Question round 1: On the ‘disaster' of the health bill & the coalition being in bed with the alcohol industry
Dr Duncan Keeley, a GP in Oxfordshire:
‘Mr Lansley thank you for coming to talk. But I am one of the many GPs that still think that the changes proposed in the bill will be damaging to the NHS and who feel that even at this late stage the bill would be better withdrawn. 400 public health doctors, led by Professor Sir Michael Marmot – the Government's advisor on health inequalities – wrote to Lords saying the same thing. I'm puzzled that yourself and the Prime Minister repeatedly assert that the changes have the support of the healthcare professions when this is clearly not the case.'
A GP in Sheffield:
‘I along with many in the profession, feel that the Government is protecting the perverse vested interests of the drinks industry. After 20 years in practice in an urban Sheffield community we have buried more people in the last year under the age of 45 than ever in my career. Why has the Government failed to find a coherent policy to address the public health impact of the UK's escalating consumption and addiction to alcohol?
Dr Angela Burnett, a GP in Hackney:
‘We as GPs have grave concerns about the increasing privatisation of the NHS. It's a mistake to move closer to the US model which is the most expensive and unequal health system in the world. We know that unequal societies make us less equal. Can you prove that your health policies and overall government policies will make a more equal society and therefore improve the health of everyone in the UK?
Dr Elizabeth Goodburn, a GP in London:
‘I think many, actually the majority of GPs, think that the health bill is going to be a disaster to the NHS. If you had your time again wouldn't you do it differently?
Answer from Mr Lansley:
‘I think Dr Keeley and Dr Goodburn essentially asked me the same question, which is why are we doing this? We're doing this because we agree about the principles and we have to put those principles into effect. Let's come down to the sheer practicalities.
‘I think that GPs across the country believe that whether it's through fundholding or practice-based commissioning they could see the possibility of being able to bring a clinical perspective to bear on commissioning and improvement on population health.
‘It was not done right on fundholding and it wasn't happening under practice-based commissioning. We didn't start with a view about GP commissioning groups that was anything other than tested by experience, but making it happen means having legislation for it.
‘Making it happen means moving from a place where PCTs with all their statutory controls and responsibilities disappear and clinical commissioning groups are established. It means arriving at a place where you change the legislation so that CCGs are their own statutory bodies, with their own powers and they are not simply doing whatever it is the Secretary of State tells them to do day by day.
‘I think if you want to have clinically-led commissioning then you have to have the Health and Social Care Bill. I also think if you really want to impact positively on social determinants of health you need to create a mechanism for local authorities by which they can do that because they have a much bigger role in relation to things like employment and education, environment, transport and housing.
‘If you actually want to do public health in the way that Sir Michael Marmot wants – he and I have been working together on not only our policy but internationally to lead on the social determinants of health. I invite anyone to go online and look at what I said at the UN General Assembly just a few weeks ago. We're absolutely committed.
‘The fact about the Health and Social Care Bill is that if you want to do those things, you have to have the legislation to make it happen. So why then, in my experience, as I talk to people do many people say I don't agree with the bill? They tend to say because they think the Secretary of State will no longer have a responsibility [for the NHS], when actually I'm clear that the Secretary of State will continue to have an absolute responsibility for the provision.
‘They tend to think it will lead to charging in the NHS, where there isn't charging. But the Bill does not allow that – the legislation does not allow any extension of charging in the NHS. It doesn't extend charges beyond any place where it currently is provided for in primary legislation.
‘Dr Burnett is saying ‘what about the US model?'. I'm not proposing the US model, I'm not proposing going anywhere near the US model. If anyone actually cares to go back and look at the Conservative Party's publications in the six years prior to the election, David [Cameron] and I expressly took the party away from any question of an insurance based co-payment system to one that is taxpayer funded, free at the point of use and available to all based on need. That is why the White Paper is about equity and excellence because equitable access to the NHS is entirely the principle.
