Examination of Witnesses (Questions 440-459)
TUESDAY 4 MARCH 2003
RT HON
ALAN MILBURN
MP AND MR
ANDY MCKEON
440. Can I take you back to the comments you
were making about Spain and Sweden and improvements. All of the
data that we have seen suggest that there is a much lower acute
hospital usage in those countries and certainly our experience
of Sweden is that perhaps one of the key factors there is better
developed preventative and community care services. Are you not
concerned that this concentration on foundation hospitals in the
acute sector is actually reversing the trend down the road that
you have gone down in putting primary care at the forefront of
the NHS and that this is reversing it and concentrating on the
acute sector?
(Mr Milburn) No. I can see why people might think
that, but I do not think that is the case. As I say, for the future
there is no reason why we should not think about something similar
for primary care trusts, but I just think it is far too early
for them. The second thing, however, is this, that—
441. You say that it is too early for them and
I think in response to Doug Naysmith you said that PCTs could
not cope with the organisational change. Does it necessarily mean
organisational change to have a more democratic representation?
The foundation trusts, no matter how many members they have got,
have responsibilities to their members, whereas the PCTs have
the responsibility for the strategic planning and provision of
services for their community.
(Mr Milburn) Of course.
442. So is it not the PCTs where the accountability
should be?
(Mr Milburn) I just do not think we are at that stage
and, as I say, there are consequences, and this is back to the
point I was making in relation to Julia's question earlier, which
flow from changes in democratic accountability and they are real.
What you must not do, in my view, is to set up this idea that
you have a local group of people who have been elected who have
a democratic mandate and then precisely have no power. Why on
earth would you do that? That would be a sort of trick which you
would be perpetrating on local communities, so either it is for
real or it is not. It is not and with the change in governance
in foundation trusts comes a complete change in accountabilities
and the freedoms flow from that, and the same would apply to PCTs,
so I do not think it as simple as saying that all you have got
to do is introduce a democratic element to the PCTs in the way
that they are run and that their relationship with Whitehall would
remain the same. It would not, so I think there are pretty important
consequences which would flow from that. The second point is this:
that the PCTs are the people, however much pressure they are under
and I understand the pressures that PCTs feel under, they are
new organisations and there is what some call "information
asymmetry" between PCTs and the acute trusts, in other words,
the acute trusts have got all the information about prices and
so on and the PCTs have not, but what the PCTs have got that the
acute trusts have not got is all the money. We have given them
the money. We have given them three years' worth of money. We
have given them average 30% growth over three years and we have
given it—the growth money—without any strings attached.
They can decide where they want to commission and they have got
to start commissioning services to meet the needs of the local
community. Now, it may well be that they will decide that they
want to spend a lot of the money on the hospital services but
my bet is that in the primary care trusts, remember that is what
they are called, for one good reason, we want to see them changing
the shape of primary and community care as well, that they will
want to invest in intermediate care and at all of these facilities
that we know from all of our constituencies sometimes are sadly
lacking. The third point is this. I think your question sometimes
presupposes that the hospitals have this rather naive belief that
every problem that they have got can only be solved within the
four walls of the hospital. I do not believe that is the case
any longer, I really do not. Wherever I go, particularly the hospitals
that have got A&E problems—okay, we have a lot of people
in A&E waiting a long time—what they all say to me,
and fundamentally understand, is that the problem in the A&E
cannot be solved in the A&E and it cannot even be solved in
the hospital. It is about the provision of primary care services,
intermediate care services and so on. One of the great benefits,
I think, which would flow from NHS foundation trust status is
that I would expect to see—and we will look at this very
carefully in the application process—NHS foundation trusts
coming up with proposals for how they can use their borrowing
freedoms, their access to capital, not just to provide better
diagnostic and treatment centres and more surgery, but how, for
example, they can provide better intermediate care or help with
primary care. Now, I think if they start doing that, which is
what they want to do, what they always tell me that they want
to do, what you have got an opportunity of doing is really making
sure that the linkages between primary care and secondary care
rather than being undermined are actually strengthened.
443. Do you not think that is perhaps a little
wishful thinking?
(Mr Milburn) Talk to people.
444. Do you not think the likelihood is that
proceeds from asset realisation, operating surpluses, will be
reinvested in the acute sector and not reinvested strategically
which they would be if the PCT—
(Mr Milburn) John, what is the biggest call you have
heard for from hospitals when you have been conducting your inquiries?
Okay, they want more beds and all that sort of jazz but they want
also to see their beds freed up. Every hospital that I go to,
every single hospital that I go to talks about the problems in
the community and talks about issues of social service capacity.
Social services capacity, not even the health service. So I honestly
think there is a recognition nowadays within the health service
that all of these organisations, whether it is a hospital or a
primary care trust or a community care trust, they have to start
thinking much more about how to develop partnerships.
445. Will the foundation trust be able to use
its surpluses to pay for patient care?
(Mr Milburn) Yes, absolutely. We would want to actively
encourage them to do so.
