NHS 60

Fiona Godlee: Ladies and gentlemen, I’m Fiona Godlee, editor of the BMJ and delighted to welcome you to what I hope will be the first of many collaborations between the BMJ and the King’s Fund to cover issues of importance to the future of healthcare. We’re delighted to be here in the newly refurbished Royal Institution, which I gather Faraday himself has spoken in this very place. I’m also delighted to have four extremely distinguished speakers to educate, inform and entertain us this evening. I have to announce, though, that there has been a change in the line-up – rather unavoidable – Alan Milburn at the very last moment was required in the House of Commons to vote in the planning vote which takes place this evening, and so we were very, very pleased that his former special advisor, Paul Corrigan, agreed to step in at the last moment. Paul Corrigan has been special advisor not only to Alan Milburn, but to John Reid and to Tony Blair, and is currently Director of Strategy & Commissioning for London. Now just to add to the tension of the moment, Paul himself can’t join us until 7:00, so we’re absolutely on a knife-edge to make sure we’ve got people on both sides to debate this important motion.

The debate is being videoed and the video will appear on the King’s Fund website and BMJ.com, both live and on demand, so I’d be grateful if you could all just check that you’ve turned off your mobile phones. Now as well as your vote tonight, we’ll be announcing the result of the BMJ’s reader poll that has been running for the last week on BMJ.com, and in this gold envelope, which I will now – or in a moment – hand to John Humphrys, is the result of that poll, so we’ll be able to compare this audience’s vote with the very educated and inspiring group of BMJ readers.

Now our motion is: ‘the founding principles of the NHS, services funded by taxation and available to all regardless of ability to pay, are no longer relevant in 21st century Britain.’ And before I hand over to your fabulously distinguished chair for the evening, John Humphrys, I just want to read a few words from the front of the now yellowed and fragile pamphlet that launched the NHS 60 years ago. These words are, to my mind, brilliantly economical and evocative and written by some nameless civil servant, or perhaps by Nye Bevan himself. This is in your programme in case you want to read along.

“Your new National Health Service begins on 5th July. It will provide you with all medical, dental, and nursing care. Everyone – rich or poor, man, woman or child – can use it or any part of it. There are no charges, except for a few special items. There are no insurance qualifications. But it is not a charity. You are all paying for it, mainly as taxpayers, and it will relieve your money worries in time of illness."

Now in an hour or so’s time, you will decide whether we should think of these words as merely historical, of little relevance to the future of healthcare in the United Kingdom, or as an abiding statement of principle that should help to guide us in the years to come. And with that, ladies and gentlemen, I hand over to our chair, John Humphrys.

John Humphrys: Thank you very much.

[applause]

JH: The envelope, which I shall open later apparently – thank you for that. I don’t know about fabulously distinguished. What I mostly do is ask questions of politicians, whether that makes anybody distinguished. It doesn’t make you much the wiser, that’s for sure. Actually that’s not entirely fair. I do two programmes – on BBC One is the Today programme, one is Mastermind – and at least on one of them people do want to answer the questions. Enough of that.

60 years since the NHS was founded and by golly how politics has changed in that time. Imagine 60 years ago envisaging a “Labour” – I put the word in quotes – “Labour” party embracing PFI and private enterprise and all the rest of it, and a “Conservative” – I put the word in quotes again – party hugging hoodies and embracing polar bears and stuff. It’s all gone like that really, hasn’t it, over the last few years. However, there is one constant – I suppose one could say that it’s a constant – and that is that no politician still, after all that time, dares say ‘enough of the NHS, we have to find another way of doing it’. You may feel that yourselves. Obviously you may feel that yourselves. We shall find out whether you do or not during the course of this debate.

Let me just tell you first who we have on the panel. You already know the sad news about one of our guests, Alan Milburn, not being able to be here – one of our panellists. We do have Luke Johnson, who is the chairman of Channel 4 and studied medicine himself as a youngster. Didn’t go on to become a doctor. He founded Pizza Express instead, which was a far more profitable endeavour I gather. He is not impressed with Alan Sugar. I don’t know why I throw that in but it seemed a good idea. “The very idea that he is an entrepreneurial role model makes me feel sick,” I think is a fairly accurate quote, Luke. Yes? So there you are. That tells you something possibly admirable about Luke Johnson, possibly not. Karol Sikora – obviously admirable – one of the country’s foremost cancer doctors. Probably the best-known cancer doctor in the country, I would have thought. Certainly appears on the Today programme more than any other, for which we are duly grateful. Paul Corrigan you know about, because Fiona has just told you. Polly Toynbee, unless you have lived on Mars for the last 150 years, you will also know about. Actually – no, no I meant that was –

[laughter]

JH: Oh god, I’ve upset Polly. You do not want to upset Polly Toynbee, I can tell you that. If I were Richard Littlejohn, I’d – you know. What did he call you? ‘Pet’, didn’t he? Foolish man. Foolish man. Anyway, Polly is, well, there’s nothing I can tell you. But you may not know that she is officially, as it were, the country’s most influential columnist. You may not know that, but she was voted just the other day. I mean that’s a bit of a poisoned chalice in a way, isn’t it? But still a great honour.

So they are our speakers, and you know what we are going to be debating. You know the motion that we will be debating. Before we debate the motion, you will have noticed that you’ve got these things – yeah? – on your? – and you know how they work. You will know how they work because that shows you. The important bit about that is that you can change your mind during the course of the vote if you wish. So have a quick look at it to see if you can figure out how? It’s not difficult, I don’t think. Not like a brain surgery. Now I’m going to ask you to vote – not vote – I’m going to ask you to use this gadget so we can find out who you are, and here is what you going to tell us: what is your main relationship to the NHS? I notice there’s not a category there that is ‘hostile’, but whatever. One of those, you can press – I’ll let you read it for yourself rather than tell you because you can see it.

[music]

JH: Right, have you all managed to press a button? Did you? Yes? Good. So that’s who you are. Most of you are ‘independent providers’. Next, ‘patient public representatives’. A lot of ‘researchers and commentators’. A lot of ‘others’ around the place. And quite a few ‘clinicians’ and so on. So there we are. That’s who you are. Now let’s put up the motion. Don’t vote on it just for now. I just want to labour the point. Forgive me because you are all very intelligent people but there we are. I want to make the point that if you do not believe that the founding principles are relevant, well you can see what I’m getting at. It’s not confusing but it’s not as obvious as it might be. In other words, if you support the motion, you are saying that the founding principles of the NHS are no longer relevant. So I suppose you could say if you are ‘agin it’, you vote, erm, yes.

[laughter]

JH: You’ve got it. Thank you. Right. So let’s get an idea what you think now before we have the debate. Would you please vote now for or against the motion – preferably not a ‘don’t know’.

[music]

JH: Ah, all right. Well that’s – a bit early to applaud yet? We may turn it around completely during the course of the debate. Who knows? There are very few – gratifyingly – ‘don’t knows’. Gratifying in one sense. Well, hmm, they’re not exactly going to swing it, are they? But nonetheless, let’s see if those who support the motion are going to be able to swing it. And let us hear first – and they will have 10 minutes and no more – I shall stop them at 10 minutes. Let’s hear from Luke Johnson first. Luke? 10 minutes.

