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Once again, a kind Health Policy Insight reader has given up more of their valuable free time to transcribe a media appearance by Our Saviour And Liberator Andrew Lansley. This one was The Jeremy Vine Show on BBC Radio 2, 16 March 2011. Vine is, when at his best, an excellent and incisive interviewer.
Just one editorial observation before the transcript starts: it is interesting that Mr Lansley answers a question he was not asked. About 3/4 of the way down, he tells Tim Tennant of Wellington in Somerset "Well, number one, it’s not about privatisation at all".
Mmmm. A little over-media-trained?
Jeremy Vine: The man behind these huge changes for the NHS is the Health Secretary, Andrew Lansley. He’s been listening to the views of those GPs and healthcare experts on the show this lunchtime and he joins us in the studio now. Hello to you, welcome.
Andrew Lansley: Hello, good afternoon.
Vine: So, where do we start here? We started with Dorothy, with her hurting knee, didn’t we? And we said that she goes in to her GP and the GP is now in charge of the money. And that’s, in very simple terms – that’s how it’ll work, is it?
Lansley: Yes. Do you know what the most important thing is from Dorothy’s point of view?
Lansley: – is that she gets really good care. And let’s say she needs a knee replacement and she wasn’t able to walk about and wasn’t able to drive, maybe she wasn’t able to go to work – that afterwards those things improve. Now, one of the key things here – you know, I’m passionate about an NHS that delivers the best possible care. I know the people who work in the NHS are themselves passionate and committed to delivering the best possible care. So at the heart of what I’m doing is empowering people at the – in the NHS to be able to do that but, of course –
Vine: Or to save money as well, of course.
Lansley: – but holding everybody to account for the outcomes we deliver, because actually if, I mean – precisely that point. If Dorothy has her knee operation at the moment the NHS goes “tick box – knee operation done”. Well, they don’t go back and check afterwards and say “let’s look at people who’ve had knee operations and make sure that after they had knee operations they did get better mobility, that they were able to carry on working.”
Vine: I thought that was the whole point of all these targets that you hate so much, that they kept going back and back and back again!
Lansley: No, no. The targets is “knee operation done – tick”, within 18 weeks. Well, that’s important, waiting is important, people don’t want to wait a long time, but they also want the care to be really good and at the moment, actually – because, you know, the studies are clear, that it varies considerably, whether or not knee replacement operations, for example, actually improve the outcome for patients.
Vine: Well let’s stick with the –
Lansley: So we’re actually looking at what is absolutely at the heart of this – is getting the best possible results for patients.
Vine: Sure, and I remember speaking to some people who’d had some knees and hips done a couple of years ago and they were subject to some kind of patient survey afterwards –
Lansley: Yeah, exactly.
Vine: But that’s what you’re talking about. It’s been going on already, hasn’t it, these –
Lansley: Well, no because actually –
Vine: – “are you happy with the operation?”
Lansley: – actually, what we’ve done in these last few months is set out for the first time a really systematic view of what those outcomes ought to be – you know, that people aren’t dying prematurely when they shouldn’t, that people are safe when they go into hospital, things like whether they catch infections, things of that kind, whether people are getting good experience of this kind that we’re describing, whether people living with long-term conditions are properly looked after and have the kind of opportunities for work and mobility and so on they should if their condition is properly looked after. And we’ve published for the first time – and internationally, you know, people are looking at this and saying “wow! You know, here in England for the first time they’re looking systematically at what results they are achieving for patients”. And that’s absolutely at the heart of this. Now, there is a principle about –
Vine: Can we just go back to the knee for a second and Dorothy, without meaning to stretch the poor old knee too much? ’Cause it could be that in Dorothy’s area a private company sets up a sort of knee place where they do a hundred over a weekend, or whatever – and they do them fast, they do them well. Now if they – if the doctors start to go “Hah! This place is good!” – right? – “and we’re going to send our patients there”, and they start to put all the money towards the special knee unit that’s been set up by an entrepreneur, brilliantly, I might add, the local hospital – suddenly out of business! What happens to it?
Lansley: Well, in a way, you’re not precisely describing how it works. I think Anna Dixon explained fairly carefully, and that’s strictly speaking how it works now – is that the NHS sets a price, let’s say it says £6,000 for a knee replacement – but the key thing is, that’s the price, based on, you know, looking at the costs of looking after – doing a knee replacement. But we need there to be quality. Now, once you’ve done all that, the GPs – the GPs aren’t directing all the money to a new unit or anything like that. What they do is, they and their patients make decisions about who is the best person to provide – or the hospital or clinic to provide that surgery –
Vine: They commission the care.
