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JOHN HUMPHRYS: So, Dr Fox, let's see if
I have got this right. You would spend at least as much money on the NHS
as the Labour Government is doing and is planning to do, but you don't
think it's enough even so, so you would have to raise more money by getting
more of us to pay more private health insurance.
LIAM FOX MP: Well, first of all can I take
the point about commitment to the NHS as an NHS trained doctor who spent
all his working life before Parliament in the NHS I'm hardly the one who
wants to dismantle it. The important thing is do we get the quality of
health care in this country that we deserve. You mentioned in that film
comparisons with other countries and what I think we need to be doing rather
than talking about the input side and just how much we're spending is what
we're doing and the biggest problem we have is that our outcomes in terms
of heart disease, in terms of cancer are actually well below the levels
predicted in Germany, or France or Holland and now I want them brought
up. And the question we have to ask is how much do we have to spend and
how do we have to spend the money, more importantly, to get ourselves those
outcomes. Now we have said that we will match Labour's planned increases
in expenditure as laid out in the Budget but that I also want to see expansion
of the private sector at the same time. It's not a question of one or
the other, we want to see both an expansion of the NHS and an expansion
in private healthcare so that we can get the sorts of partnership in the
United Kingdom that we've got up to a limited extent at the present time
but which they have far more in other countries.
HUMPHRYS: But you are a bit nervous
about bringing in the policies that would produce that result aren't you,
expanding private medicine, private insurance?
FOX: I'm not nervous about
it at all. It's a question of how you bring it in and the way that you
get the best results. For example, it was mentioned in the film about private
tax relief and the Labour Party are always accusing the Conservatives of
wanting to bring in tax relief for the wealthy so that they can pay more
easily for the private healthcare that they already have. Now that's a
complete nonsense. The best way to get any increase in provision is to
get a quality product that is more accessible to people because it's cheaper.
Now I don't have private healthcare at the moment, one of the reasons is
the same as many people out there, that I believe it's very expensive,
I believe it's inflexible and for many people it has too many exemptions,
for the elderly for example, they feel that they can be treated for anything
except anything they've already had and that's a big disincentive. Now,
what I want to see is an NHS which works in a way to treat priorities so
that the sickest patients are treated first. Now there is a very good upside
to that in the private sector because if you or I knew that we were going
to get treatment for our heart disease or our cancer within a guaranteed
time in the NHS why would we possibly want to insurance ourselves privately
for that. We have indications from many of the private insurers that if
the NHS guaranteed to do that work and they didn't have to provide any
insurance privately for that, they could reduce their premiums by say thirty
per cent. Now that is a far better way of getting an increase in the number
of people who might be attracted to that than using the taxation system.
HUMPHRYS: But the taxation system
is clearly very important, at least you believe that to be the case. The
sort of thing you want, this expansion of private insurance that you want
is not going to happen unless and until you offer everyone tax incentives
is it.
FOX: I don't actually agree
with that John. I think that the most important thing is to make sure that
people have something they want to buy at a price that they can afford
to pay for it and I don't think...
HUMPHRYS: ..but that's crucial,
the pay you can afford to pay for it and that's determined by whether you
get tax relief on the premiums that you have to pay because it brings down
the cost of the premium.
FOX: Not necessarily as
I've just said there are ways of bringing that cost down without using
the taxation system. But you are talking there about personal medical
insurance, that's one side of the equation, there's another group which
is those covered by business schemes, through their employers. Now that's
about three point seven million people at the moment in the United Kingdom.
That's where I would like to see the big increase coming because all the
evidence from other countries is that that is the best way to get (a) an
increase in the total number of people covered to get an expansion of the
private sector and to give it to people who couldn't otherwise or wouldn't
otherwise choose to buy it themselves.
HUMPHRYS: There would be tax relief
then on company schemes as far as you are concerned.
FOX: At the moment there
are two major disincentives...
HUMPHRYS: Each on insurance.
