................................................................................ ON THE RECORD VIRGINIA BOTTOMLEY INTERVIEW RECORDED FROM TRANSMISSION BBC-1 DATE: 21.2.93 ................................................................................ NICK ROSS: Mrs. Bottomley, let's start with London. It is a special case but it has implications really for the whole of the country. Now everyone has welcomed the pledge of extra funding - a hundred and seventy million pounds you're going to put over six years into primary care and into GPs - but if you're really that keen on the Tomlinson Report which has been waiting of your desk for five months, why have you now - as some see it - prevaricated for another six months. Are you being tough or, basically, are you a consensual politician saying "well, let's see what everybody thinks about it". VIRGINIA BOTTOMLEY: Tomlinson made a hundred and six recommendations. We've accepted or acted on ninety-six of them. We've set out a very tight time-table for change, radical change, because the problem of London, I think now, is well understood. Forty-three hospitals is too many. Twelve undergraduate teaching hospitals achieved at the price of distorting the budget across the Thames Region so more money goes into London than is fair. Twenty per cent of the money for fifteen per cent of the people. And also distorting the budget away from primary care and, as you rightly said, not only a hundred and seventy million for the capital programme for primary care, forty million next year to go into revenue as well, seven and a half million to go into the voluntary organisations to help develop Crossroads, Hospital at Home schemes, those sort of initiatives, as well as ten million pounds into the waiting fund, really making the point that I think Matthew Carrington was making - we've got to continue to improve services for people as we take forward the changes. ROSS: Can I come back to my question though. You've Committeed yourself, rather than committed yourself, as much as you've got Tomlinson to take a look at the thing - that's been hanging around for nearly half a year, there's another half a year now - on some of the key recommendations. For example, Bart's and Charing Cross. I mean is there still a chance that they could be saved? BOTTOMLEY: What's very clear is we set out the timetables for change and the procedures. I want to act as urgently as I reasonably can. I'm bothered about a spiral of decline. If we don't take decisions then morale will ... uncertainty for staff. ROSS: But that's what I'm asking you. Why don't you take decisions? BOTTOMLEY: Because we have to take forward the next stage which is the speciality reviews. The problem of London is there are fourteen cardiac services, thirteen cancer services, thirteen renal services, and neuro-sciences. We're setting up speciality reviews - who'll say "Alright, how can we rationalise those". Because at the moment they're not cost-effective, there's excessive duplication. Bring them down to a more sensible number - I hope some of them will go to other parts of the country - and then give further time for those more detailed decisions where we require further depth, economic appraisal, narrowing in on the particular options. So, for example, Guys and Thomas' - we talk about them coming together as a Trust and then having a site appraisal as to which of the sites it should be. And UC, Middlesex - again that going forward for them to come together. The option at Bart's - that maybe they should close or maybe they could become a single speciality hospital, but they'd have to stand the test of the Reviews and they'd have to have prices that the purchasers were going to support, all coming together with the Royal London and, at the moment, that's the option they look as though they're exploring. So, difficult decisions, where it's right to give a little more time but, like others, I want to make the decisions, because I believe it's important to do so for the National Health Service not only in London but more widely. ROSS: But if I say I suspect that what's happened is that your colleagues have come to you and said - "Look, Virginia, for heavens sake - after the debacle over the coal mine closure, for heavens sake be cautious about this, even if you intend to do the whole lot, make it look as though you're putting it all out to consultation". But actually, at the end of the day, you've no intention of saving either Charing Cross or Bart's, or the other great institutions. BOTTOMLEY: Quite wrong. My view on what had to be done in London hasn't changed since the day I became the Secretary of State. This is a problem that is long-standing. We've had twenty reports in the last one hundred years saying tackle London, and I'm going to tackle it, and my test is not only my colleagues, not only - dare I say - the press, my test is in twenty years' time I want to say I did that properly; the Health Service in London is stronger as a result. And everyone knows that as the districts out of London take their patients away, the fixed overhead costs in London become ever more difficult. If we're going to grow primary care, GPs and the Community Nurses, that's where it really all begins, then we've got to allow the resources to go into primary care. This has to be done. It has to be done though sensibly and, so far, we have achieved a remarkable degree of agreement. The Royal College of Nursing, the BMA, other independent commentators and professionals, all saying this is the right thing to do, but they did say there are areas where decisions need a little more depth and detail. I agree with that, but it can't go on and develop uncertainty, so as fast as we reasonably can we have to make sure that we take the decisions for the benefit of London and Londoners and the Health Service
