Examination of Witnesses(Questions 240-259)
RT HON
ALAN MILBURN
MP AND JACQUI
SMITH
TUESDAY 5 NOVEMBER 2002
240. Why not do the carrot rather than the stick
approach? Instead of fines why do you not have bonuses where they
manage to avoid and overcome the problems of delayed discharges?
(Jacqui Smith) If you have an effective partnership
it is not just about whether or not you feel warm to each other,
it is about whether or not you have managed to reduce the number
of old people who are struck in hospital when they should not
be. If you have succeeded in doing that you will have lived up
to your responsibilities and you will not as social services be
paying the costs of those older people in hospital. If partnership
works then it fits precisely into the system that we are proposing.
241. Absolutely. I accept in many respects what
you just said. I accept that. Surely to encourage it to work a
carrot approach of incentives is better than a stick approach,
which introduces a blame culture and arguing of fines? Why not
be positive rather than negative in the approach?
(Jacqui Smith) We are being extremely positive in
terms of—
242. You cannot be.
(Jacqui Smith)—recognising what local authorities
have said to us, that is part of the reason they feel they have
not always been able to exercise their responsibility with respect
to older people in hospital because they have not had the resources
to develop the alternatives. We are pushing in place the resources
in order to enable them to develop the alternatives but alongside
that, as Alan says, it is also crucial that given that there are
particular responsibilities that we have a system that reflects
those responsibilities and reflects it in terms of who pays when.
If an older person is in hospital and there is agreement that
they should be the responsibility of social services but they
are still in hospital how is it reasonable that the hospital is
paying the costs of that when it is not their responsibility?
243. We are not arguing that point. The point
we are making is, why not have a positive system to encourage
the problem to be overcome rather than a negative one?
(Mr Milburn) Can I answer that, at least in part,
I think there is a positive incentive in the scheme as consulted
on in at least one major respect. I think local authorities need
a positive incentive to ensure that social services money that
has been given by the Government is actually spent on social services.
This is a pretty positive incentive in order for them to do so.
244. It would be of even more positive benefit
if they benefited financially.
(Mr Milburn) Next time you visit Redditch you need
to talk to some of the directors of social services. My discussions
with them have been interesting, on the one hand they want more
autonomy, that is fine, and we are happy to do that, as the local
government White Paper sets out, and on the other hand, I think
there is a general concern in social services, that the protection
afforded to social services by ring-fencing and earmarking money
may well be disappearing. One of the very important drivers to
ensure that social services cash is indeed spent on building up
social care capacity is precisely this scheme. I think you will
find that although there will be lots of protests about this now
and concern, and so on and so forth, we have to take all of that
properly into account. When the scheme is operating people will
see that it has beneficial incentives within it.
Chairman
245. At this stage we have been under way about
an hour on social services and I hope we have done some justice
to that very important area. On the last occasion the Secretary
of State appeared before us I was taken to task subsequently for
the length of the answers I allowed you to give. At this stage
can I appeal, as obviously we are time limited, for brief questions
and brief answers. I would like to move on to the issue of the
NHS workforce. Clearly the starting point will be the issue of
consultants' contracts. The last time you were here, Secretary
of State, you will recall it was the day that you were making
an announcement about the progress we thought at that stage had
been made on the consultants' contracts. Clearly the vote announcements
last week will affect your workforce planning assumptions, what
assumptions are you now making in that area of policy and obviously
in relation to outputs what are the implications currently?
(Mr Milburn) I remember the day well. As a point of
clarification I did not announce it, the British Medical Association
announced it that morning but I used the opportunity here to discuss
how we thought it was beneficial. I do not think it has a huge
impact in terms of workforce planning, to tell you the truth.
Clearly the result of the ballot was disappointing, I think, not
least because consultant leaders themselves argued very strongly
in favour of it.
246. What are your views as to the reasons why
they voted the way they did?
(Mr Milburn) I think there are a mixed set of reasons.