FOX: National Insurance
on employers, the government recently slapped a hundred million pounds
worth of tax on employers, who, in their view, had the audacity to become
involved in the healthcare of their employees and employees are taxed as
a benefit in kind. Now in the long-term we would like those disincentives
to disappear. How quickly you can get rid of them depends on the overall
performance of the economy and how much you are spending on the NHS and
as we have already said we plan a big increase in that and you have to
balance that against the benefits you might get for abolishing disincentives
in terms of the growth of the private sector and the sort of increase capacity
you get in your economy for employees actually being healthier.
HUMPHRYS: So let's be clear about
this, you would or you would not get rid of tax payments, you would allow
company schemes to qualify for tax relief.
FOX: Yes in the long-term
we would .....
HUMPHRYS: ..in the long-term -
you don't know how long that would be?
FOX: Well there are ways
of doing it and it's..you wouldn't expect me to simply promise anything
without strings. For example, I would ...
HUMPHRYS: ..I don't know, I heard
it done before...
FOX: I would like to see
any increase done in a way that encouraged particular schemes, for example,
with good preventative medicine schemes to make sure that what's happening
in the private sector is complimentary to the NHS and is not simply doing
something different.
HUMPHRYS: But there would be relief
for company schemes. In other words somebody is on a company scheme they
would not be taxed as though that would be benefit in kind - that is what
you are saying - ultimately that's what would happen under..
FOX: ..ultimately that's
where we would like to go. The pace of course is dependent on a great number
of economic factors.
HUMPHRYS: In that case, why not
for all individuals, why should somebody who works for the sort of company
that provides that kind of scheme, have that kind of benefit when other
people - especially the elderly - don't.
FOX: Well it's a matter
of what the NHS can provide and how we can practically do it...
HUMPHRYS: But that's not fair..
FOX: But it how we can
practically do it John, we're living in a real world and not some sort
of think tank virtual world...
HUMPHRYS: Well You'll to penalise
the elderly for instance and benefit those people who are in jobs?
FOX: The best way to improve
care for the elderly is to ...what the NHS actually does and perhaps we
can talk about that.
HUMPHRYS: But I mean let's just deal with
that one for a moment, a very large number of elderly people watch this
programme and they will be concerned about this because they would like
to have private insurance schemes and many of them can't afford to and
clearly if they are going to get some sort of incentive, then they'd be
more tempted and they are looking at this scheme now where people in work
get this benefit, they wouldn't get it. You've got to have a equitable
system haven't you?
FOX: The real question
is how can more people afford to get it, now as I've already said when
the Labour Party abolished the tax incentive for the elderly that resulted
in a ten per cent reduction in the number of people with private medical
insurance. Our evidence suggests that if we go ahead with our Patients'
Guarantee model and the NHS is guaranteeing cancer treatment times and
cardiac treatment times that the premiums will actually fall by about thirty
per cent and that will result in an increased uptake of about twenty to
forty per cent. So you are getting up to four times as many people being
able to take it up as a result of that model. To be frank with you, if
you are going to introduce tax incentives in the way that has been suggested,
there is very much a dead weight to be borne there, in other words you'd
actually be paying a lot of people who already have private health cover
to keep the same cover going. That's very expensive and what I want to
make sure is that we are able to treat more patients with a higher quality
care and that means trying to look at the various options available to
us to see where we can get the biggest increase in the size of the cake
in total.
HUMPHRYS: So you're very reluctant
to offer carrots, except for the people in company schemes as we've established.
What about the stick - in effect saying to people "Look, the NHS cannot
do everything, yes, we'll deal with the urgent things that have to be dealt
with. Obviously we always have and we always will, but it can't do everything,
certainly not in the time that you need, therefore, there are some things
that you will have to pay for yourself".
FOX: Well, that has been
proposed by the IOD and others that we move to what's called the core model
NHS and I actually reject that and let me tell you why. Because it requires
politicians to make decisions about clinical conditions which I don't think
they are actually able to make. A very good example.....
HUMPHRYS: I thought that was exactly
what you were saying, that we had to make choices. You said that on many
occasions.
