Again thanks to a selfless Health Policy Insight reader for their labour, we can bring you a transcript of Our Saviour And Liberator Andrew Lansley's appearance on BBC News Hard Talk.
Sarah Montague: [to camera] England’s National Health Service, the NHS, is one of the largest employers in the world. It is a huge organisation. But then its job is to provide free healthcare to the whole population. And, for all its faults, it’s something British people are immensely proud of – which is why the British Government’s plans for the biggest reform in its history have become hugely controversial. My guest today, the Secretary of State for Health, Andrew Lansley, wants to hand control of 80 per cent of the NHS’s budget in England to family doctors, so that they, rather than bureaucrats, can decide where the money goes. Will it work? Or will it sink both the NHS and the Government?
[to Andrew Lansley ] Andrew Lansley, welcome to HardTalk.
Andrew Lansley: Thank you.
Montague: Why will the new system, what you are proposing, be better than what is in place now?
Lansley: Well, I think the first thing I should say, so we’re absolutely clear about this, is that there are things which are absolutely central to the values of the National Health Service and which will not change – that it is a comprehensive healthcare service, that is provided to everybody, that it’s free, based on their need and not on their ability to pay. That’s something which we believe in that is going to be sustained. But the reforms that I published – now what is it? – six months ago, just over six months ago, what they are intended to do is to combine that sense of equity of access to healthcare services, which is valued and envied across the world, with an expectation that we should also deliver excellence. It’s not good enough that we provide a uniform Health Service. We need to provide an excellent healthcare service. So this is really focused on delivering the best possible outcomes, the best results for patients. And that issue, right at the heart of this, is about making the service much more responsive to patients, making those who deliver care, particularly at the front line, more responsible for the care they deliver and delegating, decentralising the day-to-day control of resources to deliver those better results.
Montague: And the Chief Executive of the NHS, David Nicholson, has described what you do – what you are proposing as “so big you can see it from space”. Because what it will mean –
Lansley: He has a turn of phrase, doesn’t he?
Montague: [laughs] Well, in a sense, I mean it’s – what’s surprised so many people is the scale of it. We’ve got, what, £80 billion of the NHS’s –
Lansley: Nothing in the NHS is small. And it’s not – in that sense, we are dealing, as you rightly said –
Montague: Sure. Nothing –
Lansley: – we are dealing with a very big organisation.
Monatgue: But it’s 80 per cent of the budget. The budget is £100 billion and £80 billion of it will be handed from bureaucrats, from managers, to GPs.
Lansley: Well, I’ve always been clear that we – what we have to do is to have a service that doesn’t have day-to-day political interference. I mean, people watching us in other countries, they’re not going to be thinking, you know, well, it’s normal for ministers, health ministers, politicians to be deciding day-to-day issues about what services should be provided. Actually, they say what’s normal is for doctors and nurses and health professionals to be responding to the needs of patients. That’s the more normal thing. And in the NHS, yes I am talking about devolving decision-making into the NHS on the basis of an agreement between the Government and the NHS – a mandate, as it were, about what services should be provided, what objectives should be achieved and how they’re to be achieved with those resources.
Montague: And what it will –
Lansley: But the decision-making will be both at a national level for some services and at a local level through General Practices, family doctors working together in local commissioning groups.
Montague: So – and what it will mean is – you have 152 Primary Care Trusts at the moment, which is part of the architecture of the NHS –
Montague: – and Strategic Health Authorities, both of which you are going to sweep away, to be replaced by GP consortia.
Lansley: Well – which in many places already exist and indeed I –
Montague: Because –
Lansley: I inherited –
Montague: They exist because you had heralded that you wanted to do this. They’ve been rapidly being set up –
Lansley: No, no. They existed in part because the previous government thought that what they described as Practice-Based Commissioning, commissioning by General Practitioners, was a good idea. They just didn’t make enough progress on it. So I inherited 900 local commissioning groups, 150 Primary Care Trusts, ten Strategic Health Authorities, dozens of additional national bodies – and, yes, I am going to sweep them away. I’m taking a lot of management, and tiers of management, out of the system, which, frankly, is one of the things we do have to do anyway, regardless of all of this.
Montague: But what are you replacing them with? Because when we look at the GP consortia, 141 have already been set up –
Montague: – and that covers about half of the country.
Lansley: Just over half.
Montague: So the implication would be that there would be, what 300 GP consortia?
Lansley: Well, I can’t say, because it depends upon how the consortia come forward.
