BBC On The Record - Broadcast: 21.04.02

Interview: ALAN MILBURN MP, Health Secretary.

Will the Government's reforms really mean that patients will be able to choose the time and the place that they receive hospital treatment?

JOHN HUMPHRYS: That's true isn't it, what he said at the end there, Mr Milburn, you've made a lot of promises, a lot of commitments that have to be delivered, that must be delivered by around about the time of the next election, you won't deserve another term if you don't deliver on those will you? ALAN MILBURN MP: Well I think we're all happy to be judged on them but it's worth saying, as I said in the Commons the other day, that what we've got here is a ten year plan which we published in July 2000... HUMPHRYS: Another ten year plan. MILBURN: Well it isn't another ten year plan, it's the only ten year plan... HUMPHRYS: published it a couple of years. MILBURN: We published it in July 2000, that is the plan. What we were able to do last week was set out, because of the extra investment that is going in, what we were going to do, how the money was going to be spent and most importantly of all, how it was going to be accounted for. The important thing is this, this is not more money for more of the same, this is more money for a different sort of Health Service, where patients do have more choices, where it's more de-centralised, where there's greater plurality in provision, more diversity with the public and private sector working more closely together and that way you get the waiting times down for treatment. Now, we are not going to get there over night, of course we're not, this is going to feel like evolution but the end product I think will be a revolution in the way that health care is delivered and how it is organised. HUMPHRYS: Right, let's pick up on this question of choice then and let me quote a sentence that you'll know very well indeed from your own plan delivering the NHS plan, chapter 5, or whatever it is, verse 5, line 6, by.... MILBURN: ...I don't think it quite has that... HUMPHRYS: it's not the Holy Book yet, but "by 2005 all patients and their GPs will be able to book appointments at both a time and a place that is convenient to the patient". Now, no ifs, ands and buts about that, that is the commitment right, they will have that choice. MILBURN: Yes that's right. I mean basically what will happen is that we are going to do two things, we've got to first of all expand the capacity of the Health Service. I think everybody now recognises and actually I think on this point at least there's a consensus in the country that if we want world class health care it's got to be paid for. The big debate is how you are going to pay for it, we think that the best way of paying for it is through general taxation because it provides a good insurance policy for everybody based on your need and not on your ability to pay it. Now, what you've got to do then is use the money to grow the capacity. Now, clearly that isn't going to happen over night either because you need more doctors, more nurses, they take time to train. You've got to take the beds in and the hospitals and so on and so forth. But what we also know is this, that at the moment in this city, in London, the average waiting times for a hospital operation vary between, what about seven weeks and twenty-three weeks. The problem for you, as a patient, is that you've got to go to where you're sent. HUMPHRYS: Ah, well exactly. MILBURN: So, what we've got to do, is match the capacity that is available on the one side with the choices that people want to make. Now that doesn't mean a free for all for everybody... HUMPHRYS: Oh, it doesn't? MILBURN: Well what it does mean is that where capacity is available, so say there is spare capacity to treat....(interruption)..obviously you can't treat people in a hospital where there isn't the capacity to do the operation. HUMPHRYS: No, but what you've said is by 2005 all patients will be able to book appointments at both a time and a place... MILBURN: That is absolutely right...according to the capacity that is available. Obviously what you've got right now in London and in other parts of the country, in my own local hospital in Darlington for example, a doctor wrote to me recently and said, look, we could treat more people quite easily now, actually we could do more operations and get the waiting times down if you give us the money to do so, so what you've got to do is match the capacity with the patient choice and... HUMPHRYS: I take your point... MILBURN: ...and then crucially and this is the final point, what you've then got to do is pay the hospital by results. So at the moment what we do, is we pay every hospital basically the same, regardless of whether it is a good performer or a bad performer. Now what I want to do is to move to a situation where the good performers get paid more for doing more, the poorer performers I'm afraid have an incentive to improve. HUMPHRYS: And I want to go to that in a minute. But let's just stick to the question of choice. So if I want in 2005/2006, if I want to go to that nice BUPA hospital down the road, that nice shiny one with the carpets and the lovely prints on the walls and all the rest of it, rather than the slightly down at heel NHS hospital that's also close, I will be able to do that, that will be my choice, no question about it? MILBURN: What you will be able to do is to see where the operations are available... HUMPHRYS: Ah, it's not a yes or no answer to that then? MILBURN: Well, you will be able to see where the operations are available, you should actually be able to see too, more information about not just the performance of the hospital - hold on - more performance of the hospital, but more information too about the performance of the individual clinical team and if the Primary Care Trust and if your local GP and you yourself as a patient decide... HUMPHRYS: Ah, well so there's lots of ifs... MILBURN: