=================================================================================== .................................................................................... ON THE RECORD FRANK DOBSON INTERVIEW RECORDED FROM TRANSMISSION: BBC ONE DATE: 28.3.99
.................................................................................... JOHN HUMPHRYS: Frank Dobson, you're obviously putting quite a lot of hope on this National Institute for Clinical Excellence, NICE as we're now going to have to start calling it somewhat confusingly. Isn't the reality that when it makes it recommendations for them to work and to achieve the sort of efficiencies you're looking for they're going to have to be enforceable? FRANK DOBSON: Well let me make clear for a start because a false impression may have been created by your introductory film that the establishment of the National Institute for Clinical Excellence is welcomed by the medical profession, welcomed by the nursing profession, the midwives, the professions allied to medicine - everybody welcomes it, everybody wants this function carried out I promised all the professions that it would be the... the board would be made up of people who had a great deal of professional competence and when I announced the appointment of Sir Michael Rawlings, the professor of Clinical Pharmacology at Newcastle the former Chairman of the Committee on Safety in medicines, that announcement was welcomed from the platform of the meeting I was at by the Chairman of the BMA, virtually everybody in the profession welcomes it. It's a huge step forward...... HUMPHRYS: No I'm not worried about that. What I want to know is how it's going to work? DOBSON: It's a huge step forward and it's what the profession has been asking for so we're delivering what they want and I'm confident it will mean better patient care and a more straightforward life for the professionals. HUMPHRYS: And what I'm asking you is whether that will happen only if its recommendations are enforceable? DOBSON: Well I don't think it will need to have enforceable recommendations. It will be very authoritative guidance and if people don't follow that guidance and anything goes wrong then they will have some explaining to do but I don't want to end up forcing people if we can possibly avoid it. That isn't the way to deal with skilled and dedicated professionals, it wouldn't be in your business and it certainly isn't in the health service. HUMPHRYS: The problem is though that if you don't it simply may not have the impact on efficiency that you want it to have. You think about the problem with the cost of drugs generic drugs versus the more expensive proprietary drugs. The health service is always asking doctors to cut out all these expensive things or some of the expensive things and turn to the cheaper generic drugs - it hasn't happened to any great extent and the reason for that is because there hasn't been enforceability. DOBSON: Well I'm afraid you're plain wrong there John because we have the highest use of generic drugs of any country in Europe...... HUMPHRYS: Ah but still not enough...... DOBSON: And there are parts of the country now where it's into sixty or seventy per cent of the drugs that are prescribed are generic and what we're doing, quite separate from NICE, is saying to those areas where it's only forty per cent and therefore costing the health service a lot more money for exactly the same drug is if they can do it in one part of the country, if they can bring their costs down by using generic rather than branded drugs in one part of the country then you in another part of the country ought to be doing the same thing. HUMPHRYS: That's what I'm saying. You've got to do that with NICE haven't you. You've got to lean on people today. DOBSON: We don't need NICE to do that. We can do that I think ...... HUMPHRYS: No no I don't mean that specifically, I'll just clear up any misunderstanding, what I mean is that approach is the approach you're going to have to need with the recommendations that come out of NICE aren't you? DOBSON: Yes. The approach will be that some very very distinguished people on the board of NICE advised by very distinguished people working for the National Institute for Clinical Excellence will come out with authoritative guidance on whether a particular drug or a particular new technique or form of treatment is worthy of being spread across the country and my expectation is that most of the time it will result in new techniques and new pharmaceutical products being spread round the country quicker that they've been at present getting away from the deplorable variations that we've got where we do have postcode prescribing and postcode availability of certain treatments. HUMPHRYS: Yeah I want to come onto that in a second but just to deal with these new drugs and all the rest of it for the moment they are some of them terribly terribly expensive. Now will this organisation, NICE, the Institute, will it be able to deal with affordability of drugs as well as effectiveness of drugs? DOBSON: Well it will certainly consider that but I mean you are reflecting the views of I think a fairly narrow group of people involved in this because it isn't the case that the introduction of new drugs is necessarily more expensive. Let me take one very good example which no-one can challenge: Until fairly recently if somebody had a peptic ulcer and it got really bad the only thing that could be done about it was to have an operation. It was a nasty operation. It was a painful operation. It took a long time. It took people a long time to recover and it cost a fortune and then the pharmaceutical industry came up with a pill which you could take for a fortnight and it would cure most peptic ulcers. That was good for the