as a whole. ROSS: I must say, medical staff I've spoken to make it sound rather less consensual than your impression of them, but I wonder if the biggest problem isn't so much the medical staff - I think the public will accept that there's been this cabal which has, for a long time, been shroud-waving and saying you mustn't close this, you can't do that, but the public are going to find it - voters are going to find it - very, very odd to hear a Secretary of State saying London is over-provided for, when last month many of London's hospitals were on "Yellow Alert" which means they can only accept emergency cases because there simply weren't enough beds. BOTTOMLEY: Absolutely the right question that Londoners should ask, and the reason that we have this paradox in London is because of the forty-three hospitals, because of the different specialist centres, we don't achieve the same efficiency, we don't achieve the same activity of other parts of the country. We have a distortion towards specialist services away from what it is that Londoners want. And also, because we don't have the properly developed primary care, very often we use the beds inappropriately. So, if I can give you an example - at one of the casualty departments at King's. Something like forty per cent of the people going there elsewhere would have gone to their family doctor. At Mary's they estimated that something like fifteen per cent of the beds were occupied by people who should be able to go home to the community if only we had the community services in place. So Londoners are right to say that "Look, Secretary of State, we want to be sure that this action for change will go alongside the development of community services". And that's why we're putting forty-three million pounds next year alone into the Community Services, because we recognise the point that we must make sure the Community Services build up as we rationalise the Hospital Services, but my benchmark must be services for patients, not protecting institutions. I must count the right outcome measure and that is improving services for patients. ROSS: Quite, quite so. None the less, it seems to me that you've got a hell of a job squaring the circle. You've got a waiting list in London (if you combine them all) of between a hundred and twenty, a hundred and thirty thousand people, waiting to get into hospital, and you're saying "but, wait a minute - we can close two and a half thousand beds". Electors just find this difficult to comprehend. BOTTOMLEY; And what we have last year alone, is the number of people waiting more than a year in London, falling by forty-one per cent, the whole waiting list in London falling by eight per cent. ROSS: That still leaves a-hundred-and-twenty-two thousand...... BOTTOMLEY: A very substantial change, and that's why we've announced ten million pounds next year, to carry on the progress with the waiting times, but of course it is a managed programme. We're talking about three to six years, but it takes time for medical schools, for research units to decide the way forward. I hate to say it took St.George's twenty-one years to get from Hyde Park Corner down to Tooting. We're talking about three to six years, and we'll need that time to build up the community facilities and to find the most rational way of amalgamating units of moving medical schools. There is a difference between the name of the hospital, the building, the site, the particular unit and the medical school, and so this is a very complex programme of change, that's why we've set up the London implementation group to drive it forward, but I shall be breathing down their neck to see results. ROSS: But what you're doing here is you're saying, "Look I am prepared to stand up to the medical lobby", and I understand that, and it's pretty clear from your actions that you are, but can you withstand the electoral lobby, can you persuade the likes of me that there is a logic to what you're doing, that it's honest, apart from anything else to say "Look, you're going to get a better service if we remove a fifth of the provision"? BOTTOMLEY: Well, the medical lobby for the most part want us to take forward change, understandably people who work at a particular institution are loyal to it, are fond of it, I am myself extremely attached to many of those great institutions, but I'm not there to be an arm of the Department of Heritage, I have to see change. At the end of the war there was something like two hundred thousand TB beds in this country. You can imagine people saying, but these have had a great history, but the point is I want to work for the future, not the past, and I totally accept it is my job and the team of people I work with constantly to explain to the public, to general practitioners and others how those changes are going to be driven forward, and above all, what we want is those proper community facilities like the West Lambeth Community Care Centre, where you have nursing beds