There are lot of ifs about this - decide that what you want to do is to be treated in that hospital, then providing it's got the capacity that's fine. What we've got to do is use all of the capacity that's available and this idea that somehow or another, that you know, if you use the private sector to treat NHS patients, then don't remain NHS patients, well of course they do. HUMPHRYS: Of course we're accepting that. But this is the point isn't it, I will want to be, there's no mystery about this, I will want for my heart operation, or for my child's operation, the very, very best hospital that there is bar none, right, so will my neighbour, so will my auntie, so will everybody. We will all want that very best hospital, we obviously can't all have that very best quality. MILBURN: I think that's quite an interesting question actually because I suspect that what most people want in the end is the choice of a good local hospital. I think that's what most people want... HUMPHRYS: We want the best local hospital, the three star, the best local hospital. MILBURN: And therefore, what you've got to do and this, with respect was the sort of big failing in the past I think with the Conservatives' internal market. What you can't just do, is unleash naked competition on the National Health Service and... HUMPHRYS: So we will be able to choose then? MILBURN: Yes, of course you will be able to choose but what you've also got to do in order to ratchet up standards in hospitals, is to make sure that you get the combination right, of the right incentives for the hospital and at the moment they are wrong, so you pay hospitals according to the results, then what you've got to do is to have the National Standards in place and the help for people to improve. What we've never been able to do in the National Health Service, and this is where I think the reform package is so important, is if you again Nye Bevan's phrase "to generalise the best". You see there's always been pockets of good performance... HUMPHRYS: I understand that.. MILBURN: ...but then there's been pockets of bad performance... HUMPHRYS: ..but you've still, if I may say so.... MILBURN: ...what you've got to do, you've got to be able to raise the standards everywhere and I think... HUMPHRYS: But you can't do all that all at the same time, obviously, and what you are not doing and really I do think, I'm reluctant always to ask for a yes or no answer, but sometimes they are necessary and this is one of those cases. Yes or No - I want to choose that particular hospital, may I choose it? MILBURN: Yes - providing... HUMPHRYS: Ah! MILBURN: Well of course providing, because... HUMPHRYS: Well it isn't an absolute choice is it? MILBURN:'s like when you go to Marks and Spencer's or Tesco's, they've got to actually have the product in, haven't they John? HUMPHRYS: Er, er... MILBURN: know, so if... HUMPHRYS: if I arrive at that hospital and they say "sorry, old bean, you know, all your neighbours liked it as well, and all the beds are full" then I've got to go somewhere else haven't I? MILBURN: This is where we've always been clear about this, and the NHS Plan said it and what we said last week repeated it, that you can only expand choice as you grow capacity in the National Health Service. HUMPHRYS: So it might be five years, it might be ten years, it might be fifteen, twenty-five years? MILBURN: Well no, it'll start in July of this year. It'll actually start in July of this year. Oh I wouldn't belittle it because this for patients... HUMPHRYS: ...I'm not belittling it, on the contrary... MILBURN: ...this is for patients with probably the more serious clinical condition of all, waiting for a heart operation, so those people will say in July of this year, look you have been waiting for six months, now, there's a choice. Either you could decide for reasons of convenience and I think many people will want to opt to is, to stay a little bit longer, wait a little bit longer, at the local hospital, but some patients will want to say, well actually what I'd prefer to do is look at those hospitals where I know of, because the doctors told me I could be treated more quickly and actually I want to travel a bit further in order to get treated more quickly but that will be the choice of the patient. You see, why this is so important is that what it reverses is how the National Health Service has been for fifty years. HUMPHRYS: No I do take that point, but you see, I go back to the point that this promises more than you are going to be able to deliver, for reasons as you yourself have spelled out perfectly clearly, there is not going to be the capacity by 2005 for me to say, 'I want that particular hospital' because my GP and I'll come to him in a minute, is going to say 'sorry, you can't have that hospital, there aren't enough beds there, there, it's already fully booked, there aren't enough operations for, you know' you can't do it, so you, you've made a promise here that you cannot deliver on. MILBURN: No, yes we can you see, because what you'll have by 2005 and it'll be a very different situation from now, but it is true to say, that not everything is going to be solved by 2005, of course it isn't. HUMPHRYS: ...and this promise won't be deliverable by 2005 will it? MILBURN: ...2008 and the NHS Plan is still 2010. But by 2005, when you go into your GP's surgery, what you'll be faced with is this - the GP will sit at their desk and they'll be able to pull up on a computer screen in a way that they can't do now, because we haven't had the IT in. HUMPHRYS: Right. MILBURN: They'll be able to - let's presume that we can get it to work and I think actually we can providing we've got the right level of money going in, the right way of managing it, you'll be able to pull up on the computer screen where the operations are available for the speciality that you need, where they are available, what time they are available, and actually they'll be able to pull up some information too about the performance of the clinical team and from that, hold on, and from that, you will be able to make an informed choice with your GP about where you would like to be treated. HUMPHRYS: But that GP will have a contract with certain hospitals, won't he. His practice will have contracts with certain hospitals, and if I go to my GP and it turns out that the hospital that I rather fancy is not one that the GP rather fancied, and, or for whatever complicated reasons, that particular practice does not have a contract with that particular hospital, who gets to decide? You're the GP. MILBURN: That's the situation at the moment, but it's that that is going to change...