[applause]

Luke Johnson: The NHS is a politically controlled state monopoly that is inefficient, outdated and unsustainable. Almost £105 billion per year of taxpayer money is spent on funding this behemoth, yet we have some of the worst survival rates in Europe for cancer and strokes. Spending on the NHS under this government has more than doubled in less than seven years. Where on earth does all the money go? Are we twice as healthy as we were? Many of the staff who work in the system are wonderful, but intellectual dishonesty and sentimentality about the NHS mean it has not been reformed to deal with Britain’s healthcare needs of the 21st century.

Every working Briton on average contributes over £3500 per year to the NHS. Are we really getting value? The issues facing the NHS are considerable. It’s run by politicians who have limited experience of management of large organisations. The ministers at the top change with alarming frequency. Mr Milburn cares so little about the NHS he couldn’t even be bothered to turn up this evening. Their exclusive interest is re-election at any cost. They waste our money with extraordinary abandon. This government boast that they have been increasing spending of our cash by 7% per annum in real terms in recent years, as if this is somehow clever, difficult or morally a good thing. After all, any fool can spend money badly. What takes effort and expertise is to spend it wisely, and that has not been done.

They have used this current spending – which they fraudulently term ‘investment – from, among other things, some of the most incompetent pay negotiations in modern history. The elite – the doctors, consultants and managers – received such staggering pay rises that the doctors’ negotiators could not believe their luck. For example, GPs received a 63% increase in salary, while many were allowed to stop working out of surgery hours. Nowhere else in the entire world can such a lavish settlement have been agreed for such minimal productivity gains. This spending spree is wholly unsustainable, represents a tragic missed opportunity, and perhaps as much a £270 billion of taxpayers’ money wasted over the last 10 years.

Difficult issues face the NHS because so much has changed in the last 60 years. People have much better access to medical information. Everyone in society now sees themselves as a consumer. There’s been considerable innovation in drugs through medical technology. The population is both larger and getting older, and there have been substantially better survival rates at birth. There are far greater instances of chronic illnesses like cancer, stroke and dementia, and a sharp increase in obesity. These factors all mean the old model is broken and needs completely reinventing.

The NHS is riven with bureaucracy. The General Medical Council has a budget of £73 million, up by 300% under New Labour. The Health Protection Agency spends £252 million. Almost £750 million per year is spent on various quangos and bureaucrats. And for what? A paperwork nightmare of targets, demotivated staff, and jobs for ‘the boys’. In the last 10 years the number of NHS managers has doubled from 20,000 to 40,000 while the number of hospital beds has actually fallen from 250,000 to 180,000. The NHS now has fewer than five beds per manager. What on earth does this army of pen-pushers actually do? Presumably they help authorise the £600 million per year the NHS spends on consultants.

In 2002 the NHS national programme for IT was unveiled – the world’s largest and most exciting centrally directed IT project. It has inevitably turned into a complete catastrophe. At the last estimate, it is expected to cost at least £13 billion – many times the original plan. It will arrive six years late at least, and it will fail to do much of what was promised. It’s no surprise it was hardly mentioned in the last NHS annual report. No doubt the politicians and officials would rather the programme headed into obscurity, despite the criminal waste of our money and the nation’s resources.

Another semi-hidden nightmare created by the NHS is the contribution it makes towards the £1 trillion – that’s £1 trillion – public sector pension deficit. NHS workers are the largest component of this massive unfunded liability, and their growth in numbers and salary increases means the burden has grown dramatically in recent years. The taxpayer and the NHS simply do not get value for money from these off balance sheet undertakings, and they create profound inequality in pension provision between the private sector and state employees.

And one of the nastiest hidden commitments New Labour has taken on are PFI schemes. Admittedly the Tories invented them, but this government has carried them on. Traditionally the NHS owned its own land and buildings and paid no rents. Now many properties are leased and paying ever higher rents. As ever, the civil servants have been regularly outwitted in negotiations, and expensive long-term obligations have been entered into with huge fees, inflexible terms, high interest costs, and poor value for the taxpayer as ever. There are now £180 billion worth of PFI schemes, many of which will be burdens for the NHS for decades to come.

The NHS was not designed for the modern world and its attitudes – for example, the minefield of clinical negligence. This year the NHS is likely to have to pay out £750 billion to claimants total. The NHS litigation authority has put aside provision over £8 billion to cover all the claims in the system. This is cash still to be shelled out. In 1948, patients were grateful for limited treatment. Today, anyone who suffers problems is quick to sue, thanks to our culture of litigation and ambulance chasing lawyers.

Another example of growing problems: prescription drugs. Overall drug use has increased by 27% over the last 5 years alone. Last year GPs prescribed 918 million medicines. Doctors on average are now prescribing 81 prescriptions per year compared with 64 just five years ago. The total NHS drugs bill: £10 billion per year. Patients expect to leave with a pill. Inevitably the combination of fee-exempt patients and the NHS encourages massive over-prescribing. The NHS has always failed to extract the economies of scale it should have from the pharmaceutical companies. Too many patients do not value what the NHS provides because they see it as free and costing nothing. The NHS struggles itself to know what anything costs. In essence it is a giant spending machine, out of control. Patients waste its resource and fail to appreciate the quality of care and the ability of its staff because they see it as an absolute entitlement from birth, rather than a privilege delivered at vast cost. My wife worked as a pharmacist in the NHS for many years at places like Great Ormond Street Hospital and used to get profoundly frustrated at the waste by patients of expensive drugs, because everyone just sees the NHS as a bottomless pit.

In the coming few years a serious economic downturn will put massive pressures on the finances of citizens and the government as tax receipts fall. The near certain recession is likely to start in the next 12 months which, coming as Whitehall grapples with a huge budget deficit, will mean significant public spending cuts. This must hit the NHS since it has the largest budget of any department, yet our expectations for healthcare are greater than ever thanks to ill-judged political promises and advances in medical science. It is inevitable there will be disappointment. The NHS was designed for a different era, an age of deference when people had much shorter life expectancies and no one could learn about expensive treatments on the internet. Now people have a powerful sense of entitlement which the NHS can never possibly satisfy. It is doomed to disappoint much of the time.

Politicians of all parties lie to the public about healthcare and the NHS. It’s seen as sacrosanct – almost a religion. But we all know financial and personnel resources are finite and must be rationed, NHS or no NHS. The idea that we can all have all the health treatment we want at any time is a fantasy.

JH: A minute to go.

LJ: Even the BMA accept there is almost limitless potential for spending on patient demands thanks to things like unproved treatment and lifestyle support. Radical structural change to the NHS is vital. My colleague Dr Karol Sikora will talk about some of the changes we would suggest but I will give a few thoughts now. The inefficient, monopolistic structure must be scrapped. True competition must be brought in to improve standards just as it does in the private sector. There should be a move away from provider-dominated services to give patients more choice. Competition and choice will drive up quality and access just as they have in so many fields. Sensible incentives must be put in place to link performance and outcomes and prevention of waste. Overall there should be payment for results rather than a bias towards treatment built in as is currently the case. Overuse of expensive acute services should be prevented. Modern financial methods should be brought in to take proper control of budgets and spending. Ideally the closed-shop unions and professional bodies should be challenged, and more flexible working arrangements should be sought. Innovation as a way of life must be embraced, and the Whitehall command and control model should be dismantled and local decision-making encouraged where possible. More insurance, co-payment and proper pricing must be brought in, with the NHS as a safety net only. The search for value and realism, healthcare treatment in the UK will not be easy. It will take bold changes and brave decisions, but cost effectiveness must enter into the equation. Thank you very much.

JH: Just stay there for one second because I just want to ask you this. You say intellectual dishonesty. On the part of whom? Who is being intellectually dishonest?