If you listen to what the consultants themselves are saying and
if you look at the dispersal of the vote, the fact that they voted
yes in Scotland and in Northern Ireland and no in Wales and in
England there are probably a variety of reasons in truth. I think
this was always going to be a difficult reform. Clearly individual
consultants have the right to have a vote, there is no argument
with that, to express their views about this. I should say, to
be clear about this, in my view NHS consultants overwhelmingly
do an outstanding job for NHS patients, I do not think there is
any argument about that, however the contract is in essence 50
years old and it is designed for quite a different world and a
different health service. We have to move forward. What we were
trying to do, as you know, through the consultant contract framework
that we agreed with the BMA was in essence, although some of it
was complex, it boiled down to this, how could we ensure that
we got more NHS consultants' time for the benefit of NHS patients
in exchange for paying NHS consultants more. That is the essence
of the deal. We wanted to reward those consultants that did the
most for NHS patients. To do that there were issues about how
best to plan NHS consultants time and also, as you know, to try
to solve this very vexed and difficult issue about the relationship
between partnerships and NHS work. I think that was always going
to be difficult, and so it proved. We went through two years of
extremely tough negotiations, in my view, and we are now at the
point where we are. The issue is really what we do from here on
in. I think the result of the ballot does not mean the extra resources
we put on offer are lost in the National Health Service. First
of all, we certainly stand by the financial commitment that we
want to make to NHS consultants and to NHS patients but we will
have to, I think, deliver our objective in a different way. The
objective of getting more work and time for NHS patients from
NHS consultants we try to do through the managerial route, as
enshrined in the contract. I think it is quite difficult given
the fact that at least in England it has been rejected—I
cannot speak for Scotland that would be a decision the Scottish
Executive would need to take forward itself—it is difficult
to pursue that route, we have to achieve our objectives in a different
way. What we do have is quite a substantial investment we were
planning to make in implementing a new contract for NHS consultants.
If you like, in a sense, that money has now been liberated and
we can use that in order to try to get the right incentives in
place such that NHS consultants who do the most for NHS patients
get the biggest reward. We will explore how best to do that, we
are, and we ought to come forward with our plans before too long
about this. I should say that in terms of our discussions with
the medical profession I think frankly renegotiation is impractical.
However, my door is, as it has always been, open to leaders of
the medical profession to come and discuss their concerns, if
that is what they want to do, particularly those people who show
commitment to reforming and modernising NHS services. I have written
to Dr Bogle from the BMA this afternoon, he wanted to have a meeting
with me to discuss some of the issues, we will go ahead with that
meeting. There can be no doubt in my view that if we are putting
extra resources in we have to see some changes, and improvement
in the reforms. The public will expect to see that in working
practices and in better ensuring that we get the most out of all
of our NHS consultants for the benefit of NHS patients.
247. We will move on to foundation hospitals
in the remaining session, philosophically that brings us into
the area of local negotiations, what kind of view are you taking
on individual trusts moving forward with their own agreements
on this issue? Is that a possibility? What are the implications
of that?
(Mr Milburn) We have to look at a series of options
round this. I want to be a little cautious at this stage really.
For example you could see that one option would be to allow those
hospitals that wanted to, those trusts that wanted to go ahead
with consultants' contracts as negotiated. I think, although I
cannot speak for the Scottish Executive, the fact that there was
a vote in favour there, I do not know, it may well produce a different
response, I do not know whether that will be the case or not.
Of course that is one option. What we are more actively exploring
is how we can get from the substantial resource that is now available,
I am talking about up to a quarter of a billion pounds which is
available to invest in extra consultant time, to get the right
incentive structure in place such that the NHS consultants who
do most for NHS patients get the biggest rewards. That is where
our principle efforts are geared. There will be other issues that
we will need to think about. You know in the NHS plan we published
in July 2000 we said we wanted to press ahead with new consultants'
contracts for the reasons that we have set out on previous occasions
but in the absence of that we would need to look at other measures,
and we need to look at those other measures.
