'Is Bevan's NHS under threat?' (updated), by Albert Persaud and Geraint Day

'Is Bevan's NHS under threat?' (updated), by Albert Persaud and Geraint Day

• 1.
    Is  Bevan’s  NHS  under  threat?                                  "fair  trade  in  knowledge  for  health"                                                                                                                                                                                                                                                                                                                          APGD                                                                                                                                                                                                                                                                                    2015                                                                                                                                                                                                                                                                                                                    
• 2.
  1       Albert  Persaud  (AP)  1 and  Geraint  Day  (GD)  2   This  article  is  a  revised  and  expanded  version  of  written  evidence  submitted  by  Albert  Persaud  to  the   All  Party  Parliamentary  Group  on  Primary  Care  &  Public  Health  –  of  the  United  Kingdom  Parliament  –   in  2013  for  its  inquiry  into  ‘The  sustainability  of  the  National  Health  Service  (NHS):  Is  Bevan’s  NHS   under  threat?’   Preamble   For  many  people  there  may  be  three  important  pillars  of  British  society:  the  weather,  the  monarchy   and  the  NHS.  Politicians  can  do  little  about  the  weather  and  even  less  concerning  the  monarchy,  so   the  NHS  has  become  a  politicians’  playground.  One  of  us  (AP)  joined  25  years  after  the  creation  of   the  NHS  by  the  Welsh  politician  Aneurin  Bevan.    AP  recalls  similar  questions  being  asked  then  as  are   now.  Since  that  era,  there  have  been  numerous  top-­‐down  reforms,  policy  announcements,  policy   changes,  all  politically  driven  with  one  distinctive  feature;  which  is,  all  the  pronouncements  have   been  largely  aimed  at  the  length  of  the  particular  political  party’s  life  in  government  (about  four  to   five  years).∗  Very  few  of  these  changes  have  been  evidence-­‐based,  or  properly  costed,  but  more   importantly,  have  been  deficient  of  seriously  thought  through  implementation  plans  to  bring  about   real  changes.     At  any  given  time  a  busy  NHS  hospital  ward  in  England  may  have  over  ten  kilograms  of  documents,   policies,  guidelines,  ‘good  practice’  guidelines  from  its  NHS  trust,  hospital  policies,  and  so  on,  all  on   shelves   covered   in   dust   (with   due   account   taken   of   infection   control   policies,   no   doubt).   Interestingly,  the  Temperature,  Pulse  and  Respiration  (TPR)  chart  used  today  is  basically  the  same   one  that  was  introduced  in  1948.  Also  of  significance,  the  people  –  NHS  workers  -­‐  who  are  meant  to                                                                                                                             1   Co-­‐Founder   and   Director   of   the   Centre   for   Applied   Research   and   Evaluation   -­‐   International   Foundation.   (Careif):   www.careif.org   NHS   experience:   Completed   37   years   in   the   NHS   with   the   last   ten   years   at   the   Department  of  Health  (DH).  Started  in  the  NHS  in  1974  as  a  hospital  porter,  then  trained  and  practised  as  a   clinician  in  mental  health  (psychiatry),  at  the  front  end  of  patient  care,  worked  in  public  health  and  then  at  the   DH   and   crafted   some   of   the   most   progressive   mental   health   policies   including   amendments   to   the   Mental   Health   Act.   2007.   He   is   acknowledged   as  one   of   the   top   40   people   of   Asian   origin   to   have   influenced   the   development  and  shape  of  the  NHS;  Nurturing  the  Nation:  The  Asian  Contribution  to  the  NHS  since  1948;  (DH   Runnymede  Trust;  2013:  http://nurturingthenation.org.uk       2  Health  policy  advisor,  NHS  England  Lay  Assessor;  Care  Quality  Commission  Lay  Inspector,  employee  of  a  royal   college,  former  head  of  health  policy  at  the  Institute  of  Directors,  and  former  NHS  public  health  statistician.  He   worked  with  DH  and  others  to  help  create  NHS  foundation  trusts.   He  is  a  branch  committee  member  of  a   healthcare  friendly  society  and  worked  with  Albert  Persaud  in  both  Wiltshire  and  Swindon  Health  Authorities   in  the  1990s.  www.linkedin.com/in/geraintday.  Writing  here  in  a  personal  capacity.   ∗   From   May   2010   the   UK   Government   has   been   formed   by   a   coalition   of   two   political   parties   and   with   a   parliamentary  term  fixed  at  five  years,  but  the  same  principle  applies,  we  assert.    
