24 April 2006
Tony Blair’s monthly press conference was dominated by the current debate in the National Health Service. He also answered questions on the Middle East Peace Process and Al-Qaida.
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Right. So this morning I am going to start the press conference with a brief presentation on the challenges and the opportunities facing the NHS today. I am delighted that this is at the centre of the political debate, and I think it is a debate well worth having, and I look forward to it.
Before I get into the details of what has happened since 1997, I think it is a good idea simply to remind ourselves of the types of Questions that I have been holding this press conference as we came to power in 1997, the types of Questions that you would have been asking me.
First there would have been the waiting lists which were over 1 million, and actually that included at any one time a quarter of a million people waiting more than 6 months on an In-Patient list, or you could have challenged me on cardiac care, the scandal and heartbreak of patients dying as they waited for treatment, or you could have talked about cancer patients, commonly waiting weeks to see a consultant after their initial, and somewhat frightening and disturbing, GP appointment. Or you could have asked me about the annual Winter crisis, which you may remember, or the terrible state and dilapidation of NHS buildings, or Accidents and Emergencies and the appalling waits that people suffered there. And of course at that point there was a crisis of staffing fuelled by poor pay with not enough training places for doctors or nurses.
Now that was the National Health Service in 1997 and whilst I am going to be very, very open with you about the challenges that we face now, in every single one of those areas mentioned, which were the enormous problems of the National Health Service in 1997, there has been huge improvement.
When people ask what the doubled budget for the NHS has been spent on, the facts in every one of those key areas are a record of achievement for the National Health Service and for those that work in it.
I would also just like to emphasise one other thing about the reforms and changes that are going through at the moment. As I explained last week, the National Health Service Plan that was published in the year 2000 was a 10-year plan. It was specifically therefore to gear ourselves up for change and improvement over a 10-year period. And what was the basic vision behind that? First of all to build up capacity, then to introduce new pay and conditions for staff and set strong central targets for improvement but then to move to a radically different Service in which much greater power was put in the hands of the patients, there was a proper system of financial accountability put in place and then incentives built into the system which would mean that changes and reforms from then would be self-sustaining rather than driven by central government performance management.
Now, the NHS, as you know, is a massive organisation. It treats approximately 1 million people every 36 hours. So there is no doubt if anyone, at any point in time wants to say there is a problem here, or a problem there in the National Health Service, they will always be able to find the evidence to show it.
However, whatever the challenge, and the next year will be very challenging for the reasons that we know, there have been marked significant improvements and the next stage of change within the National Health Service involves, as I said before, four major changes: the change to practice-based commissioning so that it is the GPs in Primary Care that commission the care; secondly, payment by results, so that throughout the National Health Service there is a single tariff which exposes the cost and leads to financial accountability for operations; thirdly patient choice because patients are going to be able to move around the system if they don’t get decent quality of care from their local hospital; and fourthly the use of the independent and indeed voluntary sector where that is appropriate.
Now the purpose of all this is to create a different type of National Health Service true to its values, but reformed and modernised for today’s world. I want however before I come to some of those reforms just to take you through some of the changes that have happened. These are not in any sense at all to minimise the issues and challenges, they are simply to set them in context. And with the help of my gorgeous assistant, Ben we will now take you through these.
First of all, in relation to nurses and nursing staff where as you know there has been a lot of controversy recently. These are facts. The fact is there are 85,000 more nurses than in 1997 and the numbers in training are up virtually double. The pay as well has increased significantly above the rate of inflation. So I am again not minimising any of the issues that nursing unions are talking about, but at least, for the sake of balance, let us just get that right. The number of nurses is up, the pay is up, the numbers in training are up.
The numbers of patients waiting more than 6 months, as you can see, has come down significantly. Now I want to make one thing very clear about this. It is not good enough in my view that you have a 6-month wait on an in-patient list. The purpose of these changes that we are putting through now is to get us to a situation where in 2008, as we set out in our Manifesto, you combine the out-patient and the in-patient lists, because there are also people waiting on out-patient lists. In other words first of all you wait to see your consultant, you wait between the GP and the consultant. Then you wait from the consultant to get the operation. Now all of these times have come down very significantly but actually what we want to get to is a maximum 18-week wait - maximum - though the average will be far under that, I think 7 or 8 weeks, between the GP and the door of the operating theatre. In other words out-patient and in-patient combined. If we achieve that, that is virtually the end of waiting within the National Health Service.
On the faster operations these are just examples of common operations: cataract, heart, hip. Now again you will see that not just the mean waiting time has come down significantly, but obviously that is a significant change on what was happening in 1997, and also of course, commensurate with that as you would expect, more operations.
Now in relation to some of these things, for example I would say particularly cataract and heart, there has, I would argue, been a transformation in what has happened over these past 8 or 9 years. These are major increases, if you look at the heart for example there, that is not double, but it is getting on for double the number of operations. That is a huge change.
And if you look then at the next slide - to take the case study of heart disease - the average waiting time is down, the numbers of activity is obviously up, but more than that you will find now that people often helped through the use of Statin drugs, or helped in different ways of treating them, that has transformed the patient experience in cardiac care in our Service today. So it is a big, big change for people.
