Interview with FRANK DOBSON MP – Health Minister

…………………………………………………………………….. ON THE RECORD FRANK DOBSON INTERVIEW RECORDED FROM TRANSMISSION: BBC ONE DATE: 29.11.98 …………………………………………………………………….. JOHN HUMPHRYS: Frank Dobson, let’s begin with this question of the Tory reforms that you said you were going to sweep away. The fact is, isn’t it, that the internal market remains, that we still have a purchaser and provider split, in the jargon and that hospitals are still competing with each other for the money from the GPs. FRANK DOBSON MP: Well, we want to get away from that and the changes that we are making will get away from that. There were several things wrong with what the Tories were doing and certainly the split between having fund-holding GPs and non fund-holding GPs covering a geographical area meant that some patients were actually getting advantages simply because of the nature of their GP’s relationship with the National Health Service. So we are getting rid of that. But we are also making sure that we do stop hospitals competing with one another and one of the things that we managed to do last winter, I know the weather was good and there wasn’t a flu epidemic, but the hospitals with the extra money we found last winter, did work together, work very hard so that all the hospitals in Birmingham co-operated with one another, helping one another out. That’s what we are determined to bring about and I do make it clear that we don’t want stupid competition because that’s been very harmful. HUMPHRYS: But competition will remain won’t it. Let me just quote from what your document says: ‘primary care group will be free to make choices about cost effective patterns of services and switch resources over time.’ Now as far as Dr Nagpaul, whom we interviewed there, is concerned, that means, and it clearly does mean, that competition will remain. DOBSON: Well it will mean that the GP groups will be able to compare the performances of hospitals but in many parts of the country- HUMPHRYS: And then make choices depending on that- DOBSON: And then make choices. But in many parts of the country there really only is one choice. There’s only one local hospital and the only way of offering an alternative hospital to your patients is to force them to travel long and inconvenient distances for treatment. But what we are saying is, all the figures will be published in future so that the driving force to improve efficiency will be comparing one hospital with another, comparing their performances but they won’t be strictly competing with one another. The object is not to have a sort of shop-around situation where Mr Humphrys or Mr Dobson finally decide that although they’re living in London they’d best get treatment in Norwich. The object is to make sure that their local hospital is up to scratch. HUMPHRYS: What about fund-holding. Again something you were going to abolish as I understood it and you haven’t. I mean now-you’ve modified it. We’ve now got these GPs in primary care groups, a lot of whom didn’t go into the old fund-holding system because they didn’t want to be in charge of their own budgets and all the rest of it, they’ve no choice now, they’ve got to go in to a primary care group that’s responsible for its own budget. DOBSON: Yes but that in itself is a step forward because one of the biggest problems with the introduction of fund-holding was that about half the GPs were fund-holders, the other half weren’t. It split the profession and it gave differential advantages to different groups of patients depending on the status of their doctor. HUMPHRYS: But that also means there were half who didn’t want to go into the system. DOBSON: Well that’s right but we are putting forward a system in which all of them will be involved and it has the overwhelming support of the GPs, they voted I think it was three to one at the BMA in favour of continuing the progress that we’re making. And there are now four hundred and eighty-one primary care groups in existence in this country. The boards have been chosen by the doctors and other people, in most of them they are making an amazing amount of progress. Now there’s obviously concern amongst the medical profession, it’s prefectly legitimate that they should be concerned about what’s happening. I mean they had the bitter experience of Tory reorganisation so they, you know, they have a bit of a jaundiced view of any future changes but they are going along with it. HUMPHRYS: Well going along with it you say, but obviously because only half were fund-holders under the old system, that applies that inspite of the three to one vote, that implies that half of them, it doesn’t imply, it is a clear fact that half of them did not want any part of fund-holding. Now they have no choice, it is compulsory. DOBSON: No, but we are not making everybody a compulsory funder. HUMPHRYS: Well you’ve got to be part of a primary care group. DOBSON: You’ve got to be part of a primary care- HUMPHRYS: Which is a fund-holding outfit as it were. DOBSON: Well it is in a sense and it isn’t in a sense. What we thought was, we looked at fund-holding and it would be stupid of me to deny that there weren’t some advantages