Examination of Witnesses (Questions 320
- 336)
WEDNESDAY 8 NOVEMBER 2000
RT HON
ALAN MILBURN,
MR JOHN
HUTTON, AND
MR COLIN
REEVES CBE
Chairman
320. Please be brief, we are trying to get you
away by half past six and Mr Amess has to come yet.
(Mr Milburn) That is something to look forward to.
In that case I will be very brief. I am in a hurry to get to Mr
Amess. On the second and third functions about inspection, you
are quite right that the CHCs, hitherto, have not had the right
to inspect in primary care and that has been a longstanding grievance.
It is one that we want to put right through the Patients Forum.
In the future there will be a Patients Forum in every trust, not
just in acute trusts but in primary care trusts too. They will
be drawn from patients. I happen to think that is the right thing
to do because I think in the end the best people to gauge the
performance of the local health service are the people who are
receiving local health services ie patients. We will have patients'
groups—the Alzheimer's Disease Society, the British Heart
Foundation, all of the groups who represent patients in the local
area—together with patients who have actually used the service,
represented on the Patients Forum and for the very first time
patients themselves will be able to elect a member to each and
every trust board, not appointed by Ministers, not appointed by
officials, but appointed by patients. I think that is an immeasurable
strengthening of the patients' voice and, indeed, the independence
of the patients' voice within the National Health Service. Do
not forget, each and every one of these patients fora will have
the ability to call a snap inspection to decide whether the GP
services are up to scratch from the patient's point of view. The
third function is around mediation.
321. Can you make it quick, Secretary of State,
I am conscious Mr Amess has not spoken yet and you want to get
away by half past six.
(Mr Milburn) Yes. On this point about mediation, whenever
I have anybody come to my surgery complaining about when something
has gone wrong in the National Health Service invariably I find,
and I am sure other colleagues do, that by and large when something
has gone wrong patients do not want to take the National Health
Service to court, by and large they want an answer to what has
gone wrong and they want an apology. We know that where mediation
services are in place, as they are for example in the Brighton
Trust, where you have a mediation service that is operated by
experts, perhaps people drawn from Community Health Councils,
the number of formal complaints against the local health service
falls because actually you can get answers very quickly. I think
on all these three counts we can demonstrate that we are going
to get patients a better service, that there is going to be more
independence and that patients' voices are going to be better
represented in the National Health Service. That is not to decry
for a moment the contribution the Community Health Councils have
made over the last 30 years.
Mrs Gordon
322. Can I just say I totally disagree with
you on this. The three distinct functions are quite capable of
being done by one body and I think it would have been better to
enhance the role of CHCs rather than to waste all their expertise
and their dedication.
(Mr Milburn) Let me just say this. On wasting their
expertise and dedication, that is not the position at all. In
fact, the Minister, in this case Gisella Stuart is responsible
for this area of policy, has had very fruitful and productive
meetings with the Association of Community Health Councils—ACHC.
ACHC are doing a consultation of their own amongst CHCs about
how best we move forward. It is my intention to migrate smoothly
to the new structures but we are going to go to the new structures,
that is what we are going to do and wherever possible we will
retain the expertise that does exist in some Community Health
Councils.
Mrs Gordon: You destroyed their morale.
Mr Amess
323. Five issues in seven minutes, but certainly
I agree with everything Mrs Gordon has said. When was this document,
the NHS plan, commissioned? We got it at the beginning of the
summer recess?
(Mr Milburn) You got it before the end of the summer
recess. I think you got it on 27 July which is a date that is
engrained in my brain. When was it commissioned?
324. Yes?
(Mr Milburn) Well, it was not commissioned really
I suppose.
325. No.
(Mr Milburn) I was largely responsible for writing
much of it so we decided as a Government, if you remember, in
March when the Chancellor had his Budget that we would invest
more money in the National Health Service. I took the decision
then that it would be sensible to set out in outline what we would
want to do with the money and the improvements patients would
get.
326. Between March and July?
(Mr Milburn) It was sort of then.
327. It was sheer coincidence that it came out
when the Government was on the ropes about the National Health
Service and we had all the media coverage of St Thomas's Hospital.