for people who need that longer term care in their local community, much more appropriate, much more cost effective, leaving the resources that are needed for the specialist treatment to go into a smaller number of specialist centres. ROSS: I'm not arguing for the moment, though we might come back to that, about whether you should keep the beds in existing hospitals, the ones with the grand reputations and all the rest, but I am inviting, I'm offering you a platform to explain to people about just the general number of beds available for hospitals in London. Sure, we don't need them now for TB, but we need them for an awful lot of other things, with a-hundred-and-twenty-two, a hundred-and-thirty-thousand people waiting for them. It just seems inconceivable to most people that a Secretary of State can say "All is well, don't worry. In fact we can actually now substantially cut the numbers of beds". BOTTOMLEY: The number of beds we're talking about is at the cautious end of many of the estimates that are around. The King's Fund Report, as well as Tomlinson, talked about higher figures as being a possible outcome, but my view is that this is the right place to start. What is happening very fast is all those districts outside London, Guildford where I come from, Godalming, Chelmsford, Medway, all those Home counties used to send people to London for teatment. Now they say, "We don't want to do that anymore, we want to keep them at home where it's more cost effective and it's more convenient for patients". So we have to move fast to stop those London hospitals getting into a spiral of decline as they lose patients anyway. Then take the way in which they use beds in London. In many part of the country people use fourteen beds for every thousand episodes of care, using the jargon. In London that's often up at nineteen beds. We can do better, we can't get to fourteen straight away, it will take time, but if we can provide the sort of facilities that people need when they leave care, if we can provide the sort of accident and emergency facilities which discourage people from going into hospital inappropriately, then we can make headway which puts the money into the community, and it is in community that actually ninety-five per cent of the care takes place. If we mind about immunisation, if we mind about cancer screening, if we mind about prevention, if we mind about mental health, one of the subjects I mind very much greatly about, we must release the money in London to tackle health in its broadest sense, not just hospitals. ROSS: I think many health professionals and indeed many members of the public would say, "Look Mrs Bottomley, you've got a hell of tough job and we all accept this, but why don't you just be honest, why don't you say: Look folks, we are rationing, there is simply not enough cash, you the public are a bunch of hypocrites, you say you want perfect and continuing increases in health care, but you're not prepared to pay for the taxes for it, and because you're not prepared to pay the taxes for it, frankly we're having to downsize, we're having to cut, cut, cut, so that we can spend some money here". It's rationing isn't it? BOTTOMLEY: That's not what it is. What it is though, is standing up to the traditional vested interests, those of the institutions, those of counting beds as the measure of health gain, it's rather like saying you're measuring education by counting desks. Most people would rather measure the results of education by looking at the results, so also with health. What we should be looking at is whether we're hitting those target figures for waiting times. Well, we've now got the lowest number of people waiting more than a year for treatment than we've ever had and that of course, nine out of ten are treated within the year. What we want to measure is the number of hips, the number of heart transplants and bypasses we treat, so look at the outcomes and stand up for the traditional iterests. Now just to come back to your particular question about whether it's rationing. The chattering classes as it were have discovered this new concept, but as long as I've been involved in health care, which now goes back more than twenty years, we've been involved in making choices, in setting priorities. The reason we used to have thousands, literally of children in long stay mental handicap hospitals was because there weren't the resources to settle them in the community. There are now only a handful. The reason that we've been able to take forward, whether it's transplants, whether it's hip replacements, whether it's the great range of initiatives, is of course because we've always had to make choices that releases money for the areas that'll achieve most health gain, so there's nothing different in what we're doing except that the strength of the purchaser-provider system, the strength of our reforms, is it is the District Health Aurthority's job, as you saw in your film not to prop up institutions as their first loyalty, but their first loyalty is to their local population, to say "How are we going to deal with cancer, heart disease, mental health, how shall we set cost effective priorities in place that mean local people have a better deal from the Health Service". That's right, patients first, not institutions. ROSS: You prefer the word priorities to the word rationing. It seems to me that they lead to the