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Interview with Frank Dobson |
................................................................................ ON THE RECORD FRANK DOBSON INTERVIEW RECORDED FROM TRANSMISSION BBC-1 DATE: 7.12.97 ................................................................................ JOHN HUMPHRYS: Frank Dobson, a fortnight before the election, you, your party put the frighteners on people by saying there were fourteen days to save the NHS. So, not surprisingly, people thought what you had in mind, what had to happen was a revolution. But your proposals actually aren't revolutionary at all are they? They're evolutionary rather than radical. FRANK DOBSON: Well, what we're saying to people in the Health Service, and what the professions are saying to themselves, is that they want to produce what's called "evidence based medicine", so that what's been provided for people is based on scientific evidence of what's good for people, and I think if they're aiming for evidence-based medicine, then we're under an obligation to give them evidence-based organisation. People in the Health Service want change, but they're sick to death of the huge changes which were made by our predecessors time and time again, which didn't work, which left a mess, including the mess that we've got now, and we owe it to the people in the Health Service who're working desperately hard to provide all of us with a good service, that we keep the changes to a minimum, and we try and test out any proposals before we introduce them right across the country. HUMPHRYS: So therefore you're keeping the basis, the essence of the Tory reforms? DOBSON: No, we're not keeping the essence of the Tory reforms. What we're saying is, because we're not silly, that there were some advantages and improvements came about as a result of the changes that the Conservatives made, but there were greater disadvantages. So what we want to do is to build on the better things that came out of those changes, and to discard the worst things. That's the sensible thing to do, it's a pragmatic approach, and it commands the support of the vast majority of the doctors and nurses and other people working in the Health Service. HUMPHRYS: Well, let's look at one of the things that came out of the Tory reforms then, and that's giving GPs budgets to buy their different services with, the so-called fund-holding GPs. Now, you're saying you want all GPs, because not all went for that - something over fifty per cent went for it - not all went for it - you're saying you want all GPs in effect to have control of the purse-strings, the difference is that they would be in big groups of practices, commissioning practices, rather than individual GP practices. DOBSON: Well, as I explained to you before the programme and to your producers John, we're producing a White Paper on Tuesday, which I've got to report first of all to the House of Commons, and I can't disclose the details of what's in that paper, because quite frankly if I've got to choose between upsetting you and upsetting Betty Boothroyd, the Speaker, then in my mind's eye she's a lot more fearsome than you are. HUMPHRYS: Wouldn't I know that for a moment - I'm not asking for the details. DOBSON: No, there are limits to what I can say therefore. HUMPHRYS: But you did already tell - I mean you talked before the election about..... DOBSON: Yes. Generally speaking what we would like to see is all the GP practices in the country put on the same footing, so that we don't have privileges and advantages for one group of GPs that aren't enjoyed by the other group of GPs, because of course, if one group of GPs or one section of GPs, about half of them, have got advantages, the others have got disadvantages, and that means that the patients of the other half are suffering disadvantages, and so our general idea is that we would like to see the GPs in each area getting together and commissioning from the community services and from the hospitals the services that they all want. Because we think - our general approach - I mean I think it was described as a difference in wording - but it isn't a difference in wording. The present organisation of the Health Service is very competitive at one level, setting one group of doctors against another, setting one hospital against another. We think that that's a silly way of going about things and it's been a harmful way of going about things, and we believe that it's better for people in the National Health Service to be working together for the advantage of patients rather than working against one another. HUMPHRYS: Coming to that if I may, but effectively you're extending the Tory principle in this particular case. You've accepted the broad principle that GPs should be in the driving seat, should have cash of their own to do with what they think is right, you're extending that