Then the next one just on cancer, again what you see there very, very quickly is not just things like the increase in the number of consultants and radiographers and so on, and the speed with which people are seen by a specialist, and incidentally again I accept that we have got a lot further to go on this, but what is interesting is that something like 600,000 additional women are being screened for breast cancer. Now these again, I would say, are big changes and you can see the amount of lives that have been saved as a result.
The Winter crisis. I mean again, every single year we used to have a Winter crisis. Here, what we see is, that even when we have had quite a severe Winter there is not a Winter crisis in the same way.
[Next slide]
These are just the reductions on cancer deaths and coronary heart disease.
Public attitudes. Basically people are satisfied with their own experience of the National Health Service though I entirely agree when you ask them about the overall state it is less good. And here are just some of the people. The interesting thing is - I don’t know if we have got the King’s Fund. Have we got the King’s Fund? But at the bottom there this is someone from the Nursing Times who was in general very critical of the Government, so I should make that absolutely clear, but even they when they were critical of the Government when actually pressed have there been improvements, had to say yes there have been improvements, real improvements, particularly in the last few years.
So, what I would say is that we have a tremendous challenge. Of course we do, every health care system in the world does, but actually our National Health Service is being changed and for the better and even though we will have a difficult and challenging year it is worth doing it.
Now, just to summarise, I would say this. No-one is pretending the National Health Service is without real challenges and problems. Of course it is, as every health care system in the world is. There are only two things I ask for however. One a sense of balance because yes there are problems but there have been major, fundamental and lasting improvements in patient care over these past few years, and secondly a recognition that the reforms will of course mean difficult decisions for the National Health Service as it changes. But the reforms will make the extra money that has gone into the National Health Service work better for the patient, and the challenge and the difficulty we will have, particularly over this coming year as the new system comes in, is a challenge and difficulty that I believe that the National Health Service will in the end overcome and the benefits will be felt by patients because if we reach those targets that we have set for 2008 that will mean a fundamental transformation in the patient experience in the National Health Service.
That is all by way of opening. I expect you all enjoyed that.
Question and answer session:
Question:
Prime Minister I note that you didn’t use the phrase "the NHS’s best ever year". Would you like to do so? And when you say that this is going to be a challenging year, are you saying effectively that things can only get worse in the short term. There will be more redundancies, more closures of wards, more beds closed as the reforms kick in and after that as you are able to give less of an increase in health spending than you have been in the past?
Prime Minister:
No because I think that what will happen - I mean the facts speak for themselves about the improvements in the National Health Service. When people debate is the Health Service getting better, is this the best time for the National Health Service, the facts speak for themselves and yes there are problems and there will be changes in the National Health Service where, for example, people will be implementing the Service differently. They could be employing staff in a different way. Yes there will be hospitals that have really difficult decisions to make over the next year, but in answer to the Question, even whilst that is happening, are we still going to be making progress towards better waiting, better quality of care, better treatment of cancer and cardiac disease, better treatment for the patient in the National Health Service, the answer is emphatically yes. Even as these difficulties are taking place, we will be meeting the targets that we have set.
Question:
So the nurses are ….
Prime Minister:
No, I am not saying that. I am simply saying if you have a sense of balance, I defy anyone to say that with 85,000 more nurses, pay up significantly in real terms, training places almost doubled, that we have done badly by nurses. Does that mean that there won’t be people who face difficulties over the next year because hospitals will be changing their services as the reforms come in, yes they will face that difficulty, but even at the same time as that is happening there will be improvements in patient care, and the improvements in patient care being delivered by today’s National Health Service have been greater than ever before.
Question:
Surely the issue is whether you transform the National Health Service once and for all with the once and for all glut of taxpayers’ money you have put into the system, or whether this simply has been a boon which has got - I think you would agree - more than the government calculated in terms of pay and conditions for people working in the Health Service with less therefore going to the sharp end. I mean first of all do you accept that that is true? Secondly, given that we have lost Sir Nigel Crisp - or Lord Crisp - will we soon see Patricia Hewitt heading towards the Lords? And thirdly if you look at this year’s statistics, this year’s statistics on doctors employed, nurses employed, performance, you will have to accept that things will start going backwards just at the time because there are going to be net lay-offs, aren’t there, across the country, just at the time when the tap is being turned off of taxpayers’ money?
Prime Minister:
Well, I will try to defend her against some of that. You see, I don’t accept that the resources we put in on pay are not justified. We needed to put more in. We needed to pay our consultants, our GPs and our nurses better. We are, it is right to do it.
Question:
You have put in more than you have benefited though.
Prime Minister:
Well the overall actual pay bill, I think I am right in saying as a proportion of health service expenditure is down on 1997, not up. So I don’t accept it is a bad thing to pay the GPs well, or the consultants, or the nurses. And incidentally let us just lay to rest this idea that all the GPs are getting a quarter of a million pounds a year. They are not. I mean in fact I don’t think that anyone has actually yet discovered one that is, truly is …
Question:
There was one earning £300,000 actually.