same thing, that you haven't got sufficient resources to do everything you'd like to do, so you're having to ration or you're having to make and set priorities. BOTTOMLEY: Well, the resources - I'm often described as being a Dame Margot Fonteyn of statistics and you'll have to bear with me - but the fact is we spent a hundred million pounds a day on the Health Service. Four million pounds an hour. A sixty-one per cent increase in resources since nineteen seventy nine and, for next year, a tight year, an extra thousand million pounds that'll treat an extra hundred and ninety thousand cases, that will allow another one million community nurse contacts. But I know, as somebody committed to the Health Service, that as we all live longer and as technology goes forward, and as opportunities develop, there will always be more we can do, so there will never be infinite resource to undertake infinite work. ROSS: Will there be less? BOTTOMLEY: So what I must have is the most sensible way of making those decisions that result in better health care for the people of this country. ROSS: Reports this morning suggest that you're - not suggest, they're overt - they say that you're going to be asked to identify two and a half to five per cent cuts in the Department, along with other Secretaries of State. Now that would lose you up to one point five billion pounds instead of the one billion extra for next year. Are those reports true? BOTTOMLEY: Well, we've got a very clear commitment of an increase in resources into the Health Service in real terms. That is a clear commitment and a commitment will stand. But, certainly, we're working very wholeheartedly and warmly with the Treasury saying "How can we find savings, how can we get better efficiency?" One of the areas which I know will cause a bit of noise is what we're doing on the drug bill. I can't afford to have the drug bill going up by twelve per cent, when I'm holding nurses' pay to one point five per cent. ROSS: But, specifically, have you been asked to make a two and a half or five per cent predicated cut? BOTTOMLEY: Well, I'm sure that we will work with the Treasury, looking at options, setting out ways in which we think that hundred million pounds a day could be better spent and I can tell you there are a great many savings we can make. But when the purchaser provide a system, really delivers results - because that's what this year is all about - is making it happen and deliver results, I hope we will find savings. But there's a world of difference between setting out options for the Treasury and maintaining our commitment of real terms increases for the Health Service,
which we stand by. ROSS: Can I take it from that that it is true the reports in this morning's Sunday Times you have been asked to predicate two and a half or five per cent cut? BOTTOMLEY: All spending departments are making sure they've looked at the options, but the commitment stands to maintain resources for the Health Service. Real terms increase in the Health Service stands. The efficiency benefits to go back into the Health Service. But we must be in the lead as the second largest spending department to say "Are we spending money wastefully, can we get better efficiencies?". Gone are the days when you could be in the public service and think somehow the money didn't matter - money didn't count. Costing and caring are two halves of the same coin and if we want to care better, we've got to cost better, and I'm absolutely remorseless in my determination to be sure that throughout the Service we're looking for savings, that we're behaving cost-effectively, because that's the secret to an ever better Health Service and that's what I'm committed to. ROSS: Professor Alan Maynard, the Health Economist, who I think is broadly sympathetic with much of what you're saying, none the less, is pretty blunt. He says, we've just heard in that report, we've got too many beds for the budgets available. And he also says that, frankly, what we've seen in London is going to happen (because of the internal market) in other cities too - Newcastle, Leeds, Manchester, as well as Birmingham. Do you accept his predictions - we're going to see hospital closures and quite a number of bed losses, perhaps three thousand, four thousand bed losses among those cities? BOTTOMLEY: Well, I do hope people will stop thinking beds are what you measure, because health care has changed now. Diagnostic treatments, day surgery, all sorts of micro-invasive techniques means you don't need to go into hospital for weeks at a time as in the past, because you can treat people so much faster and more effectively. Cataract operations, all sorts of operations, just on a daily basis. So counting beds really isn't the right measure. ROSS: What's Mr. Kitching if he's watching himself on television in that report going to say. He's waited ninety-one weeks, Mrs. Bottomley, to see a specialist. Now, I said - we, before we did this report - are we clear this isn't an incredible exception, that we're just going to make a mountain out of a molehill, and the more we've looked at it it isn't a terrible exception. What's he going to make of a Secretary of State who says, look things are actually getting better. Don't worry, it's not so bad. I would be outraged to wait ninety-one weeks to see a doctor, and wouldn't you? BOTTOMLEY: He's right to be very impatient. He is talking about