principle to all GPs? DOBSON: Yes, but we believe that they should be getting together, all of them, and not individual practices, because that's proved to be very bureaucratic and producing a huge paper chase. We think it's better if we have a system where all the GPs in a particular area are getting together with community nurses and other professions as well and saying, this is what we want from the services in our area. HUMPHRYS: But Chris Smith, your predecessor, he was Shadow Secretary for Health - he did suggest that some practices individual practices might be able to hold onto their funds. Is that part of what you're thinking? DOBSON: Well, again, I can't tell you that because that's part of the detail that..... HUMPHRYS: But he talked about himself, that's why I raised this question. DOBSON: Yes, but our commitments in the manifesto were that we would try to produce a commissioning system in which all the GPs and all the community nurses and the other professionals in an area would be level pegging. There'd be a level playing field, they would all be able to work together to the benefit of all their patients rather than getting into artificial competition with one another. HUMPHRYS: So given that these groups of GPs would hold the purse strings, would be in the driving seat, they would in effect be doing - and I know it's a word that Secretaries of State for Health hate - politicians never talk about it but other people do - rationing. They would actually be rationing what the NHS has to offer, what we, the patients can take from the NHS, saying we think this should happen, we think that should happened, we think maybe that shouldn't happen, either because we can't afford it or whatever. They would be doing that. DOBSON: What they'd be doing would be setting the priorities that they thought .. HUMPHRYS: Comes down to the same thing doesn't it? DOBSON : No, it doesn't entirely. There are differences in meaning between priorities and rationing, but let's not get into all that sort of - browsing through the dictionary sort of job in the middle of a Sunday after - Sunday lunch-time - but what they would be doing would be looking at the needs, the health needs of the area as presented to them by people who'd come to their surgeries, who go to their practice nurse, who go to the community nurse, looking at those and saying: well, this is the sort of thing that we need from our local hospital. HUMPHRYS: But they'll have limited budgets with which to buy that sort of thing.... therefore... DOBSON: There have always been limited budgets. The budget for the National Health Service has been limited from the day it was first introduced. HUMPHRYS: Of course, but not for GPs. I mean a GP - you wouldn't have - what..we saw that in that film, that man being told, that patient being told by his GP: sorry, but I don't have the money. That never happened in the past. DOBSON: Half the GPs have had budgets, the fundholding GPs have had budgets and they've had to keep within those budgets and it doesn't appear to have caused any great problems does it. There have been no examples so far as I know, of people not being treated because their GP didn't have a budget. HUMPHRYS: Well maybe that was because the slack was taken up somewhere else. If all GPs are holding budgets, perhaps it will be different. DOBSON: Well what we've had to do is to try to make sure that when people turn to the Health Service, it's a modern and dependable Health Service. When they go to their GP, when they go to the practice nurse, when they go to the Out Patients, or when they're an In Patient, it's there when they really need it and it's top-quality care. HUMPHRYS: And what about the drugs, we talked about hospital beds and all that, what about the drugs being there when they're needed. Presumably, one of the reasons that you want to keep GPs in the driving seat is where budget-holding GPs have operated, they have had the amount of money they can spend on drugs capped, one way or the other, because there's a finite amount of money. Presumably you believe that there will be a kind of universal capping from now on, or once all of this gets into swing and therefore that will solve, or at least help to solve the problem of over-spending on drugs. DOBSON: I don't think we want to pay too much attention to the drugs budget. HUMPHRYS: Really? DOBSON: Doctors have other budgets as well. HUMPHRYS: Oh but it's a massive amount of money isn't it. DOBSON: Well it is a massive amount of money but it's there.. the drugs are by and large prescribed for the benefit of patients and they do patients good most of the time and sometimes it's better to prescribe a drug which keeps somebody out of hospital rather than not prescribing them and then going into hospital. HUMPHRYS: But you don't telling me - you've already said that there is a finite amount of money. You're not telling