The Rest Is Politics: Leading - 3: Alan Milburn: Can the NHS be saved?

Episode Date: January 30, 2023

Is the NHS beyond saving? Could a Labour government fix it? How should Rishi Sunak deal with strikes? This week on Leading, Alastair and Rory are joined by former Secretary of State for Health, Alan Milburn. Alan is credited for delivering modernisation to the NHS in the New Labour years, introducing foundation trusts, and is Rory’s hero for his work on reform. Tune in to hear his thoughts on the struggles of being an MP, the biggest challenges facing the NHS, and Labour’s lack of clarity in opposition. TRIP Plus: Become a member of The Rest Is Politics Plus to support the podcast, enjoy ad-free listening, receive a weekly TRIP newsletter, join the TRIP Plus Discord chatroom, and receive early access to live show tickets and Question Time episodes. Just head to therestispolitics.com to sign up. Instagram: @restispolitics Twitter: @RestIsPolitics Email: [e-mail] Hosted on Acast. See acast.com/privacy for more information. Learn more about your ad choices. Visit podcastchoices.com/adchoices

Thanks for listening to The Restis Politics. Sign up to the Restis Politics Plus. To enjoy ad-free listening, receive a weekly newsletter, join our members chat room and gain early access to live show tickets. Just go to therestispolities.com. That's therestispoletics.com. Welcome to the third episode of the Restis Politics leading. And this is rather an unusual situation because we have a former Labour politician, somebody I've known and worked for for many, many years. But the reason he's here is because Rory Stewart, a former Tory cabinet minister in a previous episode of the podcast you may have heard, call this gentleman one of the heroes of the new Labour era. And there's me thinking it was dulled out of me and Tony and what are two others. Nothing to do with you at all, Alistair, the whole new Labour era it's all about Alan Melbourne.

Let me just quickly remind people why I think he's such a hero. Well, I think, listen, Rory, before we do that, I think we've got to remind people who he is. Because, you know, he's not been on the scene since 2010. Alan Milburn is a former MP for Darlington, former Chief Secretary to the Treasury, former health minister who brought in the private finance initiative. We'll have to come into that at some point. And subsequently, Secretary of State for Health and Social Care.

Some of our listeners won't know about your background and your childhood and your upbringing and how you got into politics. Just give us your kind of live story in a few minutes. It's so funny now because, you know, this, and I will do that course, and I'm very happy to do, and I've done it, you know, in more recent media interviews, I would have been terrified of doing that when I was an active cabinet minister, you know, to do that exposure, you know, because the truth is, it's easy for me to come on with you guys and have an open conversation because, frankly, who cares what I say? It doesn't really matter. But when you're in frontline politics, every word matters, right? You were the past master of this. And I regret that, actually. I think I should have probably been braver about my... to be honest. And I think I should have been more willing to talk about who I am and not that that necessarily is fascinating for people, but just to give people a sense of the guy that's in charge actually as a hinterland. So my story is I grew up in a little place called Tau Law in County Durham, which is an old mining village. All of my family were either lead miners or coal miners.

That's where they came from. I was brought up by a single mum who's still going. God bless her. I never knew my dad. Okay. We were brought up in a county. estate in Tao Law, then we moved to Newcastle, nobody had ever been to university, all of the usual stuff. And I got really lucky. I got really, really lucky. I had really good teachers. And, you know, I got some decent breaks and I ended up going to university and it changed my life. I'm very proud of the fact Rory will know this institution really well. I went to Lancaster University and today I'm Chancellor at Lancaster University. So, you know, every time I award a degree there, it sort of fills my heart with an incredible sense of both belonging and pride. And in fact, the last degree ceremony

amongst the students I gave, conferred the degree on, was my own son, which was just lovely. It was just great. So he got his masters there, which was just fantastic. So that was it. And it was a very labour place, very labour tradition. You know, I can remember even as a kid sort of, you know, labour being around as a sort of as a thing. But I've never really thought about becoming a Labour MP or any of that sort of stuff. I sort of fell into it. And this is the very odd thing about frontline politics, because people have you down as this guy, or you're deeply ambitious and you're sort of wanting this. And honestly, you know, I wasn't, I know you've had Michael on, haven't you, Michael Hazeltine on, who famously sort of charted his political career.

Back in the envelope back. Back in the end of the end of all. I was a complete inverse of that. I never had a plan. Never had a plan. I sort of fell into it. Not because I didn't believe in it. I believe in it massively and still do. So that was my life. That's where I came from. And it's where I still live. And, you know, I'm very proud of that. I'm even proud of being a Newcastle United supporter. Okay, well, listen, you've raised it on me.

Happy with the Saudis backing the whole thing? No, of course not. But, I mean, so am I happier with the team? And I'm happier with the club than under the Mike Ashley regime. Yes, I am, actually. And your general view of sport washing? I think it's a really big problem. And I think you've got this amazing industry that touches people's lives that we get

totally animated about World Cup, Burnley, Newcastle, all that sort of stuff. I don't know who'll Rory's Croatia. Yeah, yeah. Very good. And here you have this industry that is vast, it's financially extremely lucrative, and it's run, to use a very bad metaphor, it's run as an amateur sport with incredibly poor governance. And I think that's not sustainable. And the government, whoever it is, needs to change it. Just stepping back into the general for a moment. think it's very unusual to have politicians who are genuinely interested in reform and administration and running things. That sounds a strange thing to say because obviously one would expect ministers to be primarily driven by that. But many, many of my colleagues in the House of Commons came

into it because they enjoyed politics. They enjoyed fighting the other side. They enjoy getting elected. They often enjoyed serving their constituents. But the business of running stuff didn't necessarily appeal to them. Even when people were interested in running things, they weren't necessarily that good at it because it's very, very tough working out how to work in government. It's not like running a company or running a small charity. It requires very, very particular instincts to work out how to make the civil service adjust. And in the case of the health service, our guest today, was running by far the largest and most complicated part of the British government. hundreds of thousands of employees, hundreds of billions of pounds of expenditure,

quite literally dealing with people life and death. And of course, the NHS is also as close as we have in many ways to a sort of secular religion in Britain. It's something that we've been deeply proud of since the Second World War and which many politicians find easier not really to do too much of because they're worried about the public, they're worried about doctors and nurses, and they're worried about the cause reform. And Alan Milburn did things. So there be it. That's why he's my hero. So, Alan, how do you respond to this pene of praise from the right Honourable Rory Stewart? Well, all I can say is that

