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ON THE RECORD
RECORDED FROM TRANSMISSION: BBC ONE DATE:
21.04.02
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JOHN HUMPHRYS: Good afternoon. The
NHS is getting massively more money over the next few years. How do we
know it won't be wasted? I'll be asking the Health Secretary Alan Milburn.
What will the Tories do now the government's promising so much for the
public services? I'll be talking to the Shadow Chancellor Michael Howard
about their plans. And... is the far right about to gain a foothold on
the political ladder in the north of England? That's after the news read
by Sophie Raworth.
NEWS
HUMPHRYS: Thanks Sophie. Well, now
we know the figures... and by any standards, an awful lot of money the
government's going to put into the NHS. Over the next five years health
spending will rise by forty billion pounds. A meaningless sum to most
of us. What matters to all those people who saw their taxes rise in the
Budget, is whether the health care we get will be that much better. Many
experts say the service simply can't cope with all that extra spending
and this could be a very high risk gamble that the government is embarking
upon. The government says that's not true because they're going to bring
in big reforms so the NHS will be run more efficiently. I'll be talking
to the Health Secretary Alan Milburn about all that after this report from
David Grossman.
DAVID GROSSMAN: The NHS is gazing into a brighter
future . The Chancellor has poured in billions of new money in his Budget
and the Health Secretary has followed this up with a set of reforms that
are on paper at least radical. It all amounts, it's claimed, to a revolution
in the way that healthcare works.
Amid the thousands of words that Ministers have used to describe their
health reform programme, two above all deserve detailed scrutiny, devolution
and choice. The government says it's going to devolve decision-making and
spending in its new-look NHS down to the surgeries and wards, to doctors
and nurses. And that within a few years, patients will have complete choice
as to where and when they receive treatment. But some doubt whether the
government's really prepared to let go of day to day control of the NHS
or that ultimately patients will have any real meaningful choice.
The government has already
lavished billions more on the health service. IN the last year, the total
NHS budge in England rose from forty-four and a half billion to over forty-eight
point eight billion pounds. A huge rise but the results so far have been
harder to spot. Over the same period the average wait for an operation
has fallen hardly at all from four point two months in Two-thousand, to
Two-thousand and one, to four-point-one months in Two-thousand-and-one
to two, a fall of just about three days.
PROFESSOR JULIAN LE GRAND: The government pours money in,
nothing happens. I mean one of the interesting things at the moment is
that the government's been putting a lot of money into the NHS, and of
course is going to put a whole lot more, but activity and the amount of
activity going on in the NHS has remained virtually static. And the government's
really rethinking its strategy, how to deal with that.
GROSSMAN: As well as extra funds,
ministers believe that the key to delivering on their health pledges is
to devolve power and spending in the health service down to those who take
the temperatures and give the injections. In order to do this, they've
set up three-hundred-and-two primary care trusts in England and given them
an increasing chunk of the NHS's cash to spend In a few years ministers
say these PCT's will control three-quarters of the entire NHS budget. And
ministers have plans for hospitals too. They say that the better ones will
become almost completely independent. But critics say if you examine the
fine print on these freedoms, that ministers still retain far too much
control, far too much ability to micro-manage almost every aspect of health
care.
In Exeter Dr David Jenner starts his rounds - he's been part of one of
the pilot Primary Care Trusts that's already been up and running for a
year. He says the principle behind them is sound but too often local initiative
is stifled by the requirement to meet national targets. In practice too
much of his budget he says, is spent for him by Whitehall.
DR DAVID JENNER: Because the government is still
very concerned that demonstrating value for money, they are very keen to
see benefit from the money they invest. And that is expressed through what
feels on the ground, like central control. I think the time has come now,
they, they've, they've made the steps, they've set up PCTs as the new organisation,
to let these organisations go a bit and have more freedom to address things
locally.
RABBI JULIA NEUBERGER: Quite a lot of Primary Care Trusts
have complained bitterly that they don't get any freedom, that everything
is ear-marked, they're told they've got to meet this target, spend the
money on that, got to do this, not do that, et cetera. And there's been
a lot of that, that's because this government tends to be interventionist
because all governments tend to be interventionist. But, if the government
is serious about making this work, it will have to stop earmarking the
money.
GROSSMAN: Most of Dr Jenner's patients
who need hospital treatment end up here at the Royal Devon and Exeter.