in fund-holding- HUMPHRYS: I didn’t hear that being said. DOBSON: Well, this is what I am saying since I’ve been the Secretary of State. It’s clear that there have been, for patients and doctors, some advantages – some advantages – in fund-holding. Overall there were more disadvantages than advantages but what we’ve put together is a scheme which keeps some of those advantages and introduces an overall commissioning arrangement involving all the doctors which is what quite a lot of the opponents of fund-holding were developing in their area, particularly say in the Nottingham area. HUMPHRYS: But there are plently of doctors who feel they have been rail-roaded into this scheme, into something that they didn’t want to do and they’ve got to do it in a hurry, the deadline’s April isn’t it. DOBSON: Well, my own view was, we contemplated you know extending the period so it took two years rather than one. And we finally decided that although there will be, again there will be disadvantages in preceding quickly, we think overall the advantages in getting it sorted out, setting deadlines, getting people working together, was the right thing to do. And I have to say, it’s of immense credit to the profession that people, whether they were enthusiasts or not, have really buckled down and are putting them in place and doing a good job. HUMPHRYS: They don’t have any choice, the law says they’ve got to. DOBSON: Well yes, but it isn’t just that. We can’t just badger people into doing things like the previous government did. We have tried at all stages to take the profession along with us. We haven’t introduced a single policy without previously consulting the doctors, the nurses, the midwives, and the other professionals in the service and that’s why by and large, despite the fact that people have their doubts and reservations, they are in agreement with what we are doing. HUMPHRYS: Alright, money – money is the big problem isn’t it, it is and always has been, and always will be in the National Health Service. There is not enough of it, there never is. You’ve put a bit more in, but it is still under-resourced isn’t it? DOBSON: Yes, it is under-resourced. Since we’ve got in and mainly in this financial year, we’ve put in an extra two thousand million pounds, which is an awful lot of money, HUMPHRYS: Two billion. DOBSON: Two billion yes, but it is an awful lot of money – an awful lot of taxpayers’ money, and the NHS have been making brilliant use of that. They made brilliant use of the extra money we found to help with winter pressures last winter, they’re certainly making brilliant use of the five hundred million pounds extra that we found for waiting lists, because the waiting lists have come down by best part of a hundred thousand since we got the turn around in April. And they are also providing better services all over the country, bringing in new services, and that’s what we want to do and over the next three years there will be an additional twenty-one thousand million pounds, twenty-one billion pounds extra. HUMPHRYS: Well no, there won’t be. DOBSON: Yes there will. HUMPHRYS: No, because what that implies, what that states quite clearly is that instead of the x amount of money that we are getting now there will be twenty-one billion pounds extra, and there won’t be. What you’ve done, it’s really fiddling with the figures isn’t it, because what’s hapening is that you’re putting an extra three-point-eight per cent a year in, give or take a few point here or there. DOBSON: No, we’re not. HUMPHRYS: Well, that’s what your department says. DOBSON: Well, I don’t care what my department says. In the next three years we’re putting four – an average of four-point-seven increase over three years.. HUMPHRYS Ah well, again you see, it’s three-point-eight per cent over the period of this government. That is what it works out at. DOBSON: No, you started talking about the period, the three year period in which there’s twenty-one billion pounds extra. There is twenty-one billion pounds extra. HUMPHRYS: There isn’t. I mean that would imply that extra would imply that- DOBSON: Next year there will be three billion pounds extra. The year after that there’ll be six billion pounds more than we’re spending now, and the year after that there’ll be nine billion pounds more. HUMPHRYS: So you’ve added it all together and made it- DOBSON: Yes. HUMPHRYS: But that’s a ridiculous way of doing it because very single government since the year dot has – I mean under the last lot it was around three-ish per cent, give or take a little bit. Under you it’s going to be around three-point-eight per cent over the period of the government. DOBSON: No, but that’s not a reasonable thing to say, because the budget for the financial year in which we became the government had already been set by the previous government, so that’s their responsibility not ours. We’ve increased it by nearly three-point – three per cent this year, or I don’t think these percentages mean very much to the public. HUMPHRYS: No, but let me explain- DOBSON: – next year, the year after and the year after that it will be four-point-seven per cent, and all the experts including the BBC’s experts