Lansley: – so the money follows the patient.
Vine: Exactly. So if the money goes to this new unit, the brand spanking new unit set up by an entrepreneur from another country, let’s say – the hospital doesn’t get the money, so who funds it?
Lansley: Well, what – well, clearly what happens – and the Bill actually has set this out for the first time – is that the GPs and their local authority are very clear about what services have to be maintained locally and they designate those, and if they don’t get sufficient activity then they get additional resources to keep them there, because we have to ensure –
Vine: Oh! So you fund the hospital to stay working with no patients!
Lansley: Not – no, because actually what we do is, through the legislation we let people locally make decisions about which services have to be maintained for the benefit of patients. Now if you have a series of different providers and one is the one that patients actually want to go to and the other they don’t want to go to, the one they want to go to will be maintained and the other will close down.
Vine: They will close down. So the local hospital shuts down because this guy’s come in from another country –
Lansley: But if –
Vine: – and he’s doing all the knee operations brilliantly. What happens when one day he gets bought out and he doubles his price or he just decides to pack up and go?
Lansley: Well, because he can’t because that’s the whole licensing process, which is in the legislation, which says “if you commit to providing these services you have to commit under the license” – you can’t stop doing things. You have to maintain doing those things for the NHS.
Vine: But you’re creating a market and we know markets – The one thing we know from the banking –
Lansley: But it’s not a free market!
Vine: – crisis and all that that is that markets just do unexpected things, don’t they?
Lansley: No. It’s not a free market and this is, I think, most of the nonsense that’s talked about it is– what we’re setting out here to do is to say patients must have greater choice, GPs who already do really all the care, look after the decisions about the care of patients, should actually also be able to design the local services that meet their needs in caring for patients – and then there’s the regulated market, with regulated prices. But it’s a social market, it’s not a free market and actually that means there’s a lot of opportunity to step in and say “these services must be maintained and patients must have access, wherever they are in the country, to the services that they need”.
Vine: Nick [Cupper?] from Exeter has been in touch – getting lots and lots of comments on this, Health Secretary. He says: “There are three types of GP, and I know because I am one.” He says: “The majority provide a service to their patients and they want what is best for their patients. Then there are their – the GPs who see their job as a money-making operation, with patient care as secondary. And finally you’ve got a few political patsies who advise the Government.” He says “I feel like I’m watching a plane crash in slow motion. This is going to be a complete mess.”
Lansley: No, I think that’s complete nonsense, frankly. And I’ve been in Devon and I’ve talked to the Local Medical Committee, the conference of GPs in Devon and what I’ve met there – I’ve met people who were quite clear that they felt that clinical leadership was right. And actually the BMA reinforced that view yesterday when they met. But actually what they want is for doctors and nurses, health professionals, to be at the forefront of designing the best clinical care for patients.
Vine: Well, their survey just said that 89 per cent of them think that it will lead to a fragmentation of services. Maybe you want that?
Lansley: It won’t happen. No, absolutely. It will not be like that. Because we’re very clear and all of the big groups of GPs that I’ve met across the country – and now, you know, there’s more than two-thirds of the country, there are 177 groups of GPs across the country, representing 35 million patients, who are already out there as Pathfinders putting together these things – and I can tell you exactly what they’re doing, they are starting by ensuring that they design the best possible care pathways for patients, they’re looking at the quality and, as some of your – you know, your earlier GPs – Paul Charlson (Editor's Note: the programme did not mention that Dr Charlson is chair of the Conservative Medical Society, now known as Conservative Health) , for example, was saying, it’s about quality, because –
Vine: To clarify the system, Andrew, the – if you get these GPs who are in charge of the money – it’s not one GP, one cheque book. They will tend to band together, is that right?
Vine: So how – what size of consortium would you expect: a hundred GPs, twenty GPs or what?
Lansley: Well, I’m not in a position – I’m not telling them. And so –
Vine: Have a guess, then.
Lansley: I’m letting them come forward and the evidence at the moment is that we’ve got 177 groups of GPs who’ve come together. On average, they’re representing about 200,000-plus patients. So it’s quite – scale to this. But actually what they can also do is they can get together for certain purposes. So, for example, if you were commissioning cancer services, you might conclude that you really want maybe a million-and-a-half patients – or population, rather, not patients – a million-and-a-half population in order to be able to commission for the right sort of care pathway with the right centres of excellence and expertise and so on –
Lansley: And we will help them to do precisely that.