The Chief Executive Angela Pedder runs one of the best hospitals in the
NHS. The government's given it a maximum three star rating and says in
future such hospitals could be given a lot more freedom from central control,
but how much more is as yet unclear.
ANGELA PEDDER: The freedoms really haven't
yet been fully articulated, I mean what does it mean in practice, how am
I going to work those, those issues through. From this trust's point of
view we believe that we're part of a wider healthcare community, we have
to work in partnership with primary care, with local general practice.
And what we wouldn't want is any organisational structure that put additional
boundaries and barriers between us working in that seamless way,
GROSSMAN: On the children's ward
Thomas the tank engine does his rounds. The government's promising the
best hospitals much more than just the freedom to paint the food trolley.
Many believe a crucial test of how much freedom they'll really have is
whether these hospitals will be able to set pay and conditions for their
own staff.
LE GRAND: I think as yet the government
really hasn't quite decided exactly what new freedoms these new foundation
hospitals or hospitals with earned autonomy are going to have, but it's
clear that if they are going to try and achieve some of the ends that the
government wants them to achieve, they've got to have freedoms over staffing
decisions, about hiring and firing staff, about the way those staff are
used, within the hospital or within the, within the trust.
GROSSMAN: Paramedics, ready for
any emergency. The government could soon face its own crisis from Unions
and many Labour backbenchers. They're fiercely opposed to giving some hospitals
complete freedom fearing it will lead to a two tier system.
DAVID HINCHLIFFE MP: If you ended up through the
foundation system with significant differences on pay rates and pay scales
from area to area, you would end up denuding certain areas of staff because
they would clearly move towards those areas able to pay more money, that
would be not in the interests of the NHS and certainly in the interests
of the majority of patients.
BOB ABBERLEY: We've got a recruitment and
retention crisis, the last thing we need is hospitals trying to pinch other
people's staff by paying more money. Now of course we want to see staff
paid better salaries but we don't want to see it at the expense of the
NHS.
GROSSMAN: And what happens to the
less successful hospitals, the ones with no stars? Previously the government
has said that it doesn't matter who runs hospitals just so long as they're
well run - and that outside organisations like charities or the private
sector could be brought could take control.
LE GRAND: I think that it is quite
likely by the time of the next election that there may be one or more hospitals
that will be run either on a not for profit basis on mutual basis or perhaps
even on a private sector basis. I mean already in Sweden for instance
there's a, which is also a country of long established traditions of hostility
towards the use of the private sector, there's a private sector hospital
running, there's private sector organisation running a major hospital
in Sweden and rather successfully.
HINCHLIFFE: There is a belief among many
Labour MPs that the use of the private sector is not necessarily the right
way forward for the health service. I think most people have accepted that
as a short term measure to reduce waiting lists. We've had to grin and
bear it but any longer term relationship I think will be seriously questioned
by very many Labour MPs.
GROSSMAN: It's fair to say that
patient choice wasn't a high priority when the NHS was established. In
the current set up you really only have one choice, you can either take
what you're given, however bad, or you can pay for the entire cost of your
treatment in a private hospital, always assuming that you can afford to.
But the Health Secretary, Alan Milburn says that patient choice will be
the driving force behind the new NHS. That funds will follow patients around
the system, rewarding popular and effective hospitals, even paying for
some patients to be treated in private hospitals. But can this patients'
paradise really be delivered by Two-thousand-and-five, the government's
deadline for bringing it in.
NEUBERGER: I don't think it's clear quite
what the government means about everybody having absolute choice in the
health service over where they go by Two-thousand-and-five. What I think
will have happened by then, if this works, is that a great deal more of
a choice will go down to the Primary Care Trusts, that patients will be
far more involved and they do need to be in how those are run, and there
will be discussions about you know, what is the most sensible thing to
do? I don't think it'll be a question of you know you going to go and
have your heart transplant at the hospital down the road 'cos it happens
to be convenient and you would like it in August 'cos that's when you're
on holiday, because I don't think there's a reasonable way of making that
kind of decision and we won't have that kind of capacity anyway.