(Mr Milburn) On the ropes?
328. This was always planned, was it?
(Mr Milburn) I do not recognise this phrase "on
the ropes", Mr Amess.
329. The point I am coming to here is why when
you got into Government in the last century, May 1997, why did
we not have this Plan at the start of it? As you said this afternoon,
you wanted to stabilise the Health Service.
(Mr Milburn) Shall I give you the answer to that question?
We did stabilise the National Health Service. When we got in our
first task was to do precisely that. A part of the stabilisation
process was to introduce the new structures that were appropriate
for a modern health service. That meant getting rid some of the
rather alien structures that had been introduced by the previous
Government, most notably the internal market. As you will remember
in December 1997—another date that is engraved on my brain—we
produced another White Paper, the new NHS, which subsequently
led to the Health Act 1999. These laid the foundations for the
sorts of changes we can now build on in the NHS Plan. But the
reason why we did not have a NHS plan in 1997 and instead had
to undertake the structural changes was for one good reason and
one bad. We needed structural change to provide the building blocks
and the improvements that the Plan promises. Secondly, in 1997,
we had made a decision prior to the election to stick to the previous
Government's spending plans, although we did introduce some new
money, as you will remember, over the previous Government's plans
into the NHS. There was not the sort of cash going in, in 1997
and 1998, as there is this year and for the subsequent three years.
Frankly, the sort of expansion in services which the NHS Plan
holds out now was not as possible then in 1997.
330. We will just have to agree to differ because
it seems to me that this was a public sop to meet the concern
of people to try to demonstrate that you had it all under control.
(Mr Milburn) So you are not convinced by it then?
331. It seems extraordinary, to me, to stabilise
a health service by changing all the structures. I would have
thought it was clearly obvious to Ministers and the Prime Minister
himself that there is no part of the public health service in
terms of professionals who have not been concerned about things.
Finance. The Health Select Committee, as you know, has just come
back from Cuba. That is because they are not spending so much
money, £7 per head, we spend out £750 per head. We went
over there to find out whether we could learn from what they were
doing. Now in part of the NHS Plan the Prime Minister says that
we took profound decisions in Government, sorted out our public
finances, and he wants money spend to be brought up to the European
Union average. Your officials told us that they were keen to see
NHS spend rise to that European Union average of 8 per cent. I
am advised that this is unweighted and is arithmetically the mean
of the European Union percentage spend. Would you agree that the
more realistic average spend is the weighted mean, which the OECD
calculated was 8.7 per cent?
(Mr Milburn) No, I would not. There are many ways
in which you can skin this particular cat. Let me give you three
ways in which you could do it. One is your way whereby you weight
a level of health spending and the level of GDP in an individual
European Union country. Sure, if you do that you get to 8.7 per
cent. Conversely, there is another way, which is to take the overall
level of EU GDP and divide that by the overall level of EU health
care spend. That will take you to an average of 7.6 per cent.
There is a third way, to coin a phrase, which is the way that
surprisingly the Government chose, which is the way that the OECD
itself chooses. This is essentially to take the average of all
of the EU countries' health care spending as a proportion of GDP
and to divide that by the number of EU Member States and that
takes you to 8 per cent. Since that is what the OECD do, what
we are doing too, it represents the fairest way of assessing the
level of health care spending in the European Union. If we went
for the second of those, ie, European GDP divided by European
health care expenditure at 7.6 per cent, if we did that, we would
hit the Prime Minister's pledge rather earlier than even he had
anticipated.
332. What I am puzzled about is that you say
in that document: "Having looked at the alternative systems
and rejected them"—in particular you cite the examples
of France and Germany—now if you have rejected the systems
in these two countries, why do you want to tie ourselves to their
spending levels?
