Examination of Witnesses(Questions 260-279)
RT HON
ALAN MILBURN
MP AND JACQUI
SMITH
TUESDAY 5 NOVEMBER 2002
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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