Rory is a man of impeccable judgment, unlike you. So Rory, I think you and I can have a really civilized conversation for the next, whatever it is, 30 minutes. So that's very, very kind and completely unwarranted, by the way. So you're right about a couple of things. Look, I mean, the NHS is, I mean, it's traditionally viewed as the elephant's graveyard, isn't it, for a politician. You go there, it's incredibly tough, you try hard, you get kicked out, you fail for all sorts of, all sorts of reasons than some of the you've described. And I have to say, look, it was all of those things, it was incredibly difficult, you know, really challenging. It's the best job I've ever had in my life. It was fantastic, because it's sort of meaningful,

right? You know, it's a meaningful thing. And unusually in modern government, it's one of the few institutions that remain, where if you're a minister who wants to get their hands on levers, when you pull the lever, not always, but something happens. Because a lot of government nowadays, if you think about it, it isn't actually a delivery mechanism. Government doesn't deliver much. You know, local authorities and schools are kingpins in education, for example. Transport is privatized, et cetera. but the NHS remains an institution that is subject to political influence. The debate is how much political influence should be subject to.

And a lot of the changes that I was trying to make were about actually devolving power away from the centre, recognising that in the end, look, it had to be, it had to be owned by the people who are delivering the stuff. And Alan, we're calling this series of podcast interviews, which you're the third of, leading because we're hoping to engage many, many people across the field who aren't just interest in politics, but are interested in the question of what it means to be a leader, what it means to manage. And there will be, I would guess, nobody listening to this podcast who has managed something of the scale of what you were managing there. I mean, that is 180 billion pounds

a year at the moment, 1.2 million full-time equivalents. Rory, we do have serving presidents and prime ministers and heads of armies of very, very large countries who we know listen. Stop belittling our own podcast. For the 99% who have not managed things at that scale. Give us a sense of what you learned through the four years that you were doing. What was your first sense when you first turned up of what needed to be done? And how did that change over time? And at the moment when you were leaving three and a half, four years in,

what was your conclusion about what really needed to be done? So how did your mind change over time about what reform in the NHS really meant? Well, the first instinct, I remember when Tony rang me, to offer me the Minister of State position to Frank Dobson in 1997. And the truth is, by the time he'd around, because it was sort of two or three days in, and he'd obviously not got round to recognising the brilliance that Rory has been able to spot. So it was two days later. You'd clearly got bored because you briefed to C-Fax.

If anybody could remember what C-Fax is, C-Fax was that ticker-tale thing. I never briefed C-Fax. on the BBC that Alan Milburn was going to be the Minister of States. Is that how you found out? Yes. So Tony rang me and said, oh, blah, blah, blah, blah, blah. He said, I want it off you. And I said, yes, I know the job at health.

He said, how the hell do you know? I said, because Alistair's briefed it to the BBC. And anyway, then we had this interesting conversation. I said, what do you want me to do? And he said, we need a policy. Because in truth, Labour in opposition didn't have much above policy. So I spent the first five or six months literally sort of working out. what the hell was it that needed to be done? What were the levers that you needed to be changed,

etc. And my view then, this is what changed, Rory. My view then was, if the centre got it right in terms of the policy prescription, then everything would be all right out in the field. And that would sort of make it work. And my learning was, to your point about managing this enormous thing, my learning was it was unmanageable. How can you possibly manage something? Which then, by the way, It wasn't 1.8 million people then. It was less than that. It was well over a million. It was one of the biggest institutions in the world.

And you might have been as brilliant as you think I am, but it was unmanageable. So what you had to do was you had to disaggregate it. You had to make sure that the people who were actually responsible for the managing and the running and the provision of services, because as a secondary estate, you never do any of that in truth.

All that you do is create permissions and frameworks to make things happen. So my learning was it was unmanageable. And my second learning, which was probably even more, important, was that we treated the NHS as governments around the world treat their healthcare systems as if they're different from any other system or institution. And my learning was...

Especially in Britain probably. Especially in Britain because of history, because it's funded from general taxation. It's the last great remaining or was the last great remaining nationalised industry. My learning was that all of the levers that had been successful in transforming other industries, some competition, some citizen choice, some greater transparency, obviously a framework of standards and all of that sort of stuff. You had to be able to apply these to healthcare because they'd worked elsewhere. But hold on the first big things you did, for which you actually, I think, took through Parliament, Frank Dobson was Secretary of State, you were Minister of State,

but was private financial initiative. Yes. PFI. Yes. Now, that, listen, I defended it and briefed on it and all the rest of it, But I think when you talk to people in the health service now, it's kind of, they see it as a mixed blessing. Yes. It's part of the reason why they had all the investment and so forth. But now they're look at it and think, is it one of the reasons why we're in the mess that we're in now? So how do you see PFO now? Just to explain to listeners who aren't absolutely up, just in case the listener in Albania or New Zealand, it's not completely on top of a PFI.