GROSSMAN: So it may be that it's
really GPs and not patients who have the choice of where and when operations
happen. So what could you do if your local Primary Care Trust has a contract
to one particular hospital - and you don't want to go there - given that
PCTs cover such a large geographical area , do you simply have to move
house? The Conservatives say the government's commitment to patient choice
shouldn't be taken at face value.
DR LIAM FOX: This is fantasy land. And
we know that the choice is not a word that 's part of Labour's lexicon,
they believe in a top-down service where the state will tell you what it
is you're allowed to have. And patients will not get choice.
GROSSMAN: It's always busy at the
Royal Devon and Exeter. But if patients or GPs do really get more choice
what happens to the hospitals that can't attract patients? Will the government
really stand by and let them close?
NEUBERGER: Either hospitals or more likely
individual bits of hospitals, individuals services would have to close
if that were, if it were a lot of Primary Care Trusts saying, sorry, it's
not good enough. And you have to accept that if you really give power
on a local basis and you really include patients in that, they will say
sometimes, this service isn't good enough, and if services aren't good
enough they shouldn't be functioning.
ALAN MILBURN: Investment plus reform equals
results - we will be happy to be judged by them.
GROSSMAN: Patients and staff have
heard the speeches and are looking forward to a vastly improved NHS - there
are still many uncertainties about how it will work - but with all the
extra money the government's put in, if the Health Service doesn't start
improving fast, one resource ministers could soon be very short of is,
excuses.
HUMPHRYS: David Grossman reporting
there.
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: ...you 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: ...no 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: ...it'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: ...you know, so if...
HUMPHRYS: ...so 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: ...it 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: ...it 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 deliver.....you
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.
HUMPHRYS: Later in the programme I'll
be talking to the Shadow Chancellor Michael Howard about the Tories' plan
to raise and spend money. But first ... a party that has no Members of
Parliament, not even any local councillors but still manages to get talked
about a great deal. And that's because of what it represents. It's the
British National Party, the BNP, and it gave many people a bit of a shock
at the last General Election with the number of votes it collected in some
northern towns and cities. There are fears that they may pick up their
first council seats at the local government elections next month. Iain
Watson has been to Burnley to see what's going on.
IAIN WATSON: The images from our worst
nightmares can often be so vivid, they still haunt our waking hours. Since
the events of last June, Burnley has been associated in the collective
consciousness with disturbances and division. A cross-community task force
has worked hard to find ways of preventing this from ever happening again.
But there's one political party which still wants to exploit any underlying
tensions even though victims of the rioting would rather build a better
future.
Now the BNP are standing for only sixty-eight council seats out of nearly
six-thousand which are being contested across England. But they seem very
keen to target the areas which saw disturbances last summer. In Oldham
for example, they're putting up five candidates and here in Burnley they
are contesting thirteen of the fifteen electoral wards.
Now Labour are so keen that the BNP shouldn't be allowed to establish
a bridgehead in any of Britain's town halls, that they have drafted in
outside organisational expertise. But it's clear it'll take more than spin
doctoring to see off the twin viruses of deprivation and resentment on
which the BNP campaign hopes to build.
Burnley is situated in a pleasant location near the Pennine hills, but
it's clear it's still reeling from the collapse of many of its traditional
industries. Forty per cent of households are claiming state benefits,
and some pockets of poverty are amongst the worst in England. One ward
is the eighth poorest in the country. It's the discontent that comes from
deprivation which the BNP is trying to exploit. Their local organiser is
making his way into town from his home in the nearby countryside. He polled
eleven per cent of the vote as their parliamentary candidate last year.
While the BNP say they are democrats, the prospect of direct action is
never far from their thoughts.
STEVE SMITH: There's a lot of resentment
in this town, especially in regard to the imbalance of, of wealth distribution
in Burnley. And fundamentally if that is not addressed and the frustrations
and the anger addressed also, then we are going to see more of the kinds
of, of division and conflict that we saw some months ago.
WATSON: More riots?
SMITH: Yes, you cannot expect a
council that performs in the way that our council does and expect people
to take it lying down.
ACTUALITY:
WATSON: Larry O'Hara is an academic
who has written extensively about the BNP and the far right.
LARRY O'HARA: What they want is to win
one contested council seat anywhere in the country and they, and they think
that the national publicity which would follow from that would help them
onto their next plateau of growth. You know you're gonna get a small core
minority of people in any area, including Burnley, what, whatever happens
in the elections who would see themselves as racist but you will get a
larger percentage of people who will see themselves as having been abandoned
by traditional politicians. And they might think that a vote for the BNP
could be a protest vote.