248. At the weekend the press speculated about
the creation of a possible new post, was that just speculation?
Was there some substance in that idea?
(Mr Milburn) I think the people concerned looked back
to what we said in the NHS plan, we said then the biggest problem
we have today in the NHS is still a shortage of capacity. There
are issues, although overwhelmingly NHS consultants work extremely
hard in the NHS service there is quite a variation in productivity,
and so on, which everybody is aware of, and then there is the
issue of time being devoted to privately paying patients amongst
a minority of NHS consultants. Our priority as a country is to
build up the NHS services so we can get more of the time of NHS
consultants for NHS patients. We have to look at how best we can
do that. As you will remember in the NHS plan the choice was,
did we go for the new consultant contract, we tried to do that
over the last two years, with very clear objectives, and so on,
and if that did not happen we would need to look at other reforms,
the way that doctors work and the way doctors are trained. We
will need to look very, very carefully at how to do that. Incidentally
you will know that a point parallel to this the Chief Medical
Officer Professor Donaldson launched his very good consultation
document Unfinished Business just a few months ago, looking
at how we can reform the system of doctor training. We tend to
find in this country compared to Europe and even the States that
the training time is quite long. There are issues that we need
to look at about that to see whether we can get doctors qualified
and into practice earlier. There are some interesting views coming
back from some of the medical Royal Colleges about that arena
of debate. I hope that before too long I can be slightly clearer
than I am today about that. The point in essence is this, if we
are going to put more money in, which is what we want to do, we
have to have some changes.
Mr Amess
249. Without a winning workforce we do not have
a National Health Service. At the last evidence session I asked
your officials about the retention of consultants and other staff.
They gave their answers, properly, without knowing the outcome
of this contract. I listened to the sound bites of your good self
after the announcement that the contract had failed and you seemed
to be very angry and very disappointed, are you seriously telling
this Committee that you as the Secretary of State for Health are
going to take on the consultants? If you are you must be absolutely
barking mad.
(Mr Milburn) That is tricky one. Some would call it
a no-brainer, David.
250. Were you just talking tough at the time
because you were disappointed?
(Mr Milburn) I am not angry about it. People have
a perfect right, we live in a democracy, thank God, to vote and
decide what they want to decide. I respect that judgment that
people have reached individually. As a consultant body I have
to respect that judgment. Consultants are valued and valuable
people in the National Health Service. People have to look at
it from our point of view, what we are trying to do is invest
substantial extra resources into the NHS, which is the right thing
to do, to grow the capacity of the National Health Service. We
have made very explicit promises to the British public that we
are not going to put investment in but we are expecting to change
the way the system works. There have to be changes in the way
people are paid, employed and in working practices. Things have
always been conditional and it has been conditional in the consultant
contract too. I thoroughly respect what consultants have to say
and we have to take stock as a consequence of the ballot, we will.
It is quite difficult for us. Journalists put to me on the day,
"will you now impose the contract?" I think it is probably
quite difficult to do that in truth. I think the managerial route
we were exploring I think is difficult for the reasons that I
have outlined. It may be possible to do it in some trusts in the
way I indicated to the Committee. What I do know is we have a
substantial resource we want to invest, so our ends remain the
same. Our ends are, how can we ensure that those doctors who do
the most for NHS patients get the biggest reward and how can we
ensure we can buy more of the valuable time and expertise that
NHS consultants have for benefit of NHS patients? Those are the
ends. The means we have to think about in the light of the contract.
As I say, I think our efforts now should focus on how we can best
use those resources to incentivise the changes in performance
that we would want to see and the patients want to see. I do not
think the patients would regard that frankly as a terribly bad
deal.
251. Before asking a specific question about
projections, what I do not understand in all of this, and the
Chairman hinted at it, the whole style of your department is you
are pretty sure about what is going to happen when you ask questions.