Vine: So – but then they would have to – they would form a consortium with other GPs just for cancer, would they?
Lansley: Yeah, can do, yes, and get a commissioning arrangement.
Vine: So you could be one of a number of consortiums as a GP?
Lansley: No, sorry. I mean, the consortia each have their own area, OK?
Lansley: So they will be responsible for, I mean – talking of Devon, you know, there may be one that does most of Devon, let’s say, or East Devon. And then they would be responsible for that area. But if they wanted, for example, to do the peninsula, Devon and Cornwall, for cancer services, they could get together and have a commissioning arrangement that was at that higher level.
Lansley: And for national – and sometimes there are, you know, specialist conditions –
Lansley: You know? And they will be commissioned through the National Commissioning Board.
Vine: Just before we leave this, it’s just that from the way you described it, it sounds like Dorothy and the GP – suddenly the power’s all in that office and this exciting thing, the GP’s got the money and all that – but actually once you have a consortium of 150 GPs, it’s more remote than the Primary Care Trust, isn’t it?
Lansley: No. No it isn’t. Because the Primary Care Trust –
Vine: It’s just a big body – it’s a bunch of bureaucrats suddenly, isn’t it?
Lansley: Well, you know, what – the population of Primary Care Trusts varies but some of them are very large, and the point is they’re unaccountable and they’re not the clinicians exercising leadership and it’s not the person – you and I and pretty much everybody listening to us is registered with their GP. They have an expectation and, frankly, most GPs and nurses in GP practices have an expectation that where they make decisions about the care of patients whom they look after, that ought to have the deciding say about the structure of the care that’s provided in their local area, not somebody else who’s not accountable – and, frankly, a lot of what I’m doing in this legislation – we as a Government are committed to, is to actually make that accountability much more real – real to patients because their General Practices are involved in this – real because their local authorities, people whom they elect, have a say directly in –
Lansley: – all of this.
Vine: Let’s bring in somebody who works in the NHS and see how real it is to her. Susan Anderson-Rutt in Bexley, good afternoon to you.
Susan Anderson-Rutt: Good afternoon to you both.
Vine: You’re through to the Health Secretary.
Anderson-Rutt: Hi. I attend many meetings at the Trust where I work and all staff and patients hold their hands up in dismay when they hear that GPs are going to be in charge of anything. My own GP can’t manage his own appointments system, let alone run – help run a national service. But the general feeling within all of the NHS workers is that we’re wondering whether you’re deliberately setting up the NHS to fail, so that in a couple of years’ time you can pull the rug from under the lot of it and leave us in high water.
Vine: Andrew Lansley.
Lansley: Well, let me say two things. Firstly, I’m passionate about supporting the NHS. I – Before I was Secretary of State I was Shadow Secretary for six-and-a-half years. I’ve met people right across the NHS. I am committed, we are committed, David Cameron is absolutely committed. It’s why we protected the NHS in the spending review and there’s going to be three per cent extra cash next year, because we want the NHS to – increasingly to deliver the best care possible. In Bexley –
Vine: In six-and-a-half years, by the way, you should have told us that this was going to happen, shouldn’t you?
Lansley: I did. It was in the manifesto that GPs –
Vine: You said you weren’t going to have any kind of major reorganisation.
Lansley: – GPs were going to be responsible for commissioning, with budgets for their patients. It’s in the manifesto, page 46. But in Bexley, GPs are doing this thing. The clinical cabinet in Bexley, led by GPs but involving other clinicians and including hospital – and their local authority – they are already involved in doing this. And I’ll give you one example in Bexley: they put together a whole new process, a new care pathway for patients with heart problems that has been a terrific success. I’ve been in Bexley, I’ve seen the system they’ve brought in to look at the management of patients with long-term conditions, to try and avoid those having to go into hospital where they don’t need to, and the number of emergency admissions. It will help hospitals and it helps their patients to get the best possible care.
Vine: Susan, what do you actually do?
Lansley: So I’ve seen it being done in Bexley.
Vine: What do you do in Bexley?
Anderson-Rutt: I actually work for the South London Healthcare Trust and this Government’s actually almost closed one of the hospitals in Bexley, Queen Mary’s Hospital, Sidcup has lost a lot of its services.
