Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 1-19)



  1. Colleagues, can I welcome you to this meeting of the Select Committee and particularly welcome our witnesses. Can I also welcome the new members of the Committee who joined us and some new "old" members who are back with us. Julia in particular, it is good to see you. Secretary of State, can I thank you and your team for coming along at a very busy time. We particularly welcome the new Minister of State; we are very pleased to see you here. Could you briefly introduce yourselves to the Committee. Secretary of State?

  (Mr Milburn) Alan Milburn, Secretary of State for Health.
  (Jacqui Smith) Jacqui Smith, Minister of State with responsibility for community care.
  (Mr McKay) Neil McKay, Chief Operating Officer for the National Health Service.
  (Mr Douglas) Richard Douglas, Director of Finance.
  (Mr Denham) Giles Denham, Head of Social Care Policy.

  2. Thank you very much. Can I begin by saying that obviously the public expenditure inquiry covers a whole range of areas and I apologise for roaming from one area to another. Can I kick off with an area that I have some concerns about at the moment, and that is public health. One of the issues I get raised with me at a local level is a concern about the future location of public health. I know talking to various people involved in the Health Service, particularly public health around the country, that there is a worry that to some extent the focus that the Government have had on public health may have been somewhat lost in recent times. Is that a fair criticism?
  (Mr Milburn) No, I do not think it is. I know there are concerns right now which would be unsurprising really. We are going through a quite major set of structural changes and I think many of the concerns about where the public health function is going to be discharged arise from those changes. Let me share the dilemma with you that I had back in March when I made the announcement about shifting the balance of power within the NHS. There was a choice for me basically which was we could have continueed with the existing structures, and that was quite a tempting choice given that the National Health Service has got well-used to lots of structural changes over the course of the last 20 or 25 years. However, my very very strong feeling, the more I discussed this with people in the National Health Service, including with the public health people, was the gathering sense that the existing structures, with a pretty large intermediate tier of management between the Department of Health and the front-line in primary care trusts and National Health Service trusts, was increasingly untenable. What we have learned over the course of the last four or five years is what we need is a combination of what I hope we now have which is very clear national standards in place including, if I may say so, for public health—the National Cancer Plan, a very strong national service framework for coronary heart disease, and you are aware of the other measures, backed up now by inspectorates and so on and so forth. In the end improvements in standards will not be delivered unless the people on the front-line feel they have some control over the decisions taken and crucially over the resources as they are available in the National Health Service. I simply got too much evidence, I am afraid, of the fact that the people at the front-line were not receiving the benefits they should have from the big financial increases that have been going in, so I took the decision that it was the right thing to do to, effectively to take out some tiers of management. I know that is disconcerting to some colleagues around the table because you are aware that some consultation is going on now about the strategic health authorities. I think it is true to say that there is a sense within the Service that we are going through yet another structural change and, of course, I am concerned about that, however I felt it was the right thing to do and, frankly, the right thing to take a risk because I do not believe that in the end what we are going to get is the sort of improvements in services that we require unless the people at the sharp end, whether it be primary care, secondary care or anywhere else, feel they have greater ownership of the agenda and indeed of the resources in the National Health Service. There is a special place for public health in that. I am quite happy to talk further about how I think the changes we are introducing will strengthen rather than diminish the public health function because I genuinely think that is what will happen.

  3. You mentioned the strategic health authorities. Will it be the key task of these new bodies to address health inqualities?
  (Mr Milburn) Yes.

  4. Explicitly?
  (Mr Milburn) Yes, explicitly.

  5. Following on from that point, would the issues I get raised with me by health trust chief executives—I am not just talking about my own part of the world but various parts of the country—where they tell me they frequently get banged around the head by the National Health Service Executive on the issue of waiting list targets but very rarely is the issue of public health mentioned and, of course, these bangings on the heads relate to ministerial pressure on the executives to deliver results. When are we going to start banging our heads on public health?
  (Mr Milburn) I do not think the complaint about the National Health Service is that there is too little banging around the head.