me that there will be absolutely no limit on these new fundholding groups of practices and how much they can spend on drugs. DOBSON: What I said, John, was that there are other aspects to the spending of the GPs. HUMPHRYS: Yes but this is one of them and a not unimportant one. DOBSON: It's part of the total and half the GPs have had limits to their budgets, genuine limits to their budgets and most of the others have had notional limits to their budgets but again I can't give you full details of what we're preposing in the White Paper. But what we need to do, is to always make sure that GPs, when they are considering the treatment that they're giving people, their first priority has to be the interest of the patient concerned, and that is obviously the top most priority. So they can also bear in mind the costs of what they may be doing. HUMPHRYS: Precisely and in that case, given that they have to bear that in mind, given that there is bound to be some sort of cap, otherwise a budget means nothing at all if there is no cap on it, some patients might not get the drugs they need. DOBSON: Well, there have been no examples of that up to now and I can assure you that the system that we're putting forward will not involve that in the future. HUMPHRYS: So there won't be a cap. DOBSON: People should be reassured about that, they won't be told by their GP, you can't have the drugs that I think are good for you because I haven't got any money left. HUMPHRYS: You told us before the election, it was a very important part of your manifesto, that you would get rid of the internal market within the National Health Service, but you are keeping what is called in the jargon, the purchaser/provider split. Now, if you have somebody who's buying something and if you have somebody who's selling something to somebody else, then unless I'm very much mistaken, that is a market. DOBSON: No well it isn't a market and what we'll be saying is, that the GPs in a particular area, together with the community nurses and others, will be saying these are the services we want from our local hospital but we won't be expecting them to behave in a competitive manner in the way that the present system has required them to do because that has introduced all sorts of ludicrous inefficiencies and waste into the system. One of the problems has been that although places may have been apparently competing with one another, hardly anybody knew what their costs were and what we are saying is, we don't want them competing in future, but we will have them comparing. One of the best ways of keeping down costs, for instance, is let's take two great cities. In Leeds, at the moment the people running the Health Service in Leeds, don't know - a lot of the people there don't have access to the cost of providing the services in Leeds. They certainly don't know what the comparative costs are in the great city of Manchester, the other side of the Pennines. We believe that they can learn from one another and instead of these figures being kept secret for commerical, competitive reasons, the figures will all be spelt out, so that people can learn from one another. HUMPHRYS: Right, and having learnt, these group of GPs says, we don't like that hospital, it charges too much, it's not efficient, it's outcomes aren't as good as they ought to be, we'll go to another hospital. Can they do that, will they be able to do that? DOBSON: Well, they will. HUMPHRYS: Well, it's a market isn't it. DOBSON: But that's not the sensible way of looking at it, is it. HUMPHRYS: It's the only way of looking at it. DOBSON: No, the object must be to make sure that the hospital they have their doubts about, improves its standards. HUMPHRYS: Oh, in the ideal world yes. How are they to be encouraged to.. DOBSON: It isn't in an ideal world, John. In an ideal world, people's local hospital will be producing top quality services at properly comparable prices. HUMPHRYS: But in the real world, they won't all be doing that, will they. DOBSON: But in the real world, we will, for the first time in the history of the Health Service, have in place a system, which will be setting proper standards of performance. HUMPHRYS: I understand that. I understand that. DOBSON: Clinical performance, and also proper standards and management performance. But I come back - let me make this clear. From the point of view of the patient, there is no benefit in competition which denies them access to their local hospital, which is convenient for them and their relatives. HUMPHRYS: Yes, but... DOBSON: ..and forces them, as under the present system sometimes, to go to a hospital twenty or thirty miles away. HUMPHRYS: But, you're having it both ways here. You're-you're saying to me- DOBSON: Well, maybe- HUMPHRYS: Let me put this question to you. DOBSON: Right. HUMPHRYS: A very clear question: you're saying to me the GP has a choice - that