patient. The drug originally cost quite a bit but it was still a hell of a lot cheaper than an operation and it was certainly better for the patients, it saved time and money and so we can't just look at all new pharmaceutical products as though they're all going to be expensive. In many cases they're going to be a lot better for the patients, a lot better for the professionals and a lot better for the taxpayer. HUMPHRYS: Absolutely. I don't think anybody would dispute that, and very welcome it is too, but if you look at some other sorts of drugs, the drugs for dealing with HIV for instance - you'd have seen the story this morning that the Greater Manchester Health Authority are saying: we simply cannot afford to prescribe these HIV drugs anymore. Now the cost of that is precisely the opposite of what you've jut been describing, because you don't prescribe the HIV drugs, they get full blown AIDS, and then well, the consequences of that are clear. DOBSON: Yes,. sure, well, the Manchester Health Authority have been in touch with me about their problems, and I want to resolve their problems, and I want to make sure that those places in Britain, particularly certain places in London and in Manchester that are doing a brilliant job coping with people with HIV and AIDS, that they continue to get the funds that are necessary and we don't come up with some formula which suits some of the bureaucrats who've been advising me but doesn't actually deliver what we want. But even there you see, the cost of treating people for HIV and AIDS per person is coming down, as more people are treated, and it isn't very long ago that it was a assumed that that the disease was untreatable, but with the combination therapy it's now possible to stop people developing AIDS and to get them back to work, and that, you know if you set the cost of the drugs against the alternative then it's cheaper to give them the drugs, and make them better so that they can continue to work, they can pay tax and National Insurance and pay for somebody else's treatment rather than gradually dying in an awful way and costing us all a fortune. HUMPHRYS: So there's no problem with all these new drugs then. They're all entirely affordable, I mean..... DOBSON: Obviously there are problems, but we can't - there seems to be a mind set amongst some people that if you spend more on pharmaceutical products that's wrong. Well, it can't be wrong. HUMPHRYS: But if you haven't got the money..... DOBSON: We're spending more on pharmaceutical products and they're doing a lot of people a great deal of good, and what we've got to do, and that's one of the things that NICE will do, will be to look at them as they get ..... come through the new drugs and then assess them, and give authoritative advice to people in the field. And that's what people in the field have been looking for for years and that's why all the bodies who represent them welcome what we're doing. HUMPHRYS: How do you get the primary care groups for instance specifically to follow those guide lines , because they will say quite rightly, the whole purpose of us is to meet local needs, to deal with local needs and local priorities the way we think best, because we're on the ground and we know what we're meant to be doing. We know what our role is. DOBSON: Well, let me for a start tell the viewers what the primary care groups will do. People who are watching will know that under the Conservatives they ended up with a system whereby about half the country had fundholding doctors, half the country didn't. It was a system that set doctor against doctor and hospital against hospital, and we're replacing that , and in an entirely voluntary arrangement backed by the British Medical Association, primary care groups, four-hundred-and eighty-one of them will come into operation in April, that brings together all the primary care, the GP doctors in their area. On the board there will be representatives of nurses, representatives of social services and lay people planning and developing primary care services. And let me pay tribute to the medical profession, because they have voluntarily given up monopoly control of decisions in primary care because they believe that the system we're introducing is a better way forward. Now, the doctors and practice nurses, people who may have prescribing opportunities in future, again they are the very people who are looking for authoritative advice from the National Institute for Clinical Excellence because, supposing somebody appears in a doctor's surgery, the doctor has got to deal with every possible form of illness that people may present, they aren't experts in particular - they may be experts in certain fields, but they're not experts in everything, and so they look for advice and guidance from experts, and they're going to get it in an authoritative was for the very first time in the history of health care in this country, and I can tell you they welcome it. HUMPHRYS: But you cannot make them as you've already said - you've not wish to make them follow that advice, so we will still get what you talked about at the start of this interview, which is this so-called postcode prescribing, depending on where you live you may or may not get the treatment, the drugs that you want. DOBSON: But most of the people who are looking for this advice and have been asking for this sort of guidance for years, most of them will want to follow it and I expect that as professional people with professional standards and professional ethics, that nearly all of them will follow that guidance, but there may be circumstances in particular parts of the country or with particular patients where the guidance is inappropriate, and so I don't want to go round bossing people around. They had enough of Mrs Bottomley