Lansley: We haven’t done that. We haven’t done that. The Trust has done it. And, frankly, you know as well as I do, that these were problems we inherited from a Labour government, with a Trust at South London Healthcare Trust, that is in massive deficit that we inherited from a Labour government. You’ve got to admit that’s true.
Anderson-Rutt: That might be true, but what is worrying is, because we’re in such massive debt, the ones that are not – next door to us aren’t in so much debt, so what happens to our commissioning powers? Where will they want to go, will they go to a hospital that is in potentially so much debt that it’s in threat of closure or are they going to –
Lansley: But that’s why –
Anderson-Rutt: – replace it when they go to St Thomas’s or Guy’s?
Lansley: That’s exactly why, with the GPs in Bexley, they are leading a process – and they’re due to report to me on the thirty-first of March about how they can develop and sustain the services on the Queen Mary’s, Sidcup site in the South London Healthcare Trust. I am the one now, with my colleagues, with South London Healthcare Trust, who are trying to get it out of the problems that we inherited from Labour.
Vine: Can you do that with any location in England, by the way? You just get a caller from Bexley and you do the whole recent history of the healthcare Trust?
Lansley: Well, I have been Shadow Secretary of State for six-and-a-half years.
Vine: For a very long time!
Vine: But coming back ... you promised there would be no top-down reorganisation of the NHS. The Coalition Agreement said there would be no top-down reorganisation of the NHS. Now you’re delivering one. Come on!
Lansley: No we’re not. No we’re not. We’re taking tiers of management out of the NHS.
Vine: It’s a massive reorganisation!
Lansley: Well, no, we’re [laughs] – look, you had Anna Dixon (Kings Fund director of policy) here, who explained – you were saying – you know, you were saying “oh look, there’s this whole new thing where people can exercise choice about where they go”. They can do it now – they could do it under the Labour government.
Vine: It’s a small, little bit of tinkering?
Lansley: No. What we’re doing is taking a big bureaucratic system that we’ve inherited. We’re going to save £5 billion over the next four years. We’re going to strip tiers of management out. We’re going to make sure that good management gets behind the GP groups. But it’s about getting clinical leadership to the front line. It’s about focusing on outcomes. It’s about giving patients a much greater say. And it’s about giving local people a much bigger say through their local authorities and making it more democratically accountable.
Vine: You see, in the manifesto “Our Plan for NHS Improvement” – “We promise to end the damage caused by pointless and disruptive reorganisations of the NHS. We will ensure this stops, and we will not allow any meddling with existing local or regional structures” [Conservative Party, Renewal: Plan for a better NHS, 2008, p. 31]. And you’re actually abolishing them!
Lansley: Well, no. We said we would give responsibilities to GPs to commission services, using budgets on behalf of their patients. So we’re following through on that. We said we’d give local authorities the responsibility and the resources to lead public health improvements. Now, at the end of the day, Jeremy, I have to – it’s just very straightforward – if you have lots of management organisations, Primary Care Trusts and Strategic Health Authorities, which I defy most people listening to this to describe what they have been doing in the last ten years, because it’s all distant people who don’t – they weren’t – they didn’t vote them and they’re not necessarily the clinicians who look after them – We have to save money and we’re going to save in total, over – taking account of the costs of the reorg – of the –
Vine: Overhaul, reorganisation – top-down?
Lansley: – the reforms, the reforms –
Vine: Whatever you want to say – meddling?
Lansley: Taking account of the costs of the reforms, we’re going to save billions of pounds –
Vine: [laughs] OK.
Lansley: – by cutting out administration.
Vine: Tim Tennant in Wellington in Somerset says: “All the changes boil down to is this: Who’s going to tell the patient there’s not enough money to have the procedure? Currently it’s the PCT, and after the changes it’s going to be the GP. That’s what it boils down to.” There we are. Why don’t you answer that one?
Lansley: Well, number one, it’s not about privatisation at all. It’s about delivering the best possible care to the patients. And those patients will get their care through the NHS, free, based on their need, not on their ability to pay. So it’s not about privatisation. It’s not about cost, it’s about quality, and we’re very clear about that. And I do think – if you think about it, you know, we are all registered with our General Practice, we all depend upon the care that our GPs and our nurses and other health professionals give us. It – I mean, the proposition that they would somehow, because of the way – giving them more power they would suddenly become motivated only in relation to cost, rather than doing the best for their patients is nonsense. And the way we’re establishing this system, is that, yes there will be a negotiation, or a determination by the regulator of what the right price is for the services that are offered by hospitals and clinics, but the GPs making decisions about the care that is provided then do it purely on the basis of quality, so they’re constantly looking for the best quality.
