:00:00. > :00:08.handed her over. Time now for HARDtalk.
:00:09. > :00:16.Welcome to HARDtalk. In Britain, healthcare is state`funded, free at
:00:17. > :00:20.the point of delivery to all citizens. The National Health
:00:21. > :00:26.Service is routinely described by politicians of all stripes as one of
:00:27. > :00:28.the country's greatest treasures. But the NHS's reputation has been
:00:29. > :00:34.damaged by recent shocking revelations of failings in patient
:00:35. > :00:37.care. HARDTalk speaks to the chief executive of NHS England, Sir David
:00:38. > :00:39.Nicholson. Is his health service capable of meeting the shifting
:00:40. > :00:40.demands and daunting financial challenges of 21st`century
:00:41. > :01:17.healthcare? Sir David Nicholson, welcome to
:01:18. > :01:20.HARDtalk. It is fair say that the NHS in the UK and England is facing
:01:21. > :01:27.unprecedented financial pressures right now. Although it has been
:01:28. > :01:36.adjusted for inflation purposes, the cost is rising and demand is rising.
:01:37. > :01:39.Can it cope? It is not just in the UK, all healthcare systems across
:01:40. > :01:43.the world are dealing with these major issues. It is not just
:01:44. > :01:46.financial, it is to do with demographics, it is to do with
:01:47. > :01:51.technology, it is to do with the expectations of patients. All of
:01:52. > :01:55.those challenges are happening to healthcare systems across the world.
:01:56. > :02:00.We think that we are responding well. It is very difficult,
:02:01. > :02:05.undoubtedly, to satisfy all of those things. We think it is possible to
:02:06. > :02:10.not only deal with those challenges, but improve healthcare of the next
:02:11. > :02:12.few years. Would you accept that in certain significant ways the quality
:02:13. > :02:20.of the service provided, the healthcare provided, has been
:02:21. > :02:24.compromised? There are parts of the country where we have had troubles.
:02:25. > :02:36.We provide great care for the vast majority of patients. Sometimes and
:02:37. > :02:41.in some cases, we fail them. We have to put up our hand and accept that.
:02:42. > :02:44.As the boss of the NHS in England, is it not your responsibility to
:02:45. > :02:48.tell the government that their spending plans for the NHS are not
:02:49. > :02:53.working? That you are failing significant members of your
:02:54. > :02:56.population? It is, if you take the view that it is the lack of
:02:57. > :03:01.resources driving the problems we have. If you look at some of the
:03:02. > :03:05.high profile cases we have had, in terms of poor care, it has not been
:03:06. > :03:12.resources that have been the problem, it has been poor
:03:13. > :03:15.leadership. We will go through a few instances of great concern raised by
:03:16. > :03:18.professionals in your service. The College of Emergency Medicine says
:03:19. > :03:24.there are pressures in A departments. 62% of doctors said
:03:25. > :03:32.they did not believe their current job was sustainable. It is
:03:33. > :03:38.absolutely concerning. There is no doubt that emergency care has come
:03:39. > :03:43.under great pressure. All credit to the great people of the frontline
:03:44. > :03:48.who have continued to service. It is poorer than it was. We are taking
:03:49. > :03:52.action in the short term to solve those problems. They are only
:03:53. > :03:56.short`term fixes. You said you are the leader. You said often these are
:03:57. > :04:02.issues of leadership. Are we to put the blame at your door? What we need
:04:03. > :04:10.to do is identify the problems and take the appropriate action. That is
:04:11. > :04:17.exactly what we are doing at the moment. There was a long`term
:04:18. > :04:21.problem. This has been the issue for some time. We have gone for
:04:22. > :04:29.short`term fixes when we need fundamental reform and changes. It
:04:30. > :04:31.is absolutely necessary. When you hear other significant institutions
:04:32. > :04:34.such as the Royal College of GPs talking about a dangerous tipping
:04:35. > :04:38.point in services, they point out that spending is down 7% in the past
:04:39. > :04:40.year, the Royal College of Nursing talking about a huge rise in stress
:04:41. > :04:52.and work`related sickness among nurses. It is unprecedented levels
:04:53. > :04:55.threatening the quality of patient care. These are all inputs from your
:04:56. > :05:01.crucial members of staff, your team members, saying that the system is
:05:02. > :05:04.dysfunctional. But for the vast majority of our patients, the
:05:05. > :05:10.feedback we get from them is that we get excellent care. Most of the ways
:05:11. > :05:15.that you would measure the quality of care, we are improving.