bossing them around - they want to be able to exercise their professional judgement but backed up with advice from other professionals who are more expert in certain fields than they are. I mean, let me - you know it's a hard job being a GP. We've had outbreaks of meningitis . The average GP will see one meningitis case in the whole of their career, but they've got to be up for it, trying to spot it. It's a very hard job and anything we can do to give them authoritative advice and guidance is obviously helpful to them and profoundly helpful to the patients. HUMPHRYS: Oh yes, nobody, obviously nobody would argue with that. You say you don't want to boss them, you don't want to boss doctors and surgeons presumably and all the rest of it but you are prepared aren't you, as a sort of last resort, and I just want to check whether this is still the case, to hateful phrase 'name and shame' a kind of league table of surgeons. DOBSON: No, I certainly am not. That is not my approach at all. What we have said is that we want to develop measures of performance of particular units, say the cardiac unit at a hospital and try to compare them with the cardiac unit at another hospital but I certainly do not support the idea of identifying individual doctors and saying what their performance is.. HUMPHRYS: Don't people have a right to know.? DOBSON: I don't think the public do have a right to know.. HUMPHRYS: Really? DOBSON: .. I think doing that would actually harm the public because as you know, John, if you've got a major operation it isn't just the surgeon, there's an anaesthetist, there's a whole theatre team, there may be other doctors helping, somebody, any of that team could make a mistake. What I am doing, is I am trying again with the co-operation of the profession, to try to come up with measures of performance that are fair, because what we can't have is a situation where people are being judged, or units are being judged unfairly. Say it's somebody with a heart condition, we've got to make sure that we are comparing like with like. There may be one hospital which treats what you might describe as average cases, people with some cardiac problems whose health isn't particularly bad. Some specialist units will deal with people who've got more advanced cardiac problems and because of those cardiac problems their general health is much poorer than the average cardiac patient. To compare the outcomes of those two you've got to do it very carefully and fairly... HUMPHRYS: I take that point. DOBSON: ...otherwise it's damaging to the morale of the people involved it's also very misleading to the public. HUMPHRYS: Right, so you are not prepared - you've made it quite clear in this interview, you're not prepared to enforce guidelines. What you are prepared to do though, is to enforce political objectives. Now you may say that's absolutely right, that's what politicians are for. But when it comes.. DOBSON: Do you mean keep election promises John. HUMPHRYS: Well it depends.. DOBSON: Well you're in favour of that aren't you. I thought we were always being berated for not keeping promises and we're keeping all our promises in this Labour government.. HUMPHRYS: Let me finish the question and then you're see the point of it which is that what you are saying to NHS trusts, to hospitals is you have got to cut the waiting lists so that on the face of it they look shorter. Now an awful lot of people say: but hang on a minute, forcing us to do that is setting our priorities, we may not agree with you in the way that you want us to go about this but we've damn well got to do it because you've called us into your office and told us to do it, and that may distort our priorities, it may damage the service we can offer but you are fully prepared to say: you do it. DOBSON: I certainly am. At the last General Election we made promises about bringing down waiting lists, we're delivering those promises. By the end of March, by the end of this month, we will be well below the target we set ourselves for this year and over the next year we will hit the target that we promised for the whole of the parliament and we will continue to do so. And what I've said when doctors say, well, you know it may cause problems, I've said that the circular spelling all that out, said that the clinical judgement of individual doctors had to remain paramount in any particular circumstance choosing between what was done. HUMPHRYS: Except that it doesn't if you are ordering them to do this without any ifs ands or buts. DOBSON: What I am saying is what we've promised at the election - you are in favour of keeping election promises - I'm in favour of keeping election promises, but they haven't just brought down waiting lists, by the end of this financial year, they'll have treated, they'll have done getting on for half a million more operations, that's half a million more people treated than would have been the case if we hadn't given that priority. They've also treated a lot more emergency cases and they've treated a lot more out-patient cases and of course because of the huge increase in the number of people who've had operations it increases the number of out-patients as well because if you have a bit operation you've got to go to out-patients for one check-up, two check-ups, maybe three check-ups. It's immensely to the credit of the hard working people in the National Health Service that they've put in this huge effort. It's almost a ten per cent increase in the number of people who've had operations this year over the preceding year. I'm glad that's happened, the patients are glad it's happened and the people in the Health Service deserve nothing but praise for what they've done. HUMPHRYS: Frank Dobson, thank you very much indeed. DOBSON: Thank you. 3 6 FoLdEd