is the essence of this market. You concede as much. You didn't use the word 'market' but-Right-but nonetheless, the GP has a choice or the group of GPs has a choice. DOBSON: The group of GPs. HUMPHRYS: The group of GPs have this choice. That doesn't effect the working of the market in one real sense. They don't like that hospital because it doesn't meet those standards that you want - all hospitals ultimately can meet. They can, therefore, go to another hospital. Now, that would mean - would it not? - if this is to mean anything at all - that that other hospital might even have to close down because those GPs say: sorry, you're not doing the job well enough. Now, I accept your point that you want that hospital to improve. It may not be capable of improving it. It may not improve quickly enough and, in the meantime, the GPs will have taken their patients elsewhere. That might happen. DOBSON: Well, I think, it's highly unlikely because it would be stupid. Suppose- HUMPHRYS: Look? DOBSON: Supposing there's a town with a District General Hospital and its standards are not high enough and its costs are too high. To close it down, would be to punish the people who live in the area. HUMPHRYS: Of course, it would but that's the- DOBSON: And- HUMPHRYS: -end result of the doctors having their choice. DOBSON: No. No, no, it isn't. What we want to do is to give power to the doctors to insist- HUMPHRYS: Exactly! DOBSON: -on standards but we then put in place a system which will guarantee to deliver the standards. HUMPHRYS: But, you're suggesting there that that hospital hasn't been trying, you see. In the past, it may have been doing its damnedest. It, simply, can't come up to.. now. DOBSON: But, why should doctors- HUMPHRYS: Well, you should tell me why should that be? Instead of asking me why should that be, say: Look at what is happening in the Health Service - what has happened since the Health Service began. Look at any other area of human endeavour. Some people are better at doing things than others for whatever reason that may be. Now, you're saying to the doctors you can choose. They will say - some of them - inevitably. They've already said so when we've had fund holding GPs individually - different individual practice. They will say: that's not good enough, we'll go somewhere else. Tell me why that shouldn't be? DOBSON: But, that isn't the object of the exercise and it isn't but it- John-let me, let me- HUMPHRYS: I'm saying it's the outcome, not the object. DOBSON: Let me finish. You need to start off with the object of the exercise. The object of the exercise, from the point of view of the local GPs, from the point of view of Community Nurses, is that the people who live in City X will get the best services and they'll get them locally and they will bring pressure to bear, to make sure that that is done. What has been missing from the National Health Service in the past and, certainly, under the system we've inherited is some national machinery for helping them bring it about. And, what we're going to do is we - with the professions because it's got to be led by the professions - we're going to establish professional standards of performance in all spheres - national standards - and, then, the hospitals will be expected to meet them. We're going to also lay down national standards of management performance which the hospitals will be expected to meet. And, that way we'll raise the worst up to the average and the average up to the best. That's the object of the exercise and it's only if you see the additional weight and influence for the doctors and nurses in a particular locality, it's only if you see it in parallel with our proposals for spreading best practice and raising standards that you get the full picture. HUMPHRYS: Alright. Let's look at the resources available to the NHS. Now, you've been consistent in saying... great swathes out of the bureaucracy and that way we're going to save huge amounts of money and that will help. The Kings Fund - you heard them there - said you're not actually going to be able to cut that amount, if you're gonna do the kinds of things you're talking about and they're experts in this area. DOBSON: Well, they're not. HUMPHRYS: Well, come one. Somebody else is an expert. DOBSON: For a start-for a start, he doesn't know what we're proposing because he hasn't seen our White Paper. HUMPHRYS: Well, he may-He has just confirmed that group practices- DOBSON: No. HUMPHRYS: -for instance, are going to be the backbone. DOBSON: But he-But he doesn't know what we're proposing. HUMPHRYS: Alright. DOBSON: So, it's foolish for him either to claim that he's an expert about something he, apparently, can know nothing about and, also, he was saying these things are terribly expensive. HUMPHRYS: Will you tell me how much you're going to save there? DOBSON: Well, I can tell you that we will save. Our new system