• 3.
  2       use  or  observe  the  advice  or  edicts  of  these  documents,  have  for  the  most  part  since  1948,  hardly   ever  been  involved  in  their  drafting  let  alone  assessed  them  for  their  relevance  to  them,  their  work   and  the  patients  they  care  for.                                                                                                                                       With  every  new  policy  change  or  pronouncement,  what  seems  to  have  invariably  emerged  has  been   a  plethora  of  NHS  experts  in  England  in  particular  (where  most  of  the  recent  changes  have  been   occurring)  -­‐  some  self-­‐appointed  critics,  jargon  inventors  who  always  give  the  impression  of  wisdom   -­‐  they  know  what  is  right  and  what  is  wrong  with  the  NHS  and  to  those  who  work  in  it.  What  tends  to   follow  is  a  series  of  ‘word  salads’  –  a  group  of  words,  phrases  and  sentences  put  together,  that  do   not,  however,  make  a  lot  of  sense.  (Note:  such  behaviour  is  similar  to  symptoms  sometimes  found  in   people  with  a  serious  mental  illness  like  schizophrenia  that  sometimes  requires  medication).  There  is   now  an  industry  of  such  people  and  consultants  (of  the  non-­‐clinical  variety,  usually)  whose  voice  and   ability  to  lobby  may  become  the  story;  instead  of  that  of  the  patients,  their  families  and  NHS   workers.   The  NHS  is  unique  and  a  precious  pillar  of  UK  life.    What  is  never  discussed  or  indeed  recognised  is   how   it   has   moved   and   progressed   since   its   inception;   this   is   sadly   very   often   true   of   politicians   including  prime  ministers,  experts,  economists,  vested  interests,  patient  groups  and  others.  The  UK’s   NHS   has   long   depended   on   overseas   people   and   nations,   however,   what   is   and   has   never   been   adequately  recognised,  is  the  contribution  made  by  migrants.  People  came  to  the  UK  in  the  1950s   and   1960s   and   in   subsequent   years,   to   build   the   backbone   of   the   NHS.   They   came   from   the   Caribbean,  India,  Pakistan,  Malaysia,  and  Mauritius  and  elsewhere  to  add  to  those  from  England,   Scotland,  Wales  and  Northern  Ireland.  It  is  time  that  this  fact  be  truly  taken  into  account  and  openly   acknowledged.   Is  ‘Bevan’s  NHS’  under  threat?   The  All  Party  Parliamentary  Group  (APPG)  on  Primary  Care  &  Public  Health  posed  a  number  of   relevant  questions:  on  how  the  NHS  was  delivered,  its  scope,  costs,  current  structures  and  the  future   of  the  NHS.  In  what  is  written  here  we  attempt  to  go  to  the  centre  of  the  crossroads  at  which  the   NHS  finds  itself.  In  a  way  it  moves  away  from  a  certain  mindset  in  parts  of  the  NHS  that  cuts  (or   ‘efficiency  savings’,  if  you  care  to  adopt  a  particular  politically  driven  management  term)  means   fewer  ‘tea  bags  and  papers  clips’∗ .  The  same  thinking  continues  that  those  with  ‘vested  interests’   [doctors,  nurses,  royal  colleges,  the  British  Medical  Association  (BMA),  NHS  trusts,  chief  executive   officers  (CEOs),  some  patient  groups  and  organisations  and  increasingly  the  voluntary  sector  now   supposedly  wearing  the  mantle  of  the  Big  Society]  must  be  obeyed  and  venerated;  and  that,  if  you   make  ‘cheap  shots’  at  the  frontline  staff  -­‐  those  who  provide  the  care  –  that  they  must  ‘work   smarter’  –  a  concept  that  seems  to  presuppose  that  these  same  workers  have  to  accept  that  they                                                                                                                             ∗  There  is  at  least  one  -­‐  and  probably  more  -­‐  than  one  large  NHS  trust  in  England  at  which  the  staff  have  been   told  that  they  had  to  provide  much  of  their  own  stationery,  including  pens.  That  sort  of  management  and   leadership  seems  entirely  arbitrary  and  unlikely  to  contribute  much  towards  the  ‘efficiency’  savings  averaging   millions  of  pounds  per  trust  being  demanded  of  the  NHS  in  England  by  the  UK  Government.  