‘People across the world are envious. I meet ministers from other countries who are [envious], like President Obama in America or the Dutch health minister and others, who are trying to arrive at a place where we are – which is that we effectively have universal health coverage on the NHS. What we don't have is necessarily uniformly good care.
‘What I'm saying today is that this is our opportunity to drive from just saying we're very proud that everybody is covered by the NHS service to being equally proud that everyone in the NHS is getting health outcomes that are as reasonable as anywhere else in Europe.'
Question round 2: Lansley vs Clinton and NHS rationing
Dr Pete Deveson, a GP in Surrey:
‘I've got a question about definitions. You've repeatedly claimed you're not privatising the NHS, but surely that depends on how you define privatisation? Bill Clinton was able to state that he did not have sex with Monica Lewinski based on his personal definition of ‘sexual relations'.
‘Your intention to maximise the number of private providers will inevitably bankrupt the single payer, necessitating the introduction of fixed funding, of co-payments, of insurance, which surely is a privatised system. My question is, what is your definition of privatisation and can I find you more or less credible than Bill Clinton, when you say you'll never privatise our National Health Service?
Dr Martin, GP and cancer lead:
‘I'm concerned about the erosion of care to those who are dying, and particularly having choice to die at home which is meant to be the best option for most people. ON a particular note, a hospice at home was taken away when Coventry had a new hospice. It was returned all guns blazing but it was only to those that had prior funding, so I'm worried about this matter.'
A GP in Buckinghamshire:
‘You say to patients, no decision about me without me. When will you allow patients a decision on rationing versus more funding for the NHS?'
Question from GP in Sheffield:
‘You've just said that if we see something wrong we should say and ask for it to be changed. I think this bill is wrong and I'd like everyone here who thinks it is wrong to raise their hands'. (Majority of room raise hands).
Answers from Mr Lansley:
Mr Lansley: ‘I actually think a large proportion of debate about the Bill has misrepresented what the bill is doing and what is actually in the bill. I was slightly staggered when the bill was about to report in the House of Commons there was a letter from a number of organisations saying they continued to have concerns about the Bill because they were opposed to Any Qualified Provider...'
‘AQP is the precisely a mechanism by which we can move to what I think all of us think is the right thing and that is competition on quality, not competition on price which is actually what happens in the NHS at the moment.
‘It isn't an argument about the bill, it is an argument about competition. Some people say competition is bad. I say, used properly to improve quality for patients, it can be a good thing. I believe in competition, I don't believe in privatisation in the NHS. What I'm looking for is to ensure that the NHS has access to the best placed provider.
‘Now I have more confidence in the NHS than, apparently, many of you do, because I think the NHS is very well placed to be the provider of choice for you as commissioners, for you as the people that refer patients, and to your patients themselves. I actually think, the Bill if you look at it, has a provision to prevent any kind of discriminating in favour of the private sector, which is actually what happened in the past.
‘The Bill does not allow for private organisations to become, as it were, responsible for the whole commissioning. Statutory bodies, the CCGs will be responsible. So far as the public is concerned, privatisation would mean, if you ask them, would mean having to pay for their care instead of having that care provided on the NHS free at the point of use based on need. We are not going to move to a place where there is any additional payment.
‘Other people say, well privatisation means there will be more private providers involved in the NHS than there are now. I don't know whether there will be more.'
Dr Clare Gerada: ‘Over the last few days lots of people have talked about the privatisation agenda. What is your definition of privatisation? Because I suspect many people in this room will agree that the definition that state resources are moving into the ‘for profit' market...That means the money isn't there for patient care. The money is there to feed shareholders, the money is there for profit...I think there is a certain confusion because...'
Mr Lansley:
‘Privatisation is the transfer of public sector responsibilities into the private sector. We are not transferring responsibility for the NHS into the private sector. The responsibility for the NHS will continue to be the Secretary of State's, the NHS commissioning board and yourselves in Clinical Commissioning Groups as statutory bodies. The actual delivery of services will continue to be overwhelmingly with public service organisations.