WATSON: There's almost four-thousand
empty homes in Burnley; some are awaiting demolition but others have to
be boarded up as soon as a tenant leaves to prevent drug addicts breaking
in to steal fixtures and fittings to pay for their habit. Doing more to
combat crime in working class communities is territory the BNP are keen
to occupy, but there may be some distance between their rhetoric and reality.
Their organiser is certainly a conviction politician, though not in the
conventional sense. He's just come out of prison after a three month sentence
for electoral fraud.
SMITH: That matter was, has been
actually looked at by our party hierarchy and they have decided that what
I did there was no more than a misdemeanour.
WATSON: What credibility does your
party have on law and order when one of your organisers was convicted of
attacking police with a hammer, another organiser of the BNP was convicted
of storing explosives and you yourself are just out of jail?
SMITH: How, all I can tell you
is that anyone connected with the British National Party, who is in breach
of our national code of conduct, is expelled.
WATSON Does it breach your code
of conduct?
SMITH: You would need to address
that matter to the party hierarchy, I'm a branch organiser.
WATSON: Attacking police with a
hammer may not breach your code of conduct, is that what you're saying?
SMITH: If you wanted to actually
make a list or perhaps even write a book about the offences committed by
people in the Labour party you couldn't actually produce a book thick enough.
WATSON: The BNP attack Labour by
saying the government isn't spending enough on Burnley; but they also insinuate
that Asian voters are given an unequal share of an already small cake.
Not all of Burnley's old terraced housing is boarded up or awaiting demolition.
Here in the Daneshouse ward, there's an impressive programme of improvements
already underway. But what the BNP are keen to point out is that this is
predominantly an Asian part of town. But what they fail to point out is
the reason that more cash, relatively speaking, is being spent in this
area is because this ward is the most deprived in Burnley and one of the
most deprived in the whole of Britain. So the way public money is spent
in this town is being exploited for electoral reasons by the BNP.
While the charges of unfairness coming from the BNP can be refuted, the
Labour MP for Burnley thinks his own government could do more to overcome
resentment. The funds to tackle deprivation are often awarded through
special schemes tightly targeted on those areas with the greatest needs,
so some people in neighbouring districts feel left out.
PETER PIKE; One of the problems
with programmes is it looks at ward boundaries and indeed ward boundaries
that haven't existed now for a number of years. Now poverty and deprivation
doesn't end neatly at a line on a map and certainly councils need more
flexibility to be able to use their resources. Another thing that has been
a problem for Burnley is that their main core funding is now less in real
terms than it was in ten years. Now we all know that the Labour government
is going to change the structure of local government within the next twelve
months. And one of the things that it has got to do is be much more positive
to councils like Burnley to give them the freedom to be able to tackle
the problems that clearly exist here.
WATSON: The call for more cash
was echoed by representatives of the ethnic minority communities at this
meeting with the TUC
SHER ALI MIAH: Successive governments have
failed Burnley Burnley has severe problem in the form of housing, deprivation,
overcrowding, poor health -Burnley need massive injections of money
WATSON: The BNP say that more public
money would come to Burnley if they do well in the forthcoming council
elections. That's because, as they put it, the Labour government would
try to 'bribe' voters not to support the BNP in future. But they make no
mention of the potential effect they might have on private investments.
We spoke to the CBI in the region and they told us there could be an adverse
effect on business confidence if the town became associated with BNP activity,
but many of their members were just too worried to speak out. However,
the chairman of this company wasn't too afraid to tell us what he thought
about the BNP.
This is a specialist engineering
firm serving an international market. Its chairman supports Labour but
he says the reason he wants to keep the BNP out of the town hall owes as
much to economics as politics.
DEREK GILL: It would be the ultimate disaster
- I'm quite sure we would lose markets; I mean I've have been in Malaysia
, we've been in China, we've been in Japan -and we would lose markets.
It is very difficult as it is on a price basis but if we were associated
with racism as well, it would be the end of businesses like this
PETER DOYLE: I would prefer them not to
be a legal party. With the type of policies that they are putting forward
nationally, we do not want to be involved in that. I mean my father fought
people that were putting forward similar policies many, many, years ago.
