Exclusive interview: David vs the Goliaths of bossy government

He wants the NHS freed from political control, he would not have voted for the smoking ban and he thinks Patricia Hewitt is the worst health secretary ever. Conservative leader David Cameron opens up to HSJ

The Conservatives' plans to put power into the hands of clinicians should not be seen as a slight to NHS managers, who have an 'unsung' and 'important' role in the NHS, according to leader David Cameron.

Speaking to HSJ, Mr Cameron detailed his plans for a more autonomous NHS - free from the interference of politicians and with more power devolved to GPs, as outlined in the party's 'white paper' NHS Autonomy and Accountability, published last week.

Managers

The Conservative leader says: 'Of course you need managers. You need talented managers, you need empowered managers but I think that what we need is an improvement in the quality of management that's based on managing for local circumstances rather than just managing to meet the latest edict from Whitehall.'

He says the last 10 years have been about managers working towards targets, not outcomes. 'If you get your managers just to focus on hitting the process targets, of course they'll do that but everything else will go to hell. I don't think good management is just about hitting national process targets. Good management is about making sure your organisation is achieving all the goals it should in terms of treating patients, recruiting and retaining staff and keeping costs under control. Managers in the NHS do a very important and often unsung job. I think they have come into disrepute in a way because they have been seen, sometimes by the clinicians as well, as managing to satisfy the weight of Whitehall directives rather than managing for the good of the organisation.

'If you were starting from scratch you probably wouldn't have exactly the system we'd inherit [from Labour] but for the sake of not having pointless reorganisations we will keep and make work what is there. But as GPs do more and commission more, as patients have greater choice and the system of choice and voice drives standards, I think the need for great overarching bureaucracies will decline.'

However, Mr Cameron says primary care trusts and strategic health authorities would still have a role to play under the Conservatives.

'We are not suggesting tearing up the structure of PCTs or SHAs, so you have still got those parts of the health economy there. But if you look at the decisions that are being made to close hospitals - particularly community hospitals - and reconfigure services, often you find the GPs are massively against these changes.

'They don't believe it to be in the long-term interests of their patients and their local areas. So it might be better to put power and control into their hands as we are more likely to end up with a health service that reflects local needs. Then we're saying judge them on the outcomes in terms of how the health of local area is improving.'

Power to clinicians

The Conservatives' white paper would give greater power to frontline commissioners. Under practice-based commissioning, GPs would get real as opposed to indicative budgets and they would be responsible for most primary care commissioning.

Mr Cameron says: 'The big nature of the change we are arguing for is to empower GPs and clinicians and what you have then is decision-making in the NHS being led by what patients and GPs choose to do with their budgets.

'At the moment, what you tend to have is hospital closure programmes and reconfiguration being driven by deficits which have been caused by government top-down mistakes and which are implemented by bureaucracies people have very little trust in.

'The head of your PCT changes and chops endlessly. The people who you know are permanent in the health service, who have a real understanding of local health needs, are the GPs.

'So I believe genuinely in putting a lot more trust and power in their hands. I think that then where you have much-loved local hospitals and GPs understand the role they play, their commissioning decisions are more likely to make sure those local hospitals would be saved.'

Independent board

The white paper also calls for an independent NHS board to oversee the commissioning and allocation of services as well as the delivery of objectives to improve outcomes for patients, as agreed with the health secretary.

According to the NHS Confederation, the idea is something managers are not in favour of. But Mr Cameron feels otherwise: 'I think managers will be hugely relieved by the overall thrust of the proposal, which is to get rid of the top-down centralisation we have had from this government and to empower people locally.

'That includes local managers just as it includes GPs. Taking politicians out of the day-to-day running of the NHS will also be good not just for managers but for patients and the NHS.

'I like to see this as a careful progression, an evolution, not a revolution, a careful progression of sensible steps: make the priority the NHS, which I have done, explain how it will have a major call on resources under a Conservative government, entrench into law the fact that the NHS is free at the point of use and that NHS money is there for NHS patients, drive down power to the lower level to take the politicians out of the day-to-day running, and free up the DoH to become a Department of Public Health.'

He refutes the claim of NHS Confederation chief executive Dr Gill Morgan that a board 'may lead to politics appearing in a less overt and less accountable way'.

'I think the NHS will be more transparent because what we are trying to do in the white paper is set out those things that politicians are responsible for and those things they're not and that can only help. That's why Gordon Brown has looked at the issue [of an independent board] and I hope he will look at it again.'

Mr Cameron has harsh words for health secretary Patricia Hewitt, who reportedly said that an independent board 'wouldn't work as you can't run the NHS like a 1960s industry'.

He says she is 'quite self-evidently the worst NHS secretary we have ever had' and that he 'would rather listen to [his] cat'.

Mr Cameron says that one of the government's greatest failures on health policy was public health. He highlights the 'epidemic' of sexually transmitted diseases, obesity and diet, hepatitis C and drug use.

He adds: 'There are some really big public health issues that we are just not getting to grips with and the structure needs to reflect that.'

'[Shadow health secretary] Andrew Lansley has always said he would like to be the secretary of state for public health and he would like the DoH to be the Department of Public Health and that is the scale of what we are trying to achieve.'

However, Mr Cameron admits he would not have voted in favour of the smoking ban - he was on holiday at the time - as he is not a fan of a 'bossy' government.

'I believe in social responsibility and this applies to health. When it comes to health we all have got a role to play. What I have always not been keen on is a very bossy, interfering government. I believe in social responsibility rather than government control.

'So I tend to vote against government bans and over-prescriptive legislation because I believe in freedom and responsibility.'

Targets

He defends his stance against targets. 'Look at the bigger picture. We are moving from a system of trying to hold clinicians accountable through top-down targets, which are about processes, to a world where you make people accountable through the choices that patients make and through strong patient voice through HealthWatch (a national body for patient voice proposed in the white paper).

'It's as simple as that in a way. How do you make people accountable? The government tried to do it through top-down targets and publishing information on them which misses the outcomes or you can try and make people accountable through choice, information and voice.'

'Once you have got a system where hospitals have greater independence with the foundation hospitals, where you have a payment by results formula which we think can be worked on and improved and where you have patient choice and GP commissioning, those things will drive the quality of hospitals. If they don't perform they are not going to get the revenue.

If GPs do not perform, he says, they will not achieve the health outcomes they should be, 'and so you're creating a very sensible system which will drive up quality rather than trying to do it on high with process targets rather than outcome targets'.

He adds: 'A lot of people in the NHS will welcome the commitment from the Conservative party to the NHS, the commitment against opt-outs, the commitment to more money, the commitment of independence and getting the politicians out the way, the commitment to driving down power in the NHS and the commitment to public health.

'It's a very sensible, moderate progressive evolutionary agenda. It's been very well thought through and I can't think of an opposition party that has done more to set out a serious sensible agenda that people in the NHS can engage with.'