Prime Minister:
I suspect when you look at that, that will be either for the practice as a whole, or in any event it is totally atypical. But the fact is, going back to 1997 is quite interesting. In 1997 the problem was we couldn’t recruit the people, the nursing and doctors’ training places were being cut and the National Health Service staff felt that they were not being properly valued. Now I accept that having boosted the number of staff dramatically - 85,000 is a pretty big increase but you will find that the same increases are not going on year on year, but that may be because actually we will have the right numbers of staff within the National Health Service to deliver the Service in the way that we want.
And if I can just explain the relationship, because it is very, very important, between the reform programme and some of these changes, what practice-based commissioning will do in the NHS, and indeed is already doing, is it gives the doctors, the GPs, an incentive to do more work in a primary care setting and only refer to the secondary, or acute sector, those people that really need to be there. And we know for example many elderly people should not be in hospital. It would be better if they were looked after in their own home. We know too that many people get referred to Accident and Emergency when actually they really should be treated by their GPs. The new system gives an incentive for these things to be done.
Now as that happens it may well be - I know GP practices that are already performing minor surgeries for example at GP level, then you will find that some hospitals will be saying well we don’t need to do as much as we used to or for example you get day-case surgery being done more and more, even for things that 5 or 6 years ago might have meant that someone spent a week in hospital, today they can get keyhole surgery and they can be out in a day. Now that will mean that the provision that you used to have in order to do that is no longer necessary. OK, those are changes that will take place.
And as hospitals end up becoming more financially accountable and the costs of the system are truly exposed within it, yes you will find difficult and challenging change of transition, but at the same time you are going to find a better service for the patient. And that is what is actually happening out there, and all I am saying to you guys, which I hope is sort of understandable, is let us have a sense of balance. These are the problems the Health Service is facing and these are the challenges, let us at least have a bit of the other side of the picture, these are also the improvements that have been made.
Question:
Let us be very clear about this. Given the presentation you have just given, you really do believe that staff and patients have never had it so good?
Prime Minister:
Well I believe that in terms of things like waiting, the waiting times and the waiting lists are the best that the Health Service has had. The treatment for cardiac care or cancer care is best the Health Service has had. The treatment for people in Accident and Emergency is transformed from what it was a few years ago. You will be able to find a case of somebody who says well my experience is against that. But I am saying if you take an objective look at the whole of the Health Service and inject a sense of balance into it, these major lasting improvements, and in some cases transformations, have to be put alongside the perfectly understandable problems that other people are raising.
Question:
Prime Minister, are you saying that in some cases jobs lost, wards closed, even hospitals closed, are actually a sign that your reforms are working. Is that what you are saying?
Prime Minister:
No, I am not saying that, because it depends for what reason people may be laid off.
Question:
But are some closures the inevitable consequence of the reforms you are trying to put through?
Prime Minister:
What is an inevitable consequence is that the money is going to go to where the service is provided best for the patient. Let me explain another part of the reform programme which is the payment by result. At the moment what happens is there is no real financial transparency or accountability for operations done within the Health Service. There hasn’t been right from the very beginning. It is basically rationing by waiting lists. The payment by results will mean that there is a single tariff for operations of particular types throughout the National Health Service. We are not putting all of the system on this so far, but we are putting a significant part of it, and Foundation Trusts have already been operating this payment by result system. So what that means is when the care is commissioned, there is an objective cost for what the operation will be. Those hospitals that end up being able to do more work and operate more efficiently and more effectively, they will take some of the patients that had previously been in a hospital that has been doing it inefficiently. Now, if there are changes that happen as a result of that, then in my view that is a change that is for the better for the patient experience.
Question:
And a hospital that wasn’t working so effectively could have a ward closed for instance, and that would be a sign of progress.
Prime Minister:
It is only a sign of progress if the patient is getting a better deal, so I am not going to hypothesise on what may happen in any particular situation but all the way through, and also incidentally it is absolutely true, and let me be very clear about this, that as this new system comes in and hospitals have to really live within their means for the first time, you will get hospitals that have perhaps got large deficits that have to sort out their financial position. But once this system is in and fully functioning over the next few years, then what you will have is a situation where the doctors, the GPs, have an incentive to do as much as possible in the community close to the patient and only send to the acute sector the cases that need to be there.
The hospitals will have an incentive to do as many operations as they can for a fixed cost, knowing that the more they do the money follows the patient, and the patient will have the choice to go to different hospitals and different care providers based on whether they are good or bad, whether they can access them quickly or not. Now that in a nutshell is what the system is about and incidentally what is interesting is if you look round the Health Care Systems going on virtually anywhere in the world what is interesting about them is this. There are many different methods of paying for the Health Care system. Some social insurance, some tax-payer based. What is the same in virtually every Health Care system now are these types of principles. In other words, greater decentralisation, greater patient choice, greater contestability of service.
Question:
Prime Minister, a focus group for Newsnight last week conducted by the US pollster, Frank Lunts identified Labour’s problem on issues like the Health Service not in its message, but in its messenger. Simply put, they didn’t believe you when you said there were improvements. To what extent do you think in getting across this message one of the barriers is Tony Blair?