‘If I was to follow your line and say "the private sector is wrong", we'd say "we'll shut down pharmaceutical companies because they make a profit for their shareholders". Go to any hospital you like and there will be a significant portion of those services provided on that site by public sector organsiations. I can't even understand how people get to the point where profit is wrong because actually all that is hqappening is that there are different circumstances in teh NHS where different people make a surplus. In Trusts they call it a surplus. In General Practice what do you call it?...
Dr Gerada: ‘The argument of GPs being private sector has been thrown at us for sixty odd years.'
Mr Lansley: ‘Well what do you define as profit?'
Dr Gerada: ‘Well the difference between what we spend and what we pay is our salary – I mean that's the end isn't it?'
Mr Lansley: ‘If you shut off the private sector, you end up shutting off the independent sector...Andy Burnham did it in the past. He said NHS is the preferred provider and what he meant by that was that patients had to be let down twice before being able to go somewhere else...'
Dr Gerada: ‘So you are saying we have nothing to worry about then? With the hovering of the private sector and support around commissioning?'
Lansley: ‘The FT a few weeks ago said Humana, under the last Govenrment provided a lot of services to PCTs. Remember last year, before the election, PCTs bought in £250m of management consultancy from outside the NHS. People were hovering beforehand. Humana, who were a US company providing those kind of management consultancy services, left Britain because they didn't think we were providing them with enough opportunities.
Dr Gerada: ‘Ok, so your definition [of the NHS not being privatised] is that patients will not pay at the point of use. I think the audience's definition is slightly wider than that in the fact that the provision or commissioning support is done by for-profit, corporate [companies]...
Lansley: ‘Let's get this clear. CCGs are statutory bodies. You collectively, with your colleagues, will be responsible for a public service, in a publicly accountable body, it is not possible under the legislation for you to transfer that responsibility to a private sector organisation.'
GP from Birkenhead and part of local CCG: ‘I actually disagreed with the chair's introduction. I actually agree with the Minister that privatisation is actually when you have to pay for a private service. We are delusional if we think that for 35,000 practices in this country which are private businesses. We provide an NHS service, we do not take money from patients for that, but we are private enterprises. This is delusional. It is also delusional to think that the current system will provide integrated care because it has failed. Cartels keeping existing services is not going to move us forward.
‘There is a lot of appetite for commissioning. It is a shame the way [the Bill] was presented originally, I do not accept that everything about it was right and I think there have been a lot of changes. And I just wanted to put that there is a different point of view in the profession apart from all the quibbling that is going on. The question I have for the Secretary of State is this – how can you get your act together as a Government because there are conflicting messages coming and that makes people in General Practice who have embraced this in a difficult position because they don't know if this is going to go ahead and what is going to happen. But we welcome what is actually happening.'
Question round 3: On ‘patronising' GPs,
Dr Sutton, a GP trainee from London:
‘I think a lot of us have tried to read the Bill Mr Lansley and it's a little bit patronising to say we don't understand it. It is very complicated, and I'm not a lawyer, but I have tried to read all of the documents there. I think there is a complete problem in the fact that all the staff in PCTs, SHAs, are all sleepwalking to oblivion as well.
‘We're trying to save £19bn as well as delivering the best care as we possibly can to our patients, but all we see is complete chaos. If you say that we're the people to lead the NHS, that we're the people to hold the budgets, that we're the people who know what's best for our patients, our practice, our community, when all of the professions of medicine, of nursing and healthcare management say this is wrong, will you consider working together without the bill, without wholesale reorganisation and destruction of all the systems that were there.
‘Will you work with us to find a way of engaging in commissioning without the bill?
