17 October 2006
Tony Blair’s monthly press conference from inside 10 Downing Street was dominated by the medical treatment of British troops serving overseas, Muslim women wearing the veil, Iraq and faith schools.
The PM also watched presentations about change in the health service from NHS Chief Executive David Nicholson and Chief Medical Officer Sir Liam Donaldson.
Parts of this transcript may have been edited
Opening statements
Prime Minister:
Right, hello everyone. Now, let me explain how we are going to try to do this. We have got a presentation on the National Health Service which is something we have prepared for quite some time so we are going to do this first and people can ask some questions on it. I will say something and then Liam Donaldson and David Nicholson will come in and say something and then we will be able to throw it open to wider questions and I will answer those. And incidentally for any of the senior correspondents, if you want to ask on both, you can ask on both. If you ask on Health you’re not prevented from asking on other things, of which there are a myriad of possibilities.
Anyway let us first of all, because this is important obviously as a long-term issue for the country. I said back in April that the next year or so - then - was going to be a crunch time for the NHS. Essentially this is when the reform programme is going through, we are right in the middle of it, there are tough and difficult decisions being taken and it is important that people understand the context for it. And what we are trying to do is to get to a situation where the big issue that there was within the National Health Service when we came to office, namely the amount of time that people used to wait to get their operations, to get proper treatment for cancer and cardiac care, where that is genuinely transformed. And we have for 2008 the target that there will be an 18-week maximum wait, but that is in-patient and out-patient combined. In other words, when we came to office there were thousands of people waiting over 18 months just on the in-patient list, but often they waited many months on the out-patient list before they even got on the in-patient list. The concept of the 18-week target is literally door-to-door, from the GP to the operating theatre and effectively that will mean you have booked appointments and an end to waiting, certainly in a traditional sense, within the National Health Service.
Now to do that we need to make changes within the National Health Service. That is the purpose of the reforms both at primary care level in terms of payment by results in the new system operating in the NHS and also in the contestability of services. But it is all about different ways of working because the context in which health care is being delivered is changing. And I would just like to correct, if I may, some of the stuff that there has been of a negative nature in the past few weeks. For example the Health Care Commission Report last week. This was presented as negative. In actual fact, what the Chief Executive of the Health Care Commission said was there have been real improvements in the NHS, waiting times continue to fall, particularly in Accident and Emergency, for cancer treatment and access to chest pain clinics. This is having a real effect on survival rates from cancer, heart failure and stroke, which are our biggest killers. What they have done, however, is apply a much more rigorous set of standards to judging whether hospitals are succeeding or not. So it is not that the Health Care Commission was saying the NHS is getting worse. On the contrary they say it is getting better, but it has got to get even better still. And I think that is important to point out.
Yesterday there were stories about cancelled operations. Cancelled operations are 25% fewer than 4 years ago. There have been claims that there are some 20,000 jobs or people who have had their jobs lost within the NHS. Actually when you look at what is happening and track those stories down around the NHS the actual figures are far fewer. What is in fact happening however is that it is true. Some people are being redeployed to different work within the NHS precisely for the reasons that you are about to hear. In total there are at the moment round about 300,000 more people employed in the NHS today than in 1997, and before everyone says these are all managers, they are not. Actually the vast increase has been in front line staff. And that is something like a 30% uplift in the numbers working for the NHS.
It is the case today that whereas almost 300,000 people were waiting longer than 6 months for in-patient treatment, today it is virtually no-one. Waiting for cataract treatment, for example, has been slashed from 2 years to 3 months and all of this has been delivered within NHS outcomes that mean that there are round about 700,000 more operations today than there were in 1997. Incidentally on productivity as well again it is constantly said that productivity in the NHS is declining. If you include quality of care within the figures i.e. saving lives, improvements in waiting time, improvements in prevention and keeping people out of hospital, then actually productivity has risen in the NHS over the past few years, and this is borne out both by the King’s Fund Report from last December and the NHS Confederation Report from May.
So, what we will present to you today is the picture of an NHS that yes has got tremendous challenges, and indeed so have health care systems right round the world, but one where improvements are being made and where the key driving force behind the changes that are happening in the NHS today is the need to deliver health care in a different way in a changing world, and we have got to hold our nerve and see these changes through particularly over the next few months. It is the next few months that are going to be absolutely critical as to whether this happens or it doesn’t happen.
Now one final thing I just wanted to comment on before handing over to Liam is again another example of where we can get the progress on public services. Somewhat out of kilter is the report today from the PAC that claims that one million pupils are in poorly performing schools. What they are doing is changing the definition of what is a failing school in order to include a whole series of schools that are not failing in the traditional definition but simply are not performing as well as they should be. That is a completely different definition. Actually on any definition that you use, school results are improving. The number of schools in special measures has declined actually by over a half. The number of schools where under one quarter of the pupils are getting 5 good GCSEs has been cut to one sixth of what it was. Only 110 now from over 600 in 1997 and actually in every single part of this system there have been improvements. Does that mean that all the schools are doing well? No. Does it mean that they are improving? Yes. And whereas when we came to office in 1997 there were many London Boroughs with an average of 25% 5 good GCSEs, today there is not a single Borough in London, not one, that has not got a record of over 40% 5 good GCSEs. So what we would say is, there is considerable improvement. It is coming often as a result of reform, because specialist schools and City Academies are improving at an even greater and faster rate, but we need to do far more. So without any more ado. This is an interesting presentation that Liam has got to give to you.
Sir Liam Donaldson:
Good afternoon everybody. To tell the story of modern health care is very much to chronicle a march of progress in medical science and innovation. How it saves lives, how it transforms quality of life, and how it shapes the way that health care services are delivered.
This is a 57 year old film producer, William Patterson. His closest friend died of a heart attack and he then began to worry about his own symptoms that he had had over a number of years of chest pain and minor discomfort in the area of his heart. He went to see his doctor and was also diagnosed with severe coronary heart disease. He had a major blockage in one vessel and normally he would have required major surgery, open heart surgery. But he was lucky enough to meet with the team at St Mary’s hospital who had just started using robots to undertake this form of cardiac surgery and you see there the robotic system in place, the surgeon sitting there at the console, a three-dimensional image of William’s heart. He had his operation. He was out of hospital within 5 days. Those are the tiny scars that he had compared to what an open heart surgery would be, and within 2 weeks he was travelling around Europe with his job. The only down-side was that his 10 year old son wasn’t very happy about the idea of a robot that didn’t have a face and didn’t talk. But William was very happy and he had an excellent outcome of care.
