Select Committee on Health Minutes of Evidence

Examination of Witnesses(Questions 260-279)



  260. Do you think it is the end of the UK contract?
  (Mr Milburn) I really do not want to get into the position where I secondguess what colleagues in the Scottish Executive are going to do. If you ask me my view of whether or not I would be comfortable were Scotland to decide to go ahead and implement the contract then, yes, I would be comfortable about that, I think that is a perfectly reasonable decision for Scotland to take, or for Northern Ireland for that matter.

  261. Taking it a step further, presumably there are fairly marked differences in the way regions of England voted on the contract?
  (Mr Milburn) I do not know that.

  262. If a region came to you saying "we have a clear majority in favour", would you countenance a situation where a region of England would move towards new arrangements?
  (Mr Milburn) A region?

  263. I think that is partly one of the things, it is a very mixed picture geographically, is it not?
  (Mr Milburn) I honestly do not know because, remember, this is not my ballot. I know people are asking me about it but it is not my ballot, it is the BMA's ballot. The only breakdown I have seen—the Committee may want to ask the BMA about this—is Scotland, Wales, Northern Ireland, England and a breakdown by SPRs, consultants, and a breakdown by public health specialists and others. If there is a regional breakdown I certainly have not had it, so I do not know whether there is a regional pattern or there is not a regional pattern. There is much speculation about whether there is and whether the vote in favour ended just above Hadrian's Wall or whether it ended further south, I do not know the answer to that, I have got no empirical data one way or another. I do not know how a region would approach me to tell you the truth, I do not know what would be the means of doing that. I think it is more likely, and again I want to be cautious about this because there are absolutely no decisions taken about this, that I would get an approach from an individual trust, or group of trusts maybe, in which case we would have to think very, very carefully about it. I do not see a reason in principle why not.

  264. Why you would not accept an approach?
  (Mr Milburn) No, I do not see why not.

  265. I have got from what you said that the problems were ones of substance. There has been speculation that there were problems of presentation and the way that it was put over to people. Am I right to infer that you are saying that the problems were ones of substance where people did vote against the fairly substantial differences of opinion about issues that the contract had touched on?
  (Mr Milburn) I listened to some of the vox pops, like everybody did, what consultants were saying. Some of my friends are consultants.

Mr Burns

  266. Still?
  (Mr Milburn) I live with one actually.

Andy Burnham

  267. I hope she voted yes.
  (Mr Milburn) Speculate about that. I think there are different views being expressed about this, very, very different views. It is quite difficult to disentangle. Clearly there are concerns and, as I say, if there are concerns about how the NHS is working and so on and so forth then those are concerns that we have got to get into dialogue on and try to address.

  268. I have seen reports of people saying that they were against enforced weekend working and it seems there were some views out there that were not technically right.
  (Mr Milburn) Certainly on your sort of division between issues of substance and issues of presentation, on the latter I think that there were issues of misunderstanding. You probably remember that a few weeks before the final vote we tried to issue a clarificatory statement which went out jointly between the BMA and the Department of Health trying to deal with these issues about whether people were going to be compelled to work at a weekend or 10 o'clock at night and so on and so forth, which had gained a bit of currency and momentum during the discussions. Maybe those concerns were a contributory factor, I do not know. Personally I do not think there was one single factor.

Dr Naysmith

  269. Like most of the rest of this Committee, Secretary of State, I am glad that you were misquoted in the Sunday papers as going to take on the consultants. You are right, you do not write the headlines, and I am glad of that because, like you, I know that most consultants work extremely hard and are dedicated to the National Health Service. It varies a bit from speciality to speciality as I understand it, but without a doubt that is true. If I can just ruffle the waters a little bit, the existing contract that has been in place for many years has got things called job plans. I know quite a few consultants, one or two are friends, like you, and I know that job plans for consultants are enforced differently in different places and some consultants take them much more seriously than others. I just wonder is that an area that you could look at with the possibility of getting a bit more efficiency and productivity out of the National Health Service? Have you had any feedback on that?
  (Mr Milburn) I think your starting point, first of all, is right. We can both acknowledge the very important role that consultants play and the fact that they are valued by everybody in the country in my view, not just Government or Government ministers or Members of Parliament but by the community and by patients. We can acknowledge that overwhelmingly consultants do a really good job of work for the National Health Service, but also say at the same time that the existing way in which they are employed and the way in which they are paid and the way in which they work, that might have been appropriate for one period of time but it is not appropriate today. If people have interpreted what I have said as being whatever Richard's words were about tough or whatever, I think in the end people will understand, both consultants themselves, their representative organisations and, most importantly of all, patients and taxpayers, that what we cannot have is somehow reform being stalled. These changes have really got to happen. You raised one particular issue which is about job plans. Job plans are nothing new, they have been around for 10 years. In some parts of the country, in some organisations, they are taken up and they are just part and parcel of life as a consultant; in others they are not. That is a problem. Point one. There are issues about how we ensure that genuinely the National Health Service and all parts of the NHS provides a 24/7 service because that is the world we live in: more two-income earners, more women are working, people finding it difficult to go to an outpatient appointment either at 11 o'clock in the morning or two o'clock in the afternoon because people are in work, thank heavens. Point two. Three, there are issues, as David and others quite rightly know, which remain unresolved about the relationship, some would argue the conflict, between private practice and NHS work. All of these issues are issues that remain on the table and in the light of the rejection by consultants of the contract that we and the British Medical Association jointly have put to the body of consultants, they are issues that remain to be resolved. I am very seized of the fact that job planning, disciplinary procedures, there are other issues that sit there on the table and I guess most people would think this needs resolution.