:05:16. > :05:20.Nevertheless, the report needs to be dealt with. You are the boss of NHS
:05:21. > :05:23.England, you work with funds provided by central government, but
:05:24. > :05:27.you are not a part of government yourself, you are one step removed.
:05:28. > :05:31.It comes back to your responsibility to squeal long and loud if you do
:05:32. > :05:37.not believe the government is giving you the tools to do the job
:05:38. > :05:40.properly. Is it time to do that? The government has just indicated that
:05:41. > :05:47.it wants to see a pay freeze for NHS staff in 2014. Do you believe that
:05:48. > :05:51.is right or do you believe it will be a terrible mistake? What is clear
:05:52. > :05:54.to the NHS in this country is that there is unlikely to be large
:05:55. > :06:01.amounts of extra resources coming into healthcare of the next few
:06:02. > :06:04.years. That is the case for most healthcare systems across the world.
:06:05. > :06:10.In those circumstances, how do you best use the resources you have? Pay
:06:11. > :06:15.is a massive issue for us. 75% of the money we spend goes on pay.
:06:16. > :06:20.Controlling the pay element is an important thing. What the government
:06:21. > :06:24.have raised is that the consequences of that is the need to do something
:06:25. > :06:31.about the way we manage the payment, I think that is absolutely right. So
:06:32. > :06:33.when the unions of different descriptions all say that this is
:06:34. > :06:35.entirely unacceptable and unfair, given that George Osborne, the
:06:36. > :06:39.Chancellor, appeared to promise that there could be a pay rise for public
:06:40. > :06:41.sector workers, including NHS workers, you are saying, actually,
:06:42. > :06:54.the freeze is right and they are wrong. No, there is no doubt that
:06:55. > :07:00.pay restraint can only work for a temporary period. For lots of staff
:07:01. > :07:05.there is a global market for them, not just an internal market. We need
:07:06. > :07:08.to keep up with people. However, the circumstances we find ourselves in,
:07:09. > :07:15.the higher the pay award we give staff, the fewer staff would can
:07:16. > :07:20.afford to have. That trade`off is an obvious critical trade`off for me.
:07:21. > :07:26.Constraining pay but keeping jobs seems to be a much better option.
:07:27. > :07:29.How do you feel as leader NHS England about this, more than 10,000
:07:30. > :07:36.NHS managers have seen their pay rise by 13% in the past four years?
