Select Committee on Liaison Minutes of Evidence

Examination of Witness (Questions 40-59)



  Q40  Mr Barron: The central targets inside the National Health Service, it would be churlish not to say that the issue around waiting lists and waiting times, particularly for orthopaedic surgery and others, have been a success and they have certainly moved them. When the Health Select Committee was taking evidence last year in relation to the current deficit situation one thing that struck us was the central target on A & E waits of four hours—98% was the actual figure that people had to meet. We were told by several NHS Chief Executives that the movement from 95% to 98% was a very expensive figure to get that last 3% of the target. The real question is: why did we say it was 98% and not 95%? Was this evidence-based?

  Mr Blair: It was really to try and get the last bit of it done so that you really had that quantum shift in improvement in the accident and emergency services. Although, to be fair, what you have heard and I have heard myself from people who work in accident and emergency departments, as we refine those targets, moving forward, which we will do in the years to come where we have a different system operating in the health service anyway, then I think we can probably take account of some of those worries. Accident and emergency is a very good example of where, whatever people say—and there is a report from someone today saying that the targets are all fiddled—the best judgment on accident and emergency is anyone who has experienced accident and emergency today compared with 10 years ago, and it is significantly better—significantly better. I do not think that that would have been achieved without a central performance driven target backed up, of course, by the work that we had, which is the modernisation team that went to each accident and emergency department, and who said, "Here are the changes in practice that you can make." I remember the meeting in Downing Street several years back when we decided to establish that way of doing it because I was saying to people, "This is absurd. If your accident and emergency department handles millions of people a year it is, if you like, the shop window of the NHS, and since there are accident and emergency services that work well we have to be able to make that work in all different places." I think if we had not had that sentry-driven approach in this instance we would never have had the quantum shift in improvement that we had. The interesting thing is that when the BMA were attacking us on accident and emergency services a few weeks ago in parenthesis they said, "Of course, the service has been transformed over the last 10 years."

  Q41  Mr Barron: Do you think then that this top-down setting of targets in areas like this, given that there has been improvement, is the way forward for the future, or do you think that we should have local made targets in terms of what should be happening in healthcare?

  Mr Blair: That is a very good question. I think it depends on what area you are dealing with. I would say that in certain areas—cancer, again, having a central target helped. I do not believe we would have got the big changes in waiting lists if we had not gone from 18 months down to 12 months down to nine, down to six. But given that there is a virtual revolution in the financial accounting within the health service that is going on now, I think it will allow us in time to minimise the central targets and to have what I call a more self-sustaining set of changes in the system. Because the money is following the patient, patients will have greater choice, there will be incentives for GP services and primary care to pull things back out of the acute sector. The basic problem in our healthcare system, but also in healthcare systems around the world—incidentally, there is no country you can go to where there is not a raging debate about the state of their health service because you have growing numbers of elderly people, masses more cures and treatments, new technology, increasing demand and expectation—and the thing that comes out of all of them is how you get the most appropriate care in the most appropriate setting. If you ask any accident and emergency consultant they will tell you that probably half of the people who go to their A & E should not really be in A & E. If you look at the numbers of people who are going into hospital because they have a chronic condition which could be managed outside the hospital it is a very significant number of the hospital beds that we have. As you improve the numbers of people who have day-case surgery and so on you will find a big, big change, and what we have to watch is that there is a proper alignment between the central targets and the reality of very diverse local provision driven by local need. I agree that that is the big question for the next Comprehensive Spending Review certainly over the next few years for Government.

  Q42  Mr Barron: Would not the logic say, given that patient choice currently is informed in terms of waiting times at the hospitals that are on offer, as it were, that patient choice is going to take over from this national target setting and it will be the patient who will decide, on the basis of what is on offer locally, where they are going to go and not necessarily the National Health Service or Richmond House telling them what targets they should work to?