FOX: Exactly, we have to
set priorities. Can I just finish this point. For example, one of the
areas that's often talked about in a core service would be something like
varicose veins. Now, dealing with varicose veins may not be regarded as
a core function of the NHS. I mean in ninety per cent of cases that may
well simply be a cosmetic procedure, but if you happen to be one of the
elderly patients who gets leg ulcers and becomes bed-bound as a result,
I would say that was part of what the NHS really ought to be doing. So
it becomes very difficult once you look at conditions to exclude them.
What I think we have to do is something different to actually...
HUMPHRYS: Before you leave that
point, the implication of that, what you've just said is that the NHS is
just going to carry on doing everything.
FOX: No, what it says is,
that we don't exclude particular conditions, that we treat patients as
being individuals. In all of this, you see all the commentators want to
talk about patients as though they were averages, and good medicine is
seeing patients as individuals not as averages. I didn't see average patients,
I saw individuals with their own past medical history, their own particular
condition, their own family circumstances and we have to have a system
which is sensitive to that. Now, what we have to do is set priorities
and say that some treatments are more important than others. Varicose
vein treatment for old ladies with leg ulcers is more important than for
those who want cosmetic procedures done.
HUMPHRYS: If you take your own
experiences as a GP, and somebody comes along to see you, half a dozen
people come along with varicose veins, say "Look doctor, I want these sorted",
one of them you believe as a GP ought to have them done because of god
clinical reasons, others for cosmetic reasons, you're going to find it
terribly difficult aren't you to say to five of them, sorry you can't,
you're gong to pay for it, the other one's going to get it free. They
won't quite understand, it's going to be terribly difficult. This is why
ultimately if decisions on rationing, and let's be clear, this is what
we're talking about, we're talking about rationing, and I know politicians
by and large don't like to talk about rationing, but this is what we're
talking about....
FOX: I don't have a problem
with the word.
HUMPHRYS: Alright, good, most do,
and when you're in office perhaps it will be different, if you're in office.
But the fact is rationing has to happen, it has to be decided by the politicians.
FOX: Well, I don't actually
agree with that because I think that what we should be looking at is the
way of deciding treatment times that are done for specific patients. You
use the varicose vein example - let's stick with that one. I think we
need to have system in place where the patient's waiting time is dependent
upon the clinical condition, and obviously somebody with varicose veins
with a complication requires a much shorter waiting time than patients
who have no complications. Now...
HUMPHRYS: You are rationed by the
waiting time...
FOX: Well, that is how
I think it is fair to do. I think that the sickest patients should be
treated first, and I think those with minor complaints should take their
appropriate place in the queue. Now...
HUMPHRYS: Or go private?
FOX: Well that's anybody's
choice at any point whether they want to go private or not, and a hundred-and-forty
thousand patients per year in this country choose to buy their entire treatments
privately, and that's four hundred thousand more since Labour came to office
alone, so that's already happening, so we mustn't pretend ...
HUMPHRYS: And you know that, and
you would like to see that continue. That would be part of your aim, to
encourage, I was going to use the word force, I won't I'll use the softer
word encourage, encourage people to do it.
FOX: Well I think there's
a huge difference between the two. I would never force anybody to have
to buy the treatment outside the NHS.
HUMPHRYS: You'd have to use the
word encourage.
FOX: I think if people
feel that that's a reasonable choice for them I don't have a problem with
that, and I can't understand....
HUMPHRYS: It's a bit stronger than
that. If people feel that's a reasonable choice for them, they would only
feel that if the alternative was not available, and you're saying we will
so order things that the alternative will not be available. That's basically
true isn't it?
FOX: Well, it's also about
the cost of it too, and it's not just about the availability.
HUMPHRYS: Back to private insurance.
FOX: Well, I think that's..
again I think we need to look at how we can encourage it across the board
without harming a patient's faith in their ability to get treatment free
at the point of use, which I think as a doctor I regard as the most important
point of all. But we have to look and see what we could get with a better
partnership. The word I was amazed wasn't used in any point of your film
was this idea of partnership. Now in many other countries there is a much
better developed partnership than we have in the United Kingdom. In the
United Kingdom we already have quite a number of patients in the NHS who
get their treatment paid for by the NHS but in the private sector. That's
about forty thousand patients a year, so in fact as Labour again came to
office, a hundred-and-twenty thousand NHS patients have been treated in
private sector which is bigger than Labour's reduction in their waiting
lists. But within that I think there are big problems. Number one is
which patients to treat. One of the most I think staggering statistics
is that last year the number of heart by-pass operations in the NHS fell
for the first time in twenty-five years, it fell by four-hundred-and-fifty,
at a time when the government were actually buying increased number of
treatments in the private sector, and a lot of those were things like sterilisations,
inguinal hernias, and that says to me that's a bizarre.....