:07:37. > :07:44.Increases three times the rate of increase for nurses. The first thing
:07:45. > :07:47.I would say about NHS managers, generally, is that we have reduced
:07:48. > :07:54.the number considerably over the last 12 months also. We have reduced
:07:55. > :07:58.the number by just over 20,000. We have significantly decreased the
:07:59. > :08:04.number of people we have. Local organisations have to make
:08:05. > :08:10.judgements. I want your judgement. Over 7,000 of your senior management
:08:11. > :08:16.team on 6`figure salaries. More than 2,000 of them earn more than the
:08:17. > :08:20.Prime Minister. The NHS is the largest integrated health`care
:08:21. > :08:23.system in the world. 2,000 executives earn more money, in the
:08:24. > :08:31.public sector, than the Prime Minister himself. And they manage
:08:32. > :08:35.very complicated organisations. So does the Prime Minister, he manages
:08:36. > :08:40.the country. We need to get the right talent. One of the things
:08:41. > :08:43.we're doing quite a lot about is getting more and nurses and doctors
:08:44. > :08:48.involved in the management of the NHS. We had to provide salaries that
:08:49. > :08:51.are competitive. So no apologies from you at all about the scale of
:08:52. > :08:56.pay that we now see in the upper echelons of your bureaucracy? The
:08:57. > :09:01.point I would make is that we need great leaders to run the NHS. We
:09:02. > :09:07.have significantly reduced the number, we have reduced the
:09:08. > :09:10.resources. The amount of money we spend in total is tiny, one of the
:09:11. > :09:18.lowest numbers of any health`care system in the world. It is going
:09:19. > :09:21.down. You talked radicalism earlier, we will look at that in different
:09:22. > :09:24.phases. One of the more radical things you want to see happen in the
:09:25. > :09:28.NHS is a fundamental rearrangement of the provision of healthcare, so
:09:29. > :09:30.that patients get used to the notion that much more of the sophisticated
:09:31. > :09:34.healthcare takes place in hub centres, much less of it takes place
:09:35. > :09:36.in the local hospital that has traditionally had its own A
:09:37. > :09:52.department and paediatrics department. It seems that most
:09:53. > :10:00.people do not want to see their local hospital closed, or operations
:10:01. > :10:08.severely curtailed. Clearly we have a lot of work to do. Part of the
:10:09. > :10:11.issue, and the reason we are raising it, is that we think there should be
:10:12. > :10:17.that discussion across the country about what this means. Let me give
:10:18. > :10:22.the best example I have, in London we had 32 hospitals providing stroke
:10:23. > :10:32.services. We moved to eight hospitals providing stroke services
:10:33. > :10:40.over a period. We went from some of the worst outcomes, to the best. By
:10:41. > :10:42.using those examples and talking to our public and talking to
:10:43. > :10:53.populations, do we have any chance of persuading members? I do not
:10:54. > :10:57.underestimate how difficult that is. I can see it is difficult. There is
:10:58. > :11:01.a contradiction here, you are very big, you said, patient power must
:11:02. > :11:05.drive the future of the NHS. Surely that is an indication that above all
:11:06. > :11:09.else, the NHS should reflect the will of the people. In almost the
:11:10. > :11:16.same breath, you said that the NHS must escape from the tyranny of the
:11:17. > :11:22.electoral cycle. Which is it, is it to reflect local democracy or not?
:11:23. > :11:26.They were two separate points. The first is that there is no short form
:11:27. > :11:28.of this. Local people who lead NHS organisations need to talk their
:11:29. > :11:32.population and explain to them what the reality of the service that they
:11:33. > :11:42.have is, and the reality of the potential service they could have if
:11:43. > :11:45.they changed. The other point you make of the tyranny of the
:11:46. > :11:55.electorate, many of these changes we need to make long`term. They are not
:11:56. > :11:59.short`term fixes. Some of the changes would need to make to the
:12:00. > :12:02.way the healthcare is delivered, we need to organise and talk about now,
:12:03. > :12:07.and implement in three or four years' time. That sometimes does not
:12:08. > :12:10.fit in with the electoral cycle. We need to get away from that,
:12:11. > :12:16.otherwise we will not be able to make the changes and make them
:12:17. > :12:23.happen. I have worked now in this job for eight years, and for the
:12:24. > :12:28.NHS, 30. We got to the point we could not make changes the year
:12:29. > :12:30.before a general election. When it got the general election,
:12:31. > :12:38.politicians would promise all of these things, no change after the
:12:39. > :12:42.election. It meant another year or two where nothing could happen. You
:12:43. > :12:46.had a year where you could make change and then two years we
:12:47. > :12:52.couldn't. That is no way to run a health`care system. You are running
:12:53. > :12:54.a health`care system being used as a political football by politicians
:12:55. > :12:57.for their short`term interests. Is there any indication that is
:12:58. > :13:02.changing, or is that the case right now? This is the dilemma of a
:13:03. > :13:09.state`funded system. Politics will always be part of that system. It is
:13:10. > :13:12.inevitable. Politicians do the difficult thing, they take ?100
:13:13. > :13:17.billion out of taxpayers' pockets to deliver the NHS. They will always
:13:18. > :13:23.have an interest in it. There will never be a time when they are not.