Montague: But 141’s covering half the country. And what it’s led people to suggest is that you’ve – with massive job losses and huge reorganisation, got rid of Primary Care Trusts – a few years ago there were 300 of them – and you’re replacing them with 300 GP consortia, many of which will have to employ managers to do the job that was being done by the Primary Care Trusts.
Lansley: Well, leaving aside the use of adjectives, the point is that they are substantively different, because the whole difference is between local commissioning organisations that are led by clinicians, by doctors and nurses – General Practice – yes including General Practitioners – where, actually, in this country we have by international consent in the family doctor service something which has a real impact – positive impact on the care that we deliver to patients – it just, actually, over recent years has been continuously eroded by a top-down system of managerial control. So I am planning to take –
Lansley: You say it’s all about cost –
Montague: But, but –
Lansley: – but actually –
Montague: No, I didn’t say it was all about cost. I’m –
Lansley: But “at great cost”, you said. Well, frankly, we know it’s going to cost us £1.4 billion to make those management changes –
Montague: OK. But I wonder why –
Lansley: – but it will save us £5 billion in the next four years alone.
Montague: – Dr Clare Gerada of the Royal College of GPs said you could have put more GPs on the Board of Primary Care Trusts and achieved largely the same results.
Lansley: No. Well, that’s simply not true.
Montague: You could have made management savings but without all the upheaval that the NHS is going through.
Lansley: No. Well, that’s not true, because –
Montague: She’s wrong?
Lansley: – actually we wouldn’t have made those savings. And we wouldn’t have given those resources to General Practitioners to manage. And, frankly, what we’re doing is not the same thing as just putting GPs on the Boards of their local Primary Care Trusts. We are making them responsible for commissioning services, in the areas for which they have expertise.
Lansley: But, for example, all the public health –
Montague: You will know –
Lansley: – responsibilities are transferring to local authorities.
Montague: OK. But you will know –
Lansley: And I don’t want that left out –
Lansley: – because, remember, democratic accountability is important in all this and we haven’t had a service which has locally been as democratically accountable as it ought to be.
Montague: The Royal College of GPs, who I mentioned, said that they fear your reforms could cause irreparable and irreversible damage to the NHS.
Lansley: They supported the reforms.
Montague: The British Medical Association –
Lansley: Go back. No, you can’t quote a bit–
Montague: I want to – look –
Lansley: – and leave out everything else they said. They supported the reforms and the White Paper.
Montague: There are many people who support the objectives of what you are doing –
Lansley: Fine, yes.
Montague: – and the principle. But you will know – and this isn’t just me selectively picking quotes – you will know that there is widespread concern about the timing, the scale and the speed of these reforms, at a time when there are efficiency savings being pushed through the NHS.
Lansley: Well, what I know –
Montague: Which is why the British Medical Association say “much that we hold dear about our profession and NHS is deeply threatened”. The Royal College of Nurses – the midwives, the Royal College of Midwives – there are many, many people throughout the –
Lansley: But, Sarah, I could produce you a list of quotes that are equally – from many of those same organisations – that are equally supportive of what we’re setting out to do. And equally I could give you a list of organisations that are supporting the fact that we need to get on with making these changes. Because, I mean, let’s talk about General Practitioners. You know, back in October I said to General Practices across the country that those who wished to could come forward and be, in effect, the Pathfinders for this. I didn’t expect very many at that stage. I thought perhaps 10 per cent of practices across the country would come together and put themselves forward. A quarter of the country did that. And then so many –
Montague: You’d given them a deadline of next year that they’re going to have to be in a consortium.
Lansley: No, no. I said if they wanted to come forward by the end of November, and a quarter of the country came forward by November. By January – half the country. And there are more now who are doing the same.
Lansley: And I invite you, you know, and people watching this to realise that across England there are local groups, not only General Practices coming together, but they’re working together with their local authorities, and they’re working together with their local health and community services, hospitals and in the community, and they’re already putting in place some of the changes that are really going to make a difference. Because actually –
Lansley: – when we need to save money in the NHS in order to reinvest it, to meet rising demand, we need these things to happen quickly, because designing better clinical services needs to be led from the front line if it is going to be really effective.
Montague: You will know that public satisfaction with the NHS at the moment is at an all-time high. I mean, when Labour government came in back in ’97, there was something like a third of people were satisfied with the NHS. That’s doubled to two-thirds, which has led many people to wonder why you’re making the changes. What’s wrong with the NHS?
Lansley: No, I’m not doing it because the NHS is all wrong. I’m doing it because there is clearly a need for us to meet international benchmark standards of healthcare and some of the best results that people –
Montague: That we don’t meet now?