Prime Minister:
You are probably asking the wrong person, I would say, on that one. You know, people make up their own minds about this depending on what they read or hear on a day-to-day basis, but in the end it is whether they think the service has improved or not and I think that the most important thing for us to get across in a way is the difference between people’s individual experience and their collective sense, because their individual experience is based on reality and their collective sense is often based on perception. So, you know, I think we will be in a better place to judge all that once we have had a thorough-going debate, which is why I think it is a good thing that it is happening. I mean let us have the debate, and what I hope it does is to encourage you as well as doing your focus groups to do an analysis about whether the facts I have given there are true or false. That would be a good thing, so you could help me in that. There you are, there’s a good task for the BBC.
Question:
Is Patricia Hewitt the right Health Secretary to be carrying through these reforms successfully?
Prime Minister:
Well absolutely, because she is the person who is taking through a difficult change programme and standing up for what is right in doing it. These change programmes are never easy when you are doing them, and the simplest thing for anyone to say who is opposed to the change is to put out there the most graphic description of catastrophe and crisis that is going to occur, and who can prove what is right and what is wrong? All I say to you is that when we first introduced patient choice in the NHS people just said you are out of touch, you don’t understand what is happening, people don’t really care about patient choice, they just want their local hospital to be good. I won’t ask Ben to perform the task of going back through that slide again, but you can actually mark the month that we introduced patient choice and why then the decline in the waiting list, which had been gradual, then actually began really to fall. And that is my lesson about reforms. Foundation Trusts for example, the foundation trusts are in surplus, they are not providing a worse service, they are providing actually a very good service to the patient, they are in surplus. What were we told at the time? We were told at the time that the Foundation Trusts would end the National Health Service as we knew it. Now one of the reasons why some of these hospitals incidentally are facing, or making difficult decisions, is because they want to become foundation trusts and they can’t get through that process unless they have got sound financial management for the long term. So some of them are quite deliberately taking the decisions necessary now, and they are absolutely right to do it, in order to get through that difficult period. So I think that that is the important thing in the end.
Question:
The Question is not whether the reform is right, the Question is whether Patricia Hewitt is the person who is capable of carrying through those reforms successfully and promptly?
Prime Minister:
Yes, well I believe she is, and the fact is she is doing it, what is more.
(party political content)
Question:
Prime Minister, your answer on Patricia Hewitt was an interesting one, because on the one hand you said well absolutely because she has carried through the reforms and the reforms are right, and then you said: well I believe so.
Prime Minister:
I think you are reading a little bit much …
Question:
But in specific terms …
Prime Minister:
If what you are asking me is do I have confidence in Patricia to see through the reforms, absolutely and totally, yes.
Question:
Fine. And therefore do you also agree, which is also the Question that Nick asked, that this has been the best year for the NHS yet?
Prime Minister:
Well for the very reasons that Patricia has given. She didn’t just say this.
Question:
Inaudible.
Prime Minister:
Look, I am not getting into playing word games with you, but if you take these facts, why did she say what she said - she said it because waiting lists have never been lower since the Health Service records began, judging the numbers on waiting; accident and emergency treatment has dramatically improved in the last few years; cancer and cardiac care are the best they have been in the National Health Service; and we have record numbers in the past few years of extra nurses and doctors. These are facts. And what is more, the National Health Service building stock, when we came to power more of the stock was built pre the founding of the National Health Service than after it, has changed. So those are the facts, that is why she said what she said.
Question:
Prime Minister, you mentioned earlier about the difficulties ahead. Can you say what you anticipate those difficulties to be, and do they include explaining to the Primary Care Trusts who are in surplus why they have to give their surpluses and growth this year in order to pay for the overspenders? Because you have made a great play of the fact that you are not going to bale out the overspenders, but in fact there will be those transfers of money to help them out this year.
Prime Minister:
Well that is a good point, but the fact is this is the way the system has always worked, what is actually different this time is that we are keeping money back, but if we are to give it to those trusts that are in deficit, it is only on the basis that they have a proper recovery plan in place. What used to happen is that the good trusts would simply cover the bad. That is why I say you will have a difficult process of transition. Nothing that I am saying today minimises at all the difficulties and the challenges that the Health Service face, and I probably talk as much to Health Service managers and clinicians as virtually anybody else. And what they will tell you, I was talking to some last week, what they will tell you is yes it is very difficult, very challenging. The interesting thing is not a single one of them that I have met at least have said anything other than don’t give up or hold back from the change, it is necessary, it is overdue, it will be difficult but we will get there. And that is why I am confident that in the end, whatever difficulties there are, and those are very self-evident, the improvements will continue and we will have a better Health Service if we take those difficult decisions now.
Question:
Prime Minister, if I could ask you about the House of Lords. It has been reported that you now favour a democratic House of Lords and that you think it might be possible to get cross-party agreement on that quite soon, possibly within 12 months. Is that correct?
Prime Minister:
Well it is not really correct, no, since I will make up my mind on this when I have made up my mind as it were.
Question:
Do you favour a democratic House of Lords?
