BBC On The Record - Broadcast: 11.06.00



==================================================================================== NB. THIS TRANSCRIPT WAS TYPED FROM A TRANSCRIPTION UNIT RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT; BECAUSE OF THE POSSIBILITY OF MIS-HEARING AND THE DIFFICULTY, IN SOME CASES, OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS ACCURACY ==================================================================================== ON THE RECORD RECORDED FROM TRANSMISSION: BBC TWO DATE: 11.06.00 ==================================================================================== JOHN HUMPHRYS: Good afternoon. The government promises us it will improve the Health Service and it's not afraid to look for radical solutions. I'll be asking the Health Secretary Alan Milburn... HOW radical? We'll also be talking to the president of the European Commission. Is a United States of Europe what he's really after? That's after the news read by Fiona Bruce. NEWS HUMPHRYS: Romano Prodi is the most powerful figure in the European Commission. He tells us he wants Europe to enter a new phase of integration. And he thinks that Britain will join the Euro. ROMANO PRODI: "If the Euro will deliver as I think, it would be difficult to stay out." HUMPHRYS: But first the state of the NHS is one of THE big issues in British politics. The public does not believe it's good enough and, more to the point, thinks this government has failed to do what it promised at the last election. Three years, they say, and what's changed? Not a lot. But now, the government tells us, a huge amount of extra money is being spent on the Health Service and radical changes will be introduced to make sure that the money produces real improvements. But how radical is "radical"? I'll be talking to the man in charge, Alan Milburn, after this report from Polly Billington. 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. . 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. . 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. HUMPHRYS: Polly Billington reporting there. 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. HUMPHRYS: The President of the European Commission, Romano Prodi, has not been having an easy time of it since he took over the biggest job in the European Union last year. His main problem is that the Union is seen to be losing its sense of direction. Is it moving full steam ahead towards a federal Europe or drifting, rudderless? There's no doubt what Mr Prodi wants - he's an integrationist to his Italian fingertips. Paola Buonadonna has spent this past week with Mr Prodi, talking to him and watching him try to steer the European vessel in his chosen direction. PAOLA BUONADONNA: This mild-mannered university professor taking a stroll with his wife is one of the most powerful politicians in Europe. When he was appointed to head the European Commission in Brussels last September Romano Prodi had a sparkling reputation. He had brought Italy into the Euro zone during his time as Prime Minister and had been personally picked by the main governments in Europe including Britain, as the man who would resurrect the reputation of the Brussels executive. The previous President, Jacques Santer, and his commissioners had just resigned amid accusations of financial mismanagement, nepotism and corruption. I met Romano Prodi in his home town of Bologna and I asked him if he had been intimidated by the job he inherited from Mr Santer. ROMANO PRODI: If you consider which were the relations between the Commission and the governments when I arrived in Brussels you know that was a desperate situation. You know I knew that the job was difficult. I am not surprised you know because to keep countries with people and bureaucracy together you know and to try to show to have one coherent strategy is not easy. BUONADONNA: The Brussels press core is the biggest in the world - every week journalists from all over Europe gather to quiz commission spokesmen in this briefing room. Nine months into his tenure Mr Prodi's leadership is under intense scrutiny. Europe faces huge challenges - as it prepares to welcome new member countries and to reform its institutions. It's vital for Romano Prodi to show that he is the right man for the job and not just a last-minute compromise. But the affable persona which made him the darling of the press at the beginning of his journey has now been turned against him. He's been criticised for a series of diplomatic blunders, for unguarded comments about the future of Europe and for mismanaging his relations with the media. PRODI: If you want to change you have to make people unhappy you know. And the media they are merely listening to people who have been made unhappy by my first actions you know so this is life you know. But you know I didn't accept, accept this commitment in order to be popular. BUONADONNA: Another criticism is that you made some diplomatic mistakes early on such as inviting Gadaffi to Brussels. PRODI: Without giving up any principle, I said why we don't start talking. And then had such a tremendous negative reaction. And then when I went to Cairo for the meeting of African and European leader all the European Prime Minister were queuing in front of Gadaffi you know. I had to wait hours to meet Gadaffi because my former colleagues were meeting him you know, so it was a mistake or it was some forward looking idea. BUONADONNA: It's 8 am, every week Prodi meets with his closest advisers before the regular commission meeting. He has