LJ: The politicians.

JH: All right.

[applause]

JH: Polly Toynbee.

[applause]

Polly Toynbee: Well, let’s start at the beginning with some exceptionally wise and prescient words from Aneurin Bevan. He said, “We shall never have all we need. Expectations will always exceed capacity. The service must always be changing, growing and improving. It must always appear inadequate.” And he was right on every count. The pressures have never ceased and nothing will ever be enough. As a result there has been a major reform on average every five years – perpetual revolution. Each health minister takes out a clean sheet of paper proclaiming this great monolith has never been reformed since 1948 all over again. If I listed them I’d run out of time.

Why the constant reform? Because the NHS was born out of political ideals and so it will always be political to its core. And for that reason it is always under scrutiny and assault from the right – who itch to prove that it doesn’t work – just as in the USA socialised versus private medicine is at the heart of the current election campaign. So Mrs Thatcher ground her teeth when forced to promise that the NHS was safe in her hands. I think I could note how those on the right within Labour are also eager to use reforming the NHS with increasing private provision as an ideological tool for repositioning the party – and I think we’ve just heard a rather political explanation from the other side too. There is never going to be any divorcing of health from politics, and yet it isn’t a mere matter of conviction because the facts show that what is fairer also, on this occasion, happens to be cheaper.

Funding the NHS from taxation is more efficient than all other systems, with lower administrative costs than insurance-based systems, no cross-billing, no collecting from employers and employees. The accusation against a tax-funded NHS is that it’s not sustainable. Aging population, galloping technical advances, rising public expectations mean it can never keep up. But that too has been predicted absolutely from the beginning. Back in 1956, only eight years after its birth, the Conservative government set up a commission of inquiry into the costs of the NHS, expecting to prove that it was doomed for all of those very same reasons. But instead the Guillebaud report found that since the NHS’s launch in that eight years, health costs overall took up a lesser – not a greater – share of GDP. It wasn’t breaking the bank. The new universal service had actually reduced health costs.

Looking abroad where there is more private spending, in those countries that do have more private spending, costs tend to rise. Today’s IPPR report – very interesting, look at it on the internet – chronicles this with great care. Dutch and German experiments in making the rich pay for their own insurance resulted in increased overall costs both in the public and in the private sectors, and worse equity. France recently increased its tax funding as private funding for consultations caused costs to rise. Famously the US spends far more for far less overall healthcare. In the UK, areas with the highest levels of private insurance don’t result in lower NHS costs. Countries that have the highest private health insurance tend also to find their public sector health costing more too. In Australia, where they’ve raised the subsidy for people taking out private insurance quite substantially, it costs the state a fortune for no health benefit. In health, prices respond to the amount of money available, and costs rise. Private insurance systems are consistently less effective than the state at controlling those prices.

So how good is the NHS? Traditionally it has always been under-funded and it fell behind other countries, but it’s catching up. What caused most discontent traditionally from the beginning – and what was used by American doctors in their last campaign against socialised medicine – was the NHS waiting lists. We were famous for them – some of them over two years long and more. Latest figures show not only the long waits gone but more important, average waits are now down to four weeks. As Nicholas Timmins pointed out in the Financial Times, the biggest drop came in the last two years, suggesting – contrary to what Luke Johnson said – the doubling of the NHS budget in real terms is having a real impact. Meanwhile 90% of patients rate their hospital treatment as good or better and they love their GPs – who are, of course, private businesses.

Spending has risen as a proportion of GDP – up by 2005 nearly to the OECD average of 9%. Is that a problem? Not according to McKinsey’s, who point out that the richer any country gets, the bigger the share of its income it chooses to spend on health, public or private. Health is a discretionary good. As people get richer they want to spend more of the nation’s income on it. And why not? Spending it together as taxpayers is cheaper.

The charge is that we haven’t had value for money, but that’s really not the evidence. If you look at the figures for mortality amenable to healthcare, the crucial measure of avoidable deaths, latest figures – which only alas cover 1998 – 2003, so they cover only short part of Labour’s great spending boom – but even so the results show a 21% improvement during those years. That’s a much faster rate of progress in the same time than France and Germany who were around about 13%, or the US – with all that private insurance – had only 4%. So there is every reason to think that the next figures will show an even bigger leap forward as they reach to cover the time when spending really was expanding fast.

Our bad record on five-year survival for cancer – often used to show that the NHS doesn’t work – but 2005 figures relate back of course to patients who diagnosed by definition in the year 2000 before the big spend. So it doesn’t pick up any of the government’s cancer plan. There is no data yet to say how effective Labour’s cancer spending has been and we shall see in due course. Our one-year survival rates of cancer are bad, but that’s not really an NHS failure because the reason is cultural and social failure. People just don’t go to doctors soon enough in Britain, whereas they do abroad – which is another social symptom of Britain’s greater inequality than most other western democracies, and that’s hardly the fault of the way we fund our health system.

Another point in future is that we’re going to need more collective funding and not less. Once genetic testing can predict which patients are high risk and which are low risk, private insurance will become impossible. Only the pooling of the risk collectively can really ensure that a universal system survives that. There’s a pretty shaky line between private and public in the NHS. Dentistry, specs, prescriptions – things we pay for. Increasing use of private providers. I think that line will always be – there will always be a sort of grey area there. But there has been no boom in people rushing to pay for private health even in the last decade. Not any kind of boom that even begins to match the increase in disposable income for the top half of the population. You would have expected if there was a great demand for it that people would have rushed for it and they haven’t. There’s been a lowering of the numbers of people actually paying in cash for their operations.

People are pretty happy with the NHS. There is pressure to allow top-ups – drugs for hips or lenses – and we wait to see what Mike Richard’s review has to say about that. And there will always be a very tricky divide between what should be public and what should be private. But that’s often used by many – by Karol Sikora and by doctors for reform and of course by the private sector and by the drugs companies – to try to lever open the whole of the NHS settlement. There is constant pressure from those who want to make large sums out of the NHS, aided often by the gullibility or the ideology of some politicians.

JH: One minute.

PT: But that is, I would say, no argument for withdrawing from a universal tax-funded NHS. The truth is there is more politics and ideology than common sense in the arguments from those who seek to end tax-funding of the NHS. We shall spend in future as much as we can afford, and as much as the voters demand. And they will never be satisfied – exactly as Bevan predicted. They’ll always grumble and moan. There will always be egregious cases of terrible treatments to splash across the front pages of newspapers. There will always be political and commercial predators seeking to prove that it doesn’t work. They were there from day one. They are there still. But it does. The truth is, at 60 with money in the bank, now is the golden age of the NHS. It’s not a good time for our enemies. Not just now. And long may it last. Thank you.

[applause]

JH: Polly – just a quick one. You don’t like private insurance. Do you like private finance?

PT: Well I think it depends very much what it’s for, what the contract says. The trouble is the devil is always in the detail and sometimes the contracts have been drawn very badly, particularly the early ones. I don’t see any reason in principle for being against it. It’s all about what works and what gets best value.

JH: And has it worked?

PT: Sometimes it has and sometimes it’s been incredibly expensive and left us with great big bills.

JH: Mostly?

PT: I wouldn’t be able to quantify it, but I certainly have doubts about a lot of the contracts that have been signed.

JH: Thank you. And now would you welcome please Karol Sikora who is speaking for the motion.