  6. I do not think the banging around the head is the concern, it is the subject matter of the banging around the head.
  (Mr Milburn) I think the complaint might be the reverse and we have got to get a valid balance between pretty tough performance management—that is largely Neil's function and Richard's too—and there is a sense within the Service now that there are strong national frameworks and so on in place that can get on and deliver the agenda. If I am critical of some of the public health people I talk to, it is because I do not think that, frankly, they recognise that what we are trying to do in terms of improving primary care or certainly improving waiting times for cancer or coronary heart disease in terms of the outcomes that will be achieved, are important public health measures. They are important public confidence measures. We are all aware of that. Every time any one of us talks to any of our constituencies about the state of the National Health Service invariably the big concerns are about how long people wait, whether it is to see a GP, to get an ambulance or an operation. If we can make the sort of improvements that we need to see and I think are now beginning to come through, particularly on cancer and on coronary heart disease, which are at least as toughly performance managed an improvements around waiting times and waiting lists, that will have an enormous public health benefit. Over the course of the last year or so I think we have been able to make some progress as far as cancer services are concerned. We know that cancer and coronary heart disease together kill a quarter of a million people a year in our country. We know that a lot of that is preventable, incidentally through primary care rather than secondary care, and there we have some good stories to tell. We also know that if we can get people once they have got cancer or coronary heart disease into the system more quickly than we are able to at present, that will have an enormous public health benefit. If I am blunt about it, I think people ought to get out of their ghettos a bit and stop worrying about what is public health and what are waiting lists. Everything that any government should do as far as health and the Health Service is concerned should be about improving the health of the population. That is what we are trying to do and I think what we have now got in the service frameworks, the National Cancer Plan and, remember, targeted money directed at these specific services to facilitate the improvements that are so long overdue, are the means of achieving that.

  7. Would you accept that when, for example, the Tobacco Advertising Bill was not in the Queen's Speech a message did go out to the public health sector that perhaps the emphasis that has been placed on public health since this Government came to power was not being strongly reinforced by practical measures?
  (Mr Milburn) I hope not.

  8. Obviously I recall the White Paper Smoking Kills and the commitment there. We committed, as I understand it, over £50 million over three years but that money has not been spent. I am told only £43 million will be spent of that amount and the figure that I am given in terms of anti-tobacco campaigns over the three-year period including the current financial year indicates a reduction in expenditure. In 1999 -2000 it was £15.9 million, in 2000- 2001 it was down to £13.73 million, and it is down in the current year to an allocation of £13.3 million. The point is the tobacco industry is spending ten times that amount of money on advertising. It is a very worrying discrepancy between the two figures. I certainly anticipated that we would see a radical difference from this Government to the previous Government's position on smoking and tobacco.
  (Mr Milburn) I am very happy to check the figures for you and send a note, if that is helpful; I do not have them in front of me. I hope that people do not get the wrong signal about this at all. We have got a Manifesto commitment to see through the Tobacco Advertising Bill. I rather hoped we would have been able to do that in the last Parliament. Unfortunately we were not able to for a variety of reasons. We will introduce it when we are able to. If we can find legislative time soon we would like to be able to do that. You are aware of the pressures now in particular there are on the legislative timetable. The Manifesto is for the whole parliament, not just for one year or a few months. Secondly, what does amaze me about this decision about the tobacco advertising thing is that it is an important public health measure and I remain profoundly committed to it. I believe it is absolutely the right thing to do and I believe that the last Government had evidence it was the right thing to do but unfortunately did not legislate for it. However, I think the most important public health measure we have taken in relation to tobacco has not been proposals around banning tobacco advertising, it is about helping people to quit smoking. Two-thirds of smokers say they want to give up and they want help to give up and until this Government came into office there was not any help available for them other than them paying for that help themselves. The fact that we have made nicotine replacement therapy available on prescription and Zyban available in a similar way is producing results and, as I said yesterday in Health Questions, we would have expected by this stage to have some 45,000 people due to quit smoking thanks to the smoking cessation services that we have developed whereas, in fact, we have got around 65,000 so far, and the programme will go from strength to strenght. Politicians claim a lot, of course they do, but when I go around the world and talk to people about what we are trying to do in public health, people recognise we have got the best smoking cessation services anywhere in the world and we should be proud of that. I find it pretty difficulty, frankly, to square the idea that somehow or other there is a lack of commitment to deal with the scurge of tobacco and the appalling health consequence that it has with the health measures we are putting in place. We will come back to the Tobacco Advertising Bill in due course. We need to make sure that as much help, as much support as possible is available to people who genuinely say they want to give up. The advertising campaign we have got running is an important means to that end but the more direct intervention in my view is through precisely the sort of therapies that are available, particularly for smokers who find it difficult to quit.

