Editor's blog Monday 28 February 2011: Lansley, from Liberator to Saviour - the BBC Any Questions transcript
I'm very grateful to a long-standing Health Policy Insight reader who gave up an indecent amount of her weekend to provide this transcription of the NHS reform-related questions to a panel including SOS Lansley on the most recent edition of BBC Radio 4's Any Questions.
Any Questions, BBC Radio 4. Aylsham, Norfolk. 25 February 2011
Sarah Gray: As a highly satisfied user of the NHS, what do I stand to gain from the proposals for the Health Service?
Jonathan Dimbleby (chair): “As a highly satisfied user of the NHS, what do I stand to gain from the proposals for the Health Service?”
I’m not going to go for you to promote your reforms for a second. You were hoping I was going to start with you, but I’m not, Secretary of State. I’m going to start with Philip Blond!
Philip Blond: Oh, goodness!
Well, I think that, you know, two or three years ago what Andrew is arguing for, which is substantially the alignment of clinical judgement with budgetary judgement, everybody agreed with. Because what we want is doctors to have control of the budget so that clinical decisions lead and economic decisions follow. And that would be a huge eliminator of costs in the NHS. So everybody agreed with it. And I think in that sense, you know, we all share similar take.
And much of what Andrew is doing, introducing competition, Any Willing Provider, the government beforehand was already doing, so I don’t think there’s been a huge shift or change in it. So I think largely everybody kind of thinks this is the right idea.
Where the disagreement is, is over implementation, over speed and over scale. And here I think there are genuine issues.
One of the things that doctors tell me is what worries them is that the NHS isn’t primed for competition, that the price that’s given for patient services isn’t a true reflection of the price and that private sector providers will be able to game the system and cherry pick the patients and leave the NHS to pick up the pieces.
But I suspect that Andrew knows this, and so I largely support the reforms - but what I would like to see is that the genuine and legitimate fears that many people in the NHS have are listened to so that the system isn’t gamed. We don’t want another PFI.
Dimbleby: What does Sarah Gray, Secretary of State, stand to gain?
Andrew Lansley: I think she stands to gain three main things.
Firstly, that as a patient it is often the experience of patients that their individual doctor and nurse looking after them listens to them, talks to them, explains what’s happening but that the system doesn’t treat the patient as the priority.
The system treats the patient as somebody who’s on a production line. And actually, my experience of talking, over several years now – of talking to people right across the NHS is that too often they, the doctors and nurses who are responsible for giving care to patients, feel they’re on a production line and they shouldn’t.
So the first principle of the reforms was patients should always feel that it’s a case of “no decision about me without me”. They should get good information, high-quality information which at the moment we don’t get.
We should have better information, more control and even, in some circumstances, patients who are able to make really their own decisions about the nature of the care that’s provided to them. So that’s number one.
Second is, which – I won’t repeat all that Philip’s said, I was grateful for him recognising this – is that the people who are at the front line making decisions about your care should be the people who are in charge basically of the resource decisions. Doesn’t mean they turn into managers.
You know, the GPs I’ve talked to, they don’t want to become managers. What they do want, however, is when they design the services, and when they’ve decided what kind of services they need in their area, what services they want the hospital to have, how they can join things up better, they then want the managers to do that, not to be a completely separate people who keep telling them “no”.
And there’s a third of GPs across this country at the moment who are finding that they can make – they want to refer their patients but the Primary Care Trust, the health body, takes it away and controls it for them.
And the third is, is about using money far better in the NHS because there is a certain reality at the moment. We are increasing the budget by three per cent this coming year but actually the NHS has been used to increases that are more like five, six or seven per cent a year.
So if we’re going to do that we’ve got to cut bureaucracy and increase the money that gets to the front line. Now in the first six months, never mind forecasting what’ll happen in the future, in the six months after the Coalition Government came in, the number of managers in the NHS fell by 2,000 and the number of doctors and nurses and midwives all went up by over 2,000.
Dimbleby: Just in parenthesis on that, the report from the unions saying that over the next few years 50,000 jobs are going to go in the NHS –
Lansley: Yeah, I don’t recognise that at all. And indeed
Dimbleby: How many do you reckon will go?
Lansley: Well, when we –
Margaret Hodge: It was a Freedom of Information request of PCTs so, you know, there may have been one or two mistakes.
Lansley: Well look at it, Margaret, look at it. And take a place like the University Hospital of North Staffordshire, where they said “oh there are going to be 1,300 job losses at the hospital at Stoke” and, in fact, they said “no there aren’t!”
Hodge: So what job losses will there be, Andrew?
Lansley: These are jobs that are going to be transferred from the hospital into the community.
Hodge: What job losses will there be? What job losses will there be?