[applause]

Karol Sikora: Good evening. I qualified and worked for the NHS 36 years ago. The first day I went on the Middlesex Hospital wards, two nice things happened. First of all, I liked being a doctor, and secondly, I met my wife to whom I have been married to for 34 years, sitting at the back up there, arriving late as always. I don’t know how many of you have seen The Perfect Storm. It’s a great film – George Clooney as a fisherman. That’s what’s happening in healthcare. It’s nothing to do with the NHS. It’s nothing to do with Britain. It’s happening in every healthcare community, rich and poor. Ageing populations, new technology which can actually work in old people safely. When I first started in oncology, the cut-off point for a bone marrow transplant was 50 because people fell apart after 50. Now there is no age limit. Technology works in old people. So ageing populations and technology – which is expensive – with a third thing, which we have already heard about, information. The internet – the driving force – the consumerism, the fact that my kids can order an air ticket on their mobile phones. They can order all sorts of things. Even a pizza can be delivered, as Luke well knows. So society has changed. Society has moved on. Who could conceive that two of your speakers today could walk, 60 years ago, into the Royal Institution without wearing a tie? This just wouldn’t have happened.

[laughter]

KS: So as Luke says, tax systems, I fear, are always going to be doomed. Politicians are always going to lie. They always have to lie. They want to convince as many people as possible to vote for them. That is their real job – not to run healthcare, not to run transport or hospitals or schools. Only tax systems will inevitably, in the ageing population of consumers – like me with my bus pass last week – these people are going to consume, because they’re going to pay less tax after retirement, they’re going to consume money paid by younger taxpayers. There is a limit to which younger taxpayers are going to subsidise the new gerontocracy – the demanding gerontocracy. The equation just doesn’t stack up. It’s nothing to do with left or right or politics. The equation just can’t stack up. It is essentially fundamentally flawed. It is completely doomed.

If we look at the future of medicine, what have we got? Technology – fantastic. A gene chip – Polly has mentioned gene chips. Genomic screening is the future. Alan Milburn would have said the same thing tonight. He’s a passionate believer in that. Technology in all branches of medicine – magic surgery, keyhole surgery, robotics – better than a drunken neurosurgeon I can tell you – and all sorts of other bits. Society has moved on, not just the tie – all sorts of things. Feminisation of the professions. The matriarch of the Victorian era has gone. When someone gets ill in the family, there isn’t someone there to look after them, whether they’re older or younger. That person is at work now. Mothers are at work. So the NHS and society as a whole have to find a system to help there. Society has changed dramatically and the changes we’re trying to go to are not ones with the NHS – they’re not ones that work anymore from where they came from – from a hierarchical structured, very deferential society as Luke mentioned.

The third box of the future is how we deliver care. Now the row my old colleague Ara Darzi is going to get himself into on Monday is going to be quite substantial. He’s managed to piss off nearly everybody. And it’s not his fault. He’s an awfully nice guy and very convincing when you talk with him, but the polyclinic concept has just annoyed so many people. The minister – not Ara – the senior, the secretary of state has been rude to the BMA in a most obnoxious way and this isn’t the way to get things done. The concept is fantastic. Why shouldn’t GPs put together diagnostic centres and actually do things there? That’s what I want. I can’t even phone my GP, Polly. You try phoning. If I phone my wife at a GP’s surgery, I can’t get through to her for god’s sake, unless it’s at 9:00 and I want to get a booking for 48 hours’ time. It’s just an amazing system. So delivery of care is going to change.

And then the last bit is paying for care. And I think the 20% that voted the tax system is essentially not the way forward are quite right. It just can’t do it for the reasons I’ve outlined. Now let me just explain one thing. You want a cup of coffee. You’re sitting in Albemarle Street: 20 places within 100 yards where you can get a cup of coffee. How are you going to choose which one to go to? Well, you’ll do a value proposition. Public sector can’t do this. The value equals access plus quality divided by cost. Let’s look at that in a cup of coffee. If there is a queue going right around the corner and the coffee is 20p, you still don’t bother. You go somewhere else. If the coffee tastes like urine and it’s still 20p, you don’t go back to that place. If the coffee costs £10 – the cost is ludicrous – you don’t go there. So all the time in the real world you, as consumers, whether it’s a fridge or car insurance – maybe not the BBC TV license; you have no choice there – but what you do is you make that value equation subconsciously. In a publicly funded, publicly delivered system – and I was clinical service director for West London Cancer for 12 years – there was no need to have any value coming out. Why bother? It’s hard work. People are working late at night. There is no incentive to squeeze value out of it. In Luke’s background, totally different. Fast moving consumer pizzas – ultimate consumer good. Everyone knows the value equation there. So it’s just not going to work the way we’ve got it, plus with the problem of political football.

I know Tony Delamothe is in the audience. I can’t see him. He’s written an excellent series that has been running in the BMJ that I have been glued to because of this debate. And on Saturday he wrote about the founding values. A lot of misunderstanding about the founding values. He says there are three. Universality – fantastic, we have that. Equity – we certainly don’t have that. There are people going to the high court next week for judgements to overturn appeals to the PCT about cancer drugs. Some will get them. Some won’t. This is not equity. And when you look at who these people are, they’re white, middle class, educated folk. They represent not the average NHS patient, and certainly not those disadvantaged. The third of the founding values is quality, and you know the quality in the NHS is so variable. You can get the best cancer treatment in the world in many parts of England and the rest of the country. You can also get some of the worst cancer treatment. One is ashamed to see some of the second opinions that I get to do – people who have been written off without properly being diagnosed. The problem we’ve got is at a time of change, the transactional model of taxpayer and then end user getting it free is just not going to work. Before the NHS there was a sort of religious feel to healthcare. It’s no wonder – St Mary’s, St Thomas’, St Bartholomew’s – religious institutions in a sense. Bartholomew’s certainly was. It was founded by a monk, Rahere, just outside the city walls. So the religious moved on with the NHS to the military. At the end of the war superintendent radiographers, lady almoners marched up and down. The nurses wore fantastic uniforms. Even my wife remembers as you progressed up the nursing hierarchy you got a different coloured belt. Different epaulettes were worn. Very militaristic. Then it moved into a sort of Stalinist era propaganda machine. That’s what we’ve been living through for the last five years. Where we’ve got to get it to, we’ve got to get some of Luke’s entrepreneurial skills into it to get it into the new era of a much more businesslike structure, getting the value out of the system.

So the solution is getting a core package funded by the taxpayer so no one falls below a line. And these are the words used by Bevan: “no one will fall below the line.” And then we allow people to pay in different ways, including charitable voluntary sector payers, different forms of insurance – mycancerdrugs.org, for example, for an innovative insurance company – and we use combinations. That’s the only way we can get more money. Otherwise it’s going to consume all our tax. And the other important thing that’s not really been debated much is the way we use the insurance function. 149 PCTs – all different, all fairly low level of people below the very senior managers trying to make difficult ethical decisions without really the support they need. This is no good. This is bound to rise in inequity. What we need is to essentially allow them to compete. I live out in Buckinghamshire with South Bucks. Maybe I could get the Westminster PCT to support me instead. Maybe it’s better. They don’t tell me what they cover. They don’t tell me if they’ll cover cancer drugs. Some will. Some won’t. This is a complete nonsense. We’ve got to get to the healthcare plateau. We’re not there yet in this country. We’re just below the plateau and we’re wasting money on inefficiency, as Luke has said.

