Examination of Witness (Questions 40-59)
RT HON
TONY BLAIR
MP
6 FEBRUARY 2007
Q40 Mr Barron: The central targets
inside the National Health Service, it would be churlish not to
say that the issue around waiting lists and waiting times, particularly
for orthopaedic surgery and others, have been a success and they
have certainly moved them. When the Health Select Committee was
taking evidence last year in relation to the current deficit situation
one thing that struck us was the central target on A & E waits
of four hours—98% was the actual figure that people had
to meet. We were told by several NHS Chief Executives that the
movement from 95% to 98% was a very expensive figure to get that
last 3% of the target. The real question is: why did we say it
was 98% and not 95%? Was this evidence-based?
Mr Blair: It was really to try
and get the last bit of it done so that you really had that quantum
shift in improvement in the accident and emergency services. Although,
to be fair, what you have heard and I have heard myself from people
who work in accident and emergency departments, as we refine those
targets, moving forward, which we will do in the years to come
where we have a different system operating in the health service
anyway, then I think we can probably take account of some of those
worries. Accident and emergency is a very good example of where,
whatever people say—and there is a report from someone today
saying that the targets are all fiddled—the best judgment
on accident and emergency is anyone who has experienced accident
and emergency today compared with 10 years ago, and it is significantly
better—significantly better. I do not think that that would
have been achieved without a central performance driven target
backed up, of course, by the work that we had, which is the modernisation
team that went to each accident and emergency department, and
who said, "Here are the changes in practice that you can
make." I remember the meeting in Downing Street several years
back when we decided to establish that way of doing it because
I was saying to people, "This is absurd. If your accident
and emergency department handles millions of people a year it
is, if you like, the shop window of the NHS, and since there are
accident and emergency services that work well we have to be able
to make that work in all different places." I think if we
had not had that sentry-driven approach in this instance we would
never have had the quantum shift in improvement that we had. The
interesting thing is that when the BMA were attacking us on accident
and emergency services a few weeks ago in parenthesis they said,
"Of course, the service has been transformed over the last
10 years."
Q41 Mr Barron: Do you think then
that this top-down setting of targets in areas like this, given
that there has been improvement, is the way forward for the future,
or do you think that we should have local made targets in terms
of what should be happening in healthcare?
Mr Blair: That is a very good
question. I think it depends on what area you are dealing with.
I would say that in certain areas—cancer, again, having
a central target helped. I do not believe we would have got the
big changes in waiting lists if we had not gone from 18 months
down to 12 months down to nine, down to six. But given that there
is a virtual revolution in the financial accounting within the
health service that is going on now, I think it will allow us
in time to minimise the central targets and to have what I call
a more self-sustaining set of changes in the system. Because the
money is following the patient, patients will have greater choice,
there will be incentives for GP services and primary care to pull
things back out of the acute sector. The basic problem in our
healthcare system, but also in healthcare systems around the world—incidentally,
there is no country you can go to where there is not a raging
debate about the state of their health service because you have
growing numbers of elderly people, masses more cures and treatments,
new technology, increasing demand and expectation—and the
thing that comes out of all of them is how you get the most appropriate
care in the most appropriate setting. If you ask any accident
and emergency consultant they will tell you that probably half
of the people who go to their A & E should not really be in
A & E. If you look at the numbers of people who are going
into hospital because they have a chronic condition which could
be managed outside the hospital it is a very significant number
of the hospital beds that we have. As you improve the numbers
of people who have day-case surgery and so on you will find a
big, big change, and what we have to watch is that there is a
proper alignment between the central targets and the reality of
very diverse local provision driven by local need. I agree that
that is the big question for the next Comprehensive Spending Review
certainly over the next few years for Government.
Q42 Mr Barron: Would not the logic
say, given that patient choice currently is informed in terms
of waiting times at the hospitals that are on offer, as it were,
that patient choice is going to take over from this national target
setting and it will be the patient who will decide, on the basis
of what is on offer locally, where they are going to go and not
necessarily the National Health Service or Richmond House telling
them what targets they should work to?