HUMPHRYS: We don't want to go into
too much detail but simply so that people will know what we're talking
about.
FOX: Hernias.
HUMPHRYS: Okay, oh yes.
FOX: We won't go into that.
It's lunchtime for a lot of people.
HUMPHRYS Well, precisely.
FOX: And I think that it's
important that we actually get a sense of priorities, and I think to be
reducing the number of heart operations at the time you're increasing minor
complaints being treated is immoral. So we have to get back to a whole
proper system that's clinically driven, and I think that's what we're missing
at the present time, and we could do that. We could actually dramatically
increase the number of NHS patients treated. If every private hospital
dealt with just three more surgical procedures a day that would treat a
hundred-and-seventy thousand more NHS patients a year, that's a huge increase.
If we prioritise that properly we could actually try to move towards the
sort of health results that they have in other countries that were mentioned
in your film.
HUMPHRYS: Right, so let's be clear
about this because it's an important part of the policy this isn't it.
You would say there are some things that the NHS has to do and we've always
said that of course, if you have to have open heart surgery, if you have
cancer whatever it happens to be we will say to you we absolutely guarantee
that you will have those operations in double quick time as quickly as
medical conditions demand and nobody is going to wait beyond that particular
time but of course there is a price to be paid for that and you are prepared
that we should face up to that price?
FOX: Yes I am. At the
moment you see there is huge distortion in the system. The current waiting
list initiative is all about numbers, it's about simply getting the appropriate
number of patients treated whether or not they're the right patients, whether
or not they're the sickest patients and I think that's a dreadful way to
run a system. I think the sickest patients should be treated first even
if that means people with more minor conditions taking their appropriate
place in the queue. At the moment that queue is distorted simply to try
and make the numbers look good and that can't be a fair or equitable basis
of running a health care system. I find that ethically quite unacceptable
as a doctor that we do that so we have to make sure the sickest patients
are treated first and it shouldn't matter to us where patients are treated,
it should matter to us when patients are treated and the quality of the
treatment that they get.
HUMPHRYS: Right, so if it means
buying a bed in a private hospital you're absolutely happy with that?
That would be fine?
FOX: And the government
have recently moved onto our territory which I welcome.....
HUMPHRYS: ....indeed.... indeed,
we had the health Secretary Alan Milburn saying that precisely on this
programme a couple of weeks ago but also acknowledging of course that there
is a cost involved in that because if you're buying beds from the private
sector it is going to cost money.
FOX: Well the NHS of course
has massive purchasing power and should be using its purchasing might to
make sure that it gets value for money. It's also difficult to measure
it against what it costs in the NHS because we don't measure things very
well in the NHS. So that's a difficult problem and it's impossible to
give you an exact example answer to the question which you're asking which
is 'would it cost more per procedure in the private sector because we really
don't know very well how much we're talking about here.
HUMPHRYS: But whether it would
cost more to do this operation in this private hospital than in that NHS
hospital is not so much the point, the point is that there would be extra
work being done, there would be more operations carried out .....
FOX: .... because there
is more capacity in the private sector. You'd see we've be running the
NHS closer and closer to full capacity because we talk about efficiency
gains and there's a limit to the efficiency gain you can get in the NHS
and doctors and now working flat out, operating theatres are working flat
out, nurses working flat out, so we have to try and find some spare capacity
somewhere else and that can be found, I think to an extent, in the private
sector. In the longer term we have to increase the number of doctors and
nurses that we have working in both the NHS and the private sector but
it's an interesting thought that of all the nurses who've left nursing
and left the NHS in the last four years, only four per cent have actually
gone into the private sector. The majority have simply stopped working
altogether. These are the people we have to try and get back. In the
longer term our constraints and going to be manpower, in getting doctors
and nurses working in both parts of the healthcare system.