Now I have tremendous respect for the next speaker. Paul, I remember meeting you in Number 10 for breakfast about a year ago and you told me that co-pay wasn’t coming, top-up isn’t coming. So last week this seems to be proven wrong. Society is moving faster than you can predict. Polly, you wrote a particularly vitriolic piece on Friday in The Guardian about co-pay for cancer drugs, blaming everybody. The only guy who came out well from that was the chairman of NICE. The problem with it, though, is that you had 276 hits on your comments, only three of which were positive. The rest said no, you’re wrong.

JH: You’re out of time.

KS: Thank you very much.

[applause]

JH: You appeared not to deal with what was, I suppose in a sense, Polly’s fundamental point – she’ll correct me I’m sure if I’m wrong – which is that funding the NHS is cheaper than any existing social insurance scheme anywhere else in the world. It is cheaper to do it that way.

KS: It is cheaper, but you waste so much money that what you could get out of it if – the efficiency savings – if you had competitive systems, choice, and payment by result would overwhelm what you lose by having to have accounting systems, because you don’t know the value. I’ve gone through life at Hammersmith not knowing where the money was going. I genuinely didn’t know where the money was going and there was no way of finding out where it was going. That can’t be the way forward. It’s got to have a more businesslike structure.

JH: All right. Thank you for that. And finally, for this bit of the debate at any rate, I’m delighted to see that he has arrived. Excellent. Welcome Paul Corrigan.

[applause]

Paul Corrigan: Thank you very much and since Karol has just got his first bus pass and so have I, the notion of retiring at 60 is absurd, Karol, and so we’re not going to do it. We’re both going to renew. Yes, well done. Even those older than 60, John.

JH: Thank you.

PC: Under those circumstances, really what I want to talk about today is something absurd in the motion, that just because something is 60 years old it somehow lacks modernity and that in fact what we have to count as modern is in some way to do with the cash nexus, and what we count as old-fashioned is in some way to do with gift and in some way to do with reciprocity. And the notion that these are in fact old-fashioned values is absurd. They are a major part of the modern world, a major part of the way in which we live our lives. And what we have to do – and this is in fact what we’ve been asked to do by the proposers of the motion – is to renew those values in the nature of a modern world. Not to throw them out, but to renew them. And so modernity does not exclude the values that the National Health Service was framed upon. It does not exclude the fact that when someone puts their hand in their pocket and pays some taxes that they see that as part of what Titmuss called a gift relationship. That is a real experience that millions of people have about that reciprocity, and we will not lose that in this country.

In fact, what we need to do, as I’ve suggested, is renew it. People have often referred to the old NHS as a command and control organisation. It wasn’t. It was a command organisation with very little control. There was a great deal of shouting and very little activity that went on underneath that shouting. And what we have set about doing – this is why Polly and I opposing this motion make such an interesting couple, because Polly can talk about, as I’ve been talking about, the enduring principles of the NHS, and I can talk about the renewal bit. And the renewal bit – it’s quite interesting listening to the proposers of the motion arguing for choice. That’s a good idea. That’s probably why we started that in 2002. It’s such a good idea that if you look at the documents that were sent out with the motion, you’ll find a leaflet put out in 1948 when I was four months old, through my front door. And the leaflet said, when you turn on the front page, the thing it said about the NHS is ‘first choose your doctor’. Now that is such a good idea, 60 years on we thought we might start doing it. And it’s such a good idea that the proposer of the motion suggests actually quite clearly that what we should do is stop the monopoly of organisations like the BMA and the second of the motion says it’s a very bad thing to upset the BMA. We’ve decided, in constructing polyclinics, to go for the former. And when you hear the BMA last week or 10 days ago – it may have been on the Today programme – actually saying that if you open a polyclinic next to an existing GP clinic, the public will choose to go to the polyclinic. Yes, they’re probably right. And that is because we thought, 60 years in, we might renew the NHS by applying the principle of choice. That’s what the proposers wanted. That’s what we’re doing. We’re doing it in secondary care. We’re doing it in primary care. We’re doing it in health promotion. That’s the nature of the new NHS where the public play an active role in creating that organisation through their choices.

They suggested that it would be a good idea – you can close your ears now, Polly – it would be a good idea to introduce competition. That’s what we’ve done, and actually what we’ve done is create some of the best public sector institutions in the world – called foundation trusts – to lead that competition. And quite rightly Karol said in his hospital, over all these years, he’s not known the price of things. If you go to University College Hospital now, they know the price of things. They know how to drive down cost. They’ve increased business by 14% in the last year. And you go to Guy’s and St Thomas’, you go to Homerton and you see institutions that are themselves now becoming leading institutions in European and in world healthcare. And that’s because we’ve got some competition. We agree that’s a good idea. That’s why we’re doing it.

It’s a good idea to give people information. That’s a good idea. That’s probably why we created one of the best websites for health services this time last year. 2 million hits every month. Should be nearer 10 million in no time at all. What we put on that website is a set of information that doctors said 10 years ago we never get, which is standard mortality rates and they’re now on the website. NHS has done that. You try and get that information in other countries and you can’t get it. We put that information in the website. The doctors didn’t want us to. The National Health Service has done that. Information has to be there for everybody and it has to be there in forms that people want. The website PatientConcern set up by GPs in Sheffield has got a whole range of anecdotes because that’s how people understand the world, not necessarily through our numbers. And people put in their anecdotes and they look at what’s happening in those hospitals and they make sense of the choices they want to make. That’s been done in the NHS.

Lastly, some words about Ara Darzi. Ara Darzi has upset people. That really upsets him, I’m sure. Ara Darzi has got a very clear vision of where the renewal of the NHS will be going. It will contain much more emphasis upon equity as an outcome from those founding principles than we’ve had before. And that’s because that’s how you renew a service that’s based upon equitable principles, by renewing that equity, not by running away from it and pretending the sort of society we want is where coffee is treated as if it’s health, and health is treated as if it’s coffee. They are not the same thing. They are very different commodities with very different meanings.

The ‘perfect storm’ that is hitting all the health services apparently is caused by two sorts of things. First of all, it’s caused by Karol and I getting old. The ageing population, I’ve come to realise, is me. And I’m going to bring down the NHS because I’ve decided not to die. That’s not the case. The ageing population of my generation and Karol’s generation, because of the National Health Service we have the opportunity to buck that trend because we have the opportunity to be an active ageing population and not a passive ageing population. And because we are active we’ll be actively involved in our own health and we’ll be actively involved in recognising, because of the reciprocity of the health service, we will have a role to play in making sure that service is there in 60 years time as well as for ourselves. So the ageing population doesn’t necessarily have to be something that causes a failure of the NHS.

Neither does new technology. The interesting thing about health services across the world – not just the NHS – is that health services apparently go bankrupt because of new technology. Every other industry does well because of new technology and health services go bankrupt because of new technology. If you look at hospitals across the world, you’ll see in almost every hospital a sort of archaeology of technologies from something very modern to something very old-fashioned. And that’s because in hospitals across the world there hasn’t been a competitive organisation to drive those hospitals into modernity, into newness. I think with foundation trusts, with payment by results and with competition, we’re starting to get this. And that’s how we’re going to squeeze enough value out of the taxation to make this happen.

Just to finish, on the issue of what created the National Health Service, what created the National Health Service was a political compact. It was a political compact between the people in government and the people themselves. It was, as my old boss John Reid used to say, the best gift the British people have ever given to themselves. And under those circumstances they’ve gone on enjoying that gift, and if you look at the love relationship that about 80% of the population have with the NHS, that is stronger now than it was 10 years ago. They’re bucking – the people are bucking the modernity trend. They’re bucking the belief that in some way modernity loses that reciprocity and they recognise that actually that’s one of the ways forward. There is 20% of the population – and many of them are in the media – who hate the NHS. They are enraged every day by the fact that we have been so bad as to give each other this gift for all this period of time and to enjoy it and to want it to go on. And the 80% will beat the 20% for the next 60 years as well. Thank you.