So PFI is a private finance initiative. And it was an idea that the government, instead of having to simply finance everything through general taxation could find a way of borrowing money and putting it off the balance sheet by getting a private provider to contract to provide services. And the advantage was, in theory, that you could set much clearer contracts and objectives. The disadvantage from the point of view of the critics was that these contracts were often very rigid and difficult to change and that they often seem to be very expensive for the government over the longer term. But maybe I've mischaracterized it. No, I think that's a very fair characterization of it. Look, I think on PFI, I think it wasn't an

ideological thing. It was a completely pragmatic thing. You know, I remember doing the press conference with Frank Dobson when we announced the first wave of PFI hospitals. And he used this phrase about it's PFI or bust. Because if you remember, Labor came into office in 1997, agreeing that we would stick by the Tory spending plans. So we were snook it in terms particularly of capital. So it was very much a pragmatic thing. It was driven by pragmatism. How could we get more money and particularly capital into the NHS? Because remember, in those days, the vast majority of NHS hospitals had been built before the NHS itself was created. So there was dilapidation and they just weren't fit for purpose. But increasingly, I took the view that there was an additional benefit, which is what

you were being able to do, was harness not just private sector capital, but also. some private sector expertise. Okay? Now, the truth is, because there had been no PFI market until Labor made one, the truth is that those first contracts were pretty expensive contracts. And that's the criticism that you hear. You know, didn't we, you know, the argument goes, didn't you mortgage the future, wasn't it more expensive than using public sector capital?

The truth is, because of a decision that Labor took before the election, which Gordon and Tony took together, it wasn't only public sector capital. So you were stuck in this sort of vice. So I think, but do you think that criticism is fair? Yeah. However, you know, the pragmatist in me continues to believe that, you know, when I walk past the UCLH building, as I often do on my way to, to the various places that I work, the truth is it wouldn't have been built without PFI.

It just wouldn't. Is there a problem within, we'll stick on health for now, but possibly across government more generally, with our procurement systems. And, you know, obviously, there's been a lot of coverage of the PPE scandals here. Is that a systemic thing or is that something that you think is particular to the fact that the Tories are perhaps allowing a little bit more corruption to the system? Why did you find that funny, Roy?

That's a fair question. So I think there's a systemic asymmetry of skills between the public and the private sector. I think, look, we've got brilliant public servants in many regards, but what they're not good at is they're not good at doing commercial deals. That's not their skill set. And it's not what we say to people coming into the civil service, is it? Oh, by the way, you've got to be really good at negotiating a deal with somebody whose job is to negotiate deals. So there's a real question in my view, which I think is a real pertinent one, about what is the

skill set that is going to be required for the future in order, particularly when you're in a fiscally constrained environment, like the next government will be, how do you ensure that you get the best value for money and the best deal? That means you've got to change the skill set, and we've got to think more broadly about what a modern civil servant really is. And I think there's another issue that I observed in government. So when I was in the Ministry of Justice, for example, I was dealing with a lot of private contracts which had been set up to deal with probation, for example. And the problem that we had there, and also with maintenance and prisons, the problems we had there were not just that the civil servants sometimes

lack the commercial skill set, but we also had a real problem with the type of industry that are developed. Private sector companies were underbidding for these contracts by that stage. So it wasn't that the government was overpaying, the government was underpaying. And then we were finding three, four years later, that all these companies, like Carillion and a lot of the probation providers were declaring bankruptcy because they'd said they could do, for example, prison maintenance, which was costing the government 120 million. They said they'd do for 40 million a year. Surprise, surprise, they couldn't do it. They went to the wall and we were all left for the contract. So I wonder whether there isn't a problem that Labor would face if they came in also about the actual

whole commercial context of these providers and the way they behave? Maybe, but look, I, you know, this is something that we probably share in common, Rory. I sort of believe in markets, really, you know, providing they're managed. I don't believe in untrammeled markets. And certainly what we did in health was not an untrable marketplace. It was the use of market mechanisms to provide the necessary ginger within the healthcare system to get it to do the things that we needed it to do. I think it's all about how the market is managed. Markets, as you know, of their own volition will always go in one direction. The question is, does government, governments, local, national, regional governments, do they have the wherewithal capability?

But critically, do they have the foresight to be able to plan to use markets to the advantage of the citizens that in the end we serve? And I think the other shortcoming that is often very obvious in politics and in policymaking is that you have people who are unnecessarily focused on the short term when many of the structural problems that any future government is going to face are long termist in nature. But we had a 10 year plan. That's the difference between today and then. We had the permission to think in 10 year terms because I worked out, and you remember these discussions, I worked out that the system was incapable. of being saved, that was our promise before the election, over a period of a few years, it was going to require deep and fundamental reform.

And the rule of thumb, by the way, when you're doing change management of that order, it always takes twice as long as you think. I do want to come on in a bit, Roy, to how we get out of the current mess that the NHS is in, and Alan's thoughts on that. But you will understand, Alan,

that when you sit here in PWC, one of the people that you work for, talking about markets, talking about choice, talking about all that stuff, you will be kind of pressing a few buttons within the Labour Party. I want to take you back to the TBGBs. I had a little look through by diaries this morning. Oh, God. I looked up Milburn in the index. 29th of 11th, 01, Alan Milburn, livid, said Gordon was trying to use his position to take over NHS policy.

He wasn't having it. Next day, Milburn, incandescent. He said, I know how Gordon works because I see now he worked when I was at the Treasury. He sees it as his right to trample on everybody else's territory. Can I go out and make a speech saying the economy ought to be doing a lot better? April 03, I could actually remember this one, was when he announced a review into health inequalities without telling you that he was going to do it. And you went absolutely berserk.

And I just wondered, because one of the things we talk about, lot is the fact that people sometimes look at politicians as machines and expect them to behave like that, but all that stuff's going on. So what's your assessment now looking back of Tony, of Gordon, of your relationship with both, and again with the benefit of hindsight, how you see that period and that government? Yeah, I mean, my one criticism of your wonderful diaries is that every entry, which mentions me, I sound like I'm insane. And as you know, I'm not. I'm so. So anyway, never trusted journalist, Rory. You were angry a lot.

I was extremely angry for good reasons. You know, because look, I mean, the two days, without going through the whole sort of thing about the TBGBs, as you put it, you know, there'd been a shared project, haven't there, new labour. And in the fundamentals, they remained a shared project all the way through. But personal ambition is a very funny thing, isn't it? On both sides, you know, both for Tony and Gordon, and it can be deeply distortive. And unfortunately, what then began to happen is that the sort of the policy consensus that these two guys had, which was fundamental to Labour's success, it began to come apart because not, I believe, of fundamental policy differences between them, but because increasingly there was personal antagonism and personal ambitions.