And as locally, the policies are - shall we say - watered down, and in
my view they are just trying to hoodwink the people.
WATSON: Why no mention of
your national policy on banning mixed marriages?
SMITH: That is a policy that
I am not aware of.
WATSON: It's national policy,
I mean it's on the website?
SMITH: Yeah well I've been
extremely busy just recently running the Burnley campaign and unfortunately
I haven't had sufficient time or opportunity to, to examine that particular
policy.
WATSON: Are you a racist?
SMITH: I don't actually recognise
that word. I believe it was a piece, it is a piece of propaganda which
effectively makes it a sin for a person to protect their racial and cultural
environment.
WATSON: So who made the word
up?
SMITH: Trotsky in the 1930's,
fact.
WATSON: So racism is all
a far left Trotskyist plot?
SMITH: Correct.
WATSON: The harsh reality is that
the BNP are appealing to a certain section of the population. We'd even
been told that this pub was displaying campaigning literature at a sensitive
time before the local elections.
Using a concealed camera,
we were surprised at the prominence given to this example of blatant support
for the British National Party. We contacted the owners of the pub, Thwaites
brewery, to ask what action they intended to take against the landlord
for allowing the poster to be put up. In a statement to On the Record,
they said :
"Daniel Thwaites brewery
runs a compulsory in house tenants training course where all our tenants
are advised to remain impartial and show no bias to any sector of the community.
Immediately this particular matter came to our attention we sent a representative
to the Bridge Inn and the poster was duly removed. A letter reinforcing
the guidelines laid down in our training course has now been sent to every
pub in our tenanted estate."
However, they were unable to
tell us if any action had been taken against the landlord for breaching
the company's own guidelines on impartiality Mozaquir Ali, a Liberal Democrat
councillor, is showing a colleague the progress being made on a new multicultural
centre; but he warns that the wounds of last June may be reopened if the
BNP do well at the ballot box
COUNCILLOR MOZAQUIR ALI: We are basing a project which
will bring children from all faiths into activities where they will meet
each other and they will grow up together into a better more cohesive Burnley,
and that's what we are aiming at. And that's the aim that the BNP are causing
a threat to, to that aim; and I'm sure, and have full confidence, and
I hope the people of Burnley will reject them in this election
WATSON: But in Burnley, voters
can to elect up to three candidates in each council ward, and there are
fears that some of them may lodge a protest against the mainstream parties
on their second or third vote. Labour says anyone who's fed up with them
should avoid the BNP at all costs
PIKE: If they are not for
Labour then vote for the independents, Tories or Liberals but don't waste
a vote for the BNP. All they will do is cause division and conflict
WATSON: The main parties are warning
that a protest vote for the BNP next month will stir up racial tensions
and erect barriers between Burnley's communities. But curing the underlying
disease of deprivation will mean the government will have to put up extra
cash and be more flexible about how it's spent, if disillusionment and
division are to be banished from Burnley.
HUMPHRYS: Iain Watson reporting
there.
JOHN HUMPHRYS: Whatever else the government
achieved with its budget last week it's put new life back into the political
debate. It's raising taxes to spend on the NHS and the old ideological
divide between Labour and Conservative has been re-opened. Or has it?
Are the Tories prepared to fight the tax increase tooth and nail and be
seen to be denying the NHS all that extra cash - are they prepared to risk
that? The Shadow Chancellor Michael Howard is with me.
Can I assume first, Mr
Howard, just to put it on the record that you are going to vote against
those National Insurance increases?
MICHAEL HOWARD MP: Yes, we will and we will, not
because we don't accept that the Health Service needs more money, it does,
but because we think that without change we won't see the difference in
the Health Service that we all want to see. We entirely accept the ideas
of the National Health Service, we believe in a first class Health Service,
available to people when they need it, without regard to their ability
to pay, we are further away from those ideas now, than probably we've never
been since the Health Service was founded and we don't think the government
has any idea as to what to do, to bring us back to those ideas to put them
into practice.
HUMPHRYS: So you would reverse
those increases, those tax increases, if and when you had the chance.
HOWARD: I don't know what the national
finances are going to look like in three years' time..
HUMPHRYS: Following from what you've
just said..
