Examination of Witnesses (Questions 200
- 219)
WEDNESDAY 8 NOVEMBER 2000
RT HON
ALAN MILBURN,
MR JOHN
HUTTON, AND
MR COLIN
REEVES CBE
200. I have read the details that you published
on the Concordat, particularly referring to elective care, which
is what you have been referring to in discussion over the last
few minutes. You could end up with a Primary Care Trust commissioning
care from a private health provider for a patient who has been
waiting on an NHS waiting list to see an NHS consultant who also
works in the private hospital where the commissioning could take
place. So we could have NHS patients who are not able to see the
local consultant directly being referred by their own GPs often,
as we are aware, because that consultant has a healthy private
practice and he is not available because he is working in the
private sector, but instead of seeing them in the NHS they will
see the same consultant in the private hospital on this contract,
whether the commissioner is PCG or PCT, at a much higher cost
surely?
(Mr Milburn) That is why I say that there are two
further important caveats. I said, first of all, that our preferred
option is genuinely to take advantage of spare facilities. If
operating theatres are not being used and if hospital beds are
lying empty and we can use those for the benefit of NHS patients
I think broadly that is a good thing to do. If people are waiting,
with respect, for an NHS operation and are waiting in pain and
discomfort, let alone needing critical care facilities, I think
the last thing that they are concerned about is frankly where
the treatment takes place, providing the care is for free.
201. But one of the reasons they are waiting,
Secretary of State, is because we have got consultants moonlighting
in the private sector. You are giving a huge boost to that moonlighting
by virtue of the answer you have just given me.
(Mr Milburn) With respect, that is your word and not
mine.
202. I think it is your word as well.
(Mr Milburn) Well, since the cameras are rolling and
since we are in public session, that is your word and not mine.
However, as you know we have a set of proposals around precisely
that phenomenon. You call it moonlighting, I call it maximising
the capacity of the National Health Service and ensuring that
we get the maximum contribution from each and every consultant.
So we have an answer to that particular question and I think there
is a further very, very important set of caveats that everybody
should be clear about. I think it is the right thing to do, to
take advantage of private sector capacity for the benefit of NHS
patients, but there are two important caveats. One is that we
should get the best value for money for the taxpayer, and there
is certainly no blank cheque here. My guess is that there will
be tough negotiations between NHS Trusts, Primary Care Trusts,
Primary Care Groups, health authorities and private sector providers
and that is how it should be, because nobody would forgive us,
least of all this Committee or the Public Accounts Committee,
if we did not get a good deal for the taxpayer. The second caveat
is that we have to be in a position where we ensure not just good
value for money for the taxpayer but the highest standards of
care for the patient.
203. I have to say that in terms of the taxpayer,
the answer that you have given me seems to indicate that in many
respects we will be paying more for the use of the private sector
than the use of the National Health Service, so that—
(Mr Milburn) With respect, Chairman.
204. Can I just finish the point? A number of
people in the NHS have already come forward with their concerns
over the way in which this Concordat will cost the public purse
more than would have been the case had we used the National Health
Service. That is a concern that certainly I have got looking at
the detail of what you are proposing.
(Mr Milburn) With respect, there are two answers to
that. First of all, you do not know and I do not know what the
deals are going to look like as they are hammered out on the ground.
Secondly, it is not a question of making a choice. The National
Health Service today, and we all know this from our own areas,
is short of capacity. So patients are being asked to wait artificially
long. We do not have enough beds, we do not have enough doctors,
we do not have nurses, we do not have enough operating sessions.
We are putting that right and the thing is moving in the right
direction and over the next few years there will be more doctors,
there will be more nurses, there will be more beds, more critical
care facilities, and at the same time we have spare capacity going
begging, lying idle, in the private sector. Personally I do not
think that there should be a sort of ideological barrier to patients,
National Health Service patients, getting treatment there.