said that if we didn’t come up with at least three per cent per annum it would be a disaster, and we’re coming up with nearly fifty per cent more than they were asking for, than the Tories were asking for, than the Liberals were asking for and various pointy-headed academics were asking for and the BBC’s correspondents. HUMPHRYS: I’m not disputing that you have put a bit more. DOBSON: So we’ve found fifty per cent more increase each year than your experts asked for. HUMPHRYS: I don’t know that we’re in a position to ask for anything, and I’m not disputing that you have put in a bit more, but to add together every increase for each year and then come up with that global figure and say ‘we’ve put in another eighteen billion pounds’ – you haven’t put in another eighteen billion pounds, you put in a bit extra on top of what would have been there anyway. The NHS – and this why the percentage- DOBSON: No, no, no. You make..we..compared with what we’re spending now, over the next three years we will be spending an extra twenty-one billion pounds. HUMPHRYS: But you’re adding each year’s figures on to itself. DOBSON: Of course. HUMPHRYS: You can’t do that. DOBSON: If we’re talking about – it’s the first time in the history of the Health Service that the Health Service has had a settlement of more than one year. Everybody in the Health Service has said what they would like to see is being able to plan ahead and know how much money they’re getting over a three year period. HUMPHRYS: What matters is how much per year it is going up by. DOBSON: Yes and it’s going each year over that three year period by an average of four point-seven per cent. HUMPHRYS: But you see you could say over the next hundred years we’re going to spend another thousand billion pounds. I mean it is a daft thing to do. DOBSON: No, but we haven’t- HUMPHRYS: It’s a misleading way of doing it. DOBSON: No, it isn’t misleading at all. In previous years all previous governments have set the money for the National Health Service just for one year ahead, right. Everybody in the Health Service says that’s unsatisfactory, we can’t plan the long-term, so we’ve said ‘alright, this is what you’re getting over the next three years extra, and over the next three years it’s twenty-one billion pounds. I don’t know why you’re arguing about it because it’s a fact. HUMPHRYS Alright, well let me tell you why I’m arguing, and then perhaps we’ll move – because as you say people do get a bit baffled by all this, and probably bored with it all as well. I’m arguing with you because you are suggesting that that is money that it would not have got otherwise. Now, the fact of the matter is that if you had not put a bean in extra and you had just kept it at its present level of spending plus inflation, the three per cent odd that has always gone in over many many years now, you would still have come out with a very very large figure. You’ve added a bit on, but then you have added together each amount of additional spending for these three years and come up with a figure that people – people say ‘what the NHS has got another eighteen billion pounds in England, my God that’ll solve a lot of problems – it hasn’t because most of that is just to keep spending where it is at the moment. DOBSON: But if somebody says: tell us how much we’re getting over the next three years we’ve told them and when Stephen Thornton who was on your clip at the beginning- HUMPHRYS: And he’s rumbled you. DOBSON: When he heard about what we were doing he said it was beyond their wildest dreams. HUMPHRYS: And then he discovered what it meant. DOBSON: And he’s not withdrawn it. HUMPHRYS: Well, okay, that, mm, well, alright. Look, if there is all that extra money then, if you’ve got so much more money you could give the nurses a lot more can’t you. You can afford to. DOBSON: No, it is a lot more money, and I said, the day we announced it on, I said ‘in view of the state that the Health Service is in and the ambitions that people in this country have for improving it, it’s still quite a tight settlement’. I don’t say it isn’t a tight settlement. HUMPHRYS: Okay. So there isn’t a lot of extra money to give the nurses and here is your problem isn’t it? You promised us there would be fifteen thousand more nurses. You know as well as I do that four out of five hospitals, more than four out of five hospitals say they’re having trouble not just recruiting nurses but retaining them as well and that is not going to change without a sizeable pay increase is it? DOBSON: Well it’s certainly partly to do with pay and we’ve given our evidence to the Independent review body on nurses and midwives’ pay which was set up at the suggestion, by the previous government, at the suggestion of the Royal College of Nursing. They’ve sumbitted their evidence and we’ll have to see what the review body comes up with and I’m hoping that they will come up with a settlement which is attractive enough to get more people to go into nursing, to keep in nursing people who are already there which is very important and also to make sure that we have an attractive service. HUMPHRYS: But you’re telling them to take into account affordability aren’t