  9. Coming back to my point about the new strategic health authorities, your reply to our question 3(1) implies that the Department will not be monitoring what happens to public health targets. How are you going to ensure that PCTs are meeting these targets and, if this is an aim, what mechanisms are in place to ensure those results occur?
  (Mr Milburn) I was going to say this earlier about why I think that what we are doing in terms of shifting the balance of power, wiping out the current health authorities, getting rid of the regional offices, devolving power down to PCTs will really make a difference in public health terms. Many of these problems we have got in relation to public health are more general problems arising from poverty, deprivation, poor housing, drugs problems and so on. I think for too long, frankly, there has been an argument around in the public health world, and elsewhere in public services, that dealing with those problems was nobody's particularly responsibility. It is actually everybody's responsibility. If you are going to deal with these problems that arise about drugs and crime and poor housing on council estates, as we know, what we need is a variety of agencies to come together. I think that getting the power and getting the resources in the Health Service away from what are certainly in my part of the world a pretty anonymous bureacracy located 20 or 25 miles away from Darlington into a Darlington-based primary care trust that, remember, will have as part of the PCT overall budget 75 per cent of the overall N HS budget in its hand, will facilitate much closer joint working together on the ground. What I would expect to see is the local primary care trusts coming together with the the local authority, with the local Police Service, voluntary agencies and others, not just to deal with health in the narrow remit, providing Zyban on prescription or whatever, but dealing with some of the root causes that we know give rise to these appalling pockets of ill-health that we see in many of our towns and cities across the country I think getting money out to the front-line will aid and abet public health rather than in some way restricting the public health for all. It is important to remember, too, that in the new primary health care structure what we want is in every PCT there to be a public health team dedicated to carrying out the public health function. As far as the strategic health authorities are concerned they should be that—strategic—and they should get out of the business of putting their noses into the day-in day-out running of the National Health Service. That is not their job. The people who do that should be the people at the front-line.

Mr Burns

  10. Secretary of State, you have been talking recently and quite a lot in the past about targets ensuring the delivery of improvement and enhancement of public health. Are you not concerned, though, if all that you are aiming and aspiring to achieve were to be undermined by things like the BMA survey which was published today that says morale is rock bottom. One in four family doctors actually want to quit the National Health Service and their GP function because 95 per cent think their workload is far too great and they do not see a future for themselves. If you have that low morale in what is to all intents and purposes a destabilisation of the whole GP network, how is the Health Service going to be able to move forward and meet its targets when on top of that one has a situation where there are serious staff shortages, and despite what your Department and you are seeking to do to get more trainees in it would seem that less and less people are going into higher education to train to be doctors and nurses.
  (Mr Milburn) I do not think it is true and I think the competition for places remains very strong. Just two or three Fridays ago I met with a group of potential medical students in my own constituency at the sixth form college. It was great to see them. They were extremely enthusiastic about it. They wanted to go into medicine but they did not have the certainty of a place and why not? Because they have got to go through a competitive process. Of course they have. What we are doing, as you well know, is dramatically expanding the number of medical school places now. They will increase by 30 per cent by 2004.