It seems to me you do not ask a question perhaps on the one that
my colleague mentioned earlier about fines, perhaps that was a
bit of a faux pas but by and large you do not ask big questions
unless you are sure of the answer. I got the distinct impression,
perhaps I was fooled by it, you were pretty confident the consultants
were going to accept the proposition. I know this has not been
done for a very long time, it was very difficult, but what the
devil went wrong?
(Mr Milburn) Remember, as I said earlier, this was
a deal that we had negotiated over two years and it was not just
agreed with the consultants' leaders and was not just then subsequently
endorsed by the consultants' negotiating committee or, indeed,
by the whole BMA Annual Conference, but it was very, very aggressively
sold and it was sold hard by consultants' leaders. This was not
a one-way street, it takes two to tango and two did indeed. That
is what we did. We came up with something and consultants have
decided that they do not want to have it. Well, we have got to
respect that judgment but we also have a wider responsibility.
We have a wider responsibility, not just to NHS doctors, and remember
there were quite a lot of doctors who voted in favour of this
as well as those who voted against, but we have a responsibility
to the whole of the National Health Service and to NHS patients.
I think what is crystal clear for most people about the National
Health Service is that it needs two things: in crude terms it
needs more money and more capacity on the one side, no argument
about that, including more consultants, more doctors, more nurses,
more therapists and all of those other things, and it needs some
pretty fundamental changes in structures, in working practices,
in incentives. It seems to me that you only get the benefit for
patients when you do those two things alongside each other. That
is precisely what we said in our manifesto.
252. I have really enjoyed everything you have
said because—
(Mr Milburn) That is fantastic.
253. It seems to me that you are not going to
take the consultants on and you are not barking mad.
(Mr Milburn) I feel as though I have been certified
sane.
254. The Wanless Report identified a shortfall
in doctors. How confident are you that you are going to get this
proposed increase in consultants of 10,000 by the year 2008 in
the light of all that has happened?
(Mr Milburn) Now that I have been certified sane I
feel even more confident, Mr Amess, I really do. I am glad that
I have been blessed in the way that I have. I think it is pretty
tough. Getting a big expansion in workforce is difficult for a
whole variety of reasons, however I think there is some good progress
under way. I think we have got around 3,000 more consultants since
the Government has been in office, which is a growth of about
23 per cent, which is good but frankly not good enough and we
need to do a lot more. How are we going to do it? Essentially,
I suppose, through five means. One, for the long-term we have
simply got to increase the number of doctors in training and there
is a very big effort, as you know, going on across the whole of
the health service and in higher education to do that with the
opening of new medical schools, the first that we have seen in
a generation or more coming on line. I think the number of new
medical students coming through has increased by about 25 per
cent in the last few years, which is good. Applications, very
hearteningly, are up, which indicates that medicine continues
to be an attractive career for young people and we should never,
ever lose sight of that. That is point one. Two, I think we have
got to look at what we can do to reform the way that doctors are
trained, in particular these issues that Liam Donaldson consulted
on about how we train doctors and the training period. A few weeks
ago I went to the Leicester and Warwick Medical School up in the
Midlands to open it and what was very interesting was to see their
scheme where they have got a graduate entry scheme for doctors
in training, people coming in and doing a four-year course. The
amazing thing about these people is their absolute enthusiasm
and so on and they had some sort of basic training in the biomedical
sciences and so on and so forth but they really want to do it.
It is slightly more mature people who are coming in and I expect
that we will see a lot more of that. That is point two. Three,
we have got to expand the number of people in the grade below
consultants, SPRs. We need to do more there, although there is
some progress, an additional 500 SPRs, I think. We have just invited
the National Health Service to come forward with proposals about
how we can further expand SPR numbers and I think we have proposals
on the table for a thousand extra, which is very, very good indeed,
so I am heartened about that. That is point three. Fourthly, we
have got to improve retention as well as recruitment. Consultants
are just like anybody else, they lead extremely busy lives, very
often they have got childcare and other family commitments as
well as work commitments and we have got to help them with that:
more part-time working, flexible working, better childcare, help
for people to stay in the profession towards the end of their
lives and so on. Finally, in order to plug some of the gaps in
capacity that we have, where it is appropriate we have got to
try to recruit doctors from abroad, providing they are appropriately
qualified and so on. Again, there is some progress there that
is pretty heartening. These are the measures that we are taking.