  Mr Blair: I think you are absolutely right. In years to come that is where you want to get to, but you are a way off it yet. I do not think we should underestimate what has been achieved in the health service over the past few years. Indeed, what I thought was interesting about the Today programme's set of analyses of the health service is that what began at the beginning of the week as "Where has all the money gone?" at the end of the week was, "Are the improvements enough?" There is no doubt at all that the health service has improved and improved significantly. I think you are right that going forward the question is that when you introduce a new financial system, which we are doing through payment by results, when you have practice-based commissioning on an across the board scale and when you have patient choice, when these three parts of the new system are embedded then the degree to which you need central targets will be significantly diminished. It is just that you are a way off that yet, and my fear is that if you withdrew the central pressure at the moment the system would start to retreat.

  Q43  Andrew Miller: The Review Paper talks about empowering consumers and reshaping Whitehall and in the Transformational Government review published a couple of weeks ago it refers to a delegated committee for developing information sharing across the public sector. The DWP in fact on 15 January made a statement about this. It is an important structural change in the way that Whitehall works. What guarantees will the public have that their data will not be improperly accessed and how do you envisage a rapid procedure being developed to ensure that errors in databases can be corrected?

  Mr Blair: We are looking at this across Government now and Hilary Armstrong is chairing the relevant Cabinet committee on it. This is a really important question but I do think we need a better public debate about it. It will be possible for people to object to their details going on the electronic patient record, but let us be under no doubt at all that an electronic patient record across the National Health Service has the possibility of immense improvements in service and savings lives. Of course you have to have proper safeguards but I find this really quite a curious situation. We think of this "Big Brother" thing coming in with an electronic patient record and using the new technology, when what it is going to mean, very simply, is that if, for example, you are taken ill in a different part of the country from where your GP is you can access immediately the details of somebody's health care—what drugs they may need or want to use—and it can hugely speed up both the quality of care and, potentially, the difference between the care being appropriate and therefore saving someone's life or not.

  Q44  Andrew Miller: Beyond health, what about departments like the DWP?

  Mr Blair: Again, it depends on what information is there, but I think it is sensible for us to share as much information as possible, subject to proper safeguards.

  Q45  Andrew Miller: How do you see the citizen having the right to correct errors that appear on this database? After all, human error occurs.

  Mr Blair: Of course, and I think the very thing that we are looking at now is how do you make sure that if an error is discovered that it is corrected as soon as possible, and also that the individual has maximum transparency of the information that is held on them? I find this curious, for example, in the context of the whole identity card debate because the actual information on the identity database is basically what is on your passport—it is not a great deal of information, the average store card has more information; and also if you take Google Earth now and what it can do in terms of going down the street in which people live. Someone was saying the other day that Government is creating this great new database with this massive information on individuals, and we are not. The technology now exists to be able to share data in order to give people an improved service; for example, many people will now do their car tax on-line—it is a better way to do it. I think provided that there are proper safeguards—and we do need to make sure it is subject to proper debate and proper scrutiny—then it would be bizarre, when in every other walk of life the technology is being used to enhance service, that in the public service we have put down a barrier.

  Mr Willis: The issue of human rights, Prime Minister. Andrew Dismore.

  Q46  Mr Dismore: Prime Minister, if someone dies in custody because of a gross failure in the management system to protect him should the prison service or the private prison company be held accountable through the Corporate Manslaughter Bill?

  Mr Blair: This is the debate we were defeated on in the House of Lords last night and we will take it away and look at it again. Let us see what we can do. The worry here is if you apply corporate manslaughter in these particular circumstances whether you end up causing a real problem for the way in which the prison or the custody system will work in respect of people who can, obviously, from time to time, pose a real threat to the people who are trying to restrain them. I do not think I will say any more about it than Patricia Scotland said last night, which we will look at.

  Q47  Mr Dismore: One further point on that. There have been various suggestions—quite strong suggestions—behind the scenes that if parliament decides that it wants to have this in the Bill the Government would withdraw the Bill rather than allowing that to go ahead. Could you dispel those suggestions now for us?