New technology, shortening recovery times for patients, reducing the risks of surgery, reducing the pressure on intensive care and shortening hospital length of stay.
Tracking technology is increasingly being used in different fields to analyse performance of - in the sports field - of individuals and teams. The blue lines on those charts are successful passes in a football game. The red are unsuccessful. The chart on the left shows one of England’s World Cup games without Wayne Rooney and the one on the right shows the team with Wayne Rooney and look at the flow of creativity and opportunity that is being created. So sports coaches are using that sort of technology.
In the health field we are also using tracking technology. On the left you see an inexperienced surgeon whose eyes are in special goggles that track his eye movements. Look at the dispersal of his eye contact with the area that he really needs to concentrate on, the wound where he needs to do a very precise procedure. On the right you see an experienced surgeon who has done many of these operations before, his eye contact honed right down to the area that needs his undivided attention.
So we are using this sort of tracking technology in an era where we want patients to receive the best quality safe care to do what, when I was training as a surgeon 30 years ago, tended to be an apprentice-style form of training, not quite fulfilling the old adage of see one, do one, teach one, but almost. So we use in modern surgical training we are starting to use, and this is the shape of the future, simulators. That is a gall bladder, but it isn’t a real gall bladder. It is a keyhole surgery virtual operation. The surgeon doing it can pull on the gall bladder. It bleeds like a real gall bladder. He can cut it out and it comes away like a real gall bladder. He can look at the complications of surgery and anticipate them in advance. So when the real patient comes to have her gall bladder taken out, it is being taken out by somebody who has practised many times before doing it on a real patient, transforming the way that surgeons hone their technique.
Barbara is a woman who has had diabetes since she was 10 and like a lot of insulin-dependent diabetes she had relied on a daily insulin injection. But she had a lot of complications with her diabetes. It wasn’t well controlled and her quality of life was poor as a result, so as a result of this technology she has a special monitor attached and implanted under her skin which delivers insulin at the time that is required in the right dose and that technology has transformed her quality of life. So that is an example of new technology putting the patient in control and reducing their dependency on hospital care.
So just a few brief conclusions. The NHS is nearly 60 years old as we all know, and during that time as I have shown in my presentation there has been immense medical progress and much of it in the last decade or so. But one thing has remained static. The sacred cow of our Health Care System to be revered and protected at all costs has been the hospital bed, yet in the best health care systems around the world the goal is not the preservation of the status quo. The holy grail is the maintenance of people’s health so that many people never have the need of that hospital bed at all, and when they do need care the highest quality care for patients needs to be delivered, not in one place necessarily of a static or fixed institution but in the place that they need it, and however it is going to be delivered to give them the best possible outcome and all of these changes driven by excellence and innovation in medical science.
Thank you for listening. I am going to hand over now to David Nicholson who is the Chief Executive of the NHS.
Mr David Nicholson:
Thank you Liam. Good afternoon. I am David Nicholson, Chief Executive of the NHS. This is my sixth week in post so hopefully I am getting to grips with some of the issues around and it is a fantastic privilege for me to do this particular job after spending the last 30 years at a variety of levels working in the NHS. And it is a very exciting time to join the NHS. My job in lots of ways is to take the sort of things that Liam has been saying there and to systemise them, so that everybody in the country has the opportunity to access those kinds of services. And it is true, underlying what Liam has just said, we will not do that by polishing the status quo. Lots of people have said, and indeed it was repeated recently, that the NHS is a much loved institution, and it is. But to be frank, we need to get away from being a much loved British institution to a 21st century health care system which meets the needs of patients. So we are going through significant change which is not without its pain in the system generally and you can all see yourselves, in your daily lives, and reading the newspapers and television and the rest of it that there are big changes happening but it is very important to stress that we need to see these changes through for the benefits of our communities and our patients.
And there are two big changes going on at the moment that I want to mention. The first thing is that the whole way in which, the structured way in which care is delivered to patients, is changing. And Liam has mentioned that a little bit and I will talk a little bit about that in future. And the second bit is that we are changing the delivery system. We are trying to reform the system so that we can get much better outcomes for our patients.
In terms of the way the structure of the Service is changing, in terms of service rather than organisation, there are two elements to that. There is the closer to home, community-based shifting resources and expertise from hospital services to community and primary care, and then there is the concentration and centralisation of services around secondary care.
In terms of services closer to home, this is a facility opened recently in Birmingham and this year, every week one of these facilities is opening somewhere in the country, a facility that not only enables a whole set of new services to be provided closer to people’s homes, but it also gives us some opportunities to develop services. One of the issues when the Prime Minister and I visited this place 2 or 3 weeks ago was to look at the partnership between the Ambulance Service and the Health Services to reduce unnecessary hospital admissions for falls. A major issue in relation to admitting elderly, frail patients into hospital is when they fall. Historically what would have happened, they would have called their GP, the ambulance would have been called, the ambulance would have taken them into hospital. Now there is a whole set of services that the paramedics can offer, can access into the social care and health care to keep the patient in their own home and to provide them with the support that they need.
The second area that I would identify in terms of community services is long term conditions. Long term conditions. 40% of households in this country have at least one member who has a long-term condition: diabetes, heart failure, emphysema, asthma, that kind of thing, and the treatment for these and the care of these patients is being revolutionised as we speak. Liam talked about some of them, but you can see the scale of utilisation of health care in this regard. And one of the major issues that we face is that a large proportion of patients in our hospitals suffer from one or more of these long-term conditions. Indeed 5% of our patients are responsible for using 42% of all the in-patient bed days. There are good alternatives for a large proportion of these patients. If we can better control and support their care in the community we can avoid a whole set of admissions into hospital services which is good for the patient and good for the service.
Inside hospitals things are changing. The length of stay is significantly reduced across the NHS as a whole, something like 20% in the last few years and the way in which we use health care in hospitals is changing as well. Approximately 70% of all in-patient elective care is currently now done on a day case basis which is an increase in numbers from 2.5 million 10 years ago, to 4 million today and that can go further, we can do more using this as the sort of technology that Liam has talked about to improve services to patients on a day case basis.