It is not just about shunting more medical students into medical
schools and then hoping that in 2008, or whenever it is, that
they are out. There is a whole variety of measures, there is no
single silver bullet, there are a lot of bullets that you have
got to fire here. I am pretty heartened by progress. On the targets
that we have set it was the same with the nurses. Back in July
2000 when we said we are going to get 20,000 more nurses people
said "you have got to be crazy, you will never do that",
but there are 20,000 more nurses, a lot more than 20,000, additional
in the NHS and I think it is the same with doctors.
Dr Taylor
255. I was saddened in health questions last
week to hear the antipathy from the Government benches for consultants
and that is why I thought I was going to have a difficult job
today but you have made my job much, much easier by—
(Mr Milburn) Bringing joy wherever I go.
256. Your first comments were to acknowledge
the dedication and hard work of the vast majority of consultants,
which is absolutely justified. Your remarks have been much more
conciliatory than I ever expected following that terrible headline
in the Sunday Times, I think it was, "Revenge. 130
million revenge on consultants".
(Mr Milburn) Richard, I do not write the headlines,
it is my friends somewhere over there. I use the word "friends"
lightly.
257. My concern with you was that the BMA negotiators
did not get it right. Dr Hawker himself wrote in Hospital Doctor,
or is quoted, "What I did not realise, but I suppose I must
take some blame for, is the depth of what can be called open warfare
between consultants and managers". This is my concern because
I have seen where relationships are excellent and systems work
brilliantly because it is a partnership between doctors, doctors
in management and managers, but it is not working in places and
how can you help that?
(Mr Milburn) I am very chary, I must say, of in any
way condoning a view that in the National Health Service there
is wholesale war between managers and consultants, I simply think
that is untrue. I think by and large relationships are good and
productive. There are tensions, of course there are, there are
bound to be, but that is just the nature of the beast. I think
it is worth remembering one very simple thing: in the end most
doctors end up being managed by doctors. Clinical directors are
doctors. Medical directors are doctors.
258. Absolutely.
(Mr Milburn) I think there is quite an issue that
obviously needs to be thought about there. I just do not accept
this sort of interpretation that somehow or other there is open
warfare. I also think the medical profession will get itself into
a difficult position, in my view, if the appearance is given at
least that somehow or other people are not prepared to be accountable
and answerable. I do not think that is where people are at personally
at all. I think people nowadays understand that actually accountability
is a good thing and not a bad thing. The days have gone where
there was that sort of—I do not know if it is particularly
helpful, but what people sometimes talk about as autonomy for
doctors (and I do not think that served doctors terribly well,
as we have seen over the course of the last few years when some
of these problems have come to light). I think people, and particularly
taxpayers, will look askance at the idea, were it to gain currency,
that somehow or other we are putting more money into the National
Health Service, resources are going in, but that is not being
accompanied by changes to working practices, changes to structures
and, indeed, some reasonable accountability about how the money
is used and how people who work in the NHS actually work for it.
I think it would be as well to be slightly cautious about that
view of the world.
Andy Burnham
259. Just a quick point. In Scotland, although
we cannot secondguess the Scottish Executive, they did vote fairly
clearly in favour of the contract. Are you worried about a situation
where they may move to that new contract and the repercussions
for workforce planning in the English system if there is a clear
difference in the levels of pay on offer in both countries?
(Mr Milburn) I understand that. I cannot speak for
Scotland and I cannot speak for the Scottish Executive, it has
got to take the decisions that are right for Scotland. As you
will remember, the contract that we negotiated with the BMA was
a UK contract. However, the reality, unfortunate though it is,
is that people have voted differently in different countries and
not just in Scotland, in Northern Ireland too, and I think that
places people in quite a difficult position.
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