• 4.
  3       are  deficient  in  intellect  (stupid)  in  the  first  place!  Similarly  a  good  case  could  be  made  that  the   current  problems  of  the  NHS  are  inherently  caused  by  politics  and  politicians  where  ideology  often   gets  confused  with  common  sense,  choice  gets  confused  with  preference  and  evidence,  facts  and   reality  get  confused  with  opinion,  folklore  and  myths.   As  far  as  England  is  concerned,  the  NHS  should  sit  alongside  the  Home  Office  and  HM  Treasury  as   primary  functions  of  the  UK  Government  rather  than  as  it  stands  number  nine  or  so  in  the  list  of   Government  relevance  and  importance.    In  England  the  Secretary  of  State  for  Health  needs  to  be  a   person  who  commands  the  respect  of  NHS  staff,  professionals  and  the  public;  capable  of  putting  the   NHS  first  rather  than  purely  party  politics,  respect  the  NHS  and  maybe  performing  the  role  of  an   advocate  rather  than,  in  some  cases,  giving  the  impression  that  the  NHS  is  some  sort  of  backwater  of   the  former  British  Empire.   New  NHS  Model   The  most  important  aspect  of  the  APPG’s  inquiry  was  the  notion  of  the  survival  of  the  NHS.   Here  we  propose  a  model  for  the  next  50  years  that  should  be  built  on  these  three  pillars:  creating  a   modern  NHS,  safeguarding  Bevan’s  values  and  founding  principles.     (1) NHS  Statute  Board   The  Government  should  establish  in  statute  a  board  to  direct  the  NHS;  similar  to  the  Bank  of   England’s  Monetary  Policy  Committee  but  not  the  current  commissioning  board  [which  has,  to  be   said,  gone  through  two  changes  of  name,  having  been  born  as  the  NHS  Commissioning  Board   Authority,  shortened  its  title  to  the  NHS  Commissioning  Board  and  now  lives  its  life  under  the  title  of   NHS  England  –  which  one  of  the  authors  (GD)  noticed  recently  may  abbreviate  to  NHSE  –  like  that  for   the  former  NHS  Executive,  which  was  abolished  in  the  year  2000,  not  having  reached  its  teenage   years].   This  board  would  oversee  and  direct  the  NHS  in  England  –  looking  at  the  NHS  as  a  long-­‐term  national   investment,  evidence  based,  focused  on  outcomes  and  the  patient,  staff  and  public  experiences.     The  board  would  set  the  policies,  cost  its  effects  and  set  out  clear  implementation  actions  and   timescales.    It  could  perhaps  be  chaired  by  a  judge  and  have  strong  legal  powers.  Although  other   options  could  of  course  be  possible.   The  board  could  set  out  in  clear  language  what  it  is  that  the  NHS  in  England  would  be  responsible  for   and  would  treat  -­‐  for  example:   • Category  A  (must  do):  for  example  dealing  with  strokes,  myocardial  infarctions  (MIs),  coronary   heart  disease  (CHD)  and  the  results  of  road  traffic  accidents,  maternity  services,  immunisations,   depression,  organ  donation  and  transplants,  and  blood  transfusion,  etc.   • Category  B  (would  do  after  serious  considerations  given  to  judicious  and  equitable  application  of   a  new  social  or  health  insurance  policy)  -­‐  long  term  and  residential  care,  and  rehabilitation,  etc.  
• 5.