And the second area relates particularly to the concentration of services in hospital and I think Liam really did show quite graphically the way in which we can train our doctors, we can concentrate skills and talents in particular teams and we can improve services to patients. Prostate cancer is a good example of that and the thing that connects these two things together, community care and hospital care, is often the Ambulance Service. It used to be the case many years ago that Ambulance Services essentially were what was euphemistically described at the time as "scoop and run". You picked the patient up and you took them to the nearest hospital as fast as you possibly can. That is radically changing as we sit here today. The big issue is when people get access to definitive care, and increasingly that definitive care is being delivered to their doorstep by highly trained and high skilled paramedics so the treatment can start in and around the patient’s home, not waiting to go to a particular A. & E. department.
It seems to me in terms of all these changes and particularly at this moment we need consistency of purpose. We need clear direction and we need to drive it forward. It is the duty of the NHS to respond to these challenges in a constructive way, but it will take imagination and courage from the clinical leadership and the managerial leadership of the NHS. And what we cannot do is leave our patients and public behind and that is why we are focusing so much attention at the moment in the way in which we communicate with our patients and public.
What we need to do is to move from a situation where the whole of the debate is around how many beds there are, how many beds there aren’t, how many hospitals have been closed, how many hospitals have been saved, to move to one where we can say how can we improve patient safety, how can we improve services and how many lives can we save.
Question and answer session
Prime Minister:
Now we have got a few minutes for questions on the Health Service.
Question:
Prime Minister, the message seems to be, get used to it, hospitals are going to be closing. Is that basically what you are saying to people, that an inevitable consequence of what you are trying to do to the NHS is that hospitals will close around the country?
Prime Minister:
No, we were not saying that. What we are saying however is that the way hospitals deliver their healthcare, the way the Health Service delivers healthcare is going to change, and it should change. And if people for example can manage their own disease better at home rather than taking up a hospital bed, that is a good thing, not a bad thing. Now actually we have got the largest hospital building programme under way since the NHS began, but what is true, as was just being said, is that if you have got 70% of elective surgery is daycare surgery today, and that is up 2.5 million to 4 million just since we have been in office, that is bound to make differences in the way healthcare is delivered. Now that doesn’t mean to say that it is going to close a hospital, but it may be for example that certain specialist services are better brought under one roof.
I was talking to cancer specialists up in Manchester the other day for young people and they were just making the point, they have an expertise, even their nurses have an expertise that if they are in a specialist centre just delivers better care. So what we are trying to say is get away from this notion, look you have got 1.3 million people employed in the Health Service, it would be bizarre if that was the only organisation anywhere in the world where everyone carried on doing the same job in the same way. So what we are trying to do is to get a rational debate about the changes in the healthcare system against the background, not just of increasing investment, but improvement in the healthcare system and not treat every service as if it had to be preserved as a special part of the status quo when sometimes services in the modern world are better delivered in a different way.
Question:
What do you say to the nurses that are working in hospitals that their posts are now being axed and they can’t actually get jobs in primary care trusts or in the community because the resources or the capacity just hasn’t been set up yet?
Prime Minister:
Well what we are trying to do is for those nurses that have gone through training, and after all it is an amazing thing, I spent the first few years in office being told we weren’t training enough nurses and we didn’t have enough nurses, and now people are saying well they are trained and they can’t get a job. Actually we are trying to make sure that any of the nurses that come out of training and can’t find a job locally are redeployed elsewhere and we will put every effort we can into doing that. But in the end, again what we have got to do is to make sure that we are employing people in the parts of the system that they are needed to be deployed. And one of the interesting things from the healthcare centre that we saw in Birmingham was the work that is being done by community nurses there is far in advance of anything they would have done even a few years ago, even five years ago. And that is why it is important that we direct the people to the places they are really going to be needed.
Question:
(removed, party political content)
Prime Minister:
Well it is certainly a reflection of the fact that we know there is a huge debate going on about it, it is not just a political debate but in the country as a whole. And what is the most frustrating thing about the Health Service today is that if you ask people what their personal experience of the NHS is, it is positive; if you ask people what the state of the NHS is, it is negative. Now that is the difference between reality as experienced and perception as seen. And we have got to bridge that gap because I don’t know anyone really, I suppose you can find them, but I don’t think there are, put it like this, many independent commentators on the NHS, that would not say there has been substantial improvement, and yet out there the public doesn’t see that.
Let me just give you an example from someone I was talking to the other day. They have had three pace-makers, and you guys had better put me right if I get it wrong with the medical terminology, but three pace-makers put in over the past few years. The first time they did it it was a general anaesthetic and required several nights stay in hospital. The last time they did it, just a short time ago, it was done by local anaesthetic and it took one and a half hours and they were out the same day. Now what that means is the way you deliver healthcare has changed, but what people see from the outside, they are told there are 20,000 job cuts and wards closing, when actually what is happening is people are trying to change the healthcare system because treatments are changing, technology is changing, working practices are changing. So yes of course the political debate is one part of this, but it is more important in a sense the public debate, because actually our NHS from the outside is seen as a massively improving system.
Question:
Since we have got the experts here, and I assume you know the answer to this, could we have a straight answer please? Recognising there has been an increase in the number of people in the NHS, but also recognising the financial constraints this year, whether for good or bad reasons how many job losses you think there are going to be across the NHS in this financial year? And could we also have what you say to doctors inspired, or trainee doctors inspired to go into the NHS by propaganda who are now finding themselves qualifying and unable to get jobs?
Prime Minister:
I think you can answer if you want to on these two things. Well why don’t you answer first and then I will follow in David.
David Nicholson:
Well NHS employers, based on a survey, they have talked about 20,000. Our information is that it will be significantly less than that. But what we are talking about here is jobs that are being lost. In any one year 130,000 people move jobs in the NHS, so you get quite significant turnover in the NHS. We would expect most of the changes that we are talking about in terms of jobs to be dealt with as part of that.
Question:
Is that net 20,000 jobs?
David Nicholson:
That is what NHS employers have done. What I am saying is that as far as the Department of Health …
Question:
You are running the Health Service, shouldn’t you know?
David Nicholson:
Do I know what, sorry?
Question:
How many jobs are going to be lost in the NHS this year net.
David Nicholson:
One of the things about the NHS is that it is 600 organisations and all operating, 1.3 million people work in it, several million people are being treated by it. All of that is being worked out at the moment as we go through. Most of the changes that we are talking about here are being driven from the bottom up, not from the top down.