Chairman
446. Can I just come back in on John's question.
He has got a very important point. One of the positives of Government
policy, in my view, and success is the way in which for the first
time since the NHS was introduced in 1948 you have moved the direction
of exploiting the genuine potential of primary care and the community.
Now what seems odd to me is that in moving in that direction,
and we still have a long way to go and I will accept that, you
suddenly roll back and then emphasise with this initiative the
acute sector. One of the most surprising things that the Committee
found out in this inquiry, we looked at comparative figures for
every country in Europe and there is only Austria—I think
it is—that has more in-patient usage of hospital beds than
we have. So the clear message we get is that we are not looking
at exactly what you are talking about, the alternatives to people
coming into hospital which is why a policy initiative, wholly
based, as it appears, on the acute sector, seems at odds with
the real agenda, your agenda, which has been successfully perceived,
in my view.
(Mr Milburn) I am glad that you said that but this
is not the only policy on the table, is it? As I was trying to
emphasise in relation to Simon's question, it is one important
policy.
447. It is, yes. You would accept—let
me make the point, it is important to make the point—one
of the failings, I think we would both accept of the NHS in the
last 54 years has been that it has emphasised the acute sector
at the expense of other areas. It appears you have recognised
that you have gone in one direction, in my view very successfully,
with PCTs and a lot of work in the community and alternatives
to admissions and a whole range of initiatives which I welcome
and then suddenly we move in a completely odd direction to reinforce
the importance of the acute sector. As far as I can see, looking
at your document, largely in isolation from the other sectors
that you recognise are so important to what happens within the
community.
(Mr Milburn) It is a fundamental misreading of the
document, with respect, because I think you know that within the
document there are very, very powerful levers that link the acute
sector to the primary care sector and to the broader community.
I think you would have a very good point if this was the only
policy that we were advocating; it is not. Primary care trusts
are an absolutely crucial part of the architecture and we want
to strengthen that. The reason, for example, that we are introducing
HRGs and new forms of financial flows in the National Health Service
is precisely to strengthen primary care and primary care services
so that commissioning works. I will tell you, on commissioning,
where the commissioners are weakest is when they have got to negotiate
prices and that is always going to be the case. Certainly international
evidence from the States and elsewhere seems to suggest that if
you move to an HRG model which is in parallel with the other changes
that we are making, then the consequence of that is better utilisation
of hospital beds, lower length of stay and consequentially more
investment in community services.
Chairman: I am going to bring in Julia and Simon,
very briefly please, and brief answers from yourself, Secretary
of State.
Julia Drown
448. Is it not illogical to say that the acute
trust, should, for example, be able to expand in the community
and provide more mental health facilities so they do not delay
discharges of people with mental health problems and not allow
the mental health trusts to have those freedoms to do so?
(Mr Milburn) I want to do that.
449. So you are doing it?
(Mr Milburn) We are not at the moment. With mental
health trusts we did what I think most people would say was a
pretty rudimentary first assessment last time round with the star
ratings. If you think that we have got difficulties in assessing
the performance of acute trusts, and you do have, as I said to
Richard, that is nothing in comparison to the assessment of the
performance that currently we are able to make for mental health
trusts.
450. They are not being invited in round 2 either.
(Mr Milburn) I think that in the future there is absolutely
no reason—and we have got to get the timing of this right,
and I have taken no final decisions about it as yet—why
foundation trust status should not be available to mental health
trusts.
451. But not in the first and second wave. Thank
you.
(Mr Milburn) I did not say anything about the second
wave, not until this first wave. I have not taken any decisions
about second waves.
Mr Burns
452. Can I ask: does it mean that foundation
trusts could develop joint projects with GP practices as well
as PCTs?
(Mr Milburn) Absolutely.
453. Thank you.
(Mr Milburn) Without the need for any prior approval
from me, they can just get on and do it.
Siobhain McDonagh
454. Recent research from Bristol University
has argued that introducing competition into the NHS damages quality
and may have contributed up to 4,000 extra deaths from heart attacks.
Although the new reforms introduce competition over capacity and
volume rather than price, it is competition nevertheless. Given
the problems associated with the internal market, why have competitive
reforms been reintroduced?
(Mr Milburn) I was not responsible for the internal
market. I was responsible for abolishing it so you will have to
ask others the questions about the consequences of the then policy.
What is right in my view is to try to get the balance right in
terms of the levers that you pull in any health care system. As
I say there is compelling evidence from World Bank studies and
from all the international evidence that we know that a one size
fits all approach to policy, never mind a one size fits all approach
to health care structure does not deliver you improvement. Of
course you are going to have national standards, and we have done
a lot on that, and we have put a lot of architecture in place
to help make that happen, whether it is national service frameworks
or NICE or the Commission for Health Improvement, but what you
have to have, also, in my view, is you have to have appropriate
incentives in the system. Without appropriate incentives, without
better engagement of staff, without decent relationships between
the community and local services, you just do not get improvement.