  4       • Category  C  (not  delivered  through  the  NHS  but  done  through  social  or  health  Insurance):   including  in-­‐vitro  fertilisation  (IVF),  tattoo  removal,  circumcision,  hair  transplants,  etc.   The  board  would  produce  policies  that  join  up  health  alongside  physical  health  policies  (for  instance   around  CHD  and  diabetes)  with  mental  health  policies  (covering  self-­‐harm,  depression  and  so  on)  so   that  the  whole-­‐person  concept  is  considered  and  delivered  through  a  more  holistic,  preventative   and  whole  care  system  delivery.  Greater  use  of  the  evidence  that  links  physical  ill  health  and  mental   health  should  be  utilised.  For  example,  factors  leading  to  perceived  stress,  which  may  itself  be  a   causative  factor  in  occurrence  of  strokes  and  other  physical  illness.  The  board  would  go  further  by   producing  policies  that  join  up  government  departments,  such  as  those  dealing  with  drug  misuse   and  crime;  treatment  may  need  many  departments  and  other  agencies  to  be  fully  implemented   (such  as  the  Home  Office,  DH,  social  services,  education  and  the  voluntary  sector).  That  could  in  the   end  lead  to  better  outcomes.       Every  quango  including  the  National  Institute  for  Health  and  Care  Excellence  (NICE)  and  the  Care   Quality  Commission  (CQC)  would  come  under  the  jurisdiction  of  this  board.  It  would  direct  and   advise  DH  ministers  and  itself  answer  to  the  UK  Parliament.    This  would  be  a  remarkable  model  of   governance  that  many  might  argue  would  threaten  democracy;  but  the  NHS  is  a  remarkable   institution   Economic  Impacts  of  mental  disorder  in  England     • To  the  economy:  about  £105  billion  annual  cost  of  mental  illness;   • To  the  NHS:  ~£12  billion  or  11%  of  the  NHS  annual  budget  spent  on  mental  illness  (and  the   biggest  single  item  of  the  NHS  budget  when  considered  by  disease  condition);   • Proportion  of  the  total  burden  of  disease:  nearly  23%  of  the  total  burden  of  disease     • To  employers:    £23  billion  annually;   • Crime:  ~  £60  billion  annual  cost  of  crime  in  England  and  Wales  by  adults  who  had  conduct   problems  during  childhood  and  adolescence.                 No  other  health  condition  matches  mental  ill  health  in  its  combined  extent  of  prevalence,       persistence  and  breadth  of  impact.     (2) Local  levy   A  local  levy  could  be  charged  and  collected  through  the  council  tax  and  ring-­‐fenced  to  be  spent  to   support  the  local  NHS  in  England.  This  would  be  based  on  local  needs  and  demands;  for  example   maternity  care  could  be  supported  with  this  type  of  funding,  if  for  example,  extra  resources  were   needed  to  meet  an  increased  child  bearing  age  population.  Funding  for  specialised  services  (such  as   burns  units  and  trauma  networks)  would  need  to  be  considered  out  of  an  England-­‐wide  budget.   (3) Elected  not  appointed   Local  NHS  non–executive  directors  (NEDs)  should  be  locally  elected  (perhaps  every  three  years).  By   submitting  to  such  a  process,  the  candidates  would  be  able  to  provide  their  own  manifesto  for   improvements  of  the  local  population’s  health.    Healthcare  and  health  services  would  have  more  
• 6.
  5       local  ownership  and  participation  –  and  accountability.  This  model  is  totally  compatible  and  would be consistent with  pursuance  of  a  merger  with  health  and  social  care  services  and  budgets   Some  other  considerations  in  support  of  the  three  pillars  above  are:   Some  of  these  points  are  offered  in  some  ways  at  present  by  policy  makers,  but  need  to  be  pursued   with  much  more  vigour:   • Perhaps  90%  of  the  public’s  healthcare  is  delivered  by  the  public  themselves;  yet  the   public,  like  most  NHS  workers  –  as  taxpayers  and  NHS  funders-­‐  have  little  or  no  say   on  how  the  NHS  is  run,  let  alone  reformed.  An  exception,  so  far  limited  in  its  scope,   is  the  NHS  foundation  trust  model  in  which  local  people  may  have  a  vote  in  electing   some  of  the  ‘governors’  who  in  turn  appoint  the  NEDs.  Other  models  of  engagement   and  participation  must  be  considered.  NHS  England  has  been  working  on  a  range  of   possibilities  but  there  is  a  very  long  way  to  go.   • The  NHS  must  stop  the  constant  recycling  of  the  golden  cabal  of  failures  (individuals)   who  move  from  one  top  job  to  another.  Most  of  these  individuals  seem  to  go  on  to   anoint  themselves  a  level  of  importance  that  any  attempt  by  the  public,  or  indeed   NHS  staff,  to  understand  this,  is  quickly  met  with  contempt  and  disbelief  by  the   public.  The  Secretary  of  State  for  Health  should  stick  to  his  quite  recent  and  very   timely  promise  made  in  the  UK  Parliament  that  no  managers  in  the  English  NHS  who   had  failed  in  their  job  should  be  allowed  to  move  to  another  similar  one,  as  has  very   often  been  done  up  to  now∗ .  