Question:
So you don’t know?
David Nicholson:
We haven’t got a figure, a complete figure for all of that at the moment, but what we do know so far is that the number of redundancies looks like a significantly fewer than is being talked about at the moment.
Prime Minister:
To put it into context for you, because these are just announcements that people are making, when you actually look at the announcements, most of it are either vacancies that aren’t being filled or posts that are being transferred. The actual numbers of compulsory redundancies, which is what most people would understand by job losses, as far as I can see from the figures that I have got and collate them going round the country is a few hundred, not 20,000.
Question:
Net a few hundred job losses?
Prime Minister:
Of compulsory redundancies. So look when you get to the end of the financial period you will then be able to say how many people are employed in the Health Service now and how many people were employed before. Now we are not at the stage where we are able to do that, because as David has just been explaining there is a huge turnover happening the whole time. But in respect of these stories there have been, because the 20,000 figure isn’t our figure, it is a figure that is collated by other people.
Question:
Inaudible.
Prime Minister:
I am sorry, I don’t think he did endorse it actually.
Question:
Well he said employers have done estimates and they were saying net 20,000.
Prime Minister:
No, what he is saying is …
Question:
He was saying he didn’t know but it was the best estimate he had available.
Prime Minister:
I don’t think he did say that actually.
David Nicholson:
… you asked me about the 20,000, I was saying …
Question:
I asked you a straight question. You are running the NHS, how many jobs net are going to be lost in the NHS this year, and you have told me you don’t know and the best estimate is 20,000. That is what you have told me.
Prime Minister:
But how can you possibly know when you haven’t got to the stage where the NHS does its head count for everyone who is in the service. And what he is saying to you is that at a local level there are all these announcements being made by local NHS employers, he is not responsible for what the local NHS employers put out, and their figure, the figure that is collated from that, the 20,000, is a figure that we don’t believe is actually compulsory redundancies at all, the vast majority of those will be posts that are either unfilled, in other words they are beacon posts they have decided not to fill, or alternatively they will be people who are redeployed. And I have said to you as far as I can see from the actual… going through announcement by announcement, the numbers of compulsory redundancy, the figure is far short of that.
Question:
Can I ask the NHS Chief Executive, you are only here because your predecessor was eased out of his job because he didn’t deal with financial mismanagement. Isn’t it misleading to come here and say that all job losses and all ward closures are due to technological change and changes in the NHS? Some of them, many arguably, are due to financial mismanagement which you are now being put in place to correct.
David Nicholson:
I am not being complacent about the financial position in the NHS which is significant and we have to deal with, but it is 0.8% of our total turnover so we need to get some perspective in all of that. But some organisations, it is absolutely true, are suffering from significant financial difficulties and they have to deal with it, and we are absolutely determined that they should deal with it. What we are faced with at the moment is trying to get in those areas sustainable health services for the future, and so difficult decisions have to be made, that is absolutely the case, but those difficult decisions would have to be made anyway. What is happening is that the financial position and the transparency of the way things work now through the reforms means it makes it much clearer now where these issues are and what needs to be done about them.
Question:
The key question for the public is this, you have given a presentation implying I think that technological change is the reason that wards are closing, hospitals and there are job losses. And my point to you is that is clearly a factor, but you omitted to say that the financial mismanagement that has you in your job for only 6 weeks is another crucial factor.
David Nicholson:
I don’t accept this issue about financial mismanagement.
Question:
Inaudible.
David Nicholson:
I went through a process and they appointed me.
Question:
Inaudible.
Prime Minister:
Come on guys. Excuse me, first of all we did not remove his predecessor because of financial mismanagement; secondly, as you know, the reason why there is a new system of financial management in the Health Service is that for years what has happened is that if one part of the Health Service ran a deficit it got bailed out by all the others. Now the only way you make a system work which is not a centrally driven system, but where people are taking their own decisions locally, is if you say this is your budget, you have got to stick within your budget and you are not going to get bailed out by other parts of the healthcare system if you are not running an effective service. And what is really important about this, and again these guys can talk about it better than me, but what is important to realise is that when you talk about financial mismanagement, yes I am sure there are areas of mismanagement, as there are in any institutional organisation, but the real problem that many of the healthcare systems have is for example you can get services that are on split sites, you can get a particular wave of the service which has grown up over the years and is now made redundant in a sense by a new method of working, not just technology, new treatments, new methods of working. And it is not so much financial management in some of these cases, it is that unless you make structural changes to the way healthcare is delivered you will end up in circumstances where the healthcare is costing more than it should because of the way the service is configured.
Question:
I have got a question for David. In terms of the move of care from acute care to primary care, in theory it saves money but you know there is a huge problem of the high fixed costs that hospitals have. Is there a danger that unless you radically downsize the hospital sector, and quickly, that actually you end up double paying, you end up paying for it in primary care and the costs still remain in acute care. So do you think there is a danger that in the short term at least you are actually going to push your costs up?
David Nicholson:
There is always that danger when you are shifting from one system to another, and where you get real problems is where you don’t have the financial flexibility to manage that. That is why it is so important that we get ourselves into financial balance in the NHS so we can create the financial headroom to be able to manage that appropriately. On the other side of course there is no shortage of things that we want to do in hospitals and increase … anyway as part of the 18 weeks that the Prime Minister has talked about anyway. So I think it can be perfectly well managed, and don’t forget most of the country are able to manage this without all of the sort of horror stories that people talk about, it is perfectly possible to manage it. There are some places that we need to focus on to help them do it better.
Prime Minister:
But you know one of the interesting things about this, and I don’t know if the figure I was given the other day is correct, but something in the region of sort of 50% of the people who go to the Accident and Emergency Department shouldn’t really be in the Accident and Emergency Department. What is the figure?
David Nicholson:
Well it must be close to that. In the United States 50% of the care provided has been judged inappropriate by experts and it is the same in most studies done across the developed world. There are big opportunities for improvement in quality of the clinical decision making and that is what all this is about really.
Prime Minister:
OK, we’ve had enough of healthcare now, we have got to move you on to something else, then we will move on to the rest of the stuff.