:13:24. > :13:25.You are saying they should look at the big picture, rather than looking
:13:26. > :13:28.at the small self`interested picture. I am asking you whether
:13:29. > :13:38.today's politicians are capable of doing that. Yes, they are utterly
:13:39. > :13:42.capable of doing that. It is tough for them, they have elections to
:13:43. > :13:44.fight, I do not underestimate that. Actually, my experience is, working
:13:45. > :13:47.with both the opposition and the government, that there is a broad
:13:48. > :14:00.consensus about what actually needs to happen to healthcare. They want
:14:01. > :14:03.to come back to a big vision before the end. Now I wanted to do a
:14:04. > :14:05.different vision. We have talked about money, the intersection of
:14:06. > :14:08.money, healthcare and politics. We'll talk about something a bit
:14:09. > :14:14.different. Accountability and transparency. You, as chief of NHS
:14:15. > :14:16.England, and before that, one of the bigger regional chiefs looking after
:14:17. > :14:18.strategic healthcare authority, which covered most of the West
:14:19. > :14:22.Midlands, you have been intimately involved with the biggest scandal to
:14:23. > :14:31.hit the NHS since its inception, it is called the Mid Staffordshire
:14:32. > :14:34.scandal. The foundation was guilty, over a four`year period, of the most
:14:35. > :14:42.terrible abuse and neglect of thousands of patients. It is
:14:43. > :14:47.believed more than 1,000 died in avoidable circumstances. In all
:14:48. > :14:59.honesty, there hasn't been accountability for that, has there?
:15:00. > :15:02.I don't want to underestimate the scale and nature of that tragedy at
:15:03. > :15:06.Staffordshire, and indeed, nor would I ever want to. The issue for us, as
:15:07. > :15:10.we think about that, not underestimating that... And do you
:15:11. > :15:13.take responsibility? At the beginning of the abuse, the
:15:14. > :15:18.mistreatment, and the scandalous behaviour, you were the regional
:15:19. > :15:24.boss. Of course, I have worked for 35 years for the NHS. I come to work
:15:25. > :15:28.in the morning wanting to improve services for patients. But to take
:15:29. > :15:32.on responsibility in the corporate for a screwup, if I can put it that
:15:33. > :15:47.way, as bad as this, would have been quite clear. Of course, I have
:15:48. > :15:50.worked for 35 years for the NHS. I come to work in the morning wanting
:15:51. > :15:54.to improve services for patients. But to take on responsibility in the
:15:55. > :15:57.corporate for a screwup, if I can put it that way, as bad as this,
:15:58. > :16:01.would have been quite clear. You would not be talking to me as the
:16:02. > :16:05.boss of the NHS, you would be out on your ear. We had an enquiry, what
:16:06. > :16:08.they said, the people who ran the hospital were responsible for it.