[applause]

JH: I know I’m an impartial chairman but if you could tell me later privately how to buck the trend of death I’d be very grateful. Intriguing notion. Competition, right? Competition means that if one party to the competition succeeds, the other fails. That’s how it works. It can only work that way. It’s pretty difficult to find the minister or the politician who will tell you that that hospital is going to close because the other hospital is better.

PC: Interestingly enough, in the West Midlands three years ago a successful hospital took over a failing hospital. Heart of England took over Good Hope Hospital and they’re now part of a larger successful organisation. Now it seems to me that is one way in which the good can take over the bad, rather than simply saying – which I think you can’t say about hospitals – we will let that one collapse and dribble away and die. So a mergers and acquisitions policy, where the good take over the bad, can actually deal with the success and failure you talk about.

JH: So it’s only a kind of competition.

PC: No, it’s competition. It’s competition where, in fact, the good do better and the worst need to catch up. Mergers and acquisitions isn’t a public sector issue. It’s a private sector issue. It happens all over the world and we are just applying that to public sector.

JH: All right. Thank you very much. Now it’s your turn, ladies and gentlemen. We’ve got a quarter of an hour for you to pitch in, and with a bit of luck we won’t hear from the speakers for the next part. We’ll hear from you. We already know what your broad view is. Maybe we should find somebody who supports the motion first to give us their reasons why they support it. Down to you. Look at all those hands shooting up. There’s always this moment, isn’t there? There we go. Yes, sir? And we’ve got microphones that are going to appear over your heads. There we are. If you could identify yourselves, obviously that would help.

Adrian Bull: Thank you, John, yes. Adrian Bull from Humana. We’ve had some very interesting speeches but we seem to have ignored some of the essences of the motion, which are funded only by taxation, available by all. Well, it seems that we abandoned that principle a long time ago. The NHS, or our healthcare, is not funded only by taxation. We pay for a variety of goods. We’ll continue to do so. There is an unfunded problem looming and we will have to address it. Now whether taxation will continue to be a part of funding is a different question and it’s the one Paul seems to be pursuing, but we will have to find a mechanism which supplements that and which addresses the generation gap that Karol was talking about. So I don’t see how the motion can stand at all.

JH: But those things that we have to pay for are relatively few you would say, wouldn’t you?

AB: Are you being relative about the motion or absolute about it? ‘Services funded only by taxation, available to all, regardless of ability to pay’. Services are not funded only by taxation. That’s a simple fact of the matter, and nor can they be.

JH: All right. Respond to that, somebody?

Wendy Savage: I’m Wendy Savage and I’m the chair of Keep Our NHS Public. The problem with debates is it’s an artificial construct, but the basic principle of funding the NHS by taxation I think is right, and I think Polly made that absolutely clear that this is the cheapest way to do it. I absolutely agree with Luke that there is a lot of inefficiency in the way this government has used the extra money. The IT programme is a scandal. The whole way that private consultants they have used, management consultants have been used, the PFI problem – all of that is wrong. But that has got nothing to do with the basic principle of the NHS, which is that it’s funded by taxation. We pool all the risk and the values of equity and fairness – all right, the NHS hasn’t always lived up to them, but I think it is a basic principle. And the universal nature of the NHS is something that the British people accept, love and will fight to the death to keep it going in the next 60 years.

JH: But if you enunciate a principle and over the years it becomes clear that it can’t be executed to the satisfaction of everybody, then surely you’ve got to rethink the principle.

WS: Well of course Bevan resigned, didn’t he, when they introduced the charges for drugs. A lot of people don’t pay. If you are over 60 you don’t pay for your NHS prescriptions. But I think that the idea in 1952, or whenever it was when they brought this in, was this would reduce demand. But one other thing I’d just like to say is that health is not a commodity. Health is not an industry. And the whole idea of treating our citizens as consumers will drive up demand but it won’t produce better outcomes in terms of health, as is quite clear from the United States’ experience.

JH: Thank you. Yes?

Shirley Murgraff: Shirley Murgraff. I’m a member of Keep Our NHS Public and have long time been an activist in the health field, community health councils, PPI forums, and currently attempting to do something about LINks with great difficulty. Mr Johnson made one of the best cases against privatisation I’ve heard. So thank you very much, Mr Johnson, for that. Mr Sikora talks about NHS information that he won’t be told and can’t get. Is he telling us that he doesn’t know that getting information about private sector providers is going to get increasingly difficult? And I’ve read only today that, in fact, even information about LINks and answering queries from LINks is going to get increasingly difficult and that is being specifically supported by one of the health ministers – Ann Keen. I’ve got the quotation somewhere.

There is also the question of money and no incentive in the NHS, Mr Sikora tells us, to get the best value for money. Let me give you an example of best value for money. Two hospital institutions in Scotland – the figures show that shareholders will reap dividends of £168 million on an equity stake of £500,000 for the infirmary and £89 million on an equity stake of £100. You call that value for money? These are figures from Alison Pollock who, I suggest, is one of the best-informed people in the country on the NHS and economics and almost certainly knows more than the whole of this room put together about how it works.

And the question of choice – my last point, Mr Humphrys, thank you very much – I’m a lot older than virtually anybody that I’ve seen in this room, certainly a lot older than the speakers. I have always chosen my doctor, thank you very much, and I have always chosen my hospital. And let me tell whoever mentioned the Homerton Hospital, I’m afraid I have a lot of experience at the Homerton over the last year and in my opinion, and I’m attempting to prove some of it, the Homerton Hospital is ticking boxes it is not entitled to tick. This is not an attack on the NHS, ok? It’s a question of how foundation trusts are working. They are extremely averse to criticism of any kind, as I have found very specifically, and there are a lot of things they don’t want to tell us or PPI forums, and they certainly won’t be telling the new LINks. This is a downward path and we have to stop it now.

[applause]

JH: At the very back there, yes? Sorry, over there and then we’ll go – yes, indeed.

Pam Garside: Pam Garside from Cambridge University among other places. I’m having a problem with the motion. I voted against it and Paul has tipped me towards keeping my position while I’ve got mates on the other side. But I worked in the US for 10 years and I absolutely am passionate that this has to be available to everybody regardless of ability to pay, but I don’t see how we’re going to be able to pay for all of this out of taxation. So I’ve got fence marks on my posterior. I just wondered if anyone else was sharing my position. Thank you.

JH: I think the lady next to you wants to tell you the answer to that. The gentleman.

PG: Gentleman!

JH: It’s the lighting. Forgive me.

PG: It’s your age.

JH: Yes.

Satya Rani: John I have done very well in foxing you.

[laughter]

SR: I’m in disguise. I’m Satya Rani. I’m a clinician and a member of the General Medical Council. I do have a question to Luke. I think he probably made an error when he presented his case, but I’ll come back to that. On the main theme of the debate, I wasn’t sure which way to vote, basically, because I think the debate is taking place somewhat late – about 10 years late. About 10 years ago when Alan Milburn introduced his ‘third way’, which he imported from the likes of Clinton, the NHS was being buried. So the question should be, is it time to resurrect it or bury it forever? Thank you.

JH: And your answer to that question is?