As I say, it is about how you calibrate all of these things. What
depresses me is when we have a reductionist discussion and we
pretend that all that is happening are NHS foundation trusts or
all that is happening is some element of contestability or some
element of patients exercising choice. It is not any of these
things by themselves which in my view will result in improvements
in services, it is how you get all of these levers working in
tandem that gets you the improvement. For example, I just think
that if we are really going to have a service that is centred
on patients then patients within the National Health Service are
going to have more choice. There is choice at the moment, if you
can afford to pay, you can just opt out, some—our political
opponents—would love for more people to opt out of the National
Health Service. I do not want that to happen, I want people to
stick with the NHS but in order to do that they have to have some
choice.
455. It is reintroducing a form of competition?
(Mr Milburn) I do not think it is about reintroducing
a form of competition in the way that people describe it. People
always say this is about the reinvention of the internal market
and clearly it is not. The internal market was competition based
on price, that was what happened, people competed on price. It
is not about that. However, I think it is quite right that both
primary care trusts, as the commissioners of services, and most
importantly of all, individual patients as the recipients of services
have some choice about where they get their health care from.
I will tell you if it was me and I wanted to have a heart operation,
I would want to know what the quality of care was like, of course
what the waiting time was like and what the appropriate outcomes
were like in different providers because sadly we do not have
uniformity in provision. Sometimes we pretend as if we do, we
do not have uniformity in provision. If people want to talk about
tiers, we have many tiers and in the end I think you can only
get performance improved if you get the right combination: standards
from the top but also the patients, the people who actually use
the services, exercising some discretion because that brings some
pressure on the system as well.
Sandra Gidley
456. Can I pick up on this choice because if
foundation hospital trusts work well then I can foresee that if
they bring down their waiting lists and do all the other innovative
things that they are supposed to do then patients will want to
vote with their feet. I come back to your answer to Jim Dowd earlier,
how do you stop patients from doing that and also ensure that
the second/third choice hospitals retain their funding streams
because the funding is going to follow the patient. You said there
is a statutory duty of partnership, where does patient choice
come into this? If lots of patients do vote with their feet funding
streams are not guaranteed and where does that leave the lesser
performing hospitals?
(Mr Milburn) Why should I want to stop patients exercising
choice? Why on earth should I want to do that?
457. Can you say where this statutory duty of
partnership comes in with the PCTs then if they are referring
people? I am not clear on that. It seems to be mutually incompatible.
(Mr Milburn) No, it is not. I think sometimes there
is a naive belief, I am not saying that you have it. Notwithstanding
that point, I am not saying that Sandra has it at all, but I think
sometimes there is a naive belief that if you fire a single silver
bullet in an organisation as complex as the National Health Service
that automatically gets you improvement, it does not at all. For
example, choice in my view would be a disaster for emergency care
and indeed one of the principal reasons why the naive internal
market failed was that the assumption of the then government was
that you could treat emergency services in the same way as you
treat elective services. At its most simple: if you are in the
back of an ambulance after a road traffic accident, the last thing
that you want to be asked is your choice of which A&E you
want to go to. You want to go to the nearest A&E. It is different
for elective surgery because you can make a positive choice about
that. Women make choices today about maternity services in this
city. When I visited St Thomas's just a few weeks ago I opened
the new Women and Children Centre which is brilliant, I met a
group of mums who had just had their babies. I asked each of them
how they got to the hospital—not by which means of transport
but how they decided to go there—each of them had made a
positive choice to go there. They could have gone to another hospital,
they decided to go to that one because they heard it has a good
reputation, it is very women centred, there are lots of midwives
providing midwife care and so on and so forth. If that is right
for maternity services why is it not right for elective surgery
services? It seems to me there is absolutely no reason why you
should not be able to do that as capacity grows.
458. I am not saying it is wrong but what is
the consequence for the other hospitals? The one star and two
star trusts neighbouring the other trusts who are losing their
patients, losing their funding stream, will find it increasing
difficult to turn it round.
(Mr Milburn) It might make them sit up and take notice.
It might make them get focused on improving quality. Nobody, with
respect, none of us has got a God given right to be Members of
Parliament, we earn that right. No public service has got a God
given right to provide services. It has got to earn that right
because either we believe in the language of patient sentiment,
either we believe that these services should be designed around
the interests of patients, either we believe that the people who
come first in public services are the people who are on the receiving
end of them or we do not. My job is to make sure as Secretary
of State for Health that what comes first is the interest of the
patient. I actually believe that where you have the right incentives
in place in the system, what it leads to is improvement across
the piece. Now I think your worries about NHS foundation trust
status would be perfectly reasonable worries if it was the case
that what is sometimes written in the newspapers is right, ie
that we are going to have an elite few up here and then we are
going to have second rate services down there. That is not the
Government's policy, it might be others' policies but it is not
mine. What I want to see is a level playing field and I am determined
that over the course of a four or five year period that is what
we will have.
459. Can I just finish up. I do not really think
that the fundamental point has been answered because there will
be some people who cannot travel and most people who exercise
choice travel.
(Mr Milburn) Absolutely.
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