or whatever it happens to be. A bigger role and I'm emphasising a bigger
role. I know it does some at the moment.
MILBURN: Potentially yes, and indeed
we're holding discussions with the private sector to see whether that is
feasible or whether that is possible. Already the NHS on the ground works
quite closely with the private sector, you know it did during the winter
for example where we took patients who needed critical care facilities
and housed them in NHS hospitals and conversely some NHS hospitals put
patients into the private sector. There's nothing wrong with that and
frankly there is a world of difference between the NHS paying for patients
to be treated in private sector hospitals but the care remaining free and
what the Conservatives are now proposing which is that patients should
be forced out of the NHS and should have to pay for their own care. So
that isn't on the agenda but what we do need to look at is to see whether
there is capacity in private sector hospitals that we can take advantage
of.
HUMPHRYS: .... Not just during
a crisis, a sort of winter crisis.....
MILBURN: But John it comes with
two big caveats and two big challenges I believe for the private sector:
We should only do that providing the private sector can demonstrate that
us buying care from them provides good value for money from the taxpayer
and doesn't in itself become a further perverse incentive for people working
in the NHS to go and work in the private sector for example. But secondly,
and the most important thing of all, is that we've got to be assured that
wherever the care is provided if it is being provided for free at the NHS
expense on the health service if you like, that the standards of care have
got to be as high as possible. So with those two caveats and those two
big challenges that the private sector has got to rise to then yes, I don't
see any reason whatsoever why, if you like, the NHS can't be doing more
work with the private sector.
HUMPHRYS: So the old days, and
I recall a government minister at the time, Sam Galbraith, saying, 'I
don't want to see NHS money spent in the private sector', those days have
gone?
MILBURN: I think if it makes sense,
if it offers value for money and if the standards of care are as high as
they are in NHS hospitals then I don't have a problem with people being
treated and cared for in private sector hospitals provided the capacity
is there. Now that's what we need to work through and as part of the national
plan we'll need to come to some conclusions about that and I say to people
in my own party, 'look, what I'm interested in as Secretary of State for
Health is ensuring that people get the care that they need when they need
it.' Now overwhelmingly the NHS does a brilliant job at that but the truth
is that there are some real gaps in capacity, we've got to plug them and
all too often right now the care that you get and the services that you
receive depend on where you live. Now we've got to change that and if
that means that we've got to work more closely with the private sector
then there should be no ideological objection to that.
HUMPHRYS: It's an interesting notion,
it means that ultimately, I mean let us assume that the private sector
rises to the challenge that you place before it......
MILBURN: ....well that is a big
challenge.....
HUMPHRYS: Of course......
MILBURN: ..... and I wouldn't underestimate
it... because just to be clear about this what I'm not prepared to do is
to spend taxpayers' money and not get good value for money out of it and
I'm certainly not going to put at risk patients' care. So those are the
two caveats.
HUMPHRYS: But if they overcome
those caveats, if they rise to that challenge then we could see an increasing
amount of private care being paid for by the NHS. I mean logically, if
you were to extrapolate, if they do terribly well at this and they all
say - 'Aha! There's some money to be made and we can do it efficiently,
you're satisfied both with the efficiency and the quality of the care...'
we could see the beginning of the end of NHS hospitals couldn't we?
MILBURN: Oh no. Of course we wouldn't
because....
HUMPHRYS: ..that's the logic of
it.
MILBURN: ...well look at the situation
now. The overwhelming majority of care that is provided, health care that
is provided in this country is through NHS hospitals....
HUMPHRYS: Absolutely, I'm looking
at the long term view (both speaking at once)
MILBURN: ...... and so it will
continue to be and the private sector is pretty small as we know in this
country.....
HUMPHRYS: ...at the moment.....
MILBURN: But if there are capacity,
if there is spare capacity in the private sector and we can take advantage
of it then that seems to me to be a perfectly sensible thing to do provided,
as I say, that these two big challenges are met and crucially of course
- the care has to be for free.
HUMPHRYS: There are some things
we should leave to the private sector aren't there, quite a few things
we should leave to the private sector? I mean this is a kind of rationing
of course and I know as Secretary of State for Health you hate the word
'rationing'......
MILBURN: John, as you know I'm
the first Health Secretary to use the word rationing...........
HUMPHRYS: You did indeed and I
congratulate you on that. But I mean there are increasingly things that
as we look at the service, I mean we heard a number of people in that film
saying however much you chuck into the service you're never going to be
able to do anything, increasingly there are things that we should leave
to the private sector whether they're relatively trivial things like tattoo
removal or varicose veins of whatever it happens to be.
MILBURN: Well I think for the overwhelming
majority of people the overwhelming majority of the time, right now, the
NHS looks after them. Now that might not be what the newspapers report
but that is what happens in practice but look, however much money you put
into the National Health Service and we are putting in more money than
has ever been seen before, there will always be difficult choices, there
will always be difficult decisions to make about how best we can use that
money to get it to best benefit patients. Now we've got a means of doing
that now, we've set up a new National Institute of Clinical Excellence
precisely to take those hard decisions. None of that is easy but it's
the right thing to do.
HUMPHRYS: You've got to make this
work haven't you? We saw another leaked memo from Number Ten this morning,
Philip Gould telling the Prime Minister that people of Britain, Middle
England, thinks he's failing to deliver, I'll quote from the memo: 'Middle
Britain blames Blair...' this is Philip Gould speaking no less, 'for not
delivering key election promises, they're out of touch....' and of course
one key election promise was the NHS. You've got to make this work haven't
you otherwise you're in deep trouble?
MILBURN: Well I think we've got
to make it work not so much for the sake of the Labour government or the
Labour party but what we've got to do is we've got to make it work for
the sake of the NHS because I think all too often in the past there has
been an assumption that somehow or other, because people in this country
are incredibly proud of the NHS, they're proud of the dedication and the
commitment of its staff and proud of what it has achieved, that somehow
or other the NHS can just continue as it always has. Well what I say to
that is that I'm afraid that in each and every generation the NHS has to
earn its spurs and has to earn its support.
HUMPHRYS: I've couched the question
in political terms because what we've seen this morning is a calamitous
drop, well more a rise in William Hague's popularity or the Tories popularity
and a drop in yours. Three per cent is the gap now so we're told by a
very (both speaking at once)
MILBURN: Well John, as you well
know when you asked me about opinion polls that showed that we were leading
by thirty per cent I refused to comment on them then and I refuse to comment
on them now.
HUMPHRYS: But it's got you a bit
rattled though hasn't it?
MILBURN: What happens in this country
in our democracy is that we elect a government, we then expect the government
to get on with the job of delivering what it said it would do. That's
what we're doing in the health service. It's a long, slow, hard business.
Sometimes it's frustrating. It's a serious business. What we're about
here is trying to turn around a service to make sure that it can do what
people in this country want it to do which is to provide high quality drugs
and treatment for people where they need it when they need it, not just
in some parts of the country but in every part of the country and we will
continue to do just that.
HUMPHRYS: Alan Milburn, thank you
very much indeed.
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