(interruption)....No it isn't. And if you read what we published on Thursday you will see that we're moving beyond that situation, that is absolutely right, you see, for fifty years we have had a situation where essentially, the hospital has chosen the patient rather than the patient choosing the hospital, now that's got to change, so henceforth what will happen, based on the patient's informed choice in the way that I've tried to describe, if you as the patient decide actually, you would prefer to go up to the hospital down the road even though it might be a bit further away, because it's got a shorter waiting time, and it's got the capacity to offer you the operation, that is where the money will go, it will go to that hospital and not to the local hospital, and the reason that's important is that what it does then is it pays hospitals by performance. So the hospital gets paid according to the results. HUMPHRYS: And that other hospital does not get paid obviously, because I haven't gone there. Now enough people like me won't want to go there either because we'll have seen the, the, it's splendid that we can tell which hospitals are doing the better job. None of us is going to want to go to that hospital, will it close down? MILBURN: Well I think that's a situation that you've got to try to avoid, so what you've got to do... HUMPHRYS: might. My local hospital might close down, that's what you're saying... MILBURN: ...what you've got to try to do, is you've got to try to put in mechanisms too, not just to reward the good performers, but to help out the poorer performers. Now we've begun to do that but I think there's more that we can do. HUMPHRYS: ....but you're penalising the bad performers by definition, if you're taking away from them the patients that they would need, maybe to get better, that's the trouble with... MILBURN: ...the system will actually work is that at the beginning of a financial year, say, you as the hospital will get a certain amount of money for treating a certain amount of patients. Now if you can treat them, fine, then everybody's happy. However, if you can't treat them, it's the poor old patient who suffers. Now, look, what we're about, and what we should be about, in government and elsewhere is having the interests of the patient, having the patient in the driving seat and the help that we will give to the poorer performers is basically this: look, we've got an NHS modernisation agency now, which is there to help people, taking in expert doctors, nurses, managers, who've got a proven track record of success and getting them into the difficult places to help the difficult ... HUMPHRYS: ...but ultimately would you let that difficult place close? MILBURN: Ultimately, what we would do is put in new management, and we would franchise the management. Basically what we would do ... HUMPHRYS: Franchise? It might be an outside management, a private company? MILBURN: Yes, it might be. HUMPHRYS: Right. MILBURN: What we're going to do, again from this summer is we're going to establish an expert register of people who've got a track record of success in turning around problem organisations, now those people might come from the NHS, they might be a successful NHS management team, but they might come from the wider public sector, they might come from university, they might come from the voluntary sector... HUMPHRYS: ...well you'll have trouble with the unions on that one, but... MILBURN: ...well I'll tell you why this is important. Why this is important is that, you see, in the end what counts for the National Health Service is the performance of the National Health Service and the services that it offers to the patient. It's the patient that counts. Now if we can harness expertise wherever it comes from for the benefit of patients, that seems to me to be a good thing to do. I think what we need to see over time is actually more diversity and more plurality in the healthcare system, but bound together, the system bound together by three simple things. First of all, wherever you go, and wherever you get treated, whether it's in a private sector hospital, or an NHS hospital, there are common standards that apply. Secondly, that there is a tough inspection and audit regime so that the public know where the money has been spent, what the standards are like, and thirdly, a common ethos, which is that care is there for free at the point of use, according to your need and not your... HUMPHRYS: So Julian Le Grand was quite right when he said by that by the time of the next election we might well have an NHS hospital being run by a private management... MILBURN: I think that is entirely possible. HUMPHRYS: Right. And it's also possible that if all else fails, that hospital might have to close down. MILBURN: Well I think we've got to avoid that... HUMPHRYS: Indeed, you of course want to avoid it, but what I'm saying is that logically, an inevitable logic of what you're saying is that if that hospital cannot be turned around, if patients, in other words, because we're driving it remember, you and me....well you're the boss, as a patient I'm driving it, okay, but we will determine effectively at the end of this long road, accept that it's going to be a long road, whether that hospital stays