And that unfortunately, the face of that was policy differences. And I was in it. How did that work for you in health with Gordon Brown? Because you left in 2003 and you left in a very dignified way saying you want to spend more time of your family. But from the outside, it looked a bit peculiar. You'd been running the health service for four years very successfully. You had another seven years to run in Parliament. And suddenly you're leaving the cabinet in this huge position.

So presumably part of that is to do with the fact that you felt you couldn't get done what you wanted to get done. No, I didn't really. I mean, that's the interesting thing. I mean, I think if Gordon had his way, we wouldn't have had foundation hospitals. But we did. I got to the point in the end where, look, there was sort of deep treasury obstructionism in terms of the reform agenda in particular, and indeed some of the objectives that I wanted to set for the NHS for the longer term, much shorter waiting times and so on. And Treasury, not unreasonably, could argue from a fiscal responsibility point of view that that wasn't a sensible

thing to do, and that's a perfectly reasonable argument. But in truth, it became increasingly political increasingly personal. And my reaction to that in the end was to say, actually, screw this for a game of soldiers. I'm going to do what I think is right. And what really helped me actually psychologically, as much as politically, was my own insight that I didn't want to do the things that some journalists were writing about me. I was going to be the future prime minister, potential success for a challenger to Gordon. I knew I didn't want to do that. And actually, it was a very liberating thing. I can remember Fraser Nelson, who was then, I don't know whether he was. who was the editor of the spectator then.

He's been around so long. I think you find that somebody by the name of Johnson might have been. No, it was post that awful period. I think it was post that awful period. I think I remember Fraser saying to me, about 18 months before I resigned, saying to me, something's happened to you, you look like and feel like a different politician,

and it was true, because I sort of, personal ambition became a second-order issue for me. I really did decide. I was going to try to do the things that were right, even though, as you say, they were deeply impopular in the Labour Party. Choice for patients, the use of the private sector, market mechanisms,

foundation hospitals, every one of these, as you know, was a dog fight inside the Labour Party. When I can remember, we talked a few weeks ago, Roy and I, about that, I can't remember when it was exactly, but I remember, was it a 35-page note that Gordon wrote about one of your proposal? Yes, it never got leaked, by the way. You said it got leaked. It never got leaked.

Oh, didn't it? No, it never ever got leaked. No, I think it didn't get leak in part, because I think John Prescott sort of had a quiet, so probably quite a loud word. I own an apology to those people who were in my mind. You can imagine who there might be, who I thought might have leaked it.

I thought it had, okay, I stand corrected on that, but the point is where I can remember the note, and I can remember thinking, and I remember you saying, this is a kind of declaration of war. I think you might have been livid, incandescent and furious that day. Right. However, when you read it and stripped away

the kind of the ambitions and the stuff and the rows that were going on between Tony and Gordon, he did have a kind of an intellectual argument. It's just that it was a different one to the one that you were putting forward. And there was a very legitimate treasury point of view,

and as the Chancellor, that was a perfectly reasonable thing for him to have a debate about, okay? Right. What it really came down to was the fact that he felt that if foundation, I think, you need to speak to him in a sense,

but I think the argument was, if you set up these foundation hospitals that were freed from centralized control, that were able to do their own thing, there was always a risk that they would fail. And even though they were autonomous, in the end, the buck would rest with the taxpayer through the treasury. So the treasury felt like they had to have more locus of control than I was prepared to give them. Perfectly reasonable argument. But the big debate wasn't really about that. That was a sort of mechanistic argument. The big debate, to Rory's point, right at the beginning of this, was what was going to make the system work better?

And the conclusion I reached might be right, might be wrong. I think, actually, if you look at the track record, particularly around access and waiting times, I was proved right, you know, because there was a moment when they began to fall. And honestly, it wasn't really about the money. It was about the reforms. It was when the reforms went in, however difficult they were, that the system then began to work. And it was only by disaggregating decision-making and allowing the people at the front line who actually knew far more about it than I ever could, that then you began to get really changed

to happen. And that was a philosophical argument. And it was an argument about how government works in practice in relation to the public services. Right. But at the heart of the philosophical argument was perhaps a legitimate fear, including Gordon, but certainly amongst people in the Labour Party, that Foundation trusts were a kind of sort of halfway house between public and private, and that you and maybe Tony at that time were moving too close in the eyes of the party and of Gordon to the private

side. Sure. The argument was that there were a Trojan horse for privatisation. Well, hold on. Well, not privatisation. No, no. That is the argument. That is absolutely the argument that the unions were making.

God rest his soul, Frank Dobson, you know, was making these were a Trojan horse for privatisation. wind forward 20 years and our foundation trust still part of the National Health Service. Yes, of course they are. The idea was never to sort of privatise them. The idea was to liberate them, to allow them, just like we did with schools, to allow the schools to get on, free from political control, to be able to manage their own affairs. And, Alan, obviously I lived this day and day out as a Conservative MP under David Cameron and Theresa May.

Or the austerity era, as we call it, the era that destroyed the health service. Yeah, well, a loss of the reforms were always in terms. as attempts to privatise the NHS. Certainly David Cameron and Theresa May would have said they were not trying to privatise the NHS. In fact, Boris Johnson, even though I detest him, I think also wouldn't really have seen himself as trying to privatise the NHS. Why is it that we get ourselves in a situation in which people perceive these reforms

as though they are an attempt to destroy the entire NHS rather than attempt to adapt? Because we confuse means and ends. That's basically why. So we associate public service with public sector. And actually, I understand why, because there's a deep emotional attachment as I have to the NHS. But they're not the same thing. And I actually think both then and even more so now, frankly, it's an ideological extravagance to say that NHS patients can't use private sector hospitals when the taxpayer is paying the bill to provide NHS care according to NHS principles. You know, my view then and now

is that every bit of capacity that you can get because one of the essential problems that the healthcare system has is a mismatch between supply and demand. We don't have enough capacity. You don't have enough doctors, enough nurses, arguably enough beds, certainly not enough primary community and mental health services. So if there's capacity available and we can do the right sort of deal to get value for money for the taxpayer and the right quality of service for the patient, why wouldn't you do it? Yeah, but Alan, you also have. You have a situation where, I mean, I swim every morning at the Lido,

and there's a doctor who's there every day, Jim Down, who's just written a brilliant book about his life as an intensive care doctor. All right. He was saying, for example, to me the other day, that there is something, two observations he made about the relationship between public and private. First is that he doesn't do private stuff, but he's aware of it, and I think he may have done it in the past, but that he does see greater efficiencies within the private satire.