set out an ambitious plan for the internal reform of the commission, ending the convention of countries always running the same departments, linking promotion to merit rather than seniority and asking officials to take personal responsibility for the mistakes of their departments. The reforms have been very unpopular and not just in Brussels PRODI: I do understand that this is a long range effort and you can't have results at the beginning so if you mean that from many points of view I was highly unpopular in this first of all, I said yes. Yes. Yes. And I think I shall be for some other time in the future. Because you can't, you can't make surgery operations without you know making some cut. Well, you can use other instruments but generally you know when you have to heal a body you have to cut it. BUONADONNA: Is this it or can more be done in future? PRODI: No, the reform of the Commission is never ended. Never ended. And this is, this is what must be done. And without it you cannot have a working Europe, you cannot have you know. This is, this is the most unknown challenge you know because people are not interested of this. But I spend half of my time to put the house in order. I don't know if I shall succeed. BUONADONNA: An hour later Mr Prodi arrives at the weekly meeting of the commission. But even here there have been allegations that he doesn't enjoy the full loyalty of all his colleagues - a German newspaper suggested that British commissioners Neil Kinnock and Chris Patten were poised to replace him. PRODI: No, this is completely untrue. My commissioners are strong men and women, I should wish that any European government has such strong men and women as my commissioners are. We work together and there is also the feeling of happiness you know of you know, people enjoy to work. Of course in all the collective bodies there are moments of tension BUONADONNA: The following day in Lisbon Romano Prodi sets off to meet Bill Clinton at a US European Union summit hosted by the Portuguese Presidency. Mr Prodi is here to represent the European institutions. Relations with the US, on trade and on defence, have not been smooth recently, so meetings like this are more than courtesy calls. The EU is trying to forge a coherent foreign and defence policy to complement its strong single market. Mr Prodi is trying to ensure the commission has a central role. Romano Prodi is used to international gatherings like this - as a former Italian Prime Minister - but he has been criticised for presenting himself as the head of the European Government. And now some wonder whether he has the right vision for the European Union and the ability to see it through. Mr Prodi says his vision for Europe isn't modelled on the United States. He is careful to avoid any suggestion of a federal super-state. Mr Prodi sees European integration in terms of a 'network' - which works with the present structure of regional, national and European institutions, devolving power wherever possible but, controversially, with a stronger commission at its centre. PRODI: This is a definition that is very, very - the guarantee for freedom. Of course, but not because of that you need a stronger Commission, but you need a stronger Commission because the needs are so important you know. BUONADONNA: Back at his home in Italy after the summit Mr Prodi prepares for the coming week. As head of the European Commission his biggest challenge is to oversee preparations for the admission into the EU of a dozen new countries. It's a huge undertaking and progress has been slow. Romano Prodi would like to see Europe ready to welcome new countries by 2003 and needs to make sure Europe gets it right. But there are signs that some member states are cooling on the idea. PRODI: What I am afraid from the enlargement is that if we don't do it well our public opinions - British, Italian, French and German - they will be scared and they will stop it. BUONADONNA: So it would be a failure for the Union if enlargement didn't happen quickly? PRODI: It certainly would be a failure for me. I link my presidency to the enlargement. BUONADONNA: But there is a deadline looming. Before new members can enjoy the benefits of European membership Europe itself must complete difficult internal reforms - to be agreed in a new Treaty by the end of the year. The reforms could cause problems for the British government. Mr Prodi wants member states to give up the right to veto in many more areas and to extend the use of Qualified Majority Voting or QMV, where a decision can be taken by a substantial majority of countries even if others are against. PRODI: You know when you are three families you can go at unanimity. But if you are twenty families it is difficult to have the unanimity. This is why the Intergovernmental Conference is so important, you know, we can survive without it but very, very, very badly. BUONADONNA: Would you like to see QMV in items such as taxation? PRODI: When it's a danger for the single market. You know if you through your taxation you compete against me and you make me going in bankruptcy well I think that we have to harmonise this type of taxation. BUONADONNA: Taxation is only one of many controversial issues in Europe at the moment. The poor performance of the single currency, which has lost more than 15 per cent of its value since its launch last year, is casting a shadow on the whole monetary union project. But the Commission President won't accept that the Euro is a weak currency. PRODI: I don't know what is a weak