BBC On The Record - Broadcast: 21.04.02

==================================================================================== NB. THIS TRANSCRIPT WAS TYPED FROM A TRANSCRIPTION UNIT RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT; BECAUSE OF THE POSSIBILITY OF MIS-HEARING AND THE DIFFICULTY, IN SOME CASES, OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS ACCURACY ==================================================================================== ON THE RECORD RECORDED FROM TRANSMISSION: BBC ONE DATE: 21.04.02 ==================================================================================== 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: 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. 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:'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:, 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. 28 FoLdEd
NB. This transcript was typed from a transcription unit recording and not copied from an original script. Because of the possibility of mis-hearing and the difficulty, in some cases, of identifying individual speakers, the BBC cannot vouch for its accuracy.