(Mr Milburn) It is not me who is advocating—I
do not know whether it is you but certainly some are—the
importation of continental models of social insurance into the
United Kingdom's health care system. I do not think, for all the
reasons that the NHS Plan outlines, that this would be the right
way forward for Britain. Those that advocate that position have
got to be able to defend this particularly continental European
model of care. I am euro-sceptic on this particular set of issues
in relation to the European social insurance model of care. However,
what I think there is no disagreement about, is that we have an
under-capacity system. The very first question that I answered
this afternoon was all about that. We do. We have a system which
is comparatively under-doctored and under-nursed. Yesterday I
was able to sign an agreement with the Spanish Government because
they have an over-provision of nurses there. We have got an under-provision
of nurses here. What that suggests to me is that the most important
thing that we can do, is to see over time what we are seeking
to do over these three or four years, which is to dramatically
expand the National Health Service and to ensure that our people
are getting the sorts of access to doctors, nurses and other health
care staff, and a modern infrastructure, that other people in
many other European countries demand and get as a matter of course.
333. Moving on very quickly, and perhaps your
official could write to us about this, could you provide the Committee
with the calculation for your second figure of 7.6 per cent.
(Mr Milburn) Certainly.
334. We are a bit puzzled by that You said much
earlier, about two hours ago, that you were very concerned about
all these beds being blocked in hospital and how awful it was.
Are you denying then that the Government has no responsibility
for these beds being blocked? This is because the industry is
saying that the reason why so many of these homes are closing
and are in difficulty, is because of the burden of regulation.
They are also saying that there is inadequate funding. Now on
the Floor of the House this afternoon we have had the Chancellor
of the Exchequer who will have given away billions. The headline
tomorrow will have statements repeated over and over that it will
be a billion. I will probably go down tonight and find I am a
millionaire as a result of this Government. If there is all this
money sloshing around in the system and the Government believes
in joined-up government, how is it, or is the general public being
softened up for a beds crisis? I can recall one of your junior
ministers being at my hospital last year reassuring everyone that
it was going to be all right. But you already you seem to be saying
that there is a capacity problem. My God, it has taken the Government
over three and a half years to realise that there is a capacity
problem and we have to get nurses. We are probably going to get
them from Cuba as well. My point is, there are beds blocked. Did
I hear you rightly that the Government is not responsible for
these beds being blocked?
(Mr Milburn) Let me deal with the two points you have
raised. On capacity problems, yes, there are capacity problems.
When the previous Government failed to train the adequate number
of doctors and actually cut the number of nurse training places,
when it did that, then that has created a capacity problem that
the National Health Service has inherited now. This Government
is putting that right. Of course, it is. It will take some time
to get there but get there we will on the basis of historic increases
in NHS spending and a commitment of the NHS staff who want to
change and improve the services they deliver. As far as this issue
of delayed discharges is concerned, perhaps I can give the Committee—or
repeat to the Committee—some of the figures which we have
already given you, which is that by point of comparison in quarter
1, 1996/97, the percentage of patients of 75 or over with delayed
discharge was running at 17.8 per cent. By 1999/2000, quarter
1, the percentage of patients aged 75 and over with delayed discharge
was running at 13.4 per cent. 13.4 per cent is far too high. That
is why we set a new target in the National Priorities Guidance,
which I issued last year, for this year, to reduce the rate of
delayed discharges for over 75 year-olds occupying acute hospital
beds to 11 per cent in 2000/2001; 10 per cent in 2001/2002; and
9 per cent in 2002/2003. Now the reason I read those figures out
is to demonstrate to you, I hope convincingly, that the Government
takes very seriously the issue of delay discharge. Indeed we are
seeing improvements precisely because of the action that we are
taking, which is around expanding the capacity of the service,
introducing more intermediate care provision, ensuring that more
and more elderly people have precisely the access to intensive
home care packages of support that they and their relatives want
to see. Of course we take it very seriously indeed and we will
see improvements. What I say to you, also, in all truthfulness,
Mr Amess, is this. I cannot promise sitting here today that we
are going to have solved every bed problem or every nurse shortage
problem by December of this year or January of next year, that
will be a pretty foolish thing to pretend. The capacity increases
that the NHS Plan holds out—more doctors, more nurses, more
beds in the system—will take time to come through. What
I think you will see over the forthcoming months and forthcoming
years is the trend moving in the right direction where for very
many decades it has been moving in the wrong direction.