Lansley: That we don’t meet now. For example, we don’t meet European levels of cancer survival rates. We don’t – in this country you’re twice as likely to die of a heart attack as somebody in France. That we don’t have early diagnosis of dementia to the extent that we should. That we don’t – we have –
Montague: The trouble is that –
Lansley: – rising levels of liver disease and many other countries have falling levels.
Montague: – those stats that you’ve used on both heart attacks and cancer rates have been challenged, not least by Professor John Appleby of the King’s Fund, who’s said “look, you’re putting this data forward as evidence of a requirement for change”, but he says that the data challenges your justification for reforming and he talks about, for example, heart attacks: “heart attack deaths have halved since 1997 and, at current rates of improvement” – which have been improving for 30 years – “the UK will have a lower death rate from heart attacks than France –”
Lansley: Well, the point is –
Montague: “– which is at the top of the European league table.”
Lansley: Actually, to be fair to John Appleby, he wasn’t, in a sense, saying anything we said was wrong. He was saying if you extrapolate into the future, we will close the gap on heart attacks.
Montague: Next year. By next year.
Lansley: No, actually, I mean – well, he can say what he likes. But the point is, we don’t have, on the latest data –
Montague: Well, the data shows –
Lansley: – we do not have levels of mortality from heart disease as good as the best in Europe.
Montague: – we will be better than France next year.
Lansley: On cancer survival rate, the latest data from Eurocare 4 shows that we are significantly behind.
Montague: Well, hold on.
Lansley: Before the election, the last Labour government said – they said in terms – in their cancer strategy they said “we don’t have anywhere in England that has cancer survival rates for the most common cancers that are as good as average in Sweden”.
Montague: But Eurocare, who you mention – their data supports the same findings as the Office of National Statistics, which says that five-year cancer survival rates improved for nearly all cancers between 2001–2006 and 2003–2007.
Lansley: Uh-huh. Improved, yes. But I didn’t say they didn’t improve. I said we haven’t closed the gap with Europe as we should. And the point is we ha – we are investing more and we’re right to invest more in this country. We did have, if you go back 10–15 years, we did have a significant, a major gap between the level of expenditure on healthcare in the United Kingdom and the level of expenditure on healthcare across the average of Europe.
Montague: Do you accept –
Lansley: We now meet European averages in terms of expenditure, but we don’t meet European averages in terms of results.
Montague: We’re still way below France. We’re actually in – as far as cancer for men, we’re – as far as cancer – death rates for lung cancer in men are now lower than France, and we spend far less than France.
Lansley: But we – but our levels of mortality overall are significantly higher than European average. I mean, take – John Appleby was quoting OECD data –
Montague: Do you accept they’re improving? Do you accept the trends are improving?
Lansley: Look at the OECD data – and there’s a particular measure they use which is mortality amenable to healthcare, which is a very good measure of where people would not die if they had best practice healthcare. And on that basis we are – we would have several thousand lives saved if we met European best levels of –
Lansley: – avoiding mortality through best healthcare. These are the kind of measures we have to put in place.
Montague: OK, well let’s move on to one of the things that will be changing. There’ve been significant reforms to the NHS and in the past decade, competition – past – recently competition was brought in, but always on the basis – or at least recently – on the basis of a set price, which was the NHS tariff. Now you are proposing effectively to get rid of that and to introduce price competition.
Lansley: Well no, actually, strictly speaking, Sarah, that isn’t true, because most of what is purchased in the NHS, that we inherited, wasn’t purchased on the tariff. Only sixty per cent of hospital activity was purchased on the tariff and virtually nothing –
Lansley: – well, nothing in mental health and nothing in the community.
Montague: But you’re getting rid of the tariff – or you’re largely getting –
Lansley: No, I’m not getting rid of the tariff at all.
Montague: But you’re introducing –
Lansley: I’m extending the tariff. I’m making it clear to people.
Montague: OK. Well, you’re introducing more – let’s be clear, you’re introducing more price competition?
Lansley: No. I’m introducing – strictly speaking, I’m not, actually. Because the last government –
Montague: Then why does the Operating Framework say –
Lansley: Because the last government put it in their Operating Framework in December 2009 and I haven’t changed it.
Montague: Well, the Opera –
Lansley: So I’m not introducing more price competition.
Montague: – the NHS Operating Framework, just published –
Lansley: On the contrary –
Montague: – says “one new flexibility being introduced in 2011–12 is the opportunity to” –
Lansley: It was set out –
Montague: Let me finish it so that people could know what we’re talking about – “opportunity for providers to offer services to commissioners at less than the published mandatory tariff price”.
