Examination of Witnesses (Questions 1-19)
ALAN MILBURN
MP, JACQUI SMITH
MP, MR RICHARD
DOUGLAS, MR
GILES DENHAM
AND MR
NEIL MCKAY
WEDNESDAY 17 OCTOBER 2001
Chairman
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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