But the other big observation he makes is that particularly now, both doctors and nurses, are working public and private. And some of the nurses, for example, are working flat out as nurses in the National Health Service and then going off to do agency work, getting paid a lot better, to supplement their full-time job

where they're absolutely on the knees all right, ready. Now, I just wonder if to that extent, there has been a bit of Trojan horse stuff going on. The private sector has become normalized in a way that is continuing to undermine the state sector, insofar as it applies to how we see the NHS. And I just wonder whether you think there's something in that. And secondly, big question, if you were still Health Secretary now, today, what would you actually do to fix the apparent, well, it's not even apparent, to fix the mess that we're in? If the size of the cake is static and all that we're doing is dividing it between public and private in terms of staffing, doctors working here and working there, it doesn't really add to the overall

volume. And we've got a volume problem, okay? Which is one of the reasons, by the way, if you remember back in the day, one of the things that we did is we didn't just sign a deal with the existing private sector to use private sector capacity to treat NHS patients. We also enticed new private sector providers to come to England. I was going to say the UK, but England, in order that we could increase the size of the cake. And that worked really well.

Now, it wasn't everywhere, and we were quite strategic about where we located those new providers, largely in areas where there was very long waiting times for treatment. But one of the reasons, and the academic studies verified this, one of the reasons that waiting times fell so dramatically is not just that those guys brought new capacity, including new staff, with them, clinical staff, but it also provided competitive pressure for the NHS in those areas to up its game because we also introduced a system of payment by results, which basically said the more you do as an NHS hospital, the more you get.

And that was a big change. Today, there's the short term and the long term. And what there isn't, first of all, is a recognition that this is a crisis. I mean, I've been around health policy for 30-odd years. This is of a different order. It's a million times worse, probably arguably the worst it has ever been. Okay. So the first thing is you've got to recognize it. And the second thing is you have to have a plan to deal with it. And right now there's neither. If you're looking at through the strategy lens, the only option is for them to go short in order to try to prove that they can turn it around a little bit. Therefore, let us finish the job. That's going to be their argument with the next general election. It's perfectly obvious. But the big problems are deep, structural and fundamental and long term. Back to the 10-year plan. So you need a plan, first of all. Secondly, you need a recognition, which is that the way that system is currently set up, neither has the capacity, but nor does it have what I'd call

the alignment with today's problems. Biggest problem for healthcare throughout the world, including in our country, is the rising tide of chronic disease, arthritis, diabetes, dementia, all of these sort of issues. And our system is not set up to deal with any of that. It's set up to deal with episodic care in hospitals. That's where the majority of the budget goes. And indeed, you look at what's happened over a period of time and increase. increasingly it's gone there. Primary care, community care, the things that could be utilized to keep patients healthy and out of hospital are underinvested in massively.

7% fall in GP numbers since 2050. So how much is this about money? Some of it's about money, but some of it is about where we get the system focused. The third thing, therefore, that you have to do is, you know, it's quite hard to get visibility on this because everybody's drowning in pessimism. It's broken, it's finished, it's over. we've got to fundamentally tear it up, start again, introduce social insurance, all of this, frankly, bollocks. Social insurance would not add one jotted difference, not a direct difference.

It would cause turmoil for 10 years. Well, we've got turmoil. You know, what we want is order, what we want is sustainability. And the way to do that is to recognize that healthcare is going through a fundamental revolution where you've got the alignment of data analytics and genomic science, which are going to allow us, indeed a beginning to allow us today, to rather than than focus purely on diagnosing and treating patients. Instead, we can predict and prevent ill health. That's what we can do. But in order to do it, we've got to fundamentally change how staff are trained, how the workforce is configured, how resources are provided, what the infrastructure is that is required. So my message is a message of possibility and optimism. And that's

the thing. There's one four-letter word that is above all else missing from the debate about the NHS, and that is hope. And the hope lies in technological change. On technology, I have always found this a bit frustrating. When I came in in 2010, it was obvious, to me, it seemed, that in rural areas particularly, we could have been making much more use of live video links for people to see GPs. You know, my neighbor, for example, had Parkinson's and she needed a monthly consultation with a doctor in Newcastle. She didn't need to drive an hour and a half over the Penn Eye. But when I spoke in those days to the consultants and GPs, they said, frankly, it's just as easy for us if people come into the surgeries, right?

They weren't particularly interested in engaging with this issue. Then the next story in 2011 was data, right? NHS potentially had the greatest source of data in the world. We could do incredible things with data, at which point, I think privacy campaigners became very, very anxious about it. And it became very, very difficult to use the data that we've presented. to do any of the magical things that seem to be possible now, particularly with AI. I'm just using those as two examples because there's both a problem of resistance within the system. People may be not pushing as hard to adopt new technology as quickly as you'd like because it doesn't make much difference to them, but it makes a difference to the patient.

That's the first example. And the second example is the ways in which many of the things we could be doing with technology and data are stopped because we're worried about them for different reasons that have nothing to do with efficacy of health. And if I can just add to that as well by asking your assessment of your negotiations of the BMA, because you did the new GP's contract, and that was pretty difficult. BMA, a very effective trade union. The most effective in the country.