two issues. First of all, the out-patient appointment and our Patients' Charter approach has been very successful, we've got rid of all the two-year waiters, we're bringing down the hips, knees, cataracts to fifteen months and, in many parts of the country they're doing better than eighteen months - they're coming down towards a year and, also, this year, we're setting targets for out- for first out-patient appointments. He's absolutely right to be impatient and to keep pressing, and that's again why we have to keep making sure it's the purchasers, it's the District Health Authority who will say - this isn't good enough and if you at this Hospital can't give me cost-effective hip replacement service in the time I want it, then I'm afraid I'm going to take the money elsewhere and see whethere another Service can actually provide a better service, and my campaign is to make much more information available, because if I want purchasers to really think creatively, to act shrewdly, they need information to do that and they do need to be able to compare with what one hospital can achieve with what another can achieve. So Mr. Kitching is quite right and he will need a bed. His is not an operation that can be done without a bed, but the fact that many operations can, means that you can release the overall need for the numbers and he is absolutely right, and I totally agree with him, we've got to keep up that pressure for more progress, but don't understate what's been achieved, because it is very remarkable the way those long waiting times have been coming down consistently and very powerfully. ROSS: If the internal market works of course it will enable you to cut a great swathe of bureaucracy away. When will you be getting rid of the Regional Health Authorities, which a lot of people say are something that you can just dispose of? BOTTOMLEY: Well, the Regional Health Authorities do need to be slimmed down. I don't want to see them employing anymore than two hundred people, many of them are much bigger than that, but they do have role, they have a role which is overseeing the purchasing function of the districts, because we've released the work of providing of hospitals as trusts. By April year, ninety-five per cent of our hospitals should be NHS trusts, which again is real progress for a very successful reform, a much better way of managing hospitals, but the engine of change as I hope I've made clear is through purchasing, assessing need, setting standards and monitoring the outcome of those contracts, and we need the regions for that strategic overview. Your film made clear, how in Birmingham, in other cities there is a process of change underway and we need to make sure that the decisions of one purchaser don't have unforeseen consequences on another person. ROSS: So there's still going to be quite a bit of intervention? BOTTOMLEY: There's going to a strategic overview as must there be, because it's a health service available to all. It needs to continue to be available to all, it's accountable to ministers and to parliament, so clearly I need to be satisfied that patients throughout the country will have access to health care regardless of their means, but it needs to be light, it needs to be effective and above all it needs to make sure that the service continues to be accountable to ministers, but decisions wherever possible are devolved to the lowest level, because it's the people and the community who can make the best decisions. ROSS: Okay, you've made it very clear, you are not going to give in an inch to what you see as the medical lobby arguing for things that really aren't in the best interest of the public overall, you're going to be quite tough on that. You're a genuine convert, - or I put that because you were a medical social worker some years ago and I wonder if you always were a convert to the idea of an internal market in the NHS, but you don't genuinely believe in it. I'm still not clear that you're going to be able to persuade people that cutting beds, you say they shouldn't count the Health Service by beds, that cutting beds is really an advance. BOTTOMLEY: Let me just take the different elements. Standing up to the medical lobby, there are a great many doctors who believe very strongly in what we're trying to achieve, that's why we've got so many GP fund holders, it's a voluntary initiative, by next April I think twenty-five per cent of patients will be covered by a GP fund-holder, because they welcome the power they're being given, the authority to make their decisions, their way. If you want to have a service that's responsive to patients, it's the GP who's the greatest advocate for patients. The people who may be less happy are those who are more rooted in the past and they do need reassurance that the specialist services will be strenghtened and be safeguarded. This is right for patients and it's right for improving health, and the internal NHS market is the engine for change. It's how we can take forward cost effective improvements in health care. Having been there three-and-a-half years, taken the legislation through parliament, fought an election on the basis of saving these changes, my job now is to make it happen. ROSS: Alright Mrs Bottomley, thank you very much. A report today suggest you're going to be Home Secretary before too long, so I don't how long you'll have to finish the job. ...oooOooo...