To  do  that  will  require  determination  and  negotiation   with  the  plethora  of  NHS  employing  organisations.  Yet  carried  through  it  must  be,  if   for  one  other  additional  reason  of  producing  equity  alongside  NHS  clinical  staff,  who   all  run  the  risk  of  dismissal  and  sanction  by  their  professional  bodies,  while  NHS   senior  managers  (or  ‘Very  Senior  Managers’,  to  use  a  term  that  has  crept  in  along   with  some  huge  salaries  in  the  last  few  years)  seem  to  operate  according  to  not  only   an  entirely  different  set  of  ethics  but  a  grossly  different  disciplinary  procedure.   • A  vibrant  NHS  needs  a  strong  and  emerging  voluntary  sector,  an  engaging  private   sector,  a  creative  and  accountable  social  enterprise  sector  and  an  engaged  public.  It   also  needs  a  much  stronger  and  transparent  partnership  with  local  authorities,  social   care,  business,  environmental  agencies,  education,  community  groups,  religious   groups,  young  people  and  entrepreneurs  of  various  sorts.  The  Labour  Party  set  out                                                                                                                             ∗    The  CQC  has  recently  published  a  regulation  to  deal  with  ‘fit  and  proper’  persons  at  director  level  in  the  NHS   in  England.  Alongside  that,  be  aware  of  a  senior  clinician,  who,  having  heard  that  the  chair  and  chief  executive   of  a  NHS  foundation  trust  had  resigned,  asked  the  question,  “I  wonder  where  they  will  pop  up  next”.  (A  luxury   denied  to  doctors  and  nurses,  for  example,  who  are  liable  to  the  risk  of  being  struck  off  their  professional   register,  it  must  be  stated.)  It  is  hoped  that  the  new  regulation  will  help  level  the  playing  field  at  least.    
• 7.
  6       its  stall  on  a  new  approach  to  NHS  policy,  in  February    2014.  That  review  (by  the   Oldham  Commission)  included  a  recommendation  to  better  join  up  health  and  social   care.  That  is  something  that  is  surely  needed.  It  also  explicitly  mentions  the   importance  of  housing.  Yet  it  is  also  a  case  of  history  repeating  itself.  Go  back  to   1945  to  realise  that  Aneurin  Bevan  was  actually  appointed  as  Minister  of  Health  role   with  a  remit  also  covering  housing.   • An  even  better  NHS  would  look  at  how  other  countries  do  healthcare;  promote   more  international  collaborations  and  see  technology,  evidence,  research  and   exchange  as  progressive  and  positive  thinking,  instead  of  a  host  of  often  disregarded   ‘pilot  initiatives’  which  may  often  seem  to  demonstrate  that  ‘not  in  my  backyard’  is  a   concept  alive  and  vociferous  in  the  world  of  the  NHS+ .   • NHS  changes  and  polices  must  be  unambiguous  about  their  impact  on  rural   communities  and  people  of  ethnic  minorities  and  be  applied  in  practice  as  opposed   to  simply  being  policy  statements  of  intent  around  such  vague  topics  as  ‘diversity’.   Thus  they  should  contain  means  of  demonstrating  how  they  are  actually  addressing   and  –  more  to  the  point  -­‐  dealing  with  inequalities.   • In  one  view  of  the  world,  those  with  vested  interests,  doctors,  nurses,  royal  colleges,   the  BMA,  other  trade  unions,  NHS  trusts,  CEOs,  some  patient  groups  and   organisations  and  the  voluntary  sector  might  be  perceived  as  speaking  for  all  but   representing  nobody  in  particular.    It  is  lazy  policy  making  when  a  government   invites  just  these  groups  (and  of  them,  ‘the  usual  suspects’  who  with  the  best  will  in   the  world  certainly  cannot  represent  all  needs)  to  meetings  and  discussions.  NHS   England,  for  instance,  has  made  welcome  moves  away  from  that  with  regard  to  use   of  more  individual  patients  and  members  of  the  public  in  recent  years,  it  is   acknowledged.   • Every  citizen,  group  or  set  of  professionals  is  an  owner  or  ‘shareholder’  of  the  NHS.   As  taxpayers  they  should  have  every  right  to  disagree  as  much  as  agree  to  what  is   proposed  about  the  NHS.  Engaging  with  the  disagreeable  is  a  sign  of  strength.  That  is   a  trait  that  seems  to  have  gone  out  of  fashion  in  far  too  many  public  bodies   nowadays,  when  it  appears  that  abilities  in  ‘good  news’  management  are  more   highly  remunerated  than  having  specialist  caring,  clinical  or  other  skills.  No  doubt   those  of  an  especially  critical  nature  might  prefer  the  term  ‘lying’  in  place  of  ‘news   management’,  especially  in  the  wake  of  the  prolonged  debacles  over  many  years  at   Mid  Staffordshire  NHS  Foundation  Trust  and  possibly  some  other  NHS  trusts.   • The  NHS  starting  point  must  be  from                                                                                                                             +  Although  thankfully  the  principle  of  nimbyism  has  not  been  enshrined  in  the  NHS  Constitution,  which  is   meant  to  guide  NHS  actions  in  England.  