Question:
Decentralisation and diversity seem to be the sort of political mantras of the time. I just wonder on the NHS how much diversity you are prepared, or the Health Service is prepared to allow. Should we for example be in a system where local authority health purchasers can say well look we want to spend money on this drug, but we are not going to spend it on that drug, so people in adjoining areas can’t get those drugs, or should we be in a situation where local authority purchasers can say look we are going to put our money into breast cancer and we are not going to put it into lung cancer. How much, when it comes to it, diversity are you prepared to allow in the Health Service?
Prime Minister:
Well that is a very good point because it is extremely difficult. Because if you allow complete diversity then you get into the postcode lottery business, and the truth is the best way is to have a balance of certain key minimum national standards and targets, which is what we have got, and then you allow the maximum diversity within this, and then for drugs you have obviously got the NICE procedures. But the truth is there is a lot more we can do on diversity still, at least of supply. To meet this 18 week target it is diagnostics, as I understand it, that will have to be changed most and what we will require is the ability to access a diverse range of suppliers in order to cut through any bottlenecks there are within the NHS.
Question:
But diversity means postcode lottery, if you have diversity by definition you will be able to get some things in some areas and other things in other areas, but not everything in every area.
Prime Minister:
That is true, but the question is where you put the line. And for example on something like cancer or cardiac care there should certainly be minimum standards you would say. So I agree, it is always a difficult decision and you have got to strike a balance. But you know the interesting thing about this debate is if you look at politics in Germany at the moment, healthcare is the number one issue, and they have got a social insurance system. Healthcare in the United States is a major issue at the present time because the insurance premiums are rising so much. In the French healthcare system, we have got a deficit of, around, 0.8%, they have got a deficit, of around 3%, or more I think. So you know whatever healthcare system you have you are going to have these issues.
The important thing that we are trying to do with these reforms though is to insist that the proper financial management is put through the system with payment by result. In other words that the money genuinely does follow the patient, so plus patient choice, plus practice based commissioning. So what should be happening within the system, and this is the importance of the next few months to this reform, is that you get a situation where the NHS is being driven effectively by the demands of the patient. So that if for example a patient is having to wait months, and months, and months for an operation and there is somewhere that can do it quicker, they have the right to go there. The money then follows the patient and the hospital then has an incentive to make sure they are providing the right type of care. The reason why Patricia was announcing the other day that doctors are going to perform more operations at a local level is that if they can do that, that takes pressure off the acute sector, and many GPs now can be specialised to a reasonably high level to provide this.
I think we are going to have to move to the next topics. I hope you enjoyed this experience. Now you know what I have to put in day in, day out. You made the right career choice there.
Question:
In fact I would have liked Sir Liam and Mr Nicholson’s opinion on this as well. Do you think it is appropriate that British soldiers, injured in combat, should be brought back to British civilian hospitals against their will and sometimes put in mixed sex wards?
Prime Minister:
We should do the very best for our armed forces when they are injured in combat, and the expert advice that we have is that for some of the most difficult injuries they are best treated within the specialist service of the NHS. But there is a case, and we are looking at this actively now, for having military managed wards within the NHS where these servicemen or women can go, because it is important they get the best care but also in an environment with which they feel comfortable, and we will try and do that.
Question:
When you say you are looking at it actively, can we expect an announcement soon?
Prime Minister:
Yes, I think you can expect an announcement soon. My understanding is that at any one time the vast majority of injuries that occur to our servicemen and women occur through the normal run of things, accidents and so on. But where there are battlefield injuries it is important they get the highest and most specialised care. That will usually be within the NHS, but it should be within an environment with which they feel familiar and comfortable. And obviously if we need to make special provision for them we are prepared to do that. So we are looking at how we could have military managed wards or units, and my understanding, but don’t pin me down on this, but the briefings that I have had on it suggest that at any one time the most you would have is two wards, so you are not talking about a massive problem either for the Health Service or the Army in arranging it. But I totally understand the concerns of service people if they have received a battlefield injury and they are in unfamiliar surroundings outside of the environment of the Army and if we can meet that, as I hope we can, then we should do so.
Question:
The head of the British Army says that Britain’s presence in Iraq exacerbates the difficulties we face round the world. You didn’t sack him. Is that because you know privately that he is right?
Prime Minister:
Well I have said what I said on Friday in response to those questions, but let me just say again and make it clear. What we are doing in Iraq and Afghanistan is important. It is important for the security of our country, for the security of the world, it is actually important for the very reasons that General Dannatt gives in his interviews, which is that if we walk away before the job is done from either of those two countries we will leave a situation in which the very people that we are fighting everywhere, including extremism in our country, are heartened … and we can’t afford for that to happen. So what we have got to do is to see that job through.
Question:
He made a very specific point, which you avoided addressing on Friday, and you have just avoided again. His quote was "Britain’s presence in Iraq exacerbates the difficulties we face round the world." Now on Friday you addressed what he had said in television and radio interviews, not that particular point.
Prime Minister:
Yes, but the reason I did that, with the greatest respect, is because if you put what he said in the interview that was published in the newspaper in the context of what he is saying on TV and radio, and look he is able to answer these questions himself, and did so, is that of course it is the case, and I said this on Friday, that for some of those areas in Iraq, particularly where the Iraqi forces now want to take control of those areas itself, it is important that we don’t overstay the time that we need to be there. But in no sense was he saying, and neither should anybody say that we should get out of Iraq before the job is done.
However, the job being done is not to stay in Iraq, even when the Iraqi forces are capable of taking on the security for themselves. And there will be a debate, and if you read it, I have actually managed to read the full transcript of the interview he gave to the newspaper, if you actually read the whole of the interview together it is very, very clear: a) he is not saying we should leave Iraq now; and b) he is saying that of course there will be people, and there are people who will claim that our presence in Iraq or Afghanistan indeed causes problems for Britain round the world. But we have got to take those people on, we have got to say to people if by being in Iraq and Afghanistan and helping those countries and the people that want democracy in those countries to get the country on their feet, to free it from the type of sectarian violence and extremism that we see there and we see in different parts of the world, including even here, if they are going to use that as an excuse to cause further extremism or violence, that is a reflection on them, it is not a reflection on the work we are doing in Iraq or Afghanistan.
Question:
Should British schoolchildren be taught by teachers who wear a veil in the classroom?