open or not. MILBURN: Well I think as I say, that's a situation that you've got to avoid, because... HUMPHRYS: might happen? MILBURN: Because, for example, in my constituency in Darlington there's one hospital. (Interruption) Letting it go down the tubes would be a disaster. Of course it would.. HUMPHRYS: Uh-ha. MILBURN: Therefore, what you've got to do is make sure that you avoid that situation at all costs by putting in the necessary .... HUMPHRYS: Alright, let me turn the question round. You say you will never allow a hospital to close. Just trying to finish that, I want to move on to devolution quickly, so... which is it, might the hospitals have to close or do you say, we will never let a hospital close? MILBURN: I think it's preferable if hospitals serving HUMPHRYS: You're not answering the question.... MILBURN: ..... - if hospitals are serving local communities then I think basically local communities will want to keep their hospital. The standards, the quality, the performance of the hospital is a different matter, and what you've got to do there is get in the right team of people in order to run the hospital to improve the performance. HUMPHRYS: As far as devolving power in the NHS is concerned, you're talking about - at the moment GPs do ninety-five per cent of work in the NHS, hugely powerful figures. They complain endlessly. We heard a GP in that film, Dr Jenner saying "I can't do what I want to do". Are you going to stop sending out orders from the centre telling GPs they've got to do this, they've got to match - meet this target, they got to do that and the other. Are you going to let them do what they want to do, effectively, use the money the way they see fit? MILBURN: Well, I think we've got to stop sending orders and I don't think that what you can do is run the NHS by dint of diktat, which is how actually it's been run for fifty years, but what you've got to do is get the balance right. You see there's no successful organisation in the world that I can think of whether it's providing health care or it's providing some other service that doesn't try to get the balance right between what happens nationally and what happens locally. Now I see the job of what happens nationally because people want to have a National Health Service where standards are more or less the same across the country. People hate the idea, quite rightly, of a lottery in care - if you've got cancer you know, you want to know that wherever you are, which ever part of the country you've got the same cancer drug. Now that's got to be right isn't it, so I think that basically the first thing is you've got to set some common national standards. I think secondly that the idea that the National Health Service can be run in the image in which it was created in nineteen-forty-eight from the top down, centralised, as an old style monolith, that those days have gone. HUMPHRYS: Right. MILBURN: People who actually see, the thing about me is, I don't deliver health care. I don't treat a single patient. The people who do are people like Dr Jenner, and we've got to get the power and resources into their hands. HUMPHRYS: And of course the hospitals themselves, and you talk about giving the hospitals greater freedom. Does that mean that if they - that they can decide exactly how - not just recruiting and all the rest, but how they pay their staff, because what you talk about in the document is - again I quote 'flexibility within the new NHS pay system', Well, flexibility within a system rather suggests that they're not going to do very much that's different. Will they be able to say: we will pay these doctors ten, twenty, thirty per cent more, or nurses, and if they do, the logic of that is we will once again as the unions have worried about, and indeed I think Julia Neuberger made this point, somebody else made that point, we will end up with a two-tier system. Some hospitals are be able to pay loads of money and they'll attract the best people, others will go ..... MILBURN: No, I heard what both Julia and indeed what Bob Abberley from UNISON were saying there and David Hinchcliffe too. I mean it depends on the nature of the new pay system doesn't it. We're negotiating that at the moment and what we want to do is get the balance right between some fairness nationally but with some local flexibility, so...... let me just explain (INTERRUPTION) No, no, no, let me explain this. You know, I live pat of the week in the south-east of England when I'm in parliament and the Department of Health. I live part of the week in the north-east of England because that's where my home is. They're two very different parts of the country with very different labour markets, and you know as well as I do that actually recruiting staff in the south-east and in London in particular is more difficult probably than it is in the north-east because the cost of living is higher and so on. What we're trying to devise within the new care system is sufficient flexibility to reflect that. So the new generation of foundation hospitals, or foundation primary care trusts will of course, you know, will be part of the National Health Service, so they will be part of the NHS pay system, but they will have the flexibility based on their local circumstances to pay the appropriate award to their staff . HUMPHRYS: And if the unions say we're not going to have it, you will say: yes you are! MILBURN: Well, we're negotiating it, and what I want to see is more devolution, more diversity, more patient choice in the system. I don't want the old style National Health Service, and frankly for this level of resources we shouldn't have the old style National Health Service. It's not going to be possible overnight, it is going to take time. I think we're on the way, we're at first base. What the resources allow us to do now is put in some big reforms. HUMPHRYS: Alan Milburn, thanks very much indeed.
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.