Mr Blair: I think you are absolutely
right. In years to come that is where you want to get to, but
you are a way off it yet. I do not think we should underestimate
what has been achieved in the health service over the past few
years. Indeed, what I thought was interesting about the Today
programme's set of analyses of the health service is that what
began at the beginning of the week as "Where has all the
money gone?" at the end of the week was, "Are the improvements
enough?" There is no doubt at all that the health service
has improved and improved significantly. I think you are right
that going forward the question is that when you introduce a new
financial system, which we are doing through payment by results,
when you have practice-based commissioning on an across the board
scale and when you have patient choice, when these three parts
of the new system are embedded then the degree to which you need
central targets will be significantly diminished. It is just that
you are a way off that yet, and my fear is that if you withdrew
the central pressure at the moment the system would start to retreat.
Q43 Andrew Miller: The Review Paper
talks about empowering consumers and reshaping Whitehall and in
the Transformational Government review published a couple
of weeks ago it refers to a delegated committee for developing
information sharing across the public sector. The DWP in fact
on 15 January made a statement about this. It is an important
structural change in the way that Whitehall works. What guarantees
will the public have that their data will not be improperly accessed
and how do you envisage a rapid procedure being developed to ensure
that errors in databases can be corrected?
Mr Blair: We are looking at this
across Government now and Hilary Armstrong is chairing the relevant
Cabinet committee on it. This is a really important question but
I do think we need a better public debate about it. It will be
possible for people to object to their details going on the electronic
patient record, but let us be under no doubt at all that an electronic
patient record across the National Health Service has the possibility
of immense improvements in service and savings lives. Of course
you have to have proper safeguards but I find this really quite
a curious situation. We think of this "Big Brother"
thing coming in with an electronic patient record and using the
new technology, when what it is going to mean, very simply, is
that if, for example, you are taken ill in a different part of
the country from where your GP is you can access immediately the
details of somebody's health care—what drugs they may need
or want to use—and it can hugely speed up both the quality
of care and, potentially, the difference between the care being
appropriate and therefore saving someone's life or not.
Q44 Andrew Miller: Beyond health,
what about departments like the DWP?
Mr Blair: Again, it depends on
what information is there, but I think it is sensible for us to
share as much information as possible, subject to proper safeguards.
Q45 Andrew Miller: How do you see
the citizen having the right to correct errors that appear on
this database? After all, human error occurs.
Mr Blair: Of course, and I think
the very thing that we are looking at now is how do you make sure
that if an error is discovered that it is corrected as soon as
possible, and also that the individual has maximum transparency
of the information that is held on them? I find this curious,
for example, in the context of the whole identity card debate
because the actual information on the identity database is basically
what is on your passport—it is not a great deal of information,
the average store card has more information; and also if you take
Google Earth now and what it can do in terms of going down
the street in which people live. Someone was saying the other
day that Government is creating this great new database with this
massive information on individuals, and we are not. The technology
now exists to be able to share data in order to give people an
improved service; for example, many people will now do their car
tax on-line—it is a better way to do it. I think provided
that there are proper safeguards—and we do need to make
sure it is subject to proper debate and proper scrutiny—then
it would be bizarre, when in every other walk of life the technology
is being used to enhance service, that in the public service we
have put down a barrier.
Mr Willis: The issue of human rights,
Prime Minister. Andrew Dismore.
Q46 Mr Dismore: Prime Minister, if
someone dies in custody because of a gross failure in the management
system to protect him should the prison service or the private
prison company be held accountable through the Corporate Manslaughter
Bill?
Mr Blair: This is the debate we
were defeated on in the House of Lords last night and we will
take it away and look at it again. Let us see what we can do.
The worry here is if you apply corporate manslaughter in these
particular circumstances whether you end up causing a real problem
for the way in which the prison or the custody system will work
in respect of people who can, obviously, from time to time, pose
a real threat to the people who are trying to restrain them. I
do not think I will say any more about it than Patricia Scotland
said last night, which we will look at.
Q47 Mr Dismore: One further point
on that. There have been various suggestions—quite strong
suggestions—behind the scenes that if parliament decides
that it wants to have this in the Bill the Government would withdraw
the Bill rather than allowing that to go ahead. Could you dispel
those suggestions now for us?