:16:09. > :16:11.The whole of the board. But you came to me talking about the importance
:16:12. > :16:15.of leadership. As far as I was concerned, I accounted for what I
:16:16. > :16:18.did. I spent 11 hours in a public enquiry, my employees... It was not
:16:19. > :16:21.how you responded to the enquiry, it is what you did at the time in key
:16:22. > :16:24.management positions. Overall responsibility for that trust and
:16:25. > :16:27.many others as well. Were you not aware? Did you never visit, did you
:16:28. > :16:34.never look into the mortality figures? Were you not aware of the
:16:35. > :16:37.terrible things that happened? That is exactly the point. Nobody was
:16:38. > :16:41.aware of what was happening in that hospital in the system as a whole,
:16:42. > :16:43.for all the problems of the system. There were fragments of information
:16:44. > :16:49.held by various people, but nobody put the whole thing together. That
:16:50. > :16:52.was the tragedy of it. Of course I feel responsible for it. But the
:16:53. > :17:01.accountability was laid at the organisation itself. That my
:17:02. > :17:04.employers, politicians, they backed me, they gave confidence, but I had
:17:05. > :17:08.to think of myself, and as anyone who runs a healthcare system, part
:17:09. > :17:10.of the original report that came out in 2008, there were two sections.
:17:11. > :17:17.The first was about what had happened in the hospital, and the
:17:18. > :17:25.second was the patient stories. What I did, I took the patient stories
:17:26. > :17:31.away and read them over a weekend. You could not read them without
:17:32. > :17:38.being moved, as an individual. Does it hang over you today? I hear the
:17:39. > :17:41.pain in your voice, but does it hang over you today, and even today, do
:17:42. > :17:45.you honestly wonder whether it was the right thing to stay, to stay and
:17:46. > :17:53.be the figurehead, the absolute figurehead of the NHS, when this is
:17:54. > :17:59.a stain on your record. That was the point I was going on to make. Of
:18:00. > :18:02.course at the time it happened, which was 2005, 2006, one of the
:18:03. > :18:06.reasons I applied for the job as chief executive of the NHS was that
:18:07. > :18:14.I thought the national leader of the NHS... It was one of the reasons I
:18:15. > :18:19.applied for the job, to make quality at the heart of it. What came out of
:18:20. > :18:30.Mid`Staffordshire reinforced my view of how important that was. I do not
:18:31. > :18:33.want to harp on this, but it turns out that you had lost the plot,
:18:34. > :18:39.because you were the regional leader. We were focusing our
:18:40. > :18:42.attention on the wrong things. The point that I am trying to make, is
:18:43. > :18:51.that that experience, it seemed to me, focused my attention like
:18:52. > :18:54.nothing else could, to put it right. In a sense, right from that time
:18:55. > :18:58.afterwards, I have been trying to put it right. In those
:18:59. > :19:02.circumstances, that is what I should do, and what I have been doing over
:19:03. > :19:07.the last 5`6 years. Let's look forward. You have been very blunt
:19:08. > :19:14.about the future. You are leaving in six months. You have said that given
:19:15. > :19:16.the current... The growing demands on the system, from demographics,
:19:17. > :19:20.raised expectations, the flipside of the real financial squeeze, you have
:19:21. > :19:33.said that by 2020, there is likely to be a ?30 billion black hole
:19:34. > :19:39.inside the National Health Service. Is there anything that you can do
:19:40. > :19:43.about it? Unless we do something about it. We know broadly what we
:19:44. > :19:48.need to do. It is not rocket science in that sense. We need to do
:19:49. > :19:51.something about the way the service is organised. We need more early
:19:52. > :19:57.intervention, more community services, more upstream activity in
:19:58. > :20:00.the NHS. We need more concentration and centralisation of specialised
:20:01. > :20:03.services to get better outcomes, we need patients to take more control
:20:04. > :20:15.over their own healthcare, change the nature of the service. We need
:20:16. > :20:19.to do all of those things. But maybe none of that is radical enough.
:20:20. > :20:21.Maybe you should be using words such as rationing, saying to people, in
:20:22. > :20:25.the end, given the financial constraints, we cannot offer you all
:20:26. > :20:39.of the services that you have been expecting. For example. Certain key
:20:40. > :20:44.drugs or key procedures will in future be rationed. The point that I
:20:45. > :20:47.will make, one of the things about the NHS, it is not just a group of
:20:48. > :20:52.organisations operating together, it is a set of ideals and principles.