(Mr Hutton) Very briefly, I know the Chairman is in
a hurry and Alan is in a hurry. Mr Amess did refer to one issue
which he identified as important which was this burden of regulation
on the care home sector. Let me just try and nail that one particularly
because I think it is an important issue. We have made very strongly
the case for national minimum standards, and I understand your
party, David, supports that. We have made it very clear to this
Committee and to others and to the Members of this place and to
the care home sector that we want to set those standards at a
realistic and affordable level, and they are going to be realistic
and affordable. Some of the changes which might require fiscal
allocations through care homes, we have given care homes seven
years to make those types of adjustments. Now I think with a sense
of fairness, which I know you are famous for, I do not think you
could argue successfully that is an unreasonable burden and I
think it is actually something that we have bent over backwards
to do sensibly and fairly in the full consultation of the care
home sector themselves. I do not accept the argument you have
made about the burden of regulation, I think that is completely
false.
Mr Amess: If the Chairman will allow me my quick
final question which is in two parts. You said NHS consultants
are working hard and they are working flat out. You mentioned
claiming foolish things. Why was it then that Southend Hospital
was "named and shamed" as not meeting waiting list targets?
Why was it that the announcement curiously happened a week after
Parliament had risen? Is anyone monitoring what is going on there
because apparently orthopaedic referrals are up by 13.7 per cent,
there has been no extra staff put into the hospital, absolutely
nothing has been achieved, other than staff morale going down.
Yet, you said this afternoon how wonderful the staff are. The
other point is on NICE. Will you tell the Committee clearly and
precisely, because I did ask your colleague Mr Reeves last week
about NICE, how it is that you can claim that NICE is truly independent?
Mr Reeves said "There are certain situations which are around
about the issues of affordability and priorities where I do believe
that the Government and NICE would work very much in concert together".
That is your official who said that last week. That is not what
Government Ministers have been saying. My colleague, Simon Burns,
raised this this afternoon. When you are talking about the products
having been under review and you mentioned beta-interferon, beta-interferon
has been under review for 15 months—15 months it has been
under review—so what steps is the Government taking to speed
up this process and can we have a clear answer now from the politicians
as to the point that I think Mr Reeves conceded last week that
this is all a complete charade?
Chairman
335. I do not think, to be fair to Mr Reeves
he said that.
(Mr Milburn) I hope you are not referring to this
hearing or specifically your questions, I am sure you are not.
On the situation at Southend, I will very gladly send you a report
on all the improvements that Southend National Health Service
has seen since 1997 if that is helpful to you. On the question
of the National Institute of Clinical Excellence, yes it is independent.
I do not decide for it what it will decide on beta-interferon,
that is a matter for clinical and other experts that make these
decisions, and that is absolutely right. There is a very simple
choice here, Mr Amess, either we allow to go on what has been
going on and, frankly, has been exacerbated by the competitive
internal market that has proceeded in the past, where hundreds
of different health authorities, hundreds of different trusts,
and now of course hundreds of different primary care groups and
thousands of different GPs all pursue very different prescribing
policies. The consequence as you will be aware from your postbag
is what we have christened a lottery of care. Either we can continue
with that sort of laissez-faire arrangement which denies
patients in one area treatment and gives patients in another area
treatment or we do what we are doing, which is to take some rational
decisions about how best to determine NHS priorities so there
is a level playing field of care between patients. I think that
is what patients want from the National Health Service.
Mr Amess
336. Was Mr Reeves right in what he told us
last week?
(Mr Milburn) Yes, he was right. There are two quite
separate distinctions. We have always been clear about this and
indeed in Committee—I do not know whether you were on the
Committee dealing with the NICE regulations or not—it was
made perfectly clear, and I have made it perfectly clear on the
floor of the House that there is a clear distinction to be made
between NICE's remit, which is about assessing clinical and cost
effectiveness and a quite separate set of decisions which are
around affordability issues. In the end you would want, I am sure,
for affordability decisions to be located with an accountable
politician who has to answer to the House of Commons and to Parliament.
It just so happens that accountable politician is me. You might
not be happy with me but I guess that you are happy with the general
process.
Chairman: Okay. Secretary of State, gentlemen,
can I thank you for your attendance. It has been a long session
and we appreciate your answers to our questions.
|