Lansley: Yes, which repeats what the previous government said would happen in 2011–12 in their Operating Framework, published in December 2009.
Montague: OK. Well –
Lansley: I didn’t introduce it at all. I mean, the point – what I am introducing –
Montague: OK. Could you –
Lansley: I’m trying to tell you what I’m introducing.
Montague: Please do.
Lansley: I’m introducing a tariff, the purpose of which is increasingly to develop it so that the people who are responsible for commissioning services can get the design of services with the quality of services they’re looking for.
Montague: Hold on. You’re introducing a tariff: does that mean that providers of healthcare, be they private, NHS, from charities, can come in and come up with a lower price?
Lansley: Not necessarily, no, because if the commissioners think –
Montague: But for any – in anywhere within –
Lansley: Well, I’ll answer the question, Sarah, if you’ll give me two seconds! If any of the commissioners think that they can meet the quality that they want best by establishing a fixed price and then asking those who want to provide services to them to meet that quality, the quality they’re looking for, or exceed it, they can do that. There is nothing in what I’m bringing in that requires commissioners – requires those who are providing services to do so on the basis of competition on price. What I am doing, which I think is much stronger than what the previous government did with the NHS, is giving patients greater choice and, of course, patients will choose on quality, because they receive the service free. The General Practice consortia – they will be incentivised to deliver improving outcomes, they’ll have a duty to improve standards and to focus on quality. So they are incentivised for quality. And there will, therefore, be a competition, yes, but a competition on quality, not on price. Quality is at the essence of this.
Montague: So the new body, Monitor, which is the economic regulator –
Montague: – which – part of its role is to promote competition.
Montague: And part of its role –
Lansley: Where appropriate, yes.
Montague: And part of its role is to set efficient prices or maximum prices. If a private provider wants to provide a service to a GP consortia at less than that GP consortia is currently paying for it, can they go to Monitor and say “look, this isn’t fair”.
Lansley: No, no, because actually the commissioners, collectively, through the NHS Commissioning Board, will themselves have decided whether they want to set a fixed price, or a standard price, or to allow for price variation – which actually could be higher or lower, depending upon which was in their best interests, because, remember –
Montague: So there will be some –
Lansley: – some services to be maintained – the so-called designated services – to be maintained, where they are essential to meet patients’ needs, might attract more than the standard price because actually they might be in circumstances where it costs more to deliver that service.
Montague: OK. So do you expect there to be price competition – more price competition than there is now?
Lansley: Not necessarily, no.
Montague: Not necessarily.
Lansley: Why should there be?
Montague: Well I –
Lansley: Because, actually, I’m not changing the system from now.
Montague: Well, except that the – you’re not changing the system from the plans already in place, which was that the Operating Framework suggested that there should be –
Lansley: But then that happens anyway, because through the contracting system at the moment most of it isn’t covered by tariff, so most of the commissioners do actually negotiate on price with their provider. So to that extent I’m not changing the situation. What I am doing – and I’ll come back to this point, is I am putting a duty of improvement of quality on all of the participants in this system because quality is at the focus of what we need to do.
Montague: But you’ll know – you’ll know –
Lansley: We’ve been here before. If you go back 20 years in this country and we did have an internal market, and it was based on price competition, and there were not sufficient quality safeguards built in. I am building those quality safeguards in: the incentives for quality; Care Quality Commission regulating for quality.
Montague: So when people talk about a race to the bottom – when you – when people – and many people within healthcare fear there’ll be a race to the bottom.
Lansley: Well, you know, “many people” – I mean, there were one or two think tanks who started talking about it, frankly, on the basis of a misunderstanding of the nature of the system we’re putting in place. It’s a race for quality.
Lansley: Why on earth should anybody who – ’cause if you incentivise to deliver better quality, then why would you not commission for quality?
Montague: OK. ’Cause everybody – this is big changes, as you say, and everybody accepts, and everyone’s trying to get their head around it. At the moment –
Lansley: Well, there’s quite a lot of evolution here. I mean, we’ve already determined – everybody out there is saying I’ve introduced price competition when in fact I’m carrying forward what was already in the system.
Montague: So will you categoric – OK, but you’re – that still means that you are – you’re going ahead with an increase in price competition.
Lansley: Not necessarily. It depends upon how the commissioners go about their task.
Montague: OK. At the moment – and these are figures that come from the Guardian, you can possibly tell me if they’re not right – that the NH – that the amount of NHS funds going to private healthcare providers who are treating NHS patients is £400 million.
Montague: Is that a figure that makes sense to you?
Lansley: Yes, I understand that figure, yes.