Lansley: Well, it’s no good hectoring me –
Lansley: – because the point is, the point is, look, you know, the fact is, if we have three per cent –
Hodge: No, but what job – answer the question!
Lansley: – increase in cash in the NHS – there will be job losses. When I published the Bill, I published an Impact Assessment that said there would be 24,000 reduced jobs in the bureaucracy in the NHS.
Hodge: And what about nurses, midwives?
Lansley: There are 50,000 administrators –
Hodge: Nurses, midwives?
Lansley: No. Well, the number of nurses and midwives has gone up since this Coalition Government came in. The number of doctors has gone up.
Dimbleby: And do you expect the total to go on rising and not –
Lansley: No I don’t.
Dimbleby: You don’t expect it to fall or do you expect it to fall as well?
Lansley: No. I hope if we get it right, we will be able to be sure that we reduce the bureaucracy and the staffing in the bureaucracy and that we focus on clinical jobs, but I cannot, as a consequence of the financial pressures we face, promise that we will keep exactly the same number of clinical jobs.
Dimbleby: Let me, before I bring in Matthew – just two sort of structural things. Private provision: is it the case that, so far as you are concerned, so long as the patient is treated free at the point of use, it does not matter whether it’s public or private, so long as there’s cost equivalence?
Lansley: So – well the quality is what will drive competition in the NHS, because that’s what the Bill is very clear about.
Our Bill puts a duty of improving standards and improving quality and a duty which the GPs leading their consortia locally have to do and patients, of course, because it’s free, they will, in so far as they exercise choice, they will choose the service that is the best quality for them.
Dimbleby: But if it’s a question of there’s equal quality between a public and a private provider but the private provider undercuts –
Lansley: Or a voluntary sector –
Dimbleby: – or the voluntary sector, undercuts the public provider, the NHS, it will be for the GP to decide?
Lansley: No, because the GPs, they may be operating on the basis of a national tariff or a tariff they’ve set because what they want to do is to drive improvements in quality because that’s the basis upon which they meet their duties and they’re incentivised to improve quality.
Dimbleby: But there must be cases where, on straight elective cold surgery, the quality being offered by this or that private or public provider is, so far as the GP can tell, much the same – does the cost then determine it?
Lansley: Not necessarily, no. Because they may well decide that what they want to do is to improve the responsiveness and the quality of service provided to their patients –
Dimbleby: But if they want it to be on a cost basis?
Lansley: – and to drive efficiency they do it better by establishing a fixed tariff rather than price competition.
Dimbleby: But that’s going to be up to them to determine.
Lansley: I’m not going to do it like Labour did it.
Dimbleby: That’s going to be up to them to determine.
Lansley: Because Labour had eleven per cent more paid to the private sector –
Dimbleby: Let’s not –
Lansley: – and guaranteed payments! I’m not going to do that!
Dimbleby: Let’s not go into what they were doing, let’s just get an answer to this. If it’s –
Lansley: Well the answer is clear, I just told you.
Dimbleby: It’s going to be – not to this question I’m about to ask you on the basis of what you just said: Will it be for the GPs to determine the basis on which they go for the public or private option?
Lansley: I’m not sure I understand what question you’re asking now!
Dimbleby: Well, I – forgive me, I think it is quite clear –
Lansley: It’s an Any Willing Provider. Any Willing Provider doesn’t mean you choose the private sector over the public sector provider.
It means whoever can meet the quality of care that you’re looking for and whoever can provide that to NHS standards within NHS prices, then they should be able to provide that service and patients should get – they will get it free and actually we know that, the public, by and large, as long as they receive NHS care that is free care, that is high-quality care, that is co-ordinated properly together and is joined up, then actually whether the hospital itself is a voluntary hospital – like it might be in a charity – I mean, there’s plenty of – about ten per cent of mental health patients are treated by the private sector now, nobody says “the private sector shouldn’t be involved”. Macmillan Cancer Nurses are voluntary sector provision: nobody says they shouldn’t be in the NHS because they’re not publicly owned.
The point is whoever can best deliver the service.
Dimbleby: The drive behind the question I’m asking you is not a question of whether it’s right or wrong, or some ideological principle. I’m trying to understand, as I think a lot of people want to understand, is it a matter of indifference so far as you’re concerned whether it’s public or private if certain criteria are satisfied?
Lansley: If the quality is satisfied, absolutely, because what we’re looking for is the best quality.
Dimbleby: Margaret Hodge.
Margaret Hodge: I think we all buy into objectives, as Andrew has set them out. You know, we all want something that’s more patient-centred, better information, get rid of bureaucracy, focus on outcomes. I don’t think anybody can quarrel with that.
But I’d like to raise really two concerns I – two major concerns I have with this. We all know the NHS has got to drive out £20 billion worth of costs over the next four or five years. Andrew, I think, accepts that and I think –
Lansley: Actually, I didn’t originally. Labour government did originally.