  Mr Blair: I have not heard that, I must say. No, I think it is important that we have the Bill but we are going to have to make up our minds on this. Our desire was to try and accommodate reasonable opinion as much as possible; it is just that, as often happens in government, we have two very diametrically opposed views as to what the right thing to do is and we need to try and make a balanced judgment about it.

  Q48  Mr Dismore: Due to the uncertainty of what is a public authority under the Human Rights Act is privatisation and contracting out not undermining the protections of the Act for the most vulnerable people, like the elderly and disabled, placed by councils, for example, in private sector care homes?

  Mr Blair: I do not think so because I think that anyone who is providing a public service is clearly subject to the same rules, but I think that this issue to do with the delivery of service is one of the main things that will come out of the Policy Review. I think the emerging conclusion is that we need to go even further in breaking down the barriers between the public, private and voluntary sector. I, for example, think that the voluntary sector can play a hugely enhanced part in delivering services, for example for offenders and offender management—it is a big debate for people—but I do not think that using the voluntary sector in this way would in any shape or form displace the basic protection of people.

  Q49  Mr Dismore: The problem is that decisions of the Court of Appeal have made it clear that the Human Rights Act does not apply, for example, to private sector care homes, and the only way it can be done is very indirectly through local authority contracting. Is that not something we need to deal with through either winning a case, which we have so far not been able to do, or, alternatively, amending the Bill to clarify that this is what applies?

  Mr Blair: I think you are right in saying that there is an issue there. The way to deal with it is to make sure that public and private bodies are treated the same when they are providing a public service, rather than stopping the private body or the private group, whether it is voluntary or independent, having a role in the delivery of services.

  Q50  Mr Leigh: Good morning, Prime Minister.

  Mr Blair: Good morning, Edward.

  Q51  Mr Leigh: I am a Conservative, so relatively speaking I am a friend of yours this morning!

  Mr Blair: Thank you!

  Q52  Mr Leigh: You talked about the voluntary sector to Andrew Dismore just a moment ago, and clearly you want to increase the role of the voluntary sector. The trouble with the voluntary sector is that it is heavily dependent on faith groups, and the inconvenient thing about faith groups is that they have strong opinions. Do you agree, for instance, with Archbishop Vincent Nicholls when he said, "Those who are elected to fashion our laws are not elected to be our moral tutors and the wise among them would not wish it either." Do you agree with him?

  Mr Blair: I think that the faith-based agencies, for example in relation to adoption, do fantastic work, and that is why we have set this two-year period, effectively, and an independent assessment of how we make sure they carry on their excellent work. But there is a problem, if I can service it very openly, which is that I certainly believe that we should not discriminate against people on the grounds of their race, their gender or indeed their sexuality. So the question is, how do you measure those things up in circumstances where a faith-based agency—and I totally understand the reasons for that—say, "We have a conscience objection" to, for example, adoption by gay couples. We are trying to find a way to make sure over this next couple of years that the catholic adoption agencies carry on their excellent work—as they do excellent work and are very dedicated people—but at the same time you remove discrimination. These types of debates are always difficult but if people are sensible enough we can find a way through it. It may be by having consortiums, for example, and there would be a gateway into adoption which would allow this issue to be taken care of, because I think it would be a tragedy if those adoption agencies did not carry on their good work. But I also think, personally, that we do not want a situation where we are discriminating against people on the grounds of their sexuality.

  Q53  Mr Leigh: So discrimination trumps conscience in this regard?

  Mr Blair: It is not that it trumps conscience, but supposing—and I am not suggesting this for a single moment—that you had a particular group that said for various reasons they believed that women were not suitable to do various things? It is very difficult. These are areas where you are absolutely at the cusp of what are difficult judgments that we all have to make as law makers and I tend, myself, to try not to take an absolutist view. But I could not in the end justify a situation where you would discriminate, where you effectively say in legislation that you are going to allow discrimination.