  11. Those are places.
  (Mr Milburn) There are more doctors coming through all the time. It is true that for the last set of figures that were published the results were disappointing for GPs. I expect the next set of figures to be much more welcome both as far as the public is concerned and perhaps even the British Medical Association too. I expect to see more and more people coming through. PMS is beginning to take off in a way that many people had said was not possible in the past. The salaried GP option is proving very, very attractive, particularly for younger doctors. When I talk to younger doctors very many of them say to me that they do not want to take the risk of buying into a business because that means a stake for life. Young people want to spend a year in Australia or whatever and good luck to them. What we have got to do is provide them with more choice and some of the choices we are providing are more flexible working so women can come back after having children to to work in general practice or in nursing or elsewhere. We have got to give them a salaried option because that provides more opportunities too. Yes, of course there are concerns about what the BMA Survey says today and we are working very hard, incidently in collaboration with the BMA, to address some of these concerns, and making general practice more attractive both to come into and stay in. I do not know whether you have had the opportunity to read the survey. What I found heartening about it in particular was amidst the myriad of concerns in the survey, there was one very, very important thing struck me very, very forcefully. GPs are working incredily hard, they are under a huge amount of pressure, and we need to do everything in our power to alleviate that pressure and to get more family doctors into the Service. Despite all of that, a clear majority of GPs were able to say that as far as they were concerned primary care services over the course of these last few years rather than deteriorating were improving. I think that is down precisely to the hard work of those GPs and we have got to build on that, dealing with the recruitment and retention problems. I am not gloomy about it at all. In fact, I think the range of measures we have put in to improve recruitment and retention, particularly of family doctors, is going to make a real difference. You can see that in nursing already; you alluded to nursing. Three or four years ago if I had come to this Committee virtually the sole topic of conversation would have been about the nursing shortage crisis. It is true we still have shortages of nurses, that is absolutely true, but we have got 17,000 more nurses now than we had then, we have got 7,000 more doctors. My own view is that we have turned the corner on shortages. I think the applications coming through are up by a fantastic number for both diplomas and university degrees for nursing. Where we have now got to focus the attention is not so much on recruitment as on retention. We have got to make it much more worthwhile for staff to stay in the National Health Service. That means pay, how you employ people and it means what help you give to a million staff to help them balance their family and their working lives, which is why we have this big commitment, for example, to improve childcare facilities.

  12. Thank you, Secretary of State. Can I come back to that. One of the things you said was that you were reassured, pleased by the number of doctors coming through and taking up appointments but, given your pleasure at that, have you also considered the number of doctors at the other end of the career span who are taking early retirement and are leaving the profession for the very reasons highlighted by the BMA Survey today? Could you give me now figures showing how many of these new doctors are coming through and how many in the same timescale are retiring and whether there is a net gain or loss?
  (Mr Milburn) I cannot give you them now but I am very happy to send you a note. I think what you will find is that although there is much talk, particularly in sections of the medical press, about the appallingly high rates of retirement, the actual rates of early retirement are barely budging. I have heard that story now for the last five years and every year I have waited for the great retirement bulge to feed through into a mass exodus from medicine, nursing, midwifery and health visiting. A lot of people talk about it but, frankly, I think there is quite a lot of scaremongering about it and in actual fact it has not come about. We have got to work doubly hard to make sure that we have got the best people working in the National Health Service and make sure we can help them stay in the National Health Service and that means, unlike in the past, we have got to move away from staging their pay, which is what used to happen, we have got to make sure there is appropriate child care in place for them and crucially, back to the opening point the Chairman raised, I think it is really really important if people stay with any service that they have got to feel some sense of ownership over it. That is really important. It is important for anybody in their working lives, even Members of Parliament want to feel a bit of ownership of the agenda day to day. I think it is quite important that the jobbing consultant, the jobbing family doctor, the jobbing nurse, the people who actually deliver the care day in, day out actually feel as if they have got a bit more ownership which is why it is really important, in my view, that we get these resources and these powers and responsibilities out to the front line. I am greatly heartened and I think the numbers coming through training in particular are very, very good indeed and I would be very glad, Mr Burns, and the Committee, to send you a note. I hope you will share the pleasure in the big increase that we are seeing and that we will continue to see in future years.