Mr Blair: I have not heard that,
I must say. No, I think it is important that we have the Bill
but we are going to have to make up our minds on this. Our desire
was to try and accommodate reasonable opinion as much as possible;
it is just that, as often happens in government, we have two very
diametrically opposed views as to what the right thing to do is
and we need to try and make a balanced judgment about it.
Q48 Mr Dismore: Due to the uncertainty
of what is a public authority under the Human Rights Act is privatisation
and contracting out not undermining the protections of the Act
for the most vulnerable people, like the elderly and disabled,
placed by councils, for example, in private sector care homes?
Mr Blair: I do not think so because
I think that anyone who is providing a public service is clearly
subject to the same rules, but I think that this issue to do with
the delivery of service is one of the main things that will come
out of the Policy Review. I think the emerging conclusion is that
we need to go even further in breaking down the barriers between
the public, private and voluntary sector. I, for example, think
that the voluntary sector can play a hugely enhanced part in delivering
services, for example for offenders and offender management—it
is a big debate for people—but I do not think that using
the voluntary sector in this way would in any shape or form displace
the basic protection of people.
Q49 Mr Dismore: The problem is that
decisions of the Court of Appeal have made it clear that the Human
Rights Act does not apply, for example, to private sector care
homes, and the only way it can be done is very indirectly through
local authority contracting. Is that not something we need to
deal with through either winning a case, which we have so far
not been able to do, or, alternatively, amending the Bill to clarify
that this is what applies?
Mr Blair: I think you are right
in saying that there is an issue there. The way to deal with it
is to make sure that public and private bodies are treated the
same when they are providing a public service, rather than stopping
the private body or the private group, whether it is voluntary
or independent, having a role in the delivery of services.
Q50 Mr Leigh: Good morning, Prime
Minister.
Mr Blair: Good morning, Edward.
Q51 Mr Leigh: I am a Conservative,
so relatively speaking I am a friend of yours this morning!
Mr Blair: Thank you!
Q52 Mr Leigh: You talked about the
voluntary sector to Andrew Dismore just a moment ago, and clearly
you want to increase the role of the voluntary sector. The trouble
with the voluntary sector is that it is heavily dependent on faith
groups, and the inconvenient thing about faith groups is that
they have strong opinions. Do you agree, for instance, with Archbishop
Vincent Nicholls when he said, "Those who are elected to
fashion our laws are not elected to be our moral tutors and the
wise among them would not wish it either." Do you agree with
him?
Mr Blair: I think that the faith-based
agencies, for example in relation to adoption, do fantastic work,
and that is why we have set this two-year period, effectively,
and an independent assessment of how we make sure they carry on
their excellent work. But there is a problem, if I can service
it very openly, which is that I certainly believe that we should
not discriminate against people on the grounds of their race,
their gender or indeed their sexuality. So the question is, how
do you measure those things up in circumstances where a faith-based
agency—and I totally understand the reasons for that—say,
"We have a conscience objection" to, for example, adoption
by gay couples. We are trying to find a way to make sure over
this next couple of years that the catholic adoption agencies
carry on their excellent work—as they do excellent work
and are very dedicated people—but at the same time you remove
discrimination. These types of debates are always difficult but
if people are sensible enough we can find a way through it. It
may be by having consortiums, for example, and there would be
a gateway into adoption which would allow this issue to be taken
care of, because I think it would be a tragedy if those adoption
agencies did not carry on their good work. But I also think, personally,
that we do not want a situation where we are discriminating against
people on the grounds of their sexuality.
Q53 Mr Leigh: So discrimination trumps
conscience in this regard?
Mr Blair: It is not that it trumps
conscience, but supposing—and I am not suggesting this for
a single moment—that you had a particular group that said
for various reasons they believed that women were not suitable
to do various things? It is very difficult. These are areas where
you are absolutely at the cusp of what are difficult judgments
that we all have to make as law makers and I tend, myself, to
try not to take an absolutist view. But I could not in the end
justify a situation where you would discriminate, where you effectively
say in legislation that you are going to allow discrimination.