  270. Finally, if you were to introduce some kind of junior consultant post, or whatever it is called, could you confirm to the Committee that you will not use that to artificially inflate the figures in order to meet the consultant numbers by 2008?
  (Mr Milburn) First of all, the term "junior consultant" is an absolutely dreadful term. Two, I think we have got to consider some of the proposals that are coming forward as a consequence of Liam Donaldson's consultation and some of the proposals that are being thought about, quite progressively in my view, in the Medical Royal Colleges about how we can get people into training. I think we are at the stage before the stage that you think that we are at on this. We have got to think very carefully how best we can do this. As we said in the NHS Plan, we have to consider ways in which we can achieve the productivity improvements and, most crucially of all, more services being delivered to NHS patients. We have got to find the best way of doing that.

Julia Drown

  271. The Independent reported recently that Magdi Yacoub, who you gave a target of 450 specialists in post in three years from abroad, had only so far managed to get 19 doctors in post from abroad, from Spain and Germany. Is that an accurate report and, if so, what needs to be done to get the overseas doctors?
  (Mr Milburn) I am just about to check that if I can find it in my big bag of things. No, I do not think it is. There are two separate but related things on international recruitment. One is the work that Sir Magdi is doing for us specifically around the International Fellowship Scheme, which is a very, very good scheme in my view and there is a huge amount of interest out there. People come for a couple of years, we pay their relocation, they get to be employed in the NHS, they get some research time and if they want to at the end of two years they can go back to the States or wherever they want to go back to. I think I am right in saying on the International Fellowship Scheme that thus far we have interviewed around 64 doctors and I think we have short-listed, it looks like 39 according to this very long table.

  272. That may well be consistent.
  (Mr Milburn) Basically I think we said that we are going to get 50 by the end of the year and I think that is what is going to happen in a variety of specialities: in histopathology, radiology, I know there is a psychiatrist up north, for example, who impressed—

  273. So the 50 by the end of the year still means you are on target to get 450 in three years?
  (Mr Milburn) Yes. There are two things. There is the International Fellowship and then there is the broader recruitment campaign from abroad and that is going well. Just for the Committee's information, we have had 2,500 firm applications of which almost 900 are felt to be suitable for employment in the NHS and are being assisted through the registration process and matched to posts. So far with these two things together we have got around 100 doctors who have already been appointed to posts and are working in the NHS or are soon to join.

John Austin

  274. Could we turn to Foundation hospitals. I think you have indicated that the first one will be possibly in shadow form and operational by the end of 2003. Could you tell us how the operation of that first tranche will differ from the traditional NHS trusts and say something about the new freedoms they will have in respect of payment, terms and conditions of staff—I think the Chairman has already asked for that—maybe to implement their own consultants' contracts and in relation to investment and dis-investment in capital assets?
  (Mr Milburn) We will be publishing very detailed proposals on this I hope before too long setting out in pretty considerable detail how they will work. NHS Foundation trusts, in outline, will be legally independent NHS organisations providing NHS services according to the principles that we know and understand: services that are free according to clinical need, not ability to pay. Their ownership and accountability will not be to me, as it has been for 50 years for every hospital and every bit of the National Health Service, it will be to local communities and to local staff. I think this is an important issue.