:20:53. > :20:55.Part of those principles is a more effective and more efficient
:20:56. > :21:03.healthcare system, one which is free at the point of use and universally
:21:04. > :21:12.available. But that itself is outdated. On the contrary, I think
:21:13. > :21:15.it is very viable. I suppose your immediate colleague and in some
:21:16. > :21:18.senses boss, Malcolm Grant, said that future governments will have to
:21:19. > :21:29.reflect on the possibility of introducing user charges to the NHS.
:21:30. > :21:32.That is in the future. I do not think that is the case in the
:21:33. > :21:36.moment. We are talking about the future. We are talking about changes
:21:37. > :21:44.that will safeguard healthcare in the country. Other countries are
:21:45. > :21:53.looking at the UK as a model. My time horizon is 4`5 years. That is
:21:54. > :21:57.something... Taking the service forward. If it comes to the point
:21:58. > :22:01.where those things I have described do not deliver the improvements and
:22:02. > :22:07.the way of working, then it is a possibility. But I do not think the
:22:08. > :22:10.British people expect us to be there, the taxpayers expect us to
:22:11. > :22:16.get the absolute value out of what we have already got. In America, we
:22:17. > :22:19.see a huge wave of political opposition, stirred up by the
:22:20. > :22:22.Opposition to Barack Obama, against what they refer to as Obamacare,
:22:23. > :22:35.some people call a socialised medicine. A lot of Americans do not
:22:36. > :22:38.seem to like it. But countries such as Mexico and India, where very
:22:39. > :22:41.competitive healthcare is being offered in a much more affordable
:22:42. > :22:44.way than ever before, I wonder whether you look at the US, the
:22:45. > :22:47.developing world, do you do some big picture thinking, thinking that the
:22:48. > :22:52.state provisional model is not the best for the future? You say state
:22:53. > :22:55.provision, but in a sense, what we have been doing over the last few
:22:56. > :22:58.years, we have been giving individual providers more freedom to
:22:59. > :23:08.get on and innovate and do the things they need to do, and we need
:23:09. > :23:11.to do more than that. But in terms of the idea of universally available
:23:12. > :23:14.free at the point of care, if you think of the alternative, if you
:23:15. > :23:22.look at alternative systems, they cost more. If you look across Europe
:23:23. > :23:30.or the United States, you end up spending more on healthcare than we
:23:31. > :23:34.do. They are inevitably less fair. That is what the British public have
:23:35. > :23:41.said all along, that we want a fair system. The major changes in things
:23:42. > :23:45.like genomics means it will be very difficult in future, if you can
:23:46. > :23:47.imagine a time, when you as an individual, when somebody reads your
:23:48. > :23:50.genome, they can predict the diseases that you will have in the
:23:51. > :24:05.future, and you have potential for multiple sclerosis and things like
:24:06. > :24:08.that, who is going to insure you? Getting social solidarity across the
:24:09. > :24:10.whole of the population is a much more viable way of delivering
:24:11. > :24:19.healthcare than breaking it up into the private sector. I wish we could
:24:20. > :24:48.go on but we are out of time. Sir David Nicholson, thanks very much.
:24:49. > :24:54.I have to say if you are getting a bit fed up of wet weather I cannot
:24:55. > :24:57.offer you anything much more promising this week.
:24:58. > :24:58.I have to say if you are getting a bit fed up of Certainly remaining
:24:59. > :25:04.very unsettled which means there will be more rain around for all of
:25:05. > :25:07.us this week. Also very windy, thanks to some big areas of low
:25:08. > :25:11.pressure coming our way. It does remain very mild. The reason for the
:25:12. > :25:16.mild weather is the southerly wind coming from the far south. Also
:25:17. > :25:21.funneling in this rain around this area of low pressure. That is the
:25:22. > :25:22.picture for today. On the recent satellite pictures, all the cloud
:25:23. > :25:24.which was piling