Prime Minister:
I think that is a decision for the education authority, they should be allowed to take that decision. I fully support the authority in the way that they have handled this, and I think there is a bigger argument that is going on here that we can see very clearly in relation to this issue and in relation to many others. And I know that the debate is happening in a somewhat haphazard way in a sense. You have got various issues coming out, whether it is the BA woman and her crucifix, or there is the veil, or the teacher in school and so on. And I think there is a debate that we need to have and it is a debate that has got two aspects to it in my view. One is the relationship between our society and how the Muslim community integrates with our society, which is an important debate that non-Muslims need to have with the Muslim community, and difficult though these issues are I think they have to be raised, and confronted and dealt with. And then there is a second issue, which is about Islam itself and how Islam comes to terms with and is comfortable with the modern world. And you know the fascinating thing about this debate, I just asked before I came here since I thought I might be asked about it, for just an analysis of what is going on around the whole of Europe and then in the wider world, and basically in most major countries in Europe today a debate similar to the one we are having now is going on there, in Germany over the opera, in France over I think the academic who wrote the polemic about Islam. It is interesting if you look at the front page of Le Monde this morning it has actually got a picture of a woman in a veil, and with the British issue this is reverberating right round. If you look at Holland, Denmark they are having the same arguments.
There has been apparently an incident in Belgium over the same type of thing, in Italy they have just published I think yesterday a set of values, which is meant in part to try and deal with this issue. There is a whole question to do with integration, and my view is that we try and deal with this debate sensitively, but we have to deal with the debate. This is an issue for the British people now. People want to know that the Muslim community in particular, but actually all minority communities, have got the balance right between integration and multiculturalism, and people want to see that that balance is got right. Now we need to conduct this debate in a sensitive way, but it needs to be conducted and it needs to be conducted in part because then round the world there are people in Islam, Muslims who are also engaged in the same type of debate about Islam, and again it is fascinating. If you look at what is happening out in the Gulf at the moment, precisely the same types of debate are going on, in Malaysia, in Indonesia, in Singapore.
Question:
Can I just clarify, because it is such an important issue? You said that you backed the local authority’s decision in the particular case of the school teacher. Does that mean to say that you think she was right to have been suspended for refusing to take off her veil?
Prime Minister:
Well I simply said that I backed their handling of the case and I can see the reasons why they came to the decision that they did, and I think this case should be allowed then to take its proper course and that is one of the reasons I am wary of getting into the particular issue, as it is a court case. But I think we need a way of having this debate because I am sure it is there, in fact it is there in every village, town and city of the British nation at the moment, and also in other European nations and worldwide, and so we need to have it and we can have it I think in a sensitive way, but it is about as well as people preserving their own distinctive identity they integrate with British society. And that is the reason why it is important in my view that people who come into the country and settle here, learn to speak English. It is about getting the balance right between integration and your distinctive identity and we need to have that debate in a sensible and serious way. And even though probably most people wouldn’t have chosen that the debate started in this way, it is under way so we should engage in it.
Question:
Prime Minister, you said just now that General Dannatt had not asked for British troops to be withdrawn now, but no media outlet suggested that he had asked for troops to be recalled now. He asked for troops to be brought out soon. And he then identified in the very transcript that you stand by, the radio interview, in effectively under 2 years. 2. 3, 4, 5 years would be too much, so within 2 years. So firstly do you accept that timetable that he has spelt out; secondly, do you accept that if you get the decision wrong you are as he put it in danger of breaking the British Army? This was the head of the British Army speaking, it can’t be finessed, that is what he said.
Prime Minister:
What he is saying, and again you can read the whole of the transcript, the fact is it is the policy of the British government to withdraw from Iraq when the job is done. But he is not saying, whether he is saying 2, 3, 4 or 5 years, the reason he is saying it could be 2 years, 3 years, 4 years …
Question:
He is not saying 2, 3, 4, 5, he said no more than 2.
Prime Minister:
I thought he said no more than 2, 3, 4.
Question:
He said 2, 3, 4, 5 would be unacceptable.
Prime Minister:
Yes, but the only question is, and I think this question is very, very plainly answered by his interviews, the only question is whether he is saying irrespective of whether the job is done or not, and he is not saying that.
Question:
He is saying you have to set a lower ambition. We don’t even know what job he now accepts you are asking him to do, he is saying you should set a lower ambition than a liberal democracy. What is our ambition now?
Prime Minister:
I think he spelt it out very clearly. It is a functioning democracy, a functioning economy and where the security is in the hands of the Iraqi forces - is exactly the policy of the government.
Question:
Inaudible.
Prime Minister:
Hang on a minute, if you would just give me a moment. It is not quite a Channel 4 interview yet. The situation is this. Look, it is our policy to come out of Iraq when the job is done. What is very dangerous is any suggestion that we get out before the job is done, and that is not his position or the position of anyone I know in the Army. Is it the case that we want as soon as possible to transfer power over to the Iraqis? Yes, that is why in two provinces we already have. But if you look at what is happening in Basra at the moment, if British troops were to get out now when we are right in the middle of this operation to try and push back the extremists in Basra and give ordinary people in Basra the chance to have a law abiding police under democratic control, if we were to withdraw before that job is done it would be disastrous for the country. Now he is saying exactly the same thing. What he is saying is of course he, like everyone else, wants to make sure we can get the job done as quickly as possible because you have got pressures on the British Army, not least the difficulties we have got in Afghanistan. But the only issue, as I say, is whether anybody has ever suggested we should get out before the job is done, and I would respectfully say to you that when he is using these terms like 2, 3, 4 years he is precisely making that point. If it was an arbitrary timetable we would have said it should be an arbitrary timetable irrespective. I suspect it is exactly the same with this report of James Baker’s incidentally, I would be absolutely astonished if he was saying we should get out of Iraq come what may.
Question:
Prime Minister, how dismayed are you at the damage done to the government by David Blunkett’s decision to publish his diaries so soon? Do you feel personally let down and did you try to get him to delay publication?
Prime Minister:
No, no, no and no. I don’t know, I have got other things to think about. He was an excellent Education Secretary and Home Secretary and Secretary of State for Work and Pensions, I do say that.
Question:
Can we return to this old subject of schools and multiculturalism, because of course the complication is the planned expansion of faith schools in this country. Could you just explain the logic of the 25% non-religious quota? And bearing in mind that I understand this is going to be forward looking, so it is going to apply to new schools but not existing schools, and that many of those new schools are planned to be Muslim schools, doesn’t this look as making a scapegoat of Muslims when the sort of Catholic schools that you have used for all four of your children are going to stay Catholic only, indeed I understand the Governors of those schools refer to children such as your own as products of mixed marriages, even although you are an active participant in the Church of England?