Prime Minister:
Yes, but that is what I am saying to you, so there is no point in sort of pressing me on it at the moment. When I am ready to say something I will say something on it. The only thing is you end up finding the more you look at this how many extremely difficult Questions there are to answer at every stage of this debate.
Question:
… you said you were prepared to be open in terms of the short term pain that flow from the changes of reform, are you prepared to admit that a potential consequence is not just job cuts and bed closures, but closures of entire NHS general hospitals?
Prime Minister:
Look, as I say there is no point in hypothesising about what may or may not happen, and I think that some of the claims being made about closures of whole hospitals are just ridiculously exaggerated. On the other hand I think the important thing is to say what is the best care for the patient. There is something a bit odd in thinking that an organisation that employs over, what is it, 1.2 million people and treats a million patients every 36 hours should remain precisely configured in the way that it always has been. No healthcare system operates like that. And I think for example if you look at community hospitals there is a whole new generation of community hospitals that we will be building, but they may not be the same as the old ones. I think that is fair enough. Again, when I look at my own constituency, and as I say if you want to go and find a bad news story there I am sure you can find it, but I know from my own constituency experience that healthcare in my area is significantly better than it was 8 or 9 years ago. And there is just a different range of problems that you have now, compared with the absolutely fundamental problems that you had about waiting times and waiting lists and old hospital buildings then.
(party political content)
Question:
The Lord Chancellor is negotiating with the other political parties on the House of Lords reform. He is seriously indicating a majority elected House of Lords. It sounds as though you are more open minded on the issue than maybe you were a while ago. What has changed your mind?
Prime Minister:
I am marginally more open minded.
Question:
But why?
Prime Minister:
Because the debate goes on. I am a very open minded bloke, I like listening to interesting debates like this. Look there is obviously no point …
Question:
Inaudible.
Prime Minister:
I know, but if I could just give you, not that you will take it, but if I can give you some advice, I wouldn’t read too much into what I am saying. That is probably the most redundant thing I have ever said at one of these press conferences.
Question:
Inaudible.
Prime Minister:
No, I didn’t say that either. They will carry on, no doubt.
Question:
I hope you have a sensible answer to this. The latest statistics on women’s pay show that part-time women workers will get equality with men in 140 years. Would you consider setting a more optimistic target, and can you credibly campaign on equal pay, or advocate women’s pay when you don’t pay your own Minister for Women and would you reconsider that?
Prime Minister:
Well I certainly take the point about the Minister for Women and it certainly should be resolved. But no, I think we have a set of proposals that gives the best chance of equalising pay, but it doesn’t just depend on government, it also depends on employers as well. But I think that we will be able, and particularly through the new machinery for equality and equal opportunity, I think we will be able to work out better how we combine with employers to make sure that we do close the pay gap, and it has closed significantly over the last couple of decades so I think 140 years sounds a bit pessimistic to me.
Question:
40 years for full time workers.
Prime Minister:
Yes, well as I say that is very, very pessimistic indeed. But I think it is possible that we can do much better than that, and I would point to the fact that we have made significant improvements so far.
Question:
When the British Ambassador to Dublin attended a recent commemoration on Easter Sunday of the 1916 rising, it was generally taken as a sign of the improvement in Anglo-Irish relations. There are now newspaper reports that The Queen, an official visit is being planned by The Queen to Ireland. I wanted to ask you, can you confirm that there is such a visit in prospect, and if it were to happen would you in some way consider that to be the end of your work on Northern Ireland? At what point would the Northern Ireland situation have had to have improved enough for such a visit to take place?
Prime Minister:
Well I don’t think I can confirm or deny anything to do with The Queen visiting the Republic, that is a matter between the Palace and the Republic and I don’t think it is either appropriate, nor am I in a position frankly to comment on it. The relations between Britain and Ireland have been transformed over the past decade and it is a fantastic thing that we work very closely together as two countries, we have worked closely in Europe, we work closely on the Northern Ireland peace process, and Ireland of course is a nation transformed. And you know people look at the Republic of Ireland today and say that is a dynamic go-ahead country and the competition that is between Britain and Ireland is of a very healthy and very equal nature today, so that is great. But for me the key thing is to get the institutions back up and running in Northern Ireland and that is why obviously the next independent monitoring commission report will be extremely important in measuring what progress we have made, but that is what I want to see because nothing else is really stable for the future in Northern Ireland.
Question:
Prime Minister, can I ask you about deadlines on health? Patricia Hewitt seems to be saying that things will start getting better by the end of 2008, you have reminded us that your 10 year plan has got another four or so years to go. When do you think the collective sense of the NHS will improve and will reach this new plan, and are you going to stick around as long as it takes …
Prime Minister:
I was wondering whether that had a particular sting in the tail, which I won’t go into. Look, there are independent reports done on the National Health Service the entire time, the Kings Fund do them, the Healthcare Commission do them, actually the Modernisation Board of the Health Service. There is no doubt what the collective view is - there have been major improvements in the National Health Service. Now if you then take that as saying everything is hunky-dory, there are no problems, the present situation has no difficulties in it, that would be absurd.