you? You’re telling these pay review bodies to take into account affordability? DOBSON: Nobody in his right mind would say, ‘Don’t take into account the affordability of pay’. HUMPHRYS: No no but on the other hand saying it and making it quite clear….. I mean what that is saying to them is – be very careful about how much more you give these nurses now. If you’re going to get the fifteen thousand pounds, fifteen thousand extra nurses that you do want it’s going to be very difficult isn’t it? DOBSON: Yes it is very difficult. I’m not pretending it’s easy. I’ve never pretended anything in this world’s easy. There are dilemmas John. But the other thing that we’re doing which all the surveys of nurses show are necessary is doing things to make nursing more attractive not just as far as the money’s concerned. The money is obviously important….. HUMPHRYS: Oh it’s THE big thing….. DOBSON: Well it’s one of the big things but it’s one…for instance, one of the things that’s very upsetting for people working in the Health Service is the number of people who have suffered from assaults and abuse. Since we’ve got in we’ve taken that very much more seriously. We’ve insisted that National Health Service managers take it more seriously with the help of Jack Straw who is responsible for the police and Derry Irvine who’s responsible for the courts, we’re getting them to take things more seriously so we’re doing things about that. We also want to make working in the Health Service easier for people who’ve got family commitments so at a big hospital they can do things like rostering the nurses so that if a nurse, male or female, wants to take the children to school in the morning or pick them up in the evening they ought to be able to do that and fit in their work as well. So there are all these sort of things that we’re…. HUMPHRYS: But you know full well that the Royal College of Nursing says, ‘this is the big thing. Money is the big thing.’ What you seem to be saying to me is that they will not get much more than a little bit above inflation but not much more’. DOBSON: Well we’ll have to see. I don’t know what the … I simply don’t know what the review body is going to recommend but I hope they recommend enough to make things attractive. The other thing we have got to do is we’ve got to bring about some radical changes in the recruitment and training of nurses because the present situation isn’t satisfactory. When the changes were introduced which in effect said – if you want to become a nurse the first thing that you’ve got to do is go on an academic course. That was attractive to some people but it put off quite a large catagory of people who previously might have gone into nursing. We want to change that. And it’s also left, as certain programmes have shown, some of the nurses who have been trained under the present system, when they actually end up working as qualified nurses they feel that they haven’t had enough on the job training and we need to make those changes because that puts people off as well. HUMPHRYS: But earlier in the interview you said you weren’t in the business of badgering the professionals in the Health Service. Well is it? Let’s talk about waiting lists because you are telling them, you’re not asking them you’re ordering them, sometimes in a pretty brusque way, quite a brutal way some people say, to cut the waiting lists. That is the priority and many of them perhaps most of them, hard to put a figure on it, but an awful lot of them think that is the wrong priority. You heard Dr Mac Anderson of the BMA there saying it’s a stupid idea. DOBSON: Well he may think it’s a stupid idea…. HUMPHRYS: A lot of people do…… DOBSON: …. but he didn’t fight the General Election on a promise to get waiting lists down….. HUMPHRYS: Ah… so you’re hung up on that promise then? It’s a political thing. It’s not a medical thing….. DOBSON: Well it’s a promise we made to the people of this country and we intend keeping all our promises…. HUMPHRYS: Even if you shouldn’t have made it? DOBSON: I think we should have made it because the waiting lists were too long, they are too long and they ought to come down and they are now coming down in addition to the…… HUMPHRYS: But what a price though….. DOBSON: In addition to the one point two billion pounds that we put into the NHS extra this year anyway we’ve found five-hundred million pounds specifically targeted on bringing the waiting lists down and with that money the people in the National Health Service have done an absolutely stunning job because they’ve come down even on the announced figures and there’ll be some coming out very shortly with a further fall, but on the announced figures they’ve come down by almost a hundred thousand and that’s a hundred thousand people who would otherwise have been waiting for treatment who are not waiting for treatment. HUMPHRYS: The trouble with that though, the money that you spend on this priority, the priority of cutting waiting lists cannot be spent on other things. DOBSON: That’s quite right yes, HUMPHRYS: That’s absolutely obvious isn’t it. We’ve got a new survey out this weekend showing that nearly half of NHS trusts, half of the hospitals offer