Question:
So isn’t it unfair that you are applying one standard of 25% to new Muslim schools and you are not applying it to Catholic schools who have already said they are against the plan?
Prime Minister:
Well until you got a bit ad hominum towards the end, if you don’t mind me saying, I actually think the point you are making is a very reasonable point and also exactly the problem that we face. Look, this is why you have got to have an honest debate about it. Why are we having the debate about faith schools? It is because we ended the discrimination that said that Jews, and Catholics and Church of England could have their own faith schools but Muslims couldn’t.
Now I took the decision, and I took the decision myself, to say you can’t say that a Christian can have their own faith school, a Jew can have their own faith school but a Muslim can’t. And let’s be clear, we wouldn’t be having this debate were it not for people’s concerns about this question to do with integration and separation of the Muslim community in British society, so we are trying to work our way through it and it is difficult. Now the reason this amendment comes about is that Ken Baker put forward a proposal which we actually haven’t accepted, but that would have forced schools to accept a certain quota. We have said well local authorities should be able to say, I mean you can’t force people to go to a faith school incidentally, so all you can do is say if people wanted to go to a school of a particular faith, even though they weren’t of that faith, then the local authority would be able to stipulate that. But it is very difficult and it is very difficult for very obvious reasons and I think it is part of this broader debate that we should have. Because actually what really matters is not simply whether you have people from another faith going to a Muslim school or indeed a Catholic school, what actually matters is what is taught in that school, whether Catholic, or Muslim, or Jewish, about religion, about the need to integrate in society, about the values of tolerance and respect for people of other faiths, and that I think is the area we need to look at. But it is very difficult and we are trying to find our way through it as best we can.
I was just, again for the purposes of coming here this morning, looking at the debate that has gone on in France and their state education system, which is a massive debate about headscarves and so on as to whether that is permissible or not permissible. These are really difficult questions but they all come back to the same basic issue: the relationship of integration of Muslims in western societies and communities; and then secondly, which I think is ultimately where the answer to this will be found, and that is the debate within Islam about Islam and its future and its relationship with the modern world.
Question:
And should Catholic and Jewish schools follow the lead of Church of England schools in voluntarily saying they want to move in this direction?
Prime Minister:
I think you know if the legislation that we are proposing goes through then local authorities will have the freedom to do that. There are of schools, different types of schools that will open places for people of other faiths, the Church of England already do it, but you can’t actually force people to go to a faith school. So there are problems there too I think.
Question:
Prime Minister, the Home Secretary urges Muslim parents to watch their children for signs that they could be becoming terrorists. Ruth Kelly castigates the Muslim community for standing on the sidelines and not engaging sufficiently in the war against terrorism. But if you go into any Muslim community they will tell you that the young people are being radicalised, at least in part, by British foreign policy specifically in Iraq and that the danger of terrorism in this country derives partly from what you have chosen to do in Iraq. Do you accept that those dangers are there and have been created by policy in Iraq? And now that you have got both General Dannatt and James Baker’s Iraq Study Group in the US basically suggesting that the Iraq policy has been wrong, don’t you think it is time for a re-think?
Prime Minister:
Well first of all I don’t think there is any point in commenting on James Baker’s study until we actually see it, and what seems to have been reported is various options that he may or may not be looking at. But again you make a perfectly reasonable point and I will deal with it absolutely head on. We are not going to defeat this extremism until we confront absolutely full on this idea that by removing Saddam Hussein or the Taleban we somehow give people a cause or a sense of grievance for coming and blowing up innocent British citizens. It is absurd. Indeed actually if you look later on in the transcript of the interview that General Dannatt gave you will see him specifically make reference to the fact, I think he calls it kind of the away element of fighting this extremism in Iraq and Afghanistan and the home element here and how they are linked together.
You can’t end up in a situation where you say when we are on the side of ordinary decent Muslims in Iraq and Afghanistan who want their own democratic government when we are there at the behest of those governments with a full United Nations resolution, that when we are protecting those countries against people who are driving car bombs into markets and mosques and so on, that we somehow are causing their extremism. It is absurd. And you won’t defeat this extremism until you take that argument head on, and the real problem that you have got is that it has got to be taken head on within the Muslim community as well. Look you could think the decision in Iraq was completely wrong, many people who are non-Muslims do, or in Afghanistan, but what is ridiculous is to say the military action was taken because those countries were Muslim countries, or the purpose of what we are doing there is to suppress Muslims, and it is particularly ridiculous in the mouths of the self same people who are trying to kill innocent people in Iraq and Afghanistan and kill innocent people here. And the reason why the western world has not yet got this strategy right, and you could argue forever about this element or that element of problems in Iraq, the reason we haven’t got this right yet is we are buying into this sense of grievance which I say again to you is absurd in relation to those two countries where if the suicide bombers and the terrorists would only stop, they would be able to function as democratic countries building themselves from failed country status to something different and better. And you know if people are trying to stop us there, our response should be not to give up and walk away but to fight them.
Question:
Prime Minister, on the same issue, almost every Muslim I speak to, they wonder why the government is speaking to non-elected so-called representatives of the Muslim community, none of them has been elected. Yet when an elected Member of Parliament started a debate he is attacked by a small vocal minority there. On the issue also of the hijab…
Prime Minister:
Inaudible.
Question:
I mean Jack Straw when he started the debate, he has been attacked by Muslims and by a combination of the usual suspects, the Left and the Muslims. On the question of the veil, the girls are now insisting on wearing the veils, their mothers 20 years ago were happy to stick to the school uniform, it is actually the politicisation of radicalisation. What is wrong with enforcing a school uniform?
Prime Minister:
This is an impolite question to ask you, and you have asked many questions at these press conferences. You are from which newspaper?
Question:
Middle East News.
Prime Minister:
Yes, and are you Muslim or non-Muslim?
Question:
Well my religion is actually a personal matter.
Prime Minister:
It is a personal matter, that is absolutely right, but all I am saying to you is that actually this is why I say part of the debate is within Islam itself. And you know the fact of the matter, well I agree with you, why can’t an elected representative raise these issues? Part of the problem that we have in engaging with the Muslim community is that we talk about the Muslim community as if there is one Muslim community with one fixed view, and of course there isn’t, there are many different voices within the Muslim community.