Yeah, and pretty good at standing up against reform. Of course. Yeah. You know, Rory's point about technology and the sort of cultural reaction to that within the system is often right. I think the big change, Rory, from when I was doing the job,

or even when you were, you know, 10 years ago, is that technology now is capable of doing things that we always wanted to be able to do, but we really didn't have the tools in the box. So remember, you know, we participated in the human genome project with Bill, Clinton, and all of that, you know, and it took billions to decode the first human genome. And now you can go and buy a test for it in New York City, and it will cost you $90. Okay. So, and buy, you know, in five years' time, it will be for free. Okay. So we're able to do things that we were never able to do. And the hope has always been that healthcare will be able to do what the founders

of the NHS wanted to do, which is to focus more on prevention than on treatment. And we've now actually got the tools to do it. The question is, who's thinking about it and what's the plan to harness it? And the answer is, no one's thinking about it and there is no plan to harness it. And that's the opportunity, frankly, that is going to be for the next Labour government. Right. So just to take it to the sort of current politics. One word answer, do you think the the jury can come back after the next election? At the next election, you mean? I think they could potentially deny Labour majority. Okay. Do you think there could be another conservative-led government? I think that's extremely unlikely. Okay. So if there's a Labor government, because the stuff that

you've just been talking about is, it might be the fringes of the debate, but it's not at the center of the debate right now. So what should the Labor Party be doing with its health policy between now and the general election? You know, at the moment, you could argue, well, there's so much to tack the Tories on, keep attacking them. Yeah. But what would you be doing in terms of setting out a positive agenda for the future. And would it start by saying, we need a new 10-year plan? Yes, it would. And I think West Streeting, who I rate very highly, by the way, the Shadow Health Secretary, I think he's sort of, he's got that idea. Look, the truth is, you know this as well as I do. There's a sort of debate, isn't there, in labour circles, between those, what I call the advocates

of the Ming Vars strategy, the people who think that, you know, we're 20 points ahead, it's all in the bag, da-da-da-da, da, let's tread carefully, let the Tories continue to screw up. and somehow rather we can get over the line. We'll not surprise you know I'm not in that camp. And I'm not in that camp either. We'll not surprise using it all. And I'm slightly caricature in that position, but that's sort of what I feel about it.

So it's a position of, I think, utter complacency and real danger for the Labour Party. And my view is that you only ever win if you have a project. The big leaders have big projects. People, including me, mightn't have like Margaret Thatcher, but boy or boy, did you know where she stood? she had a project which was to marketise Britain. That's really what it was. I'll just start with Clementality. Or Clem. And Blair, if you were asking what was the equivalent of the Thatcher

marketisation, it was the Blair modernisation. People might like it, might loathed it, but there was total clarity. And that is what the Labour Party's got to get to. It's got to get to a position of total clarity. And for Waze, my feeling is, I don't know, he's probably more in the latter camp than the former camp. And I think he's got the idea that we need a 10-year plan. It's got to be long-term. You've got to buy time. And in dealing with the trade unions and the BMA, you're 100% right. They are a very, very effective trade union, the most effective in the country. And it's not easy to negotiate with them. And Alan, just for listeners, what's the BMA? Just tell them what the BMA is. The British Medical Association. And it's the union of the doctors, consultants as well as GPs. The trap to avoid, and I certainly fell into a. the times was because the trade union is the trade union and therefore it's good at opposing things, the trap to avoid is to make doctors the enemy.

The government is sure as hell doing that right now. Yeah, but it's also a pitfall for the Labour Party. It only works if you get the doctors and the nurses on board. And this is to Rory's very first question about how you manage this thing. The trick in all of this is to be able to get people to believe that the problem, whether you're a doctor, a nurse, a social care worker or a patient, the problem is that you're having to fight a system that is not working in the interests of the people who really count. So that's the political trick that you've got to be able to perform.

And that's sort of what we did with the NHS plan, which you were alluding to. If you remember, there was a foreword to that NHS plan and people talk about how good the policy was. The really important thing was that I got the BMA, the RCS, Unison, the patient. groups, the NHS Confederation, all of these various interest groups, I got them to sign up to the principles of change. And that was a really important thing because for quite a while, people felt that this plan, which was a Labour Party, Labour government plan, was theirs. You've got to find a way buying them in. Okay, let's take a break and we're back with Alan Milburn in a second.

Hi, everybody. It's Dominic Sauerich here from The Rest is History. Now, some of you may have heard me on your show, The Restis Politics, when Rory was away and I was filling in and enjoying Alistair Campbell's tremendous banter. And I'm back to tell you about our new series on The Restis History, which is all about Britain in the 1970s, a period with a lot of uncanny resemblances to our own. So right now we're living through a moment when oil shocks generated by war in the Middle East are rippling through the world economy, when Britain feels like it's sunk in a bit of a Malays, people are arguing about Europe, the government has got a few issues with the trade unions, and we have a kind of, I suppose you'd say governing elite, a kind of political class that is

really struggling to come to terms with all of these issues. And people are asking if Britain is governable at all. So there are a lot of parallels between that Britain that I'm describing, which is our Britain and the Britain of the mid-1970s. So in this series that's coming out on the rest is history, we're looking at these and other issues. We'll be talking, about the rise of Margaret Thatcher, obviously a colossal figure in our political life even now, whether you love her or loathe her. We'll be talking about the very first Brexit referendum of 1975, a subject that I'm sure Rory and Alastair will have strong opinions about. We'll be talking about the fall of the Labour Prime Minister Harold Wilson and we'll be talking about

one of the grimest moments in Britain's economic history, the moment in 1976 when we had to go cap in hand, as people said at the time, to the... the International Monetary Fund, the IMF, for a then record bailout. Now, if that sounds good to you, how could it not sound good to you? Of course it sounds good to you. We have a clip for you to listen to at the end of this episode. And if you want to hear more, just search for The Rest is History wherever you get your podcasts. Welcome back to leading with me and Rory talking to the right, honorable, Alan Milburn.