no diagnostic treatment or rehabilitation services to people with multiple sclerosis which is a terrible disease. Thirty MPs and peers have sent a letter to Downing Street saying – ‘The NHS is conspicuously failing to provide for this need’. Now that is the price of cutting of making…. DOBSON: No. No I’m sorry John it isn’t. HUMPHRYS: One of the prices. DOBSON: No it isn’t. HUMPHRYS: But you acknowledge that you can’t spend the money twice. DOBSON: No, but you can’t say that. The Tories didn’t find- HUMPHRYS: I’m not talking about the Tories. DOBSON: Alright then, let’s say the previous government. No government over the last five years have found any extra money for bringing waiting lists down and the short-comings in the Multiple Sclerosis service existed during all that period. HUMPHRYS: So you acknowledge that there is a short-coming. DOBSON: Oh yes there are lots and lots of short-comings and that’s why we are determined not just to find extra money for the National Health Service but to help the professionals do better, as they want to do- HUMPHRYS: Ah, but they can’t you see, because you tell them they’ve got to cut the waiting lists. I was talking to- DOBSON: Let me explain. Up to now in the National Health Service everything to do with standards and quality and indeed most priorities have had very little to do with the National Health Service, most of it has been left to individual professionals and the professions, and the standards aren’t being set. Standards aren’t being met all over the country, despite the efforts, really amazing efforts of the people concerned. And what we are going to put into place are a lot of new arrangements, again utterly with the support of the profession, like the National Institute for Clinical Excellence, like the imposition of a duty of clinical governance on every hospital, like the introduction of a commission for health improvement, all of which are intended to raise standards and to get those standards applied universally and we are doing it, we are doing it with the full support of the professionals. HUMPHRYS: This is the point isn’t it, applied university. Now, what happens at the moment is that if you happen to live in a particular part of the country, you may or may not be able to get this treatment or that treatment, there was an appalling story in the Sunday Express this morning about a woman called Jackie O’Donnell, suffering from ovarian cancer, she needs some drugs called Taxol and Carboplatin which is the gold standard treatment. She can’t get it because she lives in this area – if she moved a few yards up the road she’d be able to get it because she lives in another area. Now that’s wrong isn’t it.? DOBSON: Yes.. HUMPHRYS: So what are you going to do about it? DOBSON: That’s what we are going to do. We are going to introduce a National Institute for Clincial Excellence which will look at new drugs, new techniques and offer guidance and advice right round- HUMPHRYS: Guidance, just guidance. DOBSON: Well it will be guidance but the guidance will generally speaking be followed. HUMPHRYS: How do you know, it may not be. DOBSON: Well it will because we will make sure that the system- HUMPHRYS: Make sure how? DOBSON: Let me explain right. The National Institute for Clinical Excellence, led by professionals, we’ve just announced the chairman designate, with the approval of the British Medical Association, Professional Michael Rawlings, who’s professor of clinical pharmacology at Newcastle University and a consultant at the Freeman Hospital in the Royal Victoria Infirmary, a person of great eminence and distinction. He will be joined by other people, they will look at techniques, they will look at new products and they will issue advice and guidance. HUMPHRYS: Well that’s all very well- DOBSON: But then the next thing is the hospitals will have a duty to, generally speaking, follow that guidance. HUMPHRYS: It’s all very vague – a duty generally speaking to. DOBSON: I have to say generally speaking because in the end John, we cannot take away, and I don’t want to take away, and I don’t think many of the professionals want to take away, the ultimate decision on some of these things, so that there’s some discretion for the doctor who’s faced with patient- HUMPHRYS: It depends what you mean by discretion doesn’t it. I mean let’s take IVF treatment for instance. We talked about it in that film. There are many many doctors who do not want to prescribe it, who don’t want to have anything to do with IVF because they say: look what we could spend the money on, we could spend it on MS patients for instance instead of that.Now, you, as the politician in charge of the Health Service, ought, ought you not, to say this is the government, this is what we believe the priority is to be, in other words you should use that word that people like you never, never use because you hate the political ramifications of it, rationing, and you back away from it because you know what the political consequences are. DOBSON: No, until you deliberately introduced the word rationing, what you were saying was that the government should lay down some priorities and that is what the new arrangements