  Q54  Mr Leigh: Could I just stop you there? I agree with you entirely, but then why in the 10 years that you have been Prime Minister have you left on the statute book a blatant piece of discrimination which says that if any member of the Royal Family marries a Roman Catholic then they should be kicked out of the Royal Family? Why have you left it on the statute book?

  Mr Blair: Good point, Edward!

  Q55  Mr Leigh: Is it not state organised hypocrisy in this regard?

  Mr Blair: I think it is terrible, terrible!

  Q56  Mr Leigh: Do something about it then.

  Mr Blair: Absolutely. When we come to talk about the 10-year legacy we can pick that out as a major omission. These are questions that I think people of goodwill can find a way through. Most people in our society today do not want to discriminate against people on the grounds of their sexuality, and I may say particularly in circumstances where the catholic adoption agencies do have a policy of allowing adoption by single gay men. So I think in those circumstances how do we make sure that the principle of discrimination is protected and the children that desperately need this service are also protected? I am committed to finding a way through it. I actually believe, away from all the thunder of the public debate, that we will find a way through this that will allow these adoption agencies to continue their work. For very obvious reasons I happen to believe that faith is a good not a bad thing, so I think in the end we never want to reach a situation where people who do have a religious faith feel in any sense that they are being shut out of either the political system or being able to provide a great service to people in a faith-based way.

  Q57  Mr Willis: Prime Minister, I think we will return to the Act of Settlement a little later. I think it needs a longer session!

  Mr Blair: I was just thinking that it might be something for my successor really! It is a useful one to leave around!

  Mr Willis: Dr Wright.

  Q58  Dr Wright: Prime Minister, the Strategy Review is a very good thing, in my view, and it has some chance of lifting the quality of public debate. I think you are to be congratulated for it. Could I test one of its assumptions? It talks about the state and it says in one of its conclusions that a range of pressures will require a new role for the state. What I would like to know is do you think that that role is going to be bigger, smaller or about the same size as now?

  Mr Blair: I think it will mean a smaller centre but when the state moves to what I would call a more strategic role I think it has two implications: one, that you distinguish even more between the state as commissioner and the state as provider—in other words, you open up a diversity of supply in public services. That is why you have a new system in the health service with independent providers; why you have a different range of schools, Trust Schools, City Academies, Specialist Schools, et cetera; and why you involve the voluntary sector and the independent sector more in the provision of services. So it has that implication, and the second implication is that within Whitehall itself we need a far greater focus on what I will call the delivery of project management skills, rather than the traditional policy adviser.

  Q59  Dr Wright: But those are to do with how the state organises itself. What I am asking you is, at the moment the state takes about 42% of GDP. The evidence from this Review shows that the pressures on the state are getting bigger all the time; the expectations are getting larger all the time. What I am asking you is, does that mean that the state itself gets bigger, or does it mean that we ask people in the future to pay for things that they do not pay for now?

  Mr Blair: That is obviously a very good question. That is not so much how the state organises itself, but you mean the actual overall public spending as a proportion of the national income? I do not have in my own mind—people have in politics over the last 30 or 40 years, and I remember Roy Jenkins famously doing it in the 1970s—a particular figure that is the right figure or approximately the right figure as public spending as a proportion of GDP. Supposing we even wanted to keep it round about where it is now but deal with the pressures for the future, then I think it will mean that we have to change what government spends its money on. Let me give you an example. I do not believe that we will be able to provide our pensions or public services in the future unless we raise significantly the proportion of people of working age in work, probably getting it up to 80%. That will mean, for example, that when we publish David Freud's Welfare Reform Programme, which we will do probably at the end of this month or early next month, there will be some quite difficult proposals in relation to how people come off benefit and into work—lone parents, people on incapacity benefit and so on. That is one area, if you like, in which we are going to have to look at how we rebalance what is almost a generational compact between those of working age today and those who are going to be pensioners in the future.

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