We're in a, in a sense a sad time. As Jacintra Arden, the Prime Minister of New Zealand, has announced that she's stepping down, partly because she found the job pretty brutal. And I wondered whether you, now that you've been out of it a bit, can reflect a little bit on that. There's not understandably much public sympathy for MPs. I go on Twitter, the general impression is that they're overpaid, idle, incompetent bunch who don't deserve any sympathy at all. But I wonder whether you could reflect a little bit on what was sometimes tough and depressing about the job. And not necessarily just as a Secretary of State for Health, but as an opposition backbencher, as a government backbencher, what is it that the public doesn't always see about the inner life

of MPs and the strains? And why is it ultimately you decided to leave politics? Because obviously somebody like you could easily still be in politics, you could still be in the shadow cabinet. You're a young man, Alan. 65 in 10 days time, I'm. Are you? Yeah. You 65? Yeah. So am I. Almost as old as Alistair, yeah.

Tell us a little bit about the maybe what's revealed less to constituents. So maybe you didn't reveal so much to voters when you were there, but you'd be happy to reveal now about the tough sides of the job. Yeah, look, it's, I mean, you're quite right. It's very different from any other leadership position. I lead businesses, I chair businesses, I chair charities and so on and so forth in my post-politics life. And they're all challenging, but not as challenging as politics for this reason. The accountability is everywhere, everywhere. And it's massively intensified since I left politics.

So you've got the accountability to your party, to your party, to your. your constituency to the media, to number 10, to number 11, it's just everywhere. And it's coming at you all the time. So you're in this goldfish ball of scrutiny, you know, about who you, who you are, what you're doing, and there's no escape from it. And, you know, the truth is, for me, you know, I had two young kids. We were living, I think there were two of us in the cabinet at the time. I think there was Alistair Darling and me who had the youngest families.

and it was really difficult because I was away basically five or six days a week. And, you know, Tony kept saying to both me and my wife Ruth, well, you should be like it. Why don't you come to London? But I didn't want to, you know, I'm from the northeast. I still live in the northeast. It's my home. It always has been.

The kids were really happy in state schools, et cetera, et cetera. It was fantastic. Actually, it's worked, you know, in terms of our family life. So, but the strain on family life and just being. Absent became, for me personally, that was not something that I could deal with. And in the end, my view and it took me a long time to get there and even longer to go and have the conversation with Tony to tell him that I needed to go. That was probably one of the most difficult conversations I've had in my life. In the end, despite trying to manage it, I couldn't find a way of doing so.

So I just couldn't reconcile the public and private life thing. It just didn't work for me. And it was really difficult. And I think now, I would say in some senses, it's a million times worse. Because, you know, to your Twitter point, I mean, if you're a female MP, you know, seriously, I mean, the stuff, the vitriol, the venom. The stuff that Jacinda got was unbelievable. It's just, I mean, awful. I mean, it is just incomprehensible to me how that is in any way permissible.

It's just horrendous. And it does make me fear for democratic politics. The problem is that people are, tend to be more sympathetic to people from their own political party when they're the victims of this and less sympathetic when it's the other side. So I always find myself defending conservative MPs, not so much on their policies, but just on the fact that it's a tough life. And it's pretty brutal being abused and insulted and people out there saying you're evil and stupid every day of the week.

But of course, when I say that, half the listeners will be thinking, well, they are evil and stupid. There's no problem saying they're evil and stupid. Well, you've got to pick the ones your defender. I mean, you know, Nadim Zahawahey at the moment. He's going to get a bit, isn't they? But listen, the footballers get it every time they walk out on a pitch. I think it's a bit different because I think a footballer gets it when they're a pitch. No, it is difficult.

I'm not, listen, I'm not minimizing it. But often with a politician, it goes to the heart of people's character. It's deeply humiliating. I mean, that what's so clever about Twitter is the people coming after you. And they're almost psychopaths in their ability to discover your weakest point. Only if you let them. I keep telling you, only if you let them. I'm trying to educate, Rory, to get a bit tougher in his politics, Alan,

because I think ultimately he'd like to come back and have another crack at leading the Tory party. But he's got to toughen up with this stuff. Yeah, unfortunately. And that's the thing. The way that you actually deal with these things is you do end up wearing a, you wear a psychological suit of armour. That's the way that you deal. with it. And that's not healthy either. It's not healthy personally. And it's actually not

healthy in terms of the authenticity of the politicians. Because the truth of these, okay, so it's fine. Tell them to toughen up and you've got to be more resilient at all of these things. But, you know, people are people, people are different and people feel things. And I think in today's world, I do, I really fear that it is actively deterring people. Oh, there's no doubt about that. You two guys are an interesting case in point. So here you are, you're doing this thing, and it's very successful. And loads of people listen to it. And why are the listening?

Because actually, you've got different points of view, but you're conducting the conversation in a non-vitriolic, non-venous, and definitely non-violent way. Okay? And I actually think, and I think this is where the Johnson era, in retrospect, Rory, might have been a blessing. Well, and let me tell you why. Because I think people have now realized that that style of politics,

the bling, bling, the big character, The big man, say what you like, rules don't apply, everything's malleable. Isn't it interesting that the two leaders of the political parties that we have today, whether you like Rishy or loathe Rishy, and the same with Kia, they're very much sort of, they're cut from the same block in a sense. You know, they are technocratic, probably not that political, actually. Their calling card is around competence and not chaos. And I think that that's a reflection of where the public appetite has got post-Johnson and post-Trump.

Alan, you've been hugely generous your time. I'm going to throw in my last one and then I'm going to give a last one to Alistair, but cheeky last one, if you were, and I know you wouldn't want to do this because you're a loyal Labor man, but if you were giving advice to Rishi Sunak over the next 18 months, what's his best shot of doing a decent job in that office? In terms of winning the election or actually delivering some stuff. Let's go on delivering. I think he needs to double down.

as he's trying to do on a really few sharp deliverables, okay? But he needs to be brave in the execution. And I think the thing that really worries me back to the health beat, I think they're thinking, for perfectly understandable reasons, because even though they won't say the word, the system is in crisis, they think the answer is pull everything back to the centre, performance manage the hell out of it,

sack the chief executives who are not doing a good job, all of the usual stuff, and I can tell you from bitter experience, because I've been around that course, it won't work. Not in a million years will it work? Because these people working in this system, look, they're high-caliber people. Doctors are high-caliber individuals. You've got to treat them with respect. You've got to treat the nurses with respect. You can't stand on clapping them one day and then deriding the next day. You just can't do it. It's an odd thing to say, because I think people often see being political and being a good deliverer sitting in slightly different positions,

they're not. He needs to become more political. And the first thing that he should do, understanding politics is sit down with the nurses, get them into Downing Street, do the deal. There's a deal to be done. The unions want to do it. I know they do.