• 8.
  7       ♦ care  groups:  such  as  children,  mothers,  young  people,  older  people,  men;   ♦ settings  (where  the  services  or  care  are  provided):  ranging  from  hospitals,   general  practices,  day  and  sports  centres,  the  independent  sector  to   supermarkets;   ♦ conditions  (disease  and  illness):  a  wide  spectrum,  including  depression,  CHD,   measles  and  the  consequences  of  hospital  acquired  infections.  Prevention   considerations  should  be  integrated  with  that  concerning  good  clinical   assessment,  diagnosis,  treatment  and  outcomes.   • The  current  non-­‐statutory  function  and  role  of  public  health  has  in  many  ways  failed   and  may  continue  to  fail.  It  is  not  wise  to  have  an  expensive  system  in  which  doctors   and  others  working  in  public  health  have  no  patient  or  hands-­‐on  contact,  yet  give   advice  and  what  may  come  over  as  imperious  commands  to  those  dealing  with   patients.  Many  frontline  practitioners  despise  this  system.  Public  health   practitioners  should  be  people  with  dual  roles;  both  in  patient  and  community   contacts  and  examining  population  public  health.  Such  duality  could  also  encompass   academics,  researchers,  primary,  secondary  and  social  care  practitioners.   • Who  exactly  runs  the  NHS  in  England?    Is  it  the  politicians;  is  it  the  DH  or  NHS   England?  Is  it  the  NHS  trust  boards?  The  Clinical  Commissioning  Groups?    Health  and   Wellbeing  Boards?  Or  local  councils’  Health  Overview  and  Scrutiny  Committees?   There  are  also  local  education  and  training  boards.  Or  perhaps  the  answer  is  to  be   found  in  Clinical  Senates  or  Quality  Surveillance  Groups?  The  number  of  separate   NHS  bodies  in  England  has  bloomed  under  the  Health  and  Social  Care  Act  2012.  And   the  Secretary  of  State  for  Health  has  assumed  renewed  importance  in  the  wake  of   the  Keogh  Mortality  Outlier  Rapid  Response  Review  of  14  NHS  acute  hospital  Trusts,   and  the  setting  up  of  the  CQC’s  Chief  Inspectorate  of  Hospitals,  judging  by  some  of   his  recent  UK  Parliament  and  other  statements.  Practitioners  are  responsible  for  the   treatment  of  their  individual  patient,  but  who  exactly  is  responsible  for  providing  the   tools  and  environment  required  for  care?  Recent  press  reports  suggest  that  seven   out  of  ten  members  of  the  public  don’t  seem  to  know.  If  you  are  confused  try  asking   the  staff  who  work  in  the  NHS!  Do  you  think  they  all  know?   • The  underlying  principles  of  the  creation  of  the  ‘Bevan  NHS’,  its  journey  and  all  its   historical  values  tends  to  get  lost  in  the  political,  management  and  ‘reform’  agenda.   The  anthropological  and  social  conscience  of  Bevan’s  NHS  should  resonate  in  all   undergraduate  and  postgraduate  training  in  health  and  social  care.  (Ideally  it  should   be  a  more  prominent  part  of  the  standard  school  education  curriculum).   • The  emphasis  must  be  on  implementation  to  improve  practice  and  service  delivery.   Thus  a  national  institute  with  a  specific  remit  to  bridge  policies,  practices,  services,   and  good  outcomes  is  a  necessity.  It  must  bring  together  NICE,  CQC,  the  
• 9.