currency, you know the Euro - look the, the European Central Bank it works well. The eurobond market is bigger than the dollar bond market. The agreement on how to manage the rate of interest is perfect. I do simply think that the Euro will be a currency in not a too long time probably equivalent to the Dollar. BUONADONNA: But now we're seeing Greece and soon Denmark and Sweden joining possibly within the next three years we'll see them all in, how can Britain stay out? PRODI: Well I could answer that it is your problem you know. But a lot will depend also upon the fluctuation of the pound you know it's, you had difficult case in the last month of competition for the British economy you know and it is clear that a country like Britain must be competitive. We had some case that made me thinking about that you know. The Rover case, BMW and other problem for in which the export companies were under pressure because of the rate of exchange. In my opinion some day it will become convenient. But it depends upon our behaviour. Lets say if the Euro will deliver as I think it would be difficult to stay out. If not will be easy and happy to stay out. BUONADONNA: Vision alone may not enough - some say that Romano Prodi has failed to garner enough political support of the countries that matter. France and Germany have traditionally driven European integration but their alliance has weakened making the job of the European Commission President all the more difficult. What's more the remaining big issues in Europe are increasingly being resolved by governments acting amongst themselves rather than through the commission. Europe seems less keen on big ideas these days. Many governments have domestic distractions and scepticism with European integration has surfaced even in Germany. The old consensus that succeeded in launching the Euro has faded and Mr Prodi wants Europe to find a new sense of unity. PRODI: The spirit of Europe was born with the six countries and you know Franco German alliance is a guarantee for, is a glue, lets express for that you know. So I work at a lot for that. BUONADONNA: After a weekend at home Romano Prodi heads back to Brussels. The French and the Germans are trying to regain the initiative in time for the French Presidency next month. The German Foreign Minister has suggested that European integration can only be kept on track by reinforced co-operation - where a few countries are allowed to forge ahead in certain areas. The British government is nervous that they will be left at the margins of Europe. But Mr Prodi has embraced the idea. PRODI: Yes, this is for clear you know. It's clear if you have a long train and you have a few wagons that can go only thirty kilometres per hour, you know all the train will be a failure you know. And so it's - you have rules and this is why I think that the so called reinforced co-operation is among willing countries must include many countries, not only one or two, two or three countries let's say. And second must be open. BUONADONNA: But there's a ready made core group of countries which could decide to move forward. They are the countries which have joined the single currency, whose finance ministers meet in the so-called Euro 11. The British government fears that the Euro 11, from which it is excluded, could become the economic and political engine of Europe. But Mr Prodi believes it should be strengthened. PRODI: Yes. Euro 11 as a consequence... because of its nature will require stronger co-operation. The problem of harmonising our action in the field of Euro is very very important you know, and I think that we need to take action in this direction. You need some instrument of political economy that you call instrument to fight against erratic shocks let's say you know. Unforeseen events that, and so the Euro is an instrument to reinforce the co-operation. BUONADONNA: The Commission President took over his post during a difficult time when the European institutions faced a crisis of confidence. He feels Europe's worst enemy is stagnation. Despite the fears of some countries including Britain he believes it's once again time to press ahead with political integration PRODI: Everybody was writing the debate about Europe is over you know and I know history of European Union is so simple. You have years in which you sleep. You have to consolidate to think it over and then the years of progress. We have the enormous effort for the Euro, it was an enormous effort you know. And then you had to just to sleep for a while and then the debate is here again because we understand that we have to interpret history. BUONADONNA: Romano Prodi might have been Tony Blair's personal choice when he took his new post nine months ago. But if he succeeds with his plans for political integration in Europe it could herald a very difficult time ahead for the British Government and it could jeopardise Labour's ambition to be at the heart of Europe. HUMPHRYS: Paola Buonadonna reporting there. That's it for this week. Just a reminder about our website for those of you on the internet. You can find all my latest interviews and the whole of the rest of the programme there as well. Next week we'll be back on BBC 1 at the usual time. Until then... good afternoon. ...oooOooo.... 21 FoLdEd
NB. This transcript was typed from a transcription unit recording and not copied from an original script. Because of the possibility of mis-hearing and the difficulty, in some cases, of identifying individual speakers, the BBC cannot vouch for its accuracy.