A GP in Liverpool:
‘First of all I wanted to say something positive. After all this, the move of public health into local authorities and trying to work in anintegrated way is one positive aspect. However, in Liverpool our health and wellbeing board is being setup and everything but in the meantime our city council has faced the most appalling cuts. In the last couple of days they've been making more cuts and I personally know that the city council has been working flat out to make the best of it but how is the inverse care law and protecting the health of those with the poorest health going to work if, in deprived areas.
A GP in Cambridge:
‘I think before you introduce any wholesale radical reform, you've got to be pretty sure there is some good reason to do that. How are we doing in teh NHS? We heard from Ipsos Mori that patient satisfaction ishigher than it has ever been in this service. How are we doing in terms of cancer? Every year, under the last Governemnt, since 1995 there has been a year-on-year fall in cancer mortality.
‘ The number of heart attacks has halved since 1997. We are one of the cheapest healthcare systems in Europe and we offer some of the best outcomes. It's little wonder then that there has been such anxiety, worry, outright opposition from members of the caring professions.
‘We have had some guarded responses from our own college, the Royal College of Nursing said they believe that this Government is pursuing its aim of a large scale increase of private sector provision in NHS services. Why does it feel like our words as the professionals looking after patients are falling on deaf ears? Is it because the Government doesn't understand, or is it because this Government doesn't care?
Mr Lansley's answers:
‘Well Doctor I come from Cambridgeshire as well and I think it would have been a help if you had attended the Cambridgeshire NHS AGM that I attended a few weeks ago. There, the local authority, the outgoing PCT and the representatives of the CCG demonstrated they are literally now, in effect, working in the new system. They are working in the new system in a way that is putting population health in a stronger place within the local authority, in the way that is empowering them to design new clinical pathways of care for diabetes and mental health.
‘From the point of view of GPs across Cambridgeshire this is an important step. I've visited GPs in lots of places and, in my experience, there are people who are enthusiastically embracing the concept of clinically-led commissioning, there are people that are doing it because they realise it is going to happen and they should make it happen. What I don't see is chaos. I see a change which can make a big difference in the future. I know perfectly well there are ways in which the NHS is done better.
‘I've been there with the cardiac surgeone, for example, celebrating the fact that they published their data and they improved cardiac surgery performance in this country from the bottom part of the table to right at the top of outcomes across Europe. That's what we are trying to do in other places. If you look at our record for mortality from lung disease, we are among the poorest in Europe. If you want an early diagnosis of cancer, we do badly. We know there are places we can improve.
‘If you ask those working in hospitals would they be happy if a friend or a member of their family required treatment for them to be looked after in their hospital. At the top end, 95% would agree. At the bottom end, there are 14 hospital trusts in this country where fewer than 50% agree with that. That is simply unacceptable. What we are looking at is a philosophy of continuos improvement and ofcusing on outcomes and a philosophy of achieving that by driving out adverse, unwanted variation. I think that's tremendously important.
Dr Gerada: ‘But why is the Bill needed for that?‘
Lansley: ‘The Bill is absolutely needed for that.'
Dr Gerada: ‘But we've heard about PCTs. PCTs have gone already...'
Lansley: ‘They haven't gone. They exist in clusters. Actually, this is one of the things people...If we were going to cut bureaucracy in the NHS we were going to do that anyway. The NHS in general in the year before the election, the management cost rose by 23%. £350m extra in management cost. In the first year after the election we've taken £325m out. Now I know that alot of people saying "things are disappearing before our eyes".
‘The truth of the matter is, that there is still at the end of the day, the £3bn plus administration cost of the NHS – more than enough to support an effective system. The point is that there is a fundamental philosophy here that if you are responsible for making the critical decisions about commissioning and about patient care, and you are, you should also be at the heart of decisions about how resources are best used in order to enable you to make the best possible decisions. That hasn't been the case for too long.
‘There has been a situation where there is a management system that is completely separate, and often operating in a way that is unrelated to the needs of patients and themselves, who are responsible.
