LOS ANGELES TIMES INTERVIEW : Virginia Bottomley : Britain’s Health Secretary Balances Costs and Care for a Nation

She has brought more than a touch of glamour to the British Cabinet--so much so that Health Secretary Virginia Bottomley is depicted on the irreverent Spitting Image TV show as Prime Minister John Major’s girlfriend. But she is hardly the dumb-blonde caricature of the series. Rather, Bottomley, 44, holds one of the toughest jobs in the Cabinet--con stantly under fire from the opposition, which accuses the government of trying to undermine Britain’s famed National Health Service.

And as health secretary, boss of one of the big “spending” departments in government, she is frequently locked in battle with Treasury officials who are in the business of trimming her $62 billion-a-year NHS budget. However, she has had plenty of training for her arduous job.

Born in Scotland as Virginia Hilda Brunette Maxwell Garnett, she grew up in a middle-class, socially aware family. “For me, there wasn’t really a decision about whether or not to do something in the public arena,” she recalls. “It was almost taken for granted that I would.”

She studied sociology at Essex University and took a master’s degree at the London School of Economics. At 19, she married Peter Bottomley, who became a member of Parliament and transportation minister. A mother of three, she was a researcher in child psychiatry, and was appointed a magistrate at age 27. She won election as a Conservative MP in 1984. In government, she served in various sub-Cabinet posts: in the Departments of Education, Overseas Development, the Foreign Office and Environment, before moving to Health, from which she was appointed to the Cabinet as secretary last April.

Bottomley denies that the Major government is trying to privatize the NHS, insisting that she herself has never received private medical care, and points out that her daughter is a doctor with the NHS.

She supports women’s rights and equality, and is responsible for the governmental department that is the country’s largest employer of women--some 750,000--mostly nurses.

If she doesn’t blot her copybook, her political future is bright indeed. As opposition Labor MP Frank Field, with whom she worked on joint committees, says of her “English rose” attraction and clear speaking voice: “She knows that she is incredibly good-looking--and this government is short of talking heads on the box that don’t make voters beg for the return of steam (early) radio.”

Question: There is growing criticism that, over the years, the medical research Establishment has wavered on issues that concern women more than men. For example, many critics both inside and outside the medical Establishment insist that breast cancer research has been neglected in relation to its incidence among women. Does that resonate in Britain?

Answer: I think there is little resonance of that here. Indeed, in this country we have taken forward a number of health programs directly related to women’s health. We were one of the first countries in the world to have a national call and recall program for breast cancer and cervical cancer screening. And the new steps we have taken in our general practitioner contract--our family doctors contract--give them additional rewards for reaching almost universal coverage in the cancer-screening program. So one of the strengths of the National Health Service is its universality, its accessibility to all and, through the family doctor service, we are particularly determined to reach the groups who would otherwise be reluctant to come forward for health care, and, within that target audience, the needs of women--both in terms of cancer-screening and maternity services--are a clear priority.

Last year I launched a document, “Your Health--a Guide to Services to Women,” available free to anyone who applied for it. It was extremely popular. Women are interested in health. They want to know what is available--they want to know for themselves and they want to know for their families.

Q: The allocation of resources here has been a running argument. As people live longer, health care costs are higher. How does your government, or any government, cope with these costs vs. treatment? Do you foresee solutions as to how to deal with this in a time of dwindling revenues?

A: Around the world it is clear that every country is facing the same challenges: aging population, rising expectations and the incredible ability of new medical techniques to combat diseases and disabilities that in the past would have been inconceivable. Our health service is one of the most efficient in the world. We spend a smaller share of our GNP, although a rising one, than many other countries, and it has great strength in that it is universally available, accessible to all and free at the point of delivery.

Those are fundamental principles which I shall hold to. The reforms we have introduced have been about trying to ensure that we use those resources more effectively, that we integrate what I call the cultures of caring and costing. But, because we’ve had a free health service, we’ve very often been divorced from any knowledge or understanding of price or cost at all. In the minds of professionals and patients, it felt like a free service.