SR: You can keep the NHS alive in the way that we understood it to be the case, provided you introduce the element of efficiency. I think it was Professor Karol who said that he didn’t know the maths of running the hospital. I think even today figures are being cooked up. We don’t know the real story. If we can get to the bottom of the maths then we can run, subject to people running it efficiently.

JH: All right. Here. Yes?

Angela Greatley: Treatment will be required. Hello, I’m Angela Greatley. I’m chief executive of the Sainsbury Centre for Mental Health. What I think is very interesting about the debate tonight is that people have become engaged in talking about current failures. Now if we’d gone back over the 60 years, we could have picked up at any time debates about what’s working now, what’s not working now. What this motion is about is about the principle that we pay by taxation, that we have an equitable system, and that we don’t seek to move to an insurance system. Now let’s not get caught up in whether a particular hospital works well, whether a particular bit of system – I think where Paul is right, modernity will always require that we address the way we organise these resources differently from time to time. And by the way, how lovely to hear the gift relationship again. I haven’t heard it mentioned for years. Wonderful piece of thinking. It seems to me that we have to, when we think about voting for the motion, stick to that basic principle. It’s cheaper. It’s more efficient. It’s available to anyone. And a final point from me. Maybe we’re facing a ‘perfect storm’. But as somebody who wants to be able to survive that, I do not think we organise the arrangements for dealing with this storm by making sure that only the people that can buy a place in the lifeboat are going to survive.

[applause]

JH: Yes.

Colin Low: Colin Low. I’m chairman of RNIB and a member of the House of Lords.

JH: You did say RNIB.

CL: I did.

JH: You’re very well equipped to deal with that last point, aren’t you?

CL: Well I wasn’t going to deal with the last point. What I was going to say was that I thought Wendy Savage earlier on had a very good point, and the proposers of the motion this evening have got a job on their hands, because it’s not enough for them to show that the health service is inefficient. They have to show that the inefficiencies are inherent in a publicly funded system, and they haven’t done anything to show that. The more inefficient they show it to be, the more resources there are to gather in to help us fund it going forward.

JH: We know that there are people here who voted for this motion, and it would be quite nice to hear from them. Yes, are you one of them?

Charlie McEwan: Charlie McEwan from WPA. We’re a health insurer based at –

JH: Indeed, so you are –?

CE: Maybe I was hearing things, but listening to Mr Corrigan I felt that he was in favour of supporting the motion. He talked about renewing, redesigning the NHS. Well that is actually what’s going to happen as it evolves. We’re not going to keep the same NHS. An NHS funded by taxation – well, it hasn’t been funded solely by taxation since 1951 so we’ve got to stop kidding ourselves. Our health leaders are suffering from an acute [inaudible] of making it up as they go along. Let’s be honest and let’s just evolve the NHS so it’s fit for another 60 years.

JH: And you say we’ve been paying bits of it over the years, which is true. Everybody has acknowledged that. Relative to the total cost it has been fairly modest, hasn’t it? What’s the right kind of balance?

CE: Yes, but to kid ourselves that it’s funded by taxation – it’s not. People are contributing to it. There is a huge amount of inequity in the system. Whether we believe what we see in the headlines about cancer, there are people crying out to contribute. There are others paying for their dentistry, paying for prescriptions. So let’s just evolve it. The NHS is fantastic. It’s an amazing institution which we are all wed to for various reasons. But let’s evolve it so that it’s fit for another 60 years. Let’s admit that it’s not just funded by taxation, rather than being wed to this political dogma.

JH: What do you say to the two-tier argument?

CE: It’s already multi-tiered.

JH: All right. Neil? Neil Dixon, in the front here. Just on this, which is obviously a fairly crucial point, to what extent do we now pay for what we loosely call the NHS?

Neil Dixon: I think that most people would acknowledge –

JH: Sorry, Neil Dixon – oh, you know him.

ND: I think most people would acknowledge that the health service, as has been pointed out, the basic – the absolutist position of the founding principles was undermined essentially from day one. But that doesn’t mean that you can’t describe the NHS today as being broadly a tax-funded system, because that’s what it is. Although there are areas like dentistry, which increasingly almost don’t even deserve the letters NHS beside them because it’s basically a co-payment system. But the fundamentals – the big areas of the NHS – still are tax-funded so I think it’s perfectly legitimate for one side to say – to be very even-handed about it – for one side to say well, of course the founding principles aren’t absolute. But I think it’s equally fair for the other side to say that the system still is fundamentally tax-funded, and there would be a real step if you went and said, well, we no longer accept the notion that healthcare is very broadly about your need and not your ability to pay. That would be a very fundamental shift. It’s not necessarily what the other side there are saying. They might say that there is another means of getting there. But the NHS, yes it is tax-funded and yes, broadly speaking, it is about your need and not your ability to pay that dictates the millions of treatments that have happened today and will happen tomorrow.

JH: All right. Let us move now to the final stage of the debate: the final arguments from the opposing sides. This time they get 10 minutes. They have to divide it up between them but they get a maximum of 10. They can have five minutes each if that is what they wish, or however they want to do it, and we’ll start with Paul and Polly. Polly first?

PT: I just wanted to say, for those of you like Pam Garside, she said you’re still very worried that we can’t afford it, the question is, well, what is the alternative? What are you trying to say? You didn’t say how we would set about it? We just could have less health care? Nobody here has actually said what would make it cheaper to provide, other than a tax-funded system. And that’s really what this debate is about. It’s about how we fund it. And all the evidence that we produced – I won’t go over it again – was about wherever you are in the world, the tax-funded system turns out to be the most economic as well. If you don’t want the state to pay, if you think it’s all too expensive, it’s going to take up too much of taxpayers’ money, then it must be because you want to deny healthcare to somebody or another, or squeeze it in some way. Are you going to deny it to everybody? Or just those people who can’t afford private insurance? That’s the choice that you have to make here. What does it mean to say the state can no longer pay? That’s the natural conclusion.

As for waste, I’ve seen quite a bit of the US healthcare, as I think a number of you have here too. It is a vastly wasteful system. It is hugely extravagant and fantastically expensive. And although insurers like you try very, very hard to screw down the providers – the brown books say exactly what you can have for each condition when it is diagnosed, which often leads to great injustices as well – there is enormous over-treatment, fantastic numbers of diagnostic tests nobody needs, a huge amount of needless treatment of one kind or another for those people who are insured – if they are insured to the right level of course, but only to the right level – and virtually nothing for huge numbers of other people.

Well as it turns out in this country, the thing people complain about most in inequity. It’s been very difficult for the health service to provide it fairly for everyone, and there has been a real push to try and do that, I think, in recent years, and I think it’s what annoys people most. What really distresses people is postcode lottery. And that, I think, is what is in the process of trying to be evened out. That’s what NICE is about. And of course drug companies and others pressing very hard, and people who run private cancer health treatment centres and so on, pressing really hard to bust NICE. But if you didn’t have NICE, you’d have to reinvent it. If the Tories don’t like it, they’ll have to invent something like it. There has to be some way of saying what is fair and reasonable for the NHS to provide. The popular drive at the moment is not to do away with the NHS. It’s to make the NHS fairer and certainly not less fair.

JH: Thank you. Paul, you’ve got a few minutes.

[applause]

PC: Just a few minutes about affordability, since that’s an issue that has come up. In the US, about four years ago, where a great deal of healthcare is paid for by employers, Chrysler started to pay more in that year for healthcare than it does for steel. Now, they make cars at Chrysler, so if you think about the inefficiency of that for that particular economy and for that particular manufacturer, you’ll understand why the American car business is going out of business, because actually the American healthcare system is destroying the American economy.