are intended to do. HUMPHRYS: So you will say to doctors: don’t do IVF for instance, unless- DOBSON: No, well my own view on IVF, because some of these things are personal, my own view is that there are a very large number of people who are infertile or sub-fertile, many of them are not getting the attention that they deserve and not being fertile can be immensely harmful to people’s physical and mental health and the prospects for the whole of their life. So, I think it should have quite a high priority. At the moment you can get IVF treatment but only in some parts of the country and what we are saying is, when something is generally available it ought to be generally available in the whole country. But I come back to- HUMPHRYS: You’ve ducked the rationing thing haven’t you? DOBSON: No I haven’t ducked the rationing thing, I am saying that generally speaking IVF ought to be available in most parts of the country- HUMPHRYS: And is there nothing you don’t want to be available. DOBSON: Well there may be but… HUMPHRYS: And are you prepared to say so. DOBSON: But we will take advice from the National Institute for Clinical Excellence. HUMPHRYS: And they, having given you that advice, will you then say, if they say to you, let’s just take an example about this. I know that this isn’t your view but if this NIC, if this committee said “we do not believe that it should have, IVF should have a high priority”, would you then say okay that is what I will tell, in the same way that you called in the Chairman, let me finish the question, the same way that you called in the Chairman of health authorities and said, ‘You will cut the waiting lists.’, will you say to them, ‘You will instigate this? Will you? DOBSON: Yes, but I don’t imagine that they’re going to…… HUMPHRYS: No no… whatever it is, whatever the issue….. DOBSON: But what they’re much more likely to do in most cases is to say, ‘This new drug is besides being safe and clinically effective is really worthwhile and it ought to be applied in every part of the country.’ No-one, there is no arrangement which says that at the moment John. They aren’t going to be mainly saying this isn’t a priority, I think they’re going to be mainly saying it IS a priority and I have to say that will be a huge step forward for virtually everyone in the profession. HUMPHRYS: Can I move on fairly quickly if I may to Social Services for which you are also responsible. There is growing concern about standards in residential homes as we all know, children and old people in particular. Are you worried that they are failing, too many of those homes and the Social Services are failing.. DOBSON: Yes. Too many have been failing and we are determined to do something about it and we are going to change the regulatory system. At the moment the regulatory system’s a mess. Some of it is done by local authorities regulating themselves and regulating other people. Some of it isn’t regulated at all and what we’ll be announcing very very shortly are some new arrangements which will put in place tough new independent regulation and it is intended to work as the present system has never worked. And we can’t have the same people who are doing something regulating themselves. We’ve got to have some tough outside regulation with tough national standards applied in every part of the country. I’m absolutely determined to bring that about. HUMPHRYS: So no more local authorities policing their own homes. We will have these independent – what will they committees? Because I’m hearing talk a czars and commissars who are going to be responsible for this kind of thing. DOBSON: Well I don’t know why you use all these Russian examples. HUMPHRYS: The newspapers this morning. DOBSON: Our proposition will be deeply British and they will be organisations which will have independent people on them and they will also be employing people, employing an inspectorate whose job it will be, whose sole task it will be to make sure that the standards of care provided in homes are very good but also it will go wider than that. We’re looking at them looking at standards of care for all social service provision whether it’s in the home, whether it’s in individuals’ homes or residential homes or centres. HUMPHRYS: Individual’s homes? DOBSON: Yes. What we…. You see in some places people aren’t getting a good quality service from people who are delivering services to say an old person in their home. So they need to be checked on as well. HUMPHRYS: So these organisations or these committees or whatever you’re going to call them will have more power and more money to do this job properly? DOBSON: Yes. HUMPHRYS: Statutory powers? New legislation? DOBSON: Yes. HUMPHRYS: It’s not in the Queen’s Speech. DOBSON: I know it’s not in the Queen’s Speech. It will be in the next Queen’s Speech I expect but what we are saying is that in the interim there are things that we are doing already to tighten things up and in the interim we’ll be making sure that the existing system does the best it can. It hasn’t even been doing the best it can up to now. HUMPHRYS: Well we look forward to the next Queen’s Speech. Frank Dobson, thank you very much indeed. …oooOooo…