Our reforms have been to try to secure better management control over resources so that we can maximize the ability of the service to deliver patient care. At the same time we have been introducing a health strategy so we actually get health authorities to begin to identify and assess the health need of the local population and spell out how they are going to meet that health need. Of course, that means making difficult choices between investment in intensive care, investment in the latest equipment and providing ever-improved services for mental illness or learning disabilities, for example.

Some new techniques result in greater cost effectiveness--a rapid expansion in day surgery, for example. Whereas in the past patients would have gone into hospital for days or weeks, some use of pharmaceutical products can then reduce the need for hospital admission. So it is not necessarily the case that all medical advances lead to escalating costs. But as policy-makers we are in a much stronger position in this country, on the basis of our health reforms, to try to take the process forward, maximizing our ability to use those resources that we fight hard for, to get the best possible health benefit for the population.

Q: Often you use the phrase “health reforms.” What specifically do you mean by health reforms in the general sense?

A: We have tried to reduce some of the bureaucracy and the monolithic nature of our National Health Service--so that hospitals can become free-standing organizations answerable to the (health) secretary--still part of the National Health Service but with a more effective management structure. Above all, we have separated out the role of commissioning health care, to the role of providing health care through the hospitals, both part of the National Health Service, but a clearer recognition of the functions and a greater transparency of the cost elements.

Q: You do have an elaborate health service, and you also have very good private practices. Is there any fear--either from a government point of view or from an average patient--that somehow the government service may be second-rate compared with private health care?

A: We have a modest private sector compared with almost any other country’s, and ... my position is one of respect for the private sector; but my program is almost entirely concerned with ensuring that our National Health Service is and remains the envy of the world.

Perhaps the most effective way of responding to your question is to make a personal statement, which is that I, my family, use the National Health Service. . . . I think it provides the best health care for me and my family. And what I am committed to is safeguarding that National Health Service, free, available to all, for the people of this country.

Q: You don’t want to privatize it?

A: Not remotely on the agenda. I want to use the skills though, if there are management skills in the private sector--about the use of resources, about information technology, about management, about communication--that we can apply in the public sector.

If you are characterizing our health service in the past, I would say that our clinicians were outstanding, their techniques were in the forefront. We have to make sure that our management skills are as good in a public service as our clinical skills. And this is, of course, the whole focus of the Prime Minister’s Citizens Charter program. Citizens Charter is about making sure that public services are accountable, that they give value for money, that they put the user in the forefront of concern. Our patients Charter has been the pioneer of the Citizens Charter movement, spelling out what are the rights and standards that patients can expect from the National Health Service, and we have been seeing real results in terms of falling waiting times, improved quality of service.

Q: Do you think the British experience with the National Health Service bears lessons that the United States could learn?

A: The strengths of the National Health Service are its universality, its availability to all. It seems that any health service ... needs to think about how to reach those groups who are often most at risk in terms of health need. So when it comes to HIV and AIDS, there are many anxieties about people coming forward, but having to pay for their treatment is not one of them. And those who are sick already have one handicap; we want to be sure that there is no further disincentive for them seeking treatment. The advantages of a system that encourages prevention is that you want to achieve the access. So that the strength is the universality.

An additional strength is our family doctor service, so that virtually every individual person in the country is signed on with a general practitioner--a generalist--who is the gatekeeper, the filter, a source of communication for the individual who is referred on to a hospital. Any other country taking forward a proposal has to examine those proposals in the context of its own traditions.

Q: Specifically, how does Britain keep down the cost of health care?

A: The issue will always be, for health secretaries, how to hold the ring between investing and encouraging those areas which don’t necessarily hit the headlines. In addition, some of the more glamorous, experimental treatments, which cost huge resources, but result in relatively modest improvements in the quality of life, have to be balanced against areas where there is less public and political interest, but relatively modest sums can achieve substantial improvements. . . .