Dr Taylor

  13. Secretary of State, I think I am already known as a bit of a scaremonger but I really want to alert you to what really is my very severe fear. In the early 1970s a lot of GPs came from foreign countries to particularly the urban areas of the West Midlands, South Wales, they are coming up to retirement. Surely that is going to lead to the retirement of a large number who it is going to be extraordinarily difficult to replace.
  (Mr Milburn) I think there are a number of things that we have got to do. It is very important in my view that we do not just focus at the entry end, we have to focus at the exit end. The worst possible thing to happen would be that we had huge numbers coming through the front door and then even bigger numbers leaving through the back door. We are conscious of that which is why when we announced the package of measures that we discussed with the General Practitioners Committee of the BMA prior to launching it we put as much emphasis, if you like, on golden hellos as golden goodbyes. We want to make it more worthwhile for people to stay on in their careers. What I can say to you is that although there was a bit of pooh-poohing of these initiatives at the time actually the money is beginning to bite and it is the amazing thing about the National Health Service, as you are aware, that behaviour tends to follow cash. That is a very simple thing to keep in mind. I think there are some short term things that we have got to do in terms of making it more worthwhile for people to stay with the National Health Service and not retire earlier. In the medium term, and I think this is quite a big change but I do think this is where we have got to get to, it seems to me, almost perversely, that what the National Health Service, unlike most other organisations, asks its key employees to do as they come up to retirement is to get them to work even harder. Now I think we have got to change that and I think we have got to get into a position, particularly with doctors, where essentially we are looking at three phases of their career, and this is what we are trying to achieve through the consultant contract negotiations with our colleagues in the BMA. In phase one doctors come through, they qualify, they are enthusiastic in the NHS and hopefully they are working pretty damn hard, and we want them working for the National Health Service which is precisely why we propose that providing we can reach agreement it would be good if newly qualified consultants were prepared to commit 100 per cent to the NHS for up to seven years. Then they will have a second phase when they are well established, when they become experts in their own right and where, providing again we can reach agreement, it seems perfectly reasonable to me that if they want to build up a modicum of private practice that is absolutely fine providing we can get a good deal for the NHS, and of course we will pay them more. Work more for the NHS and we will pay them more. The third phase of their career has got to be this. I think rather than expecting people to work as hard in their sixties as they did in their thirties, what we should move them towards is much more mentoring, much more training so that actually they are bringing on the next generation of doctors. I think that is as true in primary care as it is in secondary care. That seems to me to be quite a big change, quite a big cultural change to effect but if we can do that I think the benefits all round both for the older doctor and for the younger doctor having the experience passed on to them of people who have been in the system for very many decades will be enormous. Now what we have got to do is make sure that is not just an aspiration, what we have got to do is have the means to effect that. If you take my simple proposition that behaviour tends to follow money then what we have to have is a consultant contract and a GP contract too, which we are busy negotiating, which facilitates precisely that sort of structure in the workforce.

  14. Mr Chairman, the length of that answer is really teaching me a lot about what it means to be a top politician. I am certainly learning very fast. What really bothers me basically is that you have outlined all the benefits, there are not going to be literally the bodies to take up those benefits when this huge efflux goes of people from abroad who are retiring.
  (Mr Milburn) With respect, I think you are wrong about that. You want to have a look at the numbers coming through.