Hodge: Fine – even if the Labour government did originally, we know that that is where you’re going. You’re try – you are the Government. You want to drive out £20 billion –
Lansley: Margaret, just for clarity: when you say “drive out cost” –
Hodge: You want to redu –
Lansley: That money is retained within the NHS for reinvestment.
Hodge: Well, but there isn’t an infla – you know, I mean, we can go round this – there is not a growth –
Lansley: Yeah, but people listening might think it’s a £20 billion cut and there is no cut.
Hodge: Hang on a minute. There’s a £20 – You are trying to achieve a £20 billion reduction in costs, which you will then keep within the NHS.
Hodge: But the NHS is not being kept even at a level, in real terms –
Lansley: Yes it is.
Hodge: Because of ch – no, because of changing demography, because of inflation, because of new technology – all those things means that if you want to keep the NHS on an even keel you need more money and – Can I come to my arguments?
The one is that if we accept the NHS is going to drive out £20 billion of costs, embarking on this most massive reorganisation at a time when you’re –
Lansley: No! Nonsense! [sighs]
Hodge: – trying to seek out these efficiencies is just far too risky. And, Andrew, you’re taking too big a risk with our NHS. That’s my main argument really.
Dimbleby: Just on that – no, hold on there. Just on that question of taking too big a risk: Andrew, respond to that.
Lansley: Well, very clearly, because we’ve done – we have done the work and we have calculated and the cost of reorganisation is estimated at £1.4 billion and it will save over £5 billion in addition to that –
Hodge: Actually, to be honest, I don’t – those –
Lansley: – during the course of this Parliament, so we’ll be saving £1.7 billion a year because actually – what I’m doing is not – I’m saving the NHS by giving it to patients and the staff of the NHS –
Hodge: Those – no, no, no – those – can I just?
Lansley: – be responsible for, not a bureaucracy.
Hodge: There are two things – just to respond to that – it’s not that the costs, you know – whether you save, I think they’re spurious and they’re on the margin.
The point is if you’re a person working in the NHS, trying to eke out £20 billion worth of savings, and at the same time you know you’re going to have to change your job, go and work for a GP rather than work for a PCT or whatever, you are diverted, you’re not focused on the main job, which is trying to ensure –
Dimbleby: And the other point you wanted to make?
Hodge: And the other point I wanted to make was this point about what actually happens. What we’re going to have is a whole lot of free hospital trusts, foundation hospital Trusts, every hospital’s going to be a foundation trust, answerable, I may say, not to the Secretary of State, but to us in Parliament, to my Committee –
Lansley: That was in your manifesto as well!
Hodge: Let me finish. We’re going to have a whole lot of GP consortia – it’s going to be incredibly fragmented. And what you can’t answer is actually trying to – where the accountability comes from for that, when a GP practice goes wrong, when a hospital Trust goes bust. You can’t answer who’s in charge –
Blond: The patient!
Hodge: – who takes the onus? Do you take the onus on that? And what happens to the people in the borough? And I say – the people in the locality?
And I say that with really deep feelings for my constituency, as you know, where I have a hospital which isn’t performing well, which had a report in the public interest recently, which will not survive as a Foundation Trust, and if that hospital Trust is allowed to go – become – go bankrupt, as it will in the market, how will my constituents –
Lansley: It’s bust now!
Hodge: – then be able to access a local hospital –
Lansley: It’s bust now!
Hodge: – where they can get anything from an arm set to a baby born, to the more important hospitals – You’re taking just too big a risk with my NHS!
Dimbleby: Response to that, Andrew Lansley.
Lansley: I’ll tell you straight: the Labour Party manifesto – Matthew said, you know, much of this is derived from, you know, what was done under a Labour government –
Hodge: It’s not!
Lansley: Oh Philip said that!
Hodge: It’s not!
Lansley: But actually the Labour –
Dimbleby: Matthew has yet to speak! You’re going to, don’t worry!
Lansley: Sorry! Sorry, Matthew! But actually the Labour manifesto at this recent election, last year, said that the Labour Party was in favour of Any Willing Provider, said that the Labour Party was in favour of having more social enterprises in the NHS, said that the Labour Party was in favour of every hospital becoming a Foundation Trust.
Your hospital, you know – King George’s at Ilford and Queen’s at Romford that – it is bust now, that’s the truth of the matter! It’s kept alive, as it were, by, you know, infusions of money. You know, what we’re setting out for the future is that it needs to become a foundation trust; and if there is transparency then people will see.
And it doesn’t mean services will disappear –
Hodge: And if it fails?
Lansley: Then the regulator will step in and ensure that the services are provided. But we will not carry on, as we have in the past, simply feeding money into services where they’re not actually being reformed and made efficient.