I can hear it in the language that they're using. Get it done. Get that problem off your plate. He's not going to do it. And the reason he can't do it, Rory, is that your party, he's both too weak and your party is no longer a single party, it's a double party. It's a party of Singaporeans who want low taxes, small state,

and it's a party of Red Wallers who want exactly the reverse, and that isn't going to work. Yeah. And the other thing that my friend Jim Down said, I should ask you, is what would you say to a junior doctor who's coming out with a hundred thousand quids worth of debt, earning 14 pounds an hour, impossible to live in London on the sort of money that they're getting,

how do you persuade them to stay with the health service and when they're getting treated in the way that they are and derided, as you say, and attacked by the media and all this stuff? Well, I think the first thing that you've got to do is you've got to give them and other staff in the NHS and, by the way, the social care system because they're two sides of the same coin. You've got to give them a sense of hope about the future. And right now, you know, morale is always at an all-time lower than the NHS.

But it really, really is. And you can see that in the exit numbers. So I think they've got to have a sense of hope. that actually the system can be successful and sustainable. And that's the government's role. It's got to do that. Secondly, I do think that we have to do a deal with the future generation of doctors and nurses for that matter, but particularly doctors,

which is that I always thought there is a deal to be done about, okay, we can be more permissive of things like your fees, the student fees coming out, in exchange for a commitment from you that you are going to commit. to the NHS for a period of time. Maybe not for your whole career, but for a period of time. I like that. People are mobile, geographically mobile. Let's do a deal, guys.

How is listening to that one, Rory? Get the private sector back. And my final, final, final question, promise. Did we do enough on mental health? No. No, we did. I think we did some good things. I'm pleased with some of the things that I did.

But I think, given the priorities that we have, actually, it's interesting. The three clinical priorities I had were cancer, and coronary heart disease because they were the biggest killers and mental health because it was the most endemic crisis. Might have been the biggest killer, but it was the most endemic crisis. It seems to where you can do the most prevention. And you can do the most prevention.

And actually, I think that there's been a lot of progress, but not nearly enough. Not nearly enough. Well, Alan, it's been a joy. Is he still your hero, Rory? He's still very much my hero. Has he been made more your hero or less your hero by the last hour? I would vote Alan Melbourne.

So, Alan, just to get it right, you're still labour. Yes, of course. So I think Rory has just said he's going to vote Labor. Well, if Alan's running, I'm voting for him on a personal ticket. I'm not voting for the party. Oh, of course. These MPs always have a personal following. You know about that.

But personal is political. You remember that, Rory. Well, Alan, good luck at everything you do. Good luck to your wife and kids. I'm not going to say good luck to your football. Well, actually, I will because of Brendan Foster, as you know, is one of the finest men on the planet. He is absolutely. My neighbor.

Yeah. Well, thanks for coming in. Thanks for giving us so much of time. Yeah, wonderful. Thank you. All the best. All right, Rory. So there we are.

That was Alan Milburn. I should say to our listeners, if they did hear a bit of background noise, we're in an office and it's in a room, but it's sort of quite glassy. And you may have heard a few people wandering around being consultants in the background. What did you think? I thought it was really great. And thank you for getting him on. I mean, that's another of the many people that we need to give you credit for. That was you getting him on.

I was reading, doing a bit of research on the BBC, looking at Alan back in the day. And he was a proper kind of bearded CND campaigning guy. memories from Newcastle trade union leaders of him, barely being able to afford a pair of trousers, leading marches across bridges in the age of 21. And a big change now to somebody who, you know, very much looks like the businessman. In his corduroy suit, he was wearing a corduroy suit. I haven't seen those since I was at university. You sort of sensed a bit like with you, you sensed a frustrated politician in there. Yeah, well, I think he must have been so proud of what he achieved. And it's a real problem that he didn't stay. Because I think somebody

with that degree of thoughtfulness and courage is hugely important. Yeah. Although I do think he pointed out about West Streeting. I think he's right about West Streeting. I think West Streeting is not a Ming Vars guy. I think he's somebody who wants to, you know, break doors down and really make change. Here's a challenge to you. If you want to have a 97-style Blair victory,

if you want to get people like me in the centre ground voting for Labour, you're going to have to get many more people sounding like Alan. Melbourne out on the airwaves because it's very rare at the moment to hear the Labor Party acknowledging how difficult things are, acknowledge that the trade unions can be tricky, acknowledge that reform needs to happen. Everything that Alan Milburn said was deeply reassuring for a centre ground voter like me. And I'm hearing too much I feel from Kirstama and the Labor Party of Tory's rubbish. We're going to make it all better. There's going to be money for everybody. It's all going to be fine. I want to hear more Alan Milburns to vote Labour.

Well, I certainly do think in the sort of preventive approach on health. And, you know, that stuff about technology. But I think one of the things that we've lost in our politics is the politician as educator. And, you know, I know you're interested in artificial intelligence. And I was at this incredible presentation by a law firm, Pinsent Mason's last week, where they were doing a big presentation about how artificial intelligence is now being used in the legal system. There are lots of dangers of that. They're even talking about some minor cases in the States.

now which are being kind of decided by effectively by AI courts. So, you know, there's lots of dangers there. But I just feel the level of debate that's going on within that world, and it's total divorce from what's happening in politics. So what he was talking there about genome, analytics and so forth, I think there needs to be a kind of educative piece done about the possibilities and the opportunities that are there. 100%. Well, thank you.

Thank you. We should let you go. But it was great. All the best. Take care. Thank you.