  15. I would love to.
  (Mr Milburn) I will gladly show them to you. The Committee can have a look at what the training numbers in particular look like. In the short term it is true that we have a problem precisely for the reasons that you are well aware of, that it takes some considerable time to train doctors and frankly because in particular—and I think was one of the more foolish things that happened in the past—the number of both nurse training places and sadly the number of GP training places were cut back, we have had to pick up that infrastructure again. Remember it is important that we have the trainers to do the training. In the short term there is a gap and we, as you are probably aware, are actively looking abroad now to see whether we can bring in doctors, not from developing countries where the governments are unhappy about that but from countries like Germany and Italy and Spain where there are a surplus of doctors, and even America. I was in America last week in Washington and what I found amazing about being there was the sheer interest, not just in the National Health Service but in the reforms that we are introducing in the National Health Service. Many people talk, they talk about the changes that are being introduced and actually here the changes are being implemented. I believe profoundly, and certainly from the number of inquiries that we have had thus far from America and elsewhere, that what you can expect to see are very high quality people coming to work in the United Kingdom in our National Health Service because they rather like it. It would be good if all of us, every one of us, particularly in key decision making roles, talked up the National Health Service rather than, as some seek to do, running it down.

John Austin

  16. You have talked, Secretary of State, about the pressure on decision makers from consumers, from the public, from the medical profession, the pre-occupation with waiting lists, waiting times. I recognise this and you have talked about the need for effective monitoring and measuring. My concern is, and the way in which the questioning has gone and the answers in this session so far is indicative of some of this, that we started talking about the public health agenda and very rapidly moved off it. You referred in your comments on coronary heart disease to the very significant improvements that are taking place in primary care, in secondary care, in treatment, in outcomes, in survival but when we actually look at the incidence of coronary heart disease, particularly among people of my and your generation, there has not been any significant reduction. One of the issues is that public health measures which can be taken are the ways in which people can begin to bring that down.
  (Mr Milburn) Yes.

  17. But they are not immediately measurable in the short term. I think my theory is that unless there is some way of ensuring the funding for public health that with all these other pressures the public health agenda is going to slip down the priority list.
  (Mr Milburn) But what is public health? Public health is largely delivered in primary care. That is where it is delivered.

  18. As far as the NHS is concerned.
  (Mr Milburn) Yes, absolutely.

  19. A lot is outside of it.
  (Mr Milburn) Exactly. That is why we have got to forge alliances between the National Health Service and other agencies and organisations and communities precisely in order to deal with the root causes. What I have never believed is that somehow or other it would be a rather perverse proposition that somehow or other the National Health Service of all organisations in the country did not have a leading role to play in improving the health of the public and that is what we have got to do now. Where is public health best located? The answer to that, it seems to me, is in primary care. As I was saying on the floor of the House yesterday in answer to questions, inevitably for perfectly understandable reasons you know people when they talk about heart disease, for example, their biggest concern will be about how long people wait for a coronary artery bypass graft, a heart operation, and we have to do a lot more to save lives and get the waiting times down. Actually when we came to do the modelling for the National Service Framework that we published last year, what struck me so forcibly was the number of lives that we can save by doing some very simple things, secondary prevention in primary care, by prescribing aspirins, by prescribing beta-blockers, by prescribing statins, which far outweigh in outcome terms the consequences of improved waiting times for a heart operation and there the news is genuinely good. Now it is not genuinely good for Richard, as the Director of Finance, because in the course of the last year the expenditure on statins has risen by around 30 per cent but it is a good thing in public health terms because that is reducing the incidence of people having a second heart attack. The fact that we have got heart disease registers now being established in primary care with GPs looking out for the signs of heart disease and those prone to it is an enormous public health gain. These are big public health measures in their own right. Sometimes when we have this debate about public health, people think the only people who do public health are the public health doctors. It is not the public health doctors, every doctor does public health and chiefly public health is taken forward by GPs in primary care, by health visitors, by community nurses, by community midwives too. What we have got to do is give them the resources and the ability, operating within the national framework I described earlier, to make sure that we can really bear down on some of the awful incidents of these killer diseases.

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