Vine: Certainly getting a clearer picture of how it will work. Let’s see what Isla Dowds in East Sussex thinks about it, because you’ve been listening, Isla.
Isla Dowds: Yes, I have. Good afternoon.
Lansley: Good afternoon.
Vine: Hello there, and you’re through to Mr Lansley.
Dowds: Hello, Mr Lansley.
Dowds: I believe that you’ve actually tried to sell this Bill to the public, and indeed to other politicians, under a whole series of false pretences. Now just one of them you spoke about a minute ago. You spoke about removing tiers of management and getting rid of bureaucracy, by which you’re really talking about the PCTs and the Strategic Health Authorities.
Dowds: But isn’t the truth that GPs will not be able to do this commissioning without the considerable support of people exactly like those who now work in PCTs, with great expertise and knowledge, and that that work may now well be taken up by private firms? Now, the problem with that is that with private firms their primary duty is not to the patient, it is to their stakeholders.
Vine: Isla, are you working on a PCT yourself?
Dowds: I did work in a PCT but I got made redundant.
Vine: Ah. OK. Well, Andrew Lansley, there we are, you see – this is one of the people you’ve –
Lansley: Well, the answer is –
Vine: – pushed out!
Lansley: Well, I don’t know when Isla was made redundant, but anyway, that’s –
Dowds: I was made redundant very shortly after the White Paper was published.
Lansley: Ah. The issue is, of course, that the GPs already do much of the commissioning.
Lansley: They do it in the practical sense of making referrals for patients, of prescribing and the like. They actually incur much of the cost in the NHS. What they don’t do, however, is they don’t have the opportunity to control the way in which services are designed locally and that kind of commissioning –
Dowds: Well actually, Mr Lansley, I’m sorry to interrupt you –
Lansley: – that opportunity to design the care pathways – absolutely critical.
Dowds: – but I must stop you there, because they do. We have had something for some years called Practice-Based Commissioning. Now you will know –
Lansley: Yeah, I know!
Dowds: – and I know that that was a partial –
Lansley: Yeah, absolutely.
Dowds: – success. Now why was it a partial success? You might say it’s because they didn’t have enough power, but they could have been given more power.
Lansley: But they weren’t, were they, Isla? They weren’t.
Dowds: I think it’s because many GPs are either not interested or they know they have not got the skills and knowledge to be commissioners.
Lansley: But actually that’s – very interesting point, because you’re absolutely right in the sense that we’re not starting with a blank sheet of paper. I’m not inventing GP commissioning. There have been Practice-Based Commissioning groups. They weren’t big enough. There were 900 of them across the country and so they’ve tended to come together. They weren’t given power, that’s absolutely true. It is necessary for us to shift from bureaucratic organisations that are not accountable to clinically led organisations, on the one hand, and local authorities that are democratically accountable, on the other. You did make a point right at the outset, which I am happy to agree with. They will need – the GPs will need management and financial control and other support and I do expect, and we’ve made clear, in the Bill and the stuff that goes with it, that a considerable number of those people who work in Primary Care Trusts will have posts with the commissioning groups –
Lansley: – and with the local authorities, but it –
Vine: Let me just –
Lansley: We do at the same time have to cut administration costs and we’re going to save –
Vine: OK, one more question for you.
Lansley: – £5 billion by doing so.
Vine: We’re almost out of time and we really do appreciate your time this afternoon. This is a massive experiment, isn’t it? If you were making these kinds of sweeping changes to the national rail network, people would be concerned. But these changes you’re making affect people’s health and their lives. And it’s true, isn’t it: if this goes wrong, people will die?
Lansley: No. I don’t think it’s an experiment. And it’s – and because it’s actually focused, all the way through on delivering the best possible care and it’s – and outcomes and results for patients is at the heart of this – it will – it is in the context of continuously improving the standards of care we provide to patients. But it’s not an experiment. Hospitals being Foundation Trusts, you know, it’s not perfect but we know giving hospitals that kind of autonomy is a better thing to do. We were just discussing Practice-Based Commissioning groups, we know that we’ve got GPs who have sta – who know how they can take these responsibilities and do better. All over the country we’ve got GP groups, local authorities, Foundation Trusts and hospital Trusts who are ready and willing and going down the path already of putting these reforms in place to deliver better care for their patients.
Vine: Thankyou very much indeed for joining us this afternoon for our health special on Radio 2.