Montague: OK. £100 billion is the budget, so it’s relatively small.
Lansley: It’s not the total spend with the private sector, that’s elective purchasing under the contract.
Montague: Sure. OK.
Lansley: Remember the last government, the Labour government –
Montague: I wonder how – what figure –
Lansley: I tell you what these contracts were –
Montague: What figure do you think would – because people –
Lansley: No, because nobody out there will know what we’re talking about. These were contracts which –
Montague: But there are an awful lot of people within the NHS who are trying to get their head around what is going to happen to the NHS.
Lansley: Well, let me explain quite why it’s different. Because under the last Labour government, these contracts, where £400 million is being spent with the private sector, were introduced on the basis of the private sector being given guaranteed activity at, on average, eleven per cent higher price than was being offered to the NHS and NHS hospitals were closed out of the second round of those contracts. Now –
Montague: Do –
Lansley: – I am looking towards a situation where actually many of the NHS hospitals who have capacity, who have the ability, I want them to turn into social enterprises so they’re the ones who are providing these services to NHS patients. And I’m not going to rig the market –
Montague: Do you have an idea, do you have a vision –
Lansley: – in favour of the private sector, which is what Labour did.
Montague: Do you have an idea of what the NHS is going to look like in five-to-ten years or is part of this –
Lansley: Yes, yes, I do.
Montague: You do. Because, I mean, I wonder if part of it is that it doesn’t – in a sense, it doesn’t matter – it’s up to different areas to work out what’s right for them.
Lansley: No, no. I think it’s very clear what it looks like. It is for us as patients, all of us as patients in England – it is a service where not only are we registered with our local General Practice, but through that practice, collectively in our area, we know that there is an NHS organisation which is responsible for our care, people whom we can hold to account. It is democratically accountable through local government. And it has a focus on delivering the best possible results for us –
Lansley: – using NHS resources.
Montague: And could it be doing that by –
Lansley: And it continues to be free, based on our need.
Montague: And it could be doing that by commissioning IT, planning from private sectors, different forms of healthcare from the private sector. A lot of money effectively going out of what are currently NHS providers and going to private providers.
Lansley: The NHS already buys a lot of services from the private sector: most of its – much of its IT –
Montague: But will it be a more? Is it likely to be a lot more?
Lansley: – much of its drugs, its pharmaceuticals, the mental health services –
Montague: Is it likely to be a lot more?
Lansley: – about fifteen per cent of all mental health services.
Montague: Sure. OK. So –
Lansley: I can’t tell you whether it’s more or less, Sarah, because the –
Montague: But it – but you don’t really mind.
Lansley: No, no. The point is I do mind who provides the services. They need to be the best services that deliver the best possible care for patients and that’s what patients want because it’s really interesting –
Montague: – and if they’re owned by shareholders in the United States –
Lansley: – ’cause the research is really clear.
Monatague: – it doesn’t matter?
Lansley: Well, the point is that that already happens now.
Montague: If they’re good quality. OK, so–
Lansley: There are medicines provided to the NHS which are provided by international pharmaceutical companies whose headquarters might be in Britain or they might be in America or they might be in Japan. Do we say “oh no, we won’t – we’re not going to buy those drugs because they’re owned by a company from America”. This is absurd! We – but the reality is – let’s live in the real world here – I’m not – I know of no plan for an overseas company to come to Britain to build a hospital in order to provide services to the NHS. We actually have NHS capacity, we have lots of hospitals and Trusts – Foundation Trusts and hospital Trusts in this country who, I think, given the opportunity, can be far more effective – and, over the last decade, remember, under a Labour government, productivity in our hospitals in this country went down by 1.4 per cent a year.
Lansley: That’s a big reduction in productivity.
Montague: How –
Lansley: If we reverse that, if we improve productivity and efficiency in NHS hospitals, why should they not be the best people to provide the care for a patient?
Montague: And that’s the question, though, isn’t it? I wonder how much of a gamble this is, how much of a gamble you think it is.
Lansley: Well, I think – well, let me put it like this. I know that we have in General Practice in this country what is regarded internationally as a great asset. Barbara Starfield, Professor from Johns Hopkins University in America, made it very clear it was one of the central reasons why in this country we deliver better healthcare very often than we might otherwise do, given the level of resources we provide. That’s because of family doctors. So rooting decision-making close to patients in General Practice is likely to work. I also know that there is a central principle, which has been evidenced in things like physician-led groups in America, that if you combine decision-making about the care of patients with decision-making about resources, you get better results in the long-run.
Montague: Right. We must leave it there. Andrew Lansley, thank you for coming on HardTalk.