So the Question is these improvements that have been made, are we going to get to the point, and this is what I think the big thing is. There will always be problems in your healthcare system, and as I say go and look at the situation in the United States of America for example where the number of people uninsured has risen to something like 45 million over the past few years and premiums have gone up way beyond the rate of inflation. Every healthcare system does. The French healthcare system at the moment, I think I am right in saying, has got an annual deficit of 4% and it may even be a cumulative deficit of 16% … 1% of it in context. All healthcare systems have problems, but the big problem we faced when we came to power was really this, that there was a rationing by waiting list which meant that people waited months, and months, and months and sometimes years for routine elective operations.
If we get to the point at the end of 2008 where patients book their appointment, at a time of their convenience, at a place they want to go to, and they do so with an average wait door to door, from the time they are diagnosed by their GP to the very time that they have an operation, if the average is about 7 or 8 weeks and the maximum is 18 weeks that is effectively an end of that problem in the National Health Service. Now that will not mean that there aren’t other problems in the National Health Service, because there will be, but it will be a major transformation of it. Now that I think is what Patricia is saying. And I think also in relation to cancer and cardiac care you can measure over the next couple of years what will be the really critical developments there.
Question:
But you will never get to the point where you can … draw a line under it?
Prime Minister:
Look, I think it would be a pretty bold thing to say for any politician about their healthcare system that you will get to a situation where there are not going to be any problems with it. There will always be problems, something else will happen, you will get a different issue. And also the other thing that is happening is that the technology is changing the whole time. This is the reason why you need to put self-sustaining incentives in the system. You see this is the problem that you have and I think this is what we have, or I have certainly learnt over these past few years. If you drive the improvement through central performance management, which we had to do in the early days, then yes you will get changes and improvements, but only by hitting the system really hard in order to meet certain centrally set targets. What we are trying to do is to get to the stage where the GPs and the hospitals have their own in-built incentives to improve the service. Let me give you an example. If you took MRI scanners within the National Health Service, mostly they will be not used during a week more than they are used, they often won’t be used at a weekend, they often won’t be used in the evenings. Now that is a major piece of capital equipment. As we build in new incentives, which we will be doing for diagnostics in the Health Service, there will be an incentive on those hospitals to start using the capital investment more effectively, because it is not a very effective use of a big piece of machinery if it is more unused than used in a week. That is the type of thing that will happen. Or you will find, and this is already happening, as the GPs get an incentive because the less care they commission from the acute sector because it is more expensive, the more they do in their own primary care setting, then they take the financial benefit of that in their practice. Then it will mean for example, and you have got this happening already and we can show you the examples of it, where consultants are coming to do their consultations in the community, not in their hospital. Now that again is a change that is going on in the National Health Service today, but we have got to make sure that those changes, everyone is wanting to do it because they have got an incentive to do it, and that is the reason for the reform.
(party political content)
Question:
Is it your case that people who give money to set up city academies have a right to peerages or honours, and that the only thing that is wrong is that they are offered these in advance?
Prime Minister:
It is not a Question that I think I am right, but I will tell you what I do think. I think if someone gives £2 million of their own money, time, effort, energy, years of hard work, isn’t that something that we should be saying that is a great thing that they have done? And insofar as the honours system rewards people who contribute to society, contributing to the education of disadvantages kids in the inner cities is about as good a contribution to society I can think of. So you go and look at the city academies, and I know there are people who want to knock them for all sorts of reasons, I will passionately defend city academies and the best advocates for them are not me, or even the people that are helping create these city academies, the best advocates are the parents that want to get their kids into the city academies when often the city academy is replacing schools where the parents couldn’t wait to get their kids out of it.
Question:
Would it be a fair comment if, when the history books are written, your administration is judged in the words of the human rights group, Liberty, as one of the most authoritarian governments in living memory?
Prime Minister:
No. I can explain why very easily. Quite apart from anything else, we are the government that introduced the Human Rights Act that actually allows us to be challenged as an executive, and indeed as a legislature, on the basis of what we do contravenes essential human rights. We have given that power for the first time ever in British history. But when we talk about people’s civil liberties, the civil liberties of the old age pensioner who lives in fear, the civil liberties of people who get mugged, the civil liberties of people who actually want to live in communities where people show respect to one another, those civil liberties to me also count. And so this whole civil liberties debate is conducted on the basis that the only civil liberties that matter are those of the potential or accused offender, they are also the civil liberties of people out in the community who are fed up with people who create a menace and a difficulty, and drug dealers on their street and so on. And we have given them the powers, we have given the police the resources and the powers to deal with it, and what is more we have said, and I mean this, we will legislate again if they need more powers. Because I am completely determined to do everything we possibly can to make life safer for people in local communities. And I have seen for myself, and you can see this very easily, that totally contrary to what is said about it, if the antisocial behaviour legislation is used properly there are benefits for the community, and actually there are benefits for some of the young people who otherwise might get drawn into trouble.