‘We are working with local government. We in the NHS, should be only too aware of how hard it is for local government who are facing a 4.4% reduction in spending power in local authorities across the country. The reduction in social care spend in local authorities is 1.1%. One of the reasons why we are working together, and we have £648m specifically allocated in the NHS to support social care.
Question round 4: practice boundaries and England vs Wales
GP in Derby: How does your vision of more travel, no practice boundaries, more competition – which apparently uses more resources than collaboration – fit with a sustainable NHS for the future that is absolutely vital?
GP in Cardiff: I'm glad that in Wales we are protected from the damaging effects of this Bill so I won't ask about that. We've just had a wonderful presentation on an evidence-based drug harm reduction strategy and I wondered if you'd considered inviting the producers and purveyors of drugs like ecstasy and cannabis in being involved in a public health strategy as you did for the producers and purveyors of more harmful drugs such as alcohol?
GP in Wales: ‘Given that the Celtic nations seem to understand, promote and be able to implement the basic principles of collaborative care, accessible to all, provided by integrated NHS by well educated clinicians – is it now time for the devolved nations to move towards independence and be prepared to welcome all GPs and all patients because I don't believe that you and your colleagues are taking on board our concerns.'
RCGP patient representative lead:
‘My question is about patients that have been removed from GP lists. I'm not talking about violent patients, there is a system for those. I'm talking about patients where the relationship has broken down. They are unpopular, they're difficult but they have unmet care needs. Who will be responsible for them when PCTs go? Who will place them in new practices and with practice boundaries going where will they go? Who will be involved in those decisions and does any partner in that have any right to appeal?
Mr Lansley's answers:
‘I'm not abolishing, or about abolishing practice boundaries, I'm intending to extend patient choice. I suspect certainly the first question was written before the gentleman heard what I said in my speech. I said we need to look at how this works because there are patients, we've met them, who understandably want to retain the relationship with a particular practice while we've got a situation where, possibly thousands of people, technically speaking live in two areas. And who very often in that sense, want a practice in one place and a practice in another at different times.
‘The whole business of managing the relationship patients have with their practice, whether they're out of area, who visits them, how information is supplied...is a practical issue. What I've said is that it is a practical issue and we are going to work it through. I don't think a response to a practical issue is to minimise patient choice. I think we must maximise choice to patients.
‘I think Wales will regret the fact that there isn't clinical commissioning in Wales. They are trying, through the local health boards, to give GPs more say but I think actually, unless you do what the bill says, it will have no impact. The Bill is focused on delivering outcomes. When you look for example at waiting times, I visit North Wales regularly and their newspapers are regularly full of the fact that patients are waiting a lot longer for their treatments, including hip replacements, in North Wales.
‘If you look at the data, we in England achieve over 90% of patients referred and treatment within 18 weeks. In Wales it is just 7 out of 10...In Wales, the Welsh Assembly Government, according to the King's Fund, is going to reduce spending by 8.3%. We are going to increase expenditure on the NHS in England in real terms. I will happily have a debate with Wales any time they like on the relative commitment and performance of the NHS in England versus Wales.
Dr Gerada: All of the outcomes you just mentioned about the NHS England are not with the current bill. I think we have to be fair that those are not things that are round GP commissioning. To be fiar, that isn't about GPs being in charge [in England] because we are not in charge yet.'
Closing remarks from Dr Gerada:
‘I would like to thank Andrew because it is extraordinarily good of him to come to our conference. He has the most remarkable knowledge of the NHS and I think he demonstrates that. Over the year I do admire Mr Lansley, even if I have serious concerns about elements of the Bill, I do admire the fact that he has the best interests of the NHS at heart and he has got the best knowledge of any Secretary of State we have ever had.
‘Despite the issue about the bill, which we continue to talk about and he continues to get a bit irked, there are nevertheless looking at the other aspects that are so important such as enhanced training, such as addressing health inequalities and such as improving the lot of general practice in order to get more GPs having more time in the consulting room, and extended training. I think it's remarkable that we can have these differences yet still work together.'