205. I think my concerns are practical and I
have put some practical questions. You know my views on the private
sector and I think I know your views on the private sector as
well. My concerns are entirely practical. We have talked about
the Health Service being short of doctors and nurses, and certainly
the inquiries this Committee has done have shown exactly where
the doctors and nurses go; they are trained by the NHS and they
are recruited by the private sector. That is the reason why we
cannot staff our beds, because we have not got the manpower, you
are losing these people to the private sector. The concern I have
got is that what you are doing will lead to even further numbers
of people leaving the NHS and going into the private sector. I
have got a number of colleagues who want to come in on this point
but can I just finish with one quick question on quality. Currently
in the private sector, as far as I can see, and we looked at the
quality of the private sector and certainly this Committee across
the board politically had serious concerns about quality issues
in the private sector, they do not publish information on performance.
Is that an issue that you are looking at? Is there some mechanism
whereby you intend to introduce this? Certainly there have been
many witnesses that we have met at this Committee who have raised
very serious questions about the quality of the work that is currently
undertaken in the private sector.
(Mr Milburn) I understand those concerns and, as you
know, there have been concerns raised in the House about the quality
of private work, sometimes in both Houses, when things go wrong.
There are some issues there. Certainly if we are treating NHS
patients for free in independent sector hospitals then I have
to have an assurance as Secretary of State that the standards
of care are appropriate and as high as possible. There are two
important changes that we are introducing. One we have already
introduced is the Commission for Health Improvement. Remember
that its remit, if you like, is the Independent Inspectorate for
the National Health Service will follow NHS patients as they are
treated in private sector hospitals. So the Commission will have
a remit there and, of course, it will publish reports and data
and so on and so forth following its inspection visits. The second
important development is the National Care Standards Commission,
which admittedly will not come on line until 2002 but it has a
specific responsibility for, if you like, policing and inspecting
the private sector, not just acute sector hospitals in the private
sector but also residential and nursing homes and so on and so
forth and, again, it will publish more and more data. Yes, I think
this is a good question to raise and there are some corollaries.
If essentially the taxpayer is paying for more care of NHS patients
in private sector hospitals taking advantage of capacity that
is not being used at the moment, then certainly the taxpayer and
the public, as patients, have got to be assured that the standards
of care are right. I think that will mean inevitably over time
that in the private sector—hospitals we are talking about
here but the same applies to residential and nursing homes too—there
will have to be more and more openness and have to be more accountability
about their performance standards. That seems to me to be a good
thing and not a bad thing. It is always the same with this, the
good guys have got nothing to lose, the only people who are worried
about it are those who have got something to hide.
Mr Burns: Secretary of State, I was listening
very carefully to what you were saying and it seemed to me that
you were being extremely logical and putting forward an extremely
sensible suggestion.
Chairman
206. Notice where the support is coming from.
(Mr Milburn) That is particularly helpful, Mr Burns,
and I am extremely grateful for your support.
Mr Burns
207. The other thing that I thought was interesting
was one of the reasons you said why it was important to do this,
with, of course, the crucial proviso that the health care is free
at the point of delivery and always will be, was you mentioned
that of course you should do this with spare capacity because
most of our constituents are facing artificially long waiting
times at the moment and it is silly not to use such spare capacity.
I think that is absolutely right.
(Mr Milburn) I think that is right. I think, with
respect,—
Mr Burns: No, no, stop there, do not spoil it.
I have not finished my question.
Chairman
208. Let him finish his question, to be fair.
(Mr Milburn) I will spoil it in a moment.
Mr Burns: Given the logic, the sense, of all
this, could you tell us why it has taken three and half years
to do it given that the problems have not gone away and, in fact,
in some ways, particularly on waiting lists, just on the numbers,
the problems during part of that three and a half years have increased?
The other thing I would like to know, because of course you were
the Minister of State at the Department of Health for the first
18 months of this Government, is did you share these vigorous,
logical, sensible views at the time in the Department of Health
or did you feel rather constrained by your predecessor who I think
would be more like our Chairman in his views on your Concordat.
Chairman
209. He is a Yorkshire man.
(Mr Milburn) That is an extremely helpful set of questions.