Q54 Mr Leigh: Could I just stop you
there? I agree with you entirely, but then why in the 10 years
that you have been Prime Minister have you left on the statute
book a blatant piece of discrimination which says that if any
member of the Royal Family marries a Roman Catholic then they
should be kicked out of the Royal Family? Why have you left it
on the statute book?
Mr Blair: Good point, Edward!
Q55 Mr Leigh: Is it not state organised
hypocrisy in this regard?
Mr Blair: I think it is terrible,
terrible!
Q56 Mr Leigh: Do something about
it then.
Mr Blair: Absolutely. When we
come to talk about the 10-year legacy we can pick that out as
a major omission. These are questions that I think people of goodwill
can find a way through. Most people in our society today do not
want to discriminate against people on the grounds of their sexuality,
and I may say particularly in circumstances where the catholic
adoption agencies do have a policy of allowing adoption by single
gay men. So I think in those circumstances how do we make sure
that the principle of discrimination is protected and the children
that desperately need this service are also protected? I am committed
to finding a way through it. I actually believe, away from all
the thunder of the public debate, that we will find a way through
this that will allow these adoption agencies to continue their
work. For very obvious reasons I happen to believe that faith
is a good not a bad thing, so I think in the end we never want
to reach a situation where people who do have a religious faith
feel in any sense that they are being shut out of either the political
system or being able to provide a great service to people in a
faith-based way.
Q57 Mr Willis: Prime Minister, I
think we will return to the Act of Settlement a little later.
I think it needs a longer session!
Mr Blair: I was just thinking
that it might be something for my successor really! It is a useful
one to leave around!
Mr Willis: Dr Wright.
Q58 Dr Wright: Prime Minister, the
Strategy Review is a very good thing, in my view, and it has some
chance of lifting the quality of public debate. I think you are
to be congratulated for it. Could I test one of its assumptions?
It talks about the state and it says in one of its conclusions
that a range of pressures will require a new role for the state.
What I would like to know is do you think that that role is going
to be bigger, smaller or about the same size as now?
Mr Blair: I think it will mean
a smaller centre but when the state moves to what I would call
a more strategic role I think it has two implications: one, that
you distinguish even more between the state as commissioner and
the state as provider—in other words, you open up a diversity
of supply in public services. That is why you have a new system
in the health service with independent providers; why you have
a different range of schools, Trust Schools, City Academies, Specialist
Schools, et cetera; and why you involve the voluntary sector and
the independent sector more in the provision of services. So it
has that implication, and the second implication is that within
Whitehall itself we need a far greater focus on what I will call
the delivery of project management skills, rather than the traditional
policy adviser.
Q59 Dr Wright: But those are to do
with how the state organises itself. What I am asking you is,
at the moment the state takes about 42% of GDP. The evidence from
this Review shows that the pressures on the state are getting
bigger all the time; the expectations are getting larger all the
time. What I am asking you is, does that mean that the state itself
gets bigger, or does it mean that we ask people in the future
to pay for things that they do not pay for now?
Mr Blair: That is obviously a
very good question. That is not so much how the state organises
itself, but you mean the actual overall public spending as a proportion
of the national income? I do not have in my own mind—people
have in politics over the last 30 or 40 years, and I remember
Roy Jenkins famously doing it in the 1970s—a particular
figure that is the right figure or approximately the right figure
as public spending as a proportion of GDP. Supposing we even wanted
to keep it round about where it is now but deal with the pressures
for the future, then I think it will mean that we have to change
what government spends its money on. Let me give you an example.
I do not believe that we will be able to provide our pensions
or public services in the future unless we raise significantly
the proportion of people of working age in work, probably getting
it up to 80%. That will mean, for example, that when we publish
David Freud's Welfare Reform Programme, which we will do probably
at the end of this month or early next month, there will be some
quite difficult proposals in relation to how people come off benefit
and into work—lone parents, people on incapacity benefit
and so on. That is one area, if you like, in which we are going
to have to look at how we rebalance what is almost a generational
compact between those of working age today and those who are going
to be pensioners in the future.
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