HOWARD: No, because I'm telling
you what we will do - you've asked me a question about what we'll do this
week and I can answer that. You've then asked me a question about what
we'll do in three and bit years' time and I can't yet answer that.
HUMPHRYS: Well I'm assuming if
you don't like tax increases doing that kind of thing, then when you have
an opportunity you would reverse those taxes.
HOWARD: What we will do on health
very specifically is this, long before the next election we will have produced
a plan which will really show how we can live up to the ideas of the National
Health Service and we will show how that plan will be funded, how much
money it needs to become a reality and we will also explain in detail,
how it is to be financed, how much of it comes from taxation and how much
from other sources. So we will put that plan before the electorate in detail,
in good time before the next election, so that we can have a proper debate
because this is a very important issue and I want there to be a proper
debate.
HUMPHRYS: Sure and I don't expect
you to give me the detail of your plan yet obviously, because as you say
you've got a long time and why haul it up and have it shot at at this stage
even if you had it all prepared. But are you prepared at least to say
that you would match the amount of money that Labour is then spending on
the NHS and its policies to spend more.
HOWARD: What we will spend, will
depend on our plan and what it needs. We're not going to take as our starting
point what Labour is doing because they have so far failed and we think
they are going to continue to fail. We are going to work out an alternative
way, a different and a better way of providing that first class Health
Service, available when people need it, without regard to their ability
to pay and we will make sure that the resources that are needed to fund
that system will be in place.
HUMPHRYS: But they might come from
other sources. In other words the reality is that you might not spend as
much taxpayers' money on the NHS as the outgoing government?
HOWARD: That's something that we
will look at at the time and we will make it plain at the time. We will
make sure that we have a first class Health Service and that we provide
the money that's needed to make that service a reality.
HUMPHRYS: So it is possible that
you'd go into the next election, not able to say, or not prepared..not
willing to say we will spend as much as is now being spent on the NHS.
Because that's a pretty risky political position to get into.
HOWARD: It's a realistic proposition.
We're not, if you provide a different...if you are offering a different
system which is what we are going to do, then the sensible thing to do...
HUMPHRYS: You know that, you know
you'll offer a different system.
HOWARD: We know there are lessons
to be learned, that's the point. We know that other countries do things
differently, do things better and we are determined to learn lessons from
the way they do it and we have an open mind about that..
HUMPHRYS: ...you've decided that
it will be different.
HOWARD: It will be different certainly,
the government has a closed mind, it says unless this is invented here
we're not interested in it, it's not prepared to learn any lessons from
abroad, we are, we know there are lessons to be learned and we will learn
those lessons, we will come up with a plan that will deliver what the people
of this country want and we will make sure that it's properly funded.
HUMPHRYS: But you have a closed
mind to this extent. You have decided at this stage that what is in place
at the moment, and the reforms, however different it will be bearing in
mind the reforms that are now being introduced, you are quite clear as
we sit here this morning, that that is not going to work. You have a closed
mind to that extent.
HOWARD: Well, look at what's happened
since this government came to office.
HUMPHRYS: I'd rather look to the
future, rather than....
HOWARD: Well, I know, but this
is quite a good guide to the future. In 1998, Tony Blair said: we're making
a massive new investment of resources into the Health Service and it will
lead to improved patient care. It hasn't. In 2000, we had, two years later,
we had the ten year plan.
HUMPHRYS: That's what this is,
the same..
HOWARD: Well it isn't.
HUMPHRYS: He told me, I mean Alan
Milburn sat there and said...
HOWARD: There was nothing in the
ten year plan about the things that he announced last Thursday that he
was talking to you about this week. This is all we're told, new. So
it wasn't in the ten year plan. Here we have a ten year plan, this is
meant to make it clear the way we're going on health over the next ten
years. This is a government that doesn't sort of change every couple of
years or anything like that, this is a ten year plan. Two years later
we've got a completely different approach. Now we don't think this government
has the faintest idea what to do. They don't know how to deliver health
care that will really meet the needs of this country. You can test it,
you can look at what's been happening in Scotland and Wales and Northern
Ireland where they spend much, much more than we do in England, much more
per head. They spend at European standards and waiting times have been
getting a lot.....
HUMPHRYS: But they are talking
about reforming the system as you know, not just chucking more money at
it, but reforming the system and my question to you is...
HOWARD: ...they've been talking
about it for years.