Question:
But why is the government actually speaking to people who are non-elected, like the Muslim Council of Britain and various characters?
Prime Minister:
Yes, but if we didn’t speak to the Muslim Council of Britain we would get even more criticism I am sure. You know we have got to speak to everyone, but the point you are making is right, we can’t have this debate simply with the people who have one particular point of view, and actually what is necessary, and sorry I didn’t mean to be intrusive in the question that I am asking, but it is simply to make the point that there is a real debate going on within Islam as well, which you can see if you go out to the Gulf at the moment. You take Kuwait for example, which I think has just allowed women to vote but it has been a hugely controversial decision, but they are doing it. And that to me is what this is in part about is empowering the moderate mainstream Muslim community to stand up and take on the extremists.
Question:
Prime Minister, back to Iraq. Nothing really seems promising in Iraq. The Chief of Staff has called for a withdrawal soon, yesterday and today many statesmen by extreme elements in Iraq, including al Qaeda are announcing Islamic … similar to the Taleban rule in Afghanistan, no security at all, vote for federation, calls for Saddam Hussein to be released, so nothing really promising. Any change in plan? How do you see Iraq progressing in the future?
Prime Minister:
Well you have got first of all to ask yourself why is this being produced in Iraq, and it is not because of the people, the majority of people don’t want it. What is happening is that external influences, al Qaeda with the Sunni community, we know I think where the influence with the Shia community is coming from, so these external influences are linking up with internal minority extremists to try and produce civil war in the country. Our response has got to be to try and prevent them. But the reason it is tough, sometimes people say well it is tough in Iraq because there is this or that and the state of administration, it is tough in Iraq because they are fighting, you know it is tough in Afghanistan because the Taleban and al Qaeda want back in. You don’t defeat them by sending a message saying we are prepared to walk away. And that is why it is important, as I say of course we want to withdraw from Iraq when we can, but it has got to be done with the objective secured.
Question:
… like mistakes in rebuilding the army, or mistake in building the policy when you talk about training more than 200,000 soldiers or police and they can’t secure a single … in Baghdad. This is a big failure for the coalition, for whoever …
Prime Minister:
Yes, and I made some of these points myself in the past, but I would just point out two things. First of all when we initially removed Saddam there was an enormous strength of feeling about disbanding those institutions that had supported him; but secondly that is not the issue in Iraq at the moment, the issue is can these external forces linking up with internally based extremists tip the country into something obviously its people don’t want, otherwise 70% of them wouldn’t have come out and voted in the election - for a non-sectarian government incidentally.
Question:
Keith O’Brien, the head of the Catholic Church in Scotland at the weekend said he is now in favour of Scottish independence. Now we know you are a … of independence, but do you think that 6 months before an election in Scotland that is a very helpful contribution to make? Should the Catholic Church be getting into that sort of territory in Scotland?
Prime Minister:
I think he is perfectly entitled to his view, like anyone else. I wouldn’t have thought it was a matter of religious faith mind you, at least I hope not. But the reason why independence would be disastrous for Scotland is that it would wreck its economy, it would stop it functioning as part of the United Kingdom and it would be to take the country backwards. And I don’t think the Scottish people when they think …
Question:
… in favour of it then?
Prime Minister:
Hang on, I know I am being very easy in letting people come back with other questions, but I think we had better move on.
Question:
Prime Minister, do you think it is possible for a woman who wears the veil to make a full contribution in British society?
Prime Minister:
A woman who wears the veil to make a full contribution? You are not talking about education, you are talking in general? Well that is a very difficult question. It is a mark of separation and that is why it makes other people from outside of the community feel uncomfortable. Now no-one wants to say that people don’t have the right to do it, that is to take it too far, but I think we do need to as I was saying earlier to confront this issue about how we integrate people properly with our society. And all the evidence is that when people do integrate more they achieve more as well. There is a reason why minority communities that have integrated well then end up doing better, achieving more, attaining more. So look it is a very, very sensitive issue. All I am saying is we need to have this debate about integration. I am not saying anyone should be forced to do anything.
Question:
Inaudible.
Prime Minister:
Well I think that Jack raised this question that in certain circumstances it can make it very, very difficult, but I think it is part of a broader question. The veil itself is obviously something that has arisen because of the controversies of the past few weeks, but there is a broader question and that is the general question of how we make sure that the Muslim community integrates with British society in circumstances where the majority of the Muslim community do, and we should always emphasise this. There is a real danger, as someone was pointing out earlier, that we end up in circumstances where it looks as if we are saying that the whole Muslim community is in this position, they are not, but there is a minority that think that it is a problem.
Question:
Do you know how many people have died violent deaths in Iraq since coalition forces entered the country?
Prime Minister:
We simply know the figures that are put out by the Iraqi Ministry of Health and the Iraqi Body Count, and those figures are on the record and people can make their judgment about various figures that are given, but what is important to emphasise is that it is not British or American soldiers or the Coalition that is seeking to kill innocent people in Iraq, it is the same type of terrorists who in this country are trying to kill innocent people. And we have to stop them, we don’t have to concede to them, we have to stop them and we have to stop them preventing what the majority of Iraqis want, because 70% of them came out and voted for a non-sectarian government and a democracy, the same as they did in Afghanistan and we have to fight for their victory as moderate Muslims there because that in the end has a direct impact on the ability in this country and in other countries like us to withstand extremism here.
Question:
The latest escapees on control orders and the overcrowding in prisons, two of the latest problems to hit John Reid’s in-tray, he was brought in to sort out things in the Home Office but to many of our listeners things just seem to be getting worse.
Prime Minister:
Well let’s just make a point on control orders. We of course wanted far tougher laws against terrorism, We were prevented by opposition in parliament, and then by the courts in ensuring that that was done. Now of course we will do everything we can to make sure that control orders, that are not the same as house arrests, which we had tremendous difficulty with, which are not the same as detention which is what we originally wanted, of course they are not as effective. But I think people have got to be careful of forgetting completely the history of this. I wanted to make sure that the original anti-terrorist legislation was maintained in full. Control orders were never going to be as effective as detention, but of course we have got to make sure that if someone breaches their control order then they are properly sought after, and we will do that, and that is a job for the police. But the reason why it is difficult is that the legislation that we had in place, that we wanted to maintain, was then overturned. And some of the self-same people who are criticising us on control orders today were leading the charge against the legislation that would have allowed us to detain these people.
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