HUMPHRYS: Right. So we've made
this absolute commitment, a Conservative government would make that absolute
commitment to people who are really ill and need these operations and you
will spend, effectively, whatever it takes. There is no.... there can,
by definition, be no limit to your spending promise here? I mean what
you're saying to them is whatever it costs you will have that operation.
Now clearly there are knock on effects from that aren't there and clearly
one of those effects, unless you're going to find a magic pot of gold under
some rainbow that we haven't yet discovered, unless of course it is private
insurance, you're saying to people - you'll have to find another way of
doing those other less urgent operations?
FOX: Well there's a big
assumption in your question which is that there is unlimited demand. We
have of course tried to assess what demand might be there which may suddenly
come into the system if the constraints that doctors normally work under
are removed. In other words if doctors are allowed to decide the maximum
times for their patients themselves rather than being constrained by the
system. Now what we've done is to look, for example, at the range of surgical
procedures and to see what doctors think they ought to be doing and comparing
that against what they're actually doing and to our amazement we find in
many areas for example in prosthetic surgery we find that what doctors
say they should be doing is exactly the same as what they're doing, so
it seems that the capacity in that particular area is roughly the same
as the demand.
HUMPHRYS: Well it might be in that
particular area but you can't be sure across the board can you that .......
FOX: No. No. that's right....
That's right and we've looked at other areas for example in gall bladder
surgery there's quite a big difference, there's about a thirty-five per
cent difference between what doctors say they ought to be doing and what
they're capable of doing so we know there that we have to try and find
extra capacity. We have a group of very senior cardiologists working at
the moment on the same problems in heart surgery. But one of the problems
we face at the present time is that politicians are giving arbitrary waiting
times. Now not everybody waiting for a particular type of surgery is as
urgent as everybody else waiting for that particular type of surgery.
If you take again prostate cancer as a good example, a number of patients
would clinically require surgery within a month but a good number could
actually wait six, twelve months without any difference to the outcome
of their disease therefore it makes no sense to give everybody a three
month waiting time. What it does make sense to do is to operate it on
a patient by patient basis and say 'You're an individual patients therefore
you get an individual guaranteed maximum waiting time' and that's what
we want to do and I think that's a much better way of running a system
than we've done in the past. You know artificial targets are very attractive
to politicians because it lets them say, 'well we want all waiting times
to be done within three weeks or six months.' It's a nice headline figure
for the newspaper but it's not a very good way to practice medicine and
I didn't give up my career in the NHS to come into politics to see politicians
carrying out policies which I don't think, in the end, are very patient
orientated.
HUMPHRYS: But the realistic outcome
of all of this is at the moment you may have to wait a very long time for
a hip operation - I mean let's not take something that might be cosmetic
like varicose veins - take something like a hip operation which is not
life threatening, probably not anyway, but extremely painful and people
want it done and want it done as quickly as possible. There is the strong
likelihood, some people would say the certainly, we heard various contributors
in that report by Terry Dignan, some people would say there is the certainty
that those people would be pushed so far down the queue that they would
end up with no alternative but to buy that operation privately. You're
attitude, ultimately, to that is - that's fine, take out private insurance
and we will try to make that more affordable for you.
FOX: No, that's not my
attitude. Now let's think about the logic here, if we are treating the
same number of patients with an increased amount of money it's hardly likely
that the maximum waiting time would increase...
HUMPHRYS: Now, the premise is dodgy
though isn't it. You cannot be sure that it would be the same number of
patients. It's highly likely that the number of patients would increase
for reasons that were put forward in that film by Madsen Pirie.
FOX: I think that's a very
debatable point and I would say that it is possible to predict the demand
at least to a relatively reasonable level..
HUMPHRYS: History suggests otherwise..