Question:
Can you just amplify in your answer about the honours system and contributions to city academies? Are you in no way uncomfortable with the implied suggestion there that people who help financially endorse a policy that your government has put forward might then find themselves rewarded for that contribution, a valued contribution you say, through an honours system which you largely control?
Prime Minister:
Yes, but it is not a Question of endorsing my policy, it is a Question of contributing to society, and they are perfectly entitled to. People go and give money for an art gallery, or put something back into society in some way, I think it is absolutely right that we say well these are people who have done something good for our country.
Question:
(party political content). At the weekend Alan Shearer confirmed his slightly early retirement, not entirely at a time of his own choosing, is there any parallel or lessons for any other north-east icon who might have to face up to calling it a day?
Prime Minister:
It is his ligament is it?
Question:
His knee.
Prime Minister:
My knees are fine, my knees are in great working order. Although I should say for the purposes of the record that I think he has been a fantastic servant for Newcastle United and he is a great player and a great man.
(party political content)
Question:
Prime Minister, given the history of Britain in the Middle East, one finds it amazing that there hasn’t been a major contribution to the events that are happening in the Middle East, and I am talking here about the Palestinian issue and for example the Lebanese/Syrian issue. I wonder if you could kindly tell us, there has been recently a conference in Saudi Arabia for example between Britain and the Saudis, has the Abdullah Plan been revived, is there anything to revive what is happening in Palestine because as you know the situation is quite grim. It is not enough saying we don’t want to talk to Hamas while people starve for example.
Prime Minister:
Well yes, except that Britain is the biggest bilateral donor to the Palestinian Authority, so I don’t think anyone can say we haven’t made a big contribution.
Question:
… need to solve the problem.
Prime Minister:
Yes, exactly. But just on the aid issue, we are making sure that we continue to put money to the humanitarian relief in Palestine. On the political process, look I totally agree it is an absolute priority for me and the international community to make progress in the Middle East between Israel and Palestine. Without that we are going to have a continual running sore and problem that doesn’t just cause misery for many Israelis and many Palestinians, but also causes great mistrust and unrest in the world. I totally agree with that. But there is only one way we can make progress and that is by everybody accepting the principles through which progress can come, and those principles include support for an independent viable Palestinian state, with proper territorial boundaries so that it is indeed viable, but also that people accept that the state of Israel has a right to exist and its security should be properly looked after. Now if people can accept those two principles I can assure you, and I know I speak not just for myself here but for President Bush, there is every desire to take this process forward, people want to make progress but it can only be on those two bases because otherwise how do you make progress?
Question:
Yes, but the fact is that Hamas has been in power only a very few months and before this year, and people are thinking in the Middle East that what will happen if Hamas indeed stays in power for years, what is going to happen?
Prime Minister:
Well that is an issue not just for me but for the leadership of Hamas because let’s again be very clear, the reason why the Palestinian elections went ahead was because of the insistence of the international community, including people like ourselves and the Americans, that it should go ahead. And let me again make it clear, I support entirely the mandate of Hamas. They won the election fair and square, that is it, they are the elected government. Fine. But if they need our help to move this process forward, and we are willing, anxious, urgently wanting to do that, I don’t know how I approach the Israelis and say let us enter into a negotiation about two states, when one side to the negotiation is saying but we want the other side eliminated. I can’t do that. So it is of course a challenge for western leadership and for the leadership of Israel, but it is also a challenge for the leadership of Hamas.
Question:
I am just trying to get at the extent to which central government is responsible at all for any of these NHS difficulties. Is it not right that in December you said the deficit would be around £200 million, and I wonder what you would give your current estimate of the deficits will be at the end of this financial year. Can I also ask, is it not the case that you under-estimated by £600 million how much agenda for change, the consultants’ and GPs’ contracts would be? And thirdly, is it right that you are planning to introduce a system of fines for those NHS organisations that overspend? It has been reported in some places that you would withdraw the equivalent of 110%, so the equivalent of a 10% fine on a hospital that overspends.
Prime Minister:
I don’t know about fines, I have not heard that. The fact is that if hospitals are overspending, they are going to have to get back into financial balance because that goes back to what we were saying earlier, if they don’t then someone else has to come and bale them out. Look, we always take responsibility for the new system in the Health Service and that is absolutely right. I don’t know what the current prognosis is on the deficit, but the most important thing obviously in relation to the deficit is that the majority of the deficit is in a small minority of the trusts, so that obviously is its own story.
Question:
I am sure you know the …
Prime Minister:
No, you won’t know at the moment.
Question:
Well what is your current estimate then?
Prime Minister:
I don’t think it is sensible for me to give an estimate until we actually know how it turns out, because they change the whole time. I don’t think there is very much longer to wait and I think some of the figures that are banded about may prove to be a bit of an exaggeration actually.