  275. How will you ensure that governance arrangement? They will be free to start their own structures.
  (Mr Milburn) We will set out in detail what we envisage as the governance arrangements for NHS Foundation trusts. There will be some leeway but there are two essential principles that are very, very important in my view. The first is that for 50 years accountability has always been upwards to whichever government and whichever secretary of state has had the privilege to hold this office. That might have been fine for the 1940s, and probably was, but we live in a quite different world today and I think there have been increasing concerns in many parts of the country about the growing democratic deficit between local health services and local communities. Above all else, local people have a deep attachment to their local health services, their hospitals particularly but their local health services more generally. Frankly, and I have said this to this Committee before, I believe that if we fail to tackle this democratic deficit we will have considerable and growing problems from a population in this country, as elsewhere in the developed world, who are more informed, more enquiring, who want to be more involved, not just in their own health but in the provision of health care service. We have an opportunity to get the accountability and the ownership in the right place because in the end services are delivered locally, they are not delivered nationally. That is point one. Point two, for staff it is just like anywhere else wherever you work, what is most demotivating and most demoralising is if you feel that you have got no control over what happens in your working lives. In the National Health Service we have the best qualified, the most expert workforce probably of any organisation anywhere in the world. NHS services work best when we empower local staff who then have the freedom and the ability to get on and improve services for local patients. I believe fundamentally in principles of equity and, therefore, I think it is perfectly right and responsible for the job of national Government to be defined as setting standards and setting objectives because otherwise you have a free-for-all and lack of equity and provision. Where you have got to get to is a position where standards are national, if you like, but control is local. By "control", I mean both control by local staff through the appropriate government structure and control by the local community. That is where we want to get to. For those Members of the Committee who are interested in the concept of public ownership, I think that NHS Foundation trusts in their governance structures provide a genuine opportunity to see public ownership in the way that local hospitals deliver services to local communities, perhaps greater public ownership than has ever been possible through the nationalised model that Aneurin Bevan put in place in 1948.

  276. That is fine both in terms of your community accountability and staff empowerment, I do not think any of us would disagree with those concepts, but if the new freedoms are going to allow those hospitals to perform better and do this with good staff morale, is there not a real risk that those who are outside of that structure who have problems of recruitment of staff, who do not have the ability and flexibility to do that, will go into a spiral of decline and you will have a two-tier system? If it is such a good system with democratic accountability to the local community and they can perform better, why not for all trusts?
  (Mr Milburn) There are two different objections to this which your question highlighted very clearly, John. There are those who are absolutely opposed in principle to the very idea, and that is fine, let us have the discussion and the debate about where ownership and accountability should best be located. Then there are those who have a narrow objection which is, if you like, if this is good enough for some it should be available to all. Those are two quite different positions, with respect. There is an in principle objection to the very idea and then there is the idea if it is capable of working for some trusts or for some hospitals then surely it should be available to all. On the issue of two-tier health care, we are not operating a system where there are no national standards, we are not operating in a system where there is no national system of inspection, and we are certainly not operating in a system where there is no help or support or even in extremis the means of intervention to help hospitals, trusts, local health organisations, that are not doing very well. We have put in place quite a lot of that, whether it is the Commission for Health Improvement, the franchising process, the ability to remove existing managers and to put new NHS managers in. I do not think any of us, and certainly it is not part of my view about the NHS, believe that we should move to a situation where local health organisations are allowed to sink or swim. I do not think that would be responsible or right for the local communities. What you do have to do is make sure that you get both the ownership and accountability in the right place but you have also got to get the incentives in the right place. We have discussed this before in the Committee. When I go around the NHS one of the biggest complaints—I get many complaints—from clinicians and managers alike when I go and visit hospitals or anywhere else is they say the incentives are in the wrong place. Why? Because if you are doing pretty badly what happens is you get more help and financially you get bailed out but if you are doing very well you get nothing at all. If we genuinely want to encourage improved performance, aside from all of the gamut of structures and performance measures we have put in place, we have to align the incentives in that performance framework.

Mr Burns

  277. I was interested when you talked about two-tier systems because, of course, your predecessor as Secretary of State, who is a close ally of the Chancellor of the Exchequer, at the weekend in an interview condemned the foundation hospitals as creating a two-tier system. Do you think your predecessor is wrong in that assessment?
  (Mr Milburn) Frank is a good friend of mine and we have a difference of view amazingly enough about it. There we are. I think we agree on most things but we happen to disagree on this. That is life, is it not? I am sure there are things that some people inside the Conservative Party disagree on. I hesitate to use the phrase, "Unite or die".

John Austin

  278. Can I come on to the question of one of the freedoms which you referred to when you were here before, which is borrowing. I am not sure whether there have been differences of view between yourself and the Chancellor on this. One of the points I put to you last time was, does this mean if they have the freedom to borrow that they may not have to go down the PFI route, and you said, "Maybe". However, from a more recent announcement about borrowing it is my understanding that although there will be increased freedom to borrow, the borrowing will come off the Department of Health's balance sheet so the sum will still remain part of the conventional public sector. Is that right?
  (Mr Milburn) Basically they will have the freedom to borrow, that is absolutely right; they will operate according to a prudential code on borrowing—and I can talk a bit more about this if it is helpful—to ensure what they borrow they have the ability to repay so they are not over-stretching themselves; and they will have the freedom to borrow incidentally as much from the private markets as from the public sector.

  279. Presumably the Department will still underwrite—
  (Mr Milburn) Where we have got to is that their borrowing will be on the balance sheet as distinct from off it.

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