Blond: But surely –
Dimbleby: No. Matthew Taylor.
Matthew Taylor: I think you see the argument laid out before you. And I think that – I think Andrew’s intentions towards the Health Service are sincere. I don’t have any ideological hang-ups with this reform package.
But I think that Margaret is right to say that to try to drive through this scale of reform at a time when the Health Service has had the tightest financial settlement it’s ever had in its history over the next four years – and Andrew talks about the fact that “by the end of the Parliament”, you use the phrase, “by the end of the Parliament, there’ll be savings”, but that is by the end of the Parliament.
The savings are not going to be –
Taylor: No, the savings are not going to be –
Lansley: It pays back in two years!
Taylor: But, Andrew, if I may, the savings are not going to be there at the point of change.
Lansley: Yes they are.
Taylor: What is going to happen is there’s going to be a lot of change.
Taylor: And I know because I was working for the Government when Patricia Hewitt tried to drive through a similar scale of change that the only way that, as it were, we got away with that (and there was a lot of protest at the time) was because there was a lot more money going in.
Now, for all the debate, the five words from this debate that ring in my mind, and I think they – none of us know exactly what’s going to happen – is you used the words “if we get it right”.
And I hope that you do get it right, because the reality is that any Secretary of State who successfully reforms healthcare ends up being very unpopular.
Now I’m pretty sure the second bit’s going to happen to you, Andrew. I’m not quite sure about the first!
Dimbleby: I’m going to bring in our questioner, and then you can come back in again. Sarah Gray.
Gray: Do you think the GPs are the right people to manage this budget? Do you think they’re specialist enough to be able to give the money to where it’s needed? My concern is there are –
Lansley: Well, I know locally that – we’ve got two years, I mean, Matthew says, to get it right. We’ve got two years where we’ve got Pathfinder GP consortia, like the North Norfolk Healthcare Consortium, which includes here in Aylsham.
I know they would say they need to put the right expertise alongside them; they need to get the right management alongside them; they need to ensure that they are working with the local authorities and all their health professionals in their area to make it happen.
But I also know that they believe – GPs, by and large, believe that they, frontline health professionals with the responsibility for their patients and their population, are actually best placed to design the services, even if somebody else is then responsible, on the basis of the design they’re looking for – at agreeing the contracts and monitoring the contracts.
Dimbleby: Given what Matthew Taylor said, do you accept, not – you’re not going to obviously say that you have grave doubt about whether you will get it right. Do you accept that it is pretty high-wire stuff, that it’s quite risky, because you cannot discover whether actually it will work, until you’ve discovered whether it does or doesn’t work?
Lansley: No, far less so than people imagine. Because, you know, in the last ten years, in fact you can go back 20 years, the NHS has tried to do Practice-based Commissioning and fundholding previously, and there were mistakes in all of those and we’ve learned from them.
The NHS has tried to do NHS trusts and foundation trusts and we know we all need – the hospitals all need to be given greater autonomy. We know from the past that things like Payment By Results and focusing on outcomes is the right way to go, and people across the NHS believe in it.
We know from international comparisons, the more you involve patients in – with – give them information and engagement with their healthcare, the more you get good results and actually, quite often, you get less intensive and less costly healthcare as a consequence of patients being more engaged.
Dimbleby: What happens –
Lansley: So we’re actually operating on the basis of what many people in this country and elsewhere have seen are some of the basic principles we should work from.
Dimbleby: A patient’s with a GP. The GP diagnoses. The GP says “This is the best place to go”. The patient says “No, actually I want to go to that place”. It costs a bit more. What happens?
Lansley: Well, because you say it costs a bit more, actually –
Dimbleby: I’m putting that as a hypothesis.
Lansley: I mean, if it’s – on the basis actually they’re quite likely to have a tariff, it’s not going to cost more. So, to that extent, GPs and the patients should do shared decision-making.
But if the patient says “that’s where I want to go”, then, under certain circumstances, that would be the right thing to do.
Dimbleby: Under certain circumstances?
Lansley: Well, as long as it actually is the right treatment.
Dimbleby: So long as the GP thinks it’s OK for them to do it?
Lansley: Well, look, it’s called – I mean, there’s a philosophy called “the meeting of experts”. We’re experts about ourselves as patients; but, actually, the doctors and nurses are experts about the nature of the condition and the care that we should receive. And they meet together.
Dimbleby: Last quick word, Philip Blond.
Blond: The great hope for these reforms is that finally we have managers managing value and not cost, so that if pa – we all know when we have bad experiences in hospitals or schools and previously we’ve never been able to do anything about it, our relations suffered in silence.
If doctors actually involve patients and patients can actually say “this is appalling”, there’s every chance that we can actually get genuine change in our Health Service.