Question:
What, the £800 million is a …
Prime Minister:
There is no point in cross-examining me in order to get the answer I have just told you I won’t give at the present time. But in relation to pay, I just want to make this very, very clear to you because I do not agree with what people are saying on pay at all, I don’t agree at all. I think the reason why for example some of the GPs have got significant pay increases, although nothing like the £250,000 that is being talked about, their average I think is around about £90 - 95,000, but some of the reason for that is they are doing more, and that was precisely what we bargained for. And in respect of the consultants, it is the same again. What we did was we decided to reward people more for the NHS work, and so those consultants that are doing a lot of NHS work, sometimes exclusively NHS work, yes they are being rewarded better, but that is because in the new system that we are introducing we want to make sure that people have an incentive not to keep a waiting list for private practice purposes so that people end up waiting months and months and months when they can go and get it done the next week or the next month privately. So there is a rationale behind these changes. And for example in respect of nurses you have got advanced nurse practitioners and whole new grades being created in order to reward those who reach a higher skill level better. It is absurd today that you still have, and we are changing this as well, but you still have situations where highly qualified nurses who have spent several years in training can’t perform tasks that obviously they are qualified to perform. Now as I say these are the things that are changing, nurse prescribing we have changed, and other things, but there are a whole series of system changes that are being introduced on the back of the extra pay, and they are justified. And the fact that we have paid more money is because they are doing more, and that is the whole point, and sometimes doing it far more effectively than was done before.
Question:
Could you please clarify the government’s policy towards Hamas? Last week Jack Straw appeared to indicate in an exercise that there might be some relaxation of the requirements for talking to Hamas, no condemnation of terrorism, you would leave it to Mahmoud Abbas, no formal recognition of Israel, and a watering down of the requirement to accept the road map. Can you confirm that these will not in fact occur? Secondly, Osama bin Laden put out a new statement last night, do you have any comments about this threat that he has made to deal with those people against Islam? And third of all, with the local elections coming up there is a threat of the BNP taking a slice of some of the votes from both the Labour Party and other parties. It being a racist party, is there any message you wish to give to voters to avoid going down that road, and would you be considering such measures as increasing deposits and the like to get rid of frivolous …
Prime Minister:
You have got quite a lot in there. Look, I answered the Question on the BNP last week when I was doing local electioneering and the fact is that racism offers nothing but division, disunity in communities, misery for people and no-one should have any part of it at all. In respect of Hamas, no, the position remains as I have set it out. We cannot take this process forward unless it is on the basis of a renunciation of violence and an acceptance of the right of Israel to exist, and the principles of the road map, which were entered into by both the Palestinian Authority and Israel. And you might remember incidentally, some of you will remember, the fight we had over whether Israel would accept the road map. Now Israel is saying it will accept the road map.
Question:
With 14 conditions.
Prime Minister:
Well you say with 14 conditions, but when you actually analyse it it basically comes down to one, which is that they have got to know that the partner that they are dealing with is resolutely determined to drive out any possibility of violence or terrorism being the means of advancement. You know we have got to face that fact in the end. In respect of Osama bin Laden’s statement, what I thought was interesting about it was that it is a very graphic description both of the extremism that is his political philosophy, and the hatred of people who want to work with each other across the religious and racial divide. I think the interesting thing when you look at some of the trouble spots, for example Sudan that he now suddenly raises as an issue, the fact is what these people do, and what al Qaeda do, they go on the back of any conflict or dispute in the world to try and exploit it as much as possible, and theirs is a politics of hatred, not a politics of peace. And incidentally one very welcome development that is happening at the moment is the parties coming together in Iraq to form a government, it is a very, very important moment indeed.
Question:
Why do you think there is such a gulf between people’s individual experience of the NHS and the general perception of the service?
Prime Minister:
Well why do you think it is? Look, what I have asked today from you, and I ask for nothing more than this, is a sense of balance. If all that they are hearing is bad stories then their perception is likely to be bad, their personal experience is obviously their personal reality. Now the trouble with that is you say something like that and people say ah, so you are saying there are no problems in the Health Service at all. No-one is saying that. It is the feature, and it is not actually your fault, it is just the way that public debate is conducted now, it is just the way it is, but there is never any sense of balance. There is no problem that isn’t a crisis and no difficulty that isn’t a catastrophe, and if it is not a crisis or a catastrophe it kind of doesn’t exist. So that is I think probably the reason, but this would require another entire press conference to dwell on that.
Question:
On Iran, Prime Minister, last week at Prime Minister’s Questions you refused to rule out the possibility of military action, including targeted nuclear strikes against Iran. Can we therefore assume that should the diplomatic process fail to resolve the dispute over Iran’s nuclear programmes, and the US decided to pursue a military option, you would consider lending British support to that? And also given that the Foreign Secretary has described military action as inconceivable and unjustifiable, is there a split at the heart of government over this issue?
Prime Minister:
No, there is just a very, very obvious thing, which is Iran is not Iraq. Nobody is talking about military invasion, people do however want to send a very strong signal to Iran because some of the comments made by the President of Iran are totally unjustifiable, Iran is supporting terrorism in the region to the detriment of democratic governments, it is in breach of its nuclear obligations and people want it to comply. And so the real issue for me in respect of Iran is well what are you going to do about it? And all I am saying, as I said at Prime Minister’s Questions last week, is that it is not very sensible at this moment in time to send a signal of weakness, we want to send a signal of strength. But I repeat, Iran is not Iraq and people are very, very well aware of that here and over the water.
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