will improve standards and, at the same time, save- HUMHPRYS: How much? DOBSON: -hundreds of millions of pounds and I'll give you a precise figure on Tuesday. HUMPHRYS: Alright. Well, let's assume- Alright, give me precise figures, then. Let me give you hundreds of millions of pounds, then. Some people will argue about it but let me give it to you. Nonetheless, you have been saying for the past eighteen years the NHS is desperately under-funded. Now, what the Government has done for the past eighteen years is give the NHS year on year three per cent extra - sometimes more - but three per cent on an average across that time - three per cent extra. Now, you cannot guarantee that it will continue to get a three per cent extra. It, certainly, won't for the next couple of years. So, therefore, it will continue to be under-funded, won't it? DOBSON: Well, the National Health Service by any reasonable argument has been under-funded since it came into existence. But, what we are determined to do and we committed ourselves to it at the General Election is to increase funding, in real terms, year on year. And, we've set in train- HUMPHRYS: By three per cent? DOBSON: No, we didn't say that. But, don't ask us to keep promises we never made. HUMPHRYS: Oh, no, no, no! I'm asking you a question. DOBSON: We said, in real terms. HUMPHRYS: It- DOBSON: We've set in train a really thorough going examination of all the costs and the benefits of the National Health Service and we - because we want to put in place - a longterm, stable and expanding system of finance for the Health Service and we will get that sorted out by the middle of next year. HUMPHRYS: Do you think it needs to get three per cent extra year on year? DOBSON: Well, I don't know, at the moment. HUMPHRYS: But, you've known for the last eighteen years it needed more, much more than three per cent. All of a sudden- DOBSON: But it- HUMPHRYS: -you're in power and you don't know. DOBSON: Well, let me say what I do know. I do know this that we found an extra three hundred million pounds to help cope with- HUMPHRYS: Yeah....... DOBSON: No. Three days' spending - get it right. HUMPHRYS: It depends how you work this out. DOBSON: Don't-don't... HUMPHRYS: I'm talking about a Health Service that cost forty-two billion pounds a year. DOBSON: A hundred million-Hundred million pounds a day is what the Health Service spends. We found three hundred million pounds. I was advised, by my advisers, by the doctors, by the people in the National Health Service who run the National Health Service that that was the sum of money that was required. And, that money was found. That money is already going into helping cope with the problems of this winter. But, it's not true that you can't save money out of bureaucracy. We did it. HUMPHRYS: We've had that. We've had that discussion... in the longer term. DOBSON: No, no, no, no, no - let me explain. We said that we would shift money out of bureaucracy into patient care. We were faced very soon after we came into office with a decision whether to go ahead with the eighth round of fund holding. There is twenty million pounds set aside in the budget we inherited for the bureaucracy of fundholding. We've shifted. We've stopped that. We've shifted ten million pounds, which is now going into improved breast cancer treatment for women all 'round the country and five million pounds to-trying to bring up to a proper standard Children's Intensive Care. HUMPHRYS: Waiting lists are going to go on rising, aren't they? That's the reality of all this. You can't guarantee that three per cent. You're not going to fight for it, apparently. Therefore, waiting lists are going to up. DOBSON: No, no. Don't start speculating about what I do on the extra three per cent. HUMPHRYS: Well, are you going to fight for the extra three per cent? DOBSON: I'm not accepting your figure of three per cent. HUMPHRYS: But, you- DOBSON: What I am-What I am saying is this: HUMPHRYS: But, nevertheless.... DOBSON: We've found the-We've found the extra money, John, to help the people who work desperately hard in the Health Service to cope this winter and we've put in place arrangements which will make it more likely that they will be able to cope, by improving their relations with local Social Services, so that they're keeping people out of hospital, who should'nt go in and we're getting people out who should be out of hospital and back in their own homes, getting that done quicker. Sensible improvements of that sort and we're putting a huge extra sum of money into the National Health Service next year. I think, it's an extra three million pounds a day. HUMPHRYS: It's certainly not three per cent, is it? DOBSON: We never promised three per cent. HUMPHRYS: Nope! DOBSON: You're asking us to keep promises we never made. HUMPHRYS: Frank Dobson, thank you very much, indeed. DOBSON: Thank you. ....oooOooo... |