FOX: Well I would disagree
with that given the work that we've done, but the question is how do you
get, let's call them the not-life threatening but serious conditions, for
example severe arthritis of a hip, how do we get those treated. Now there
are two problems in the system at the moment. One is the overall capacity
which I mentioned in the NHS, the other is the fact that in orthopaedic
units you will always have to give priority in surgery to road traffic
accidents and very serious short-term conditions. Now, how do we avoid
that, one of the things that in fact has been proposed and the government
seem quite keen on is to move to stand alone surgical units. In other words
we have dedicated units that would do only routine hip operations and nothing
else. They wouldn't take any emergency patients...
HUMPHRYS: ..still cost money though,
resources still have to be put into it.
FOX: Of course it will
cost money but it's about creating a system which is more predicable. Now
in the increase in funding that's coming forward which the government have
proposed and which we would match, I think we have to be looking at that
increased amount of money and saying rather than pour it into the black
hole that we have at the moment, not knowing where the money is going to
go, we actually now have to try and decide where we get the best increase
in the amount of patient care for that particular amount of money. And
if the government bring that in in their national plan which they are going
to announce then I would welcome that as long as certain procedures for
quality were being followed.
HUMPHRYS: Let's look at another
big part of the budget and that is drugs, particularly nowadays as we have
had the debate this week about Interferon, how expensive that is, ten thousand
pounds a year, a huge amount of money but a lot of people say they get
benefit from it and the National Institute for Clinical Excellence, NICE,
said well we don't think actually it's a very good idea because - we know
all the arguments for that. Now you would set up an exceptional medicines
fund and as I understand it that would provide cash for these exceptional
drugs, exceptional in the sense that they are new and terribly expensive
and all the rest of it, so you'd get rid of, in theory anyway, you'd get
rid of this sort of postcode rationing that we have at the moment. But
this also would cost a great deal of money because you would be blamed
if the drugs were not available so you would have to say, or this fund
would have to say, look we need more money now because we have run out
of money. You'd have to give it to them wouldn't you?
FOX: Well, let's be completely
frank about this debate, we are talking here about rationing in healthcare
in the United Kingdom, we all know it takes place. I find the concept of
postcode rationing that you can get a drug on one side of the side and
not another, I find it deeply offensive and unethical. I think that we
have to accept however that we can't afford everything all the time for
all patients. I think more reasonable people would accept that. Therefore,
we have to find a way of making drugs available on a more equitable basis.
Let's take Beta Interferon as a good example...
HUMPHRYS: ..for Multiple Sclerosis
sufferers..
FOX: For Multiple Sclerosis.
At the moment, the mechanism will either say everyone gets it or nobody
gets it, I think that is preposterous. If it's useful for a particular
type of patient, particular type of MS sufferer then I - where we can prove
that it is effective, then I say that should be available for them throughout
the country irrespective of where they live, but it may not be available
for all patients with MS. What I think we have to do, is to get a mechanism
in place which actually makes prescribing criteria more scientific which
is based more on the medicine and doesn't try to be an all or nothing solution
because that is simply not going to be sensitive enough and when we move
into new areas looking forward in medicine to areas of progress in genetics
for example, where we may be able to identify more precisely which patients
may benefit from a drug, we have to have a mechanism of being able to prescribe
it and set criteria for doctors to prescribe it and where the funding follows
that, and I don't think that what we have in place at the moment actually
allows us to do that and I do think that the models that we have for healthcare
should be based on looking forward to this century rather than back into
the last century.
HUMPHRYS: But ultimately it has
to be the politicians doesn't it, who makes these decisions. You can't
leave it to clinicians, you can't leave it...
FOX: Yes it does, which
is why I think it is much more honest to setting a particular fund where
the total amount is set by the Secretary of State..
HUMPHRYS: Or you'd be unpopular
then if some drugs where not available wouldn't you.?
FOX: Well isn't that the
appropriate role for a politician, I am answerable to the electorate and
therefore it is appropriate that the politician makes the decision. It
is not appropriate that something like NICE, the National Institute of
Clinical Excellence, makes decisions about that, it's my job to make sure
that patients get the quality of care, it's my job to make sure they are
treated where they can be treated best, in the shortest possible time and
that we eliminate postcode rationing. I think all of those are the appropriate
jobs for the politician and it's not something I would duck in office.
HUMPHRYS: Dr Liam Fox, thank you
very much indeed.
FOX: Thank you.
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