HUMPHRYS: Alright, but now we have
a plan...
HUMPHRYS: ...and you heard me debating
it with Alan Milburn, the point I'm trying to make to you, is that you're,
you seem to be saying that, even if it works, it won't be right for the
NHS and you will have something different.
HOWARD: We don't have a clear idea
at all. Just a few months ago, long after they announced their ten-year
plan, ten months ago, on the twenty-sixth of June last year, Alan Milburn
told the House of Commons, we have a monopoly provider in this country,
and as long as there's a Labour government we will continue to have that
monopoly provider. Now if that's what we are offered by this Labour government
we know that that is not going to work.
HUMPHRYS: Isn't there a danger
that you are quite seriously out of touch with the population as a whole.
I'm looking at the results of the opinion poll that have been conducted
since last Wednesday, seventy-six per cent support, massive support for
those National Insurance increases.
HOWARD: And twenty per cent said
they didn't think it would lead to an improvement in healthcare.
HUMPHRYS: Three-quarters of the
population say they like the idea of paying more through taxation in order
to improve the NHS.
HOWARD: Yes, and I can quite understand
people wanting to pay more if indeed there was to be an improvement in
the NHS, but you will also know that in those very same opinion polls,
only twenty per cent of people said they thought that the money would actually
lead to an improvement, and I'm very sorry to say that I think they're
right.
HUMPHRYS: But they overwhelmingly
want to give this a go. Want to pay the extra money, want it to go into
the NHS and what you're saying to them this morning is, we've already decided
that that is the wrong thing to do, even though you don't know the outcome
of it.
HOWARD: What I'm saying is that
this won't work. We've heard this sort of thing before. Every couple of
years since Labour's come to office, we've had more promises, new plans,
and every couple of years those promises have been seen to be broken, we
haven't seen the improvements that we all want to see, there has to be
a better way.
HUMPHRYS: Alright. What the polls
also show, and this might encourage you I suppose, people want to look
at other ways of funding, so in a sense you're push, you may well be pushing
at an open door here, why then are you so coy? Why won't you come right
out and say that? I mean, we heard Dr. Liam Fox, your Health Spokesman,
Shadow Secretary of State for Health, saying 'we've got to break the notion',
I'm reading from what he was quoted as saying 'we've got to break the notion
that health care in the NHS are synonymous, more money has to be more self
pay' but the interesting thing about that is that was said privately, and
none of you will say that publicly. Why not?
HOWARD: We haven't got a plan yet.
And if we did have a plan, if we did have a plan John, you, you'd laugh
me out of this studio. It's ten months, it's ten months since the last
election. We are working very seriously on this. It's not a political gimmick,
it's a serious piece of work. We want to get it right. We want to put forward
a plan which will improve the health care of the people of this country,
which will improve the NHS, which will live up to the ideals of the NHS
and that's going to take time, but as soon as we are ready, because I want
there to be a proper debate on this, believe me, as soon as we are ready,
we will produce the plan, and then people...
HUMPHRYS: ...fine.
HOWARD: ...can look at the plan,
and chew over all its details and they don't need to take anything on trust...
HUMPHRYS: ...no, but...
HOWARD: ...because it will all
be there for people to see.
HUMPHRYS: But in the meantime they
are entitled to say, look, what is the broad principle that you applying
here, and we seem to hear it loud and clear from Dr. Fox, but only in private,
and nobody seems prepared to say in principle, this is our idea to make
people...
HOWARD: ...I'll tell you why we
don't do that. We won't do that because we know that if we do that it will
be absolutely misrepresented and caricatured by the government.
HUMPHRYS: ...but you're big boys,
you can defend yourselves.
HOWARD: No, but that's why it's
much better to come forward with a detailed plan so that it can't be caricatured
or misrepresented by the government so that we have all the answers and
people can see and decide for themselves whether that's the road they want
to go down, or whether they want to carry on with one I'm afraid is a failing
system, which will not give them what they want and what they deserve.
HUMPHRYS: Michael Howard, many
thanks.
HOWARD: Thank you.
HUMPHRYS: And that's it for this week.
Don't forget about our web-site if you're on the Internet. Next week we
hope to be talking to the Deputy Prime Minister, John Prescott, and to
Matthew Taylor of the Liberal Democrats. Until then, good afternoon.
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