I have indicated that I think consistency is an important quality
in politics and I hope I am always consistent. I will be consistent
in a moment, if I can, by coming to quite a sharp differentiation
between, with respect, the two parties' policies on these issues.
Mr Burns
210. Parties?
(Mr Milburn) The two parties' policies on these issues.
211. I have not mentioned parties.
(Mr Milburn) No, but I am going to mention them because
it is one of the prerogatives of those questioned here that they
are allowed to give their own answers.
212. Right.
(Mr Milburn) Let me just deal with the specific question
about why it took three and a half years. What we had to do in
1997 when we got into office was stabilise the National Health
Service. That was the right thing to do, it was the right priority.
You remember when we got in, indeed I think you were a Minister,
Mr Burns, in the Department of Health just prior to 1997, at that
point the National Health Service was spiralling out of control.
We had £500 million worth of debt in the National Health
Service and in the last year of the previous government spending
on revenue actually fell in real terms, the first time it had
done that in many, many years indeed. Morale was plummeting and,
of course, waiting lists were rising. Our first priority, quite
rightly, was to get the National Health Service back under control.
213. I do not quite remember it like that, but
carry on.
(Mr Milburn) I am happy to try to refresh your memory.
214. From one side.
(Mr Milburn) That was the right thing to do, to try
to stabilise the Health Service. It is not true to say, incidentally,
as the Chairman was indicating just a moment or two ago, that
somehow or other the Concordat, or co-operation, with the private
sector has just come out of the blue; it has not. In fact, I think
the figures the Committee have been given indicate that over the
last few years the proportion of NHS spending going into the private
sector has increased. I do not have a problem with that providing
it is getting a good deal for taxpayers and the right quality
of care for patients. Where I think there is a world of difference,
with respect, between what the Government is trying to do and
what others would seek to do, and maybe you are one of them, I
do not know, I think it is right and appropriate if there is spare
capacity available in the private sector to use that for the benefit
of NHS patients. I do not have a problem with that and I do not
think that you do either.
215. No.
(Mr Milburn) Where I have a problem is in the expansion
of the privately paid for health care sector because if that happens,
if those who advocate that the answer to our health care systems
problems in the UK are to expand the private health insurance
market and thereby expand the number of patients for their care,
if we accept, as I think we all do, that there is a constraint
capacity problem for the National Health Service, in other words
we have not got enough doctors and we have not got enough nurses,
if that is the situation and people accept that then an expansion
in the privately paid for health care sector can only be robbing
Peter to pay Paul. It can only be to the detriment of NHS patients
for a very, very simple reason, and that is that if there are
not enough doctors and nurses working for the benefit of NHS patients,
an expansion of the doctors and nurses providing care to the paid
for private health care sector can only be to the detriment of
the National Health Service. Those who advocate this policy need
to look at it again, because far from being a relief for the National
Health Service and a relieving of the burden on the NHS, it is
actually the imposition of a burden on the National Health Service.
216. What about the first 18 months as Minister
of Health?
(Mr Milburn) As I said to you, I have always been
consistent in my views about this.
217. I did not ask if you had been consistent,
I assumed, because you told me, that you are. I asked if the Department
of Health had a problem with the sort of sensible policy you are
now—
(Mr Milburn) No, and you can see that, with respect,
in the figures. The figures demonstrate that in 1997, or 1998-99,
the proportion of NHS spending going into the independent sector
was around 4.8 per cent and that had increased from our first
year in office. That would indicate that far from there being
a problem, it was always recognised as a sensible, pragmatic solution
to the immediate short-term capacity constraints that the National
Health Service faces.
Dr Brand
218. That is a fascinating answer but—
(Mr Milburn) I cannot speak for anybody other than
myself.
Mr Burns
219. I did not think that your predecessor was
on record in public taking that view. I know you are saying that
you cannot take responsibility for him, and of course you cannot
take responsibility for what your predecessor said or did, but
you were part of the team with him and he was the leader of that
team that probably set the public face of the way to move forward.
(Mr Milburn) As I say, it is also one of the prerogatives
of those coming here that they answer for themselves and not for
others.
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