The second point about cost is that because you hang on to your health system as an employee, there is a lot less movement in the labour market and that actually means there are more strikes in the US about healthcare systems than there are about wages, because that’s the issue that people care about all the time and the only way they can implement that in the American systems is through labour disputes. Is that efficient? So you are actually taking on your employer about health care? Is that helping the American economy? Is that what efficiency is about?

The third issue about the US and affordability is the United States, famously at the moment, between 16 –17% of their GDP is spent upon health. Now we hear a lot about, well, that’s private money. That’s fine. Actually, no. 50% of that money is taxation – is state money – going on Medicaid and Medicare. So the United States spends, on state health, about the same as we spend on state health as a proportion of GDP. Is that efficient? Have they got an efficient system? Have they got value for money? No. If they carry on as they are at the moment, the proportion of taxation that will go on healthcare will be much, much higher than it is in this country, because their system is out of control and our system is not. So it’s not about affordability because we have a system which we can put in elements of choice and contestability and competition because we have a system. In America they don’t have a system. They have a chaos.

JH: Thank you.

[applause]

LJ: I think the people on the other side are rather confused. I think they don’t agree with each other about lots of things to do with the NHS and also I think they are suggesting that we are somehow proposing that we adopt the US healthcare system. I don’t think either of us has mentioned that once, and it certainly wouldn’t be what we propose. I also think that a couple of people have made the simple and profound point, which is not that we can’t afford it this year, but in the medium to long term the NHS is unsustainable. It has never had anything approaching the vast increase of cash that’s been injected in the last 10 years and there are vast hidden costs which I mentioned which are not on any of the balance sheets, which will come home to roost very shortly. And thanks to the economic conditions that we face in the coming years, the taxpayer will not be able to continue to fund it at the rate that it needs. And the expectations that people have of the NHS will absolutely outstrip its resources.

As of today the NHS is functioning. But if it carries on the way it’s going now, it will simply collapse. And the very fact that a number of the remarks here today have been so almost evangelical and religious shows how irrational and how sentimental and how unpragmatic and how impractical and how emotional are the arguments. The facts are the problem and these will come home to roost. You can be in denial for as long as you want, but the truth is that the healthcare demands of our population and the expectations they have of the NHS are on a massive collision course. If we’re not realistic about them, the system will collapse. And the grandeur with which the current government has been spending on the NHS is all very well but the bills will come home and they will have to be paid. A lot of the people here have very considerable vested interests in keeping the system running as it is. Of course they would vote against the motion. But I ask them to be a bit more realistic about what will happen in five and 10 years’ time, because people perhaps of more my age or my wife’s age are going to have to pay the bills. And how are they to be paid? That’s the real question, isn’t it? Because I thought people in politics entered for altruistic reasons rather than for very short term easy vote-getting reasons for the next couple of years. Perhaps Karol would like to say a few words.

[applause]

KS: Maybe we’re all sunk in the ‘perfect storm’. I don’t know. I wasn’t really convinced. What convinced me was the evangelism. We’ve already heard that word. It’s like a religious conversion. I could listen to Paul all evening. I suggest with his bus pass he gets a job in a church and tries to convert people to some extreme religion, because even the language – ‘the founding principles enshrined’ – ‘enshrined’ – ‘enshrined in the NHS’ for god’s sake. That was in your article, Tony, last week. What’s this ‘enshrined’ business? Alan Johnson mentioned it in the House of Commons on Tuesday about the top-up payments for cancer. Why do we have to have something in tablets of stone ‘enshrined’? Society has moved on, and what I’ve learnt over the last hour is it’s moving on faster – much faster – than any of us think. You just need to look at the consumerist approaches of younger people. When they get to my age and beyond, they’re not going to tolerate the current system. They want it now. They want to go to a clinic where they can get instant access. The current GPs that get all the praise, it’s hardly instant access. The places are shut at 5:00 for goodness sake. I walk by one every day on my way home and it’s always shut after 5:00. This is no way to run a plan.

If I look at cancer – we’ve heard cancer mentioned; obviously it’s my specialty – we have seen huge improvements over the last seven years since the cancer plan. But that’s come with a really hefty price tag. We’re now spending the equivalent amounts on cancer as all western European countries, and yet there are 10 drugs you can get in Calais that you can’t get in Canterbury. That’s got to be wrong. That’s got to be inefficiency. It’s nothing to do with NICE. It’s just not having the money. We can’t have the emotional disruption in cancer patients’ lives caused by tiny bureaucrats in PCTs up and down the country trying to make decisions. Even the bureaucrats are alarmed at what they are doing. They feel very uncomfortable because they’re not qualified to make the decisions. They look up textbooks and try and come to some decision. This is no way to run either a religion or a business. So I think you’ve got to vote for me with the motion because whatever it is – I’m not sure what it is anyway now.

[laughter]

KS: But basically – I’m so confused – but because it’s really the only way that it can move forward. It’s not about making people die in the gutter when they’ve been run over because they haven’t got a credit card. It’s not creating an American system as we’ve heard. It’s about getting some way to avoid us going over with the boat in the ‘perfect storm’. Thank you.

[applause]

JH: All right. Now I’m going to remind you of that motion yet again: ‘the founding principles of the NHS, services funded by taxation, available to all regardless of ability to pay, are no longer relevant in 21st century Britain’. So that is what you vote for or against. If you believe that they are no longer relevant – those founding principles – then you vote for. If you do not, then you vote against. That’s clear, isn’t it? Right, and vote now if you would, please.

[music]

JH: Right, well you can read it for yourself. Those who support the motion have increased from 33.1% by 9.3%. And that comes, it seems to me, largely – I’m not very good at these things – part of that at any rate had come from the ‘don’t knows’ but there has been a switch from supporting the motion. So there we are. Let me now open this envelope. And the winner is – no. There’s a picture of Paul Corrigan on that side. What does that tell us? The latest results – this is the BMJ poll that you heard about earlier – same proposition, the same motion put. There were 603 votes cast, and in this case – can we just keep that thing up? Do you mind? So we can just do the last one. Here we are. That’s it. Well, actually not a lot in it, frankly. The BMJ motion, 30% agreed, 70% disagreed. So not a huge amount in it. Bear in mind obviously it’s BMJ readers, users – what’s the word? BMJ users. The vast majority of those too, as is the case this evening, are healthcare professionals. So I suppose what we have learned – and this will come as no great surprise to many people – that those who work in and for the NHS believe that those principles are still relevant. Thank you very much indeed. Neil.

[applause]

ND: Thanks very much indeed, John. Just a few words of thanks from me, really. So I suppose the question is why did we do this. And 60 did seem an appropriate time. I mean it’s not a time, as we’ve heard, for retiring as we use in the motion, but certainly it is a time for reflection and there has been quite a bit of reflection around the NHS, I think, over the last few weeks and there will be over the next week or so. But also we wanted to do it as a reminder to those in the healthcare system who believe that the funding debate – that fundamental funding debate – had disappeared, because it hasn’t. And I think we’ve lived through a period where there has been a lot of extra funding going into the health service. And by the funding debate I mean not just how it is funded but how much the NHS is funded. And that’s something that we’ve kind of forgotten about over the last seven years or so because the NHS, as we’ve heard, has had so much. And I think, frankly, the third reason is that the debate over the –

[recording ends]