  8       practitioners,  other  staff,  patients,  the  public,  undergraduate  and  postgraduate   training,  professional  bodies,  drug  companies,  the  independent  and  business   sectors,  the  legislature  and  many  more,  into  a  functional  and  effective  knowledge   centre.   It  is  recognised  that  the  main  determinants  of  health  encompass  an  enormous  range  of   factors,  as  well  as  how  the  NHS  performs.  These  include  employment  status,  housing,  diet,   exercise,  degree  of  isolation  of  an  individual  and  the  state  of  the  physical  environment  in   which  they  dwell.  The  key  to  dealing  with  these  -­‐  instead  of  simply  talking  about  or   repeatedly  measuring  them  is  to  create  real  action  between  different  departments  of   government,  public  bodies,  voluntary  groups  and  the  private  sector  -­‐  as  well  as  with   individual  people.  That  would  surely  be  preferable  to  many  of  the  'partnerships'  that  often   do  little  more  than  continually  pontificate  Or,  to  be  blunt,  hold  meetings  with  vague  agendas   for  the  sake  of  it  and  never  have  to  account  for  their  successes  or  failures  to  make  practical   achievements.   The  whole  of  the  health  promotion  or  'prevention'  agenda  is  intimately  connected  with  the   state  of  the  nation's  health  and  it  is  probably  time  for  much  tougher  talking  about  some  of   the  constraints  and  calls  upon  the  NHS  as  deliverer  of  healthcare  of  people  falling  ill.  The   addiction  of  governments  to  tobacco  taxation  shows  how  difficult  it  actually  is  to  achieve   reduction  in  harm-­‐inflicting  activities  like  smoking.  Yet  unless  we  are  all  honest  about  that,   then  mere  exhortations  about,  for  example,  changing  lifestyle  will  do  little  or  nothing  to   alter  the  fact  that  people  with  diabetes  need  to  be  treated  because  they  have  that  condition   now.  So  dietary  advice  means  real  dialogue  between  healthcare  personnel  and  food   manufacturers  and  caterers,  for  example,  ideally  with  agreements  at  the  end  of  it.     Concluding  remarks   The  above  views  are  based  on  the  evidence  that  the  current  NHS  is  not  sustainable  with  regard  to  its   structure,  governance,  management,  cost  and  ambitions.  Parts  of  it  are  decaying  (think  of  agency  or   locum  staffing,  and  some  poorly  provisioned  maternity  services  in  decaying  buildings),  parts  are  wasting   money  (ponder  the  information  and  communications  ‘links’  between  social  services,  primary  care  and   secondary  care∗ ,  NHS  infomation  and  communications  technology  system)  and  others  that  have  been   proven  to  have  a  record  of  inefficiency,  incompetence  or  worse  (of  the  which  the  CQC  was  until  not  so   long  ago,  a  well-­‐publicised  example,  it  has  to  be  said).  The  cumulative  effect  of  these  and  other  factors  is   blunting  motivation  and  inspiration  among  very  many  of  those  who  work  in  the  NHS.       “Change comes about because people are activated. People are involved." Barack Obama, President of the United States of America.                                                                                                                               ∗  That  is  without  mentioning  the  late  Connecting  for  Health  white  and  cost-­‐burdened  elephant.  
• 10.
  9       Many  of  us  came  to  the  NHS  because  we  wanted  to  care,  a  vocation  of  choice.  Healthcare  is  an  art;   professional  artistry  and  the  science  of  medical  advances  require  that  the  NHS  itself  be  fit  and  healthy  for   purpose.     If  you  would  like  to  contribute  to  the  construction  of  these  ideas;    email  to;  [email protected] Some  historical  and  most  recent  reference  points:   The  National  Health  Service  Act  1946  came  into  effect  on  5  July  1948  and  created  the  National   Health  Service  in  England  and  Wales.  Similar  pieces  of  legislation  created  the  NHS  in  Scotland  and  in   Northern  Ireland  on  the  same  day.   The  Cogwheel  Report  encouraged  the  involvement  of  clinicians  in  management  [Ministry  of  Health   (1967),  First  Report  of  the  Joint  Working  Party  on  the  Organisation  of  Medical  Work  in  Hospitals’   (the  Cogwheel  Report),  London:  HMSO.]   The  Salmon  Report  aimed  to  raise  the  profile  of  the  nursing  profession  in  hospital  management   [Ministry  of  Health  and  Scottish  Home  and  Health  Departments  (1966),  `Report  of  the  Committee  on   Senior  Nursing  Staff  Structure’  (the  Salmon  Report),  London:  HMSO.]   The  NHS  Reorganisation  Act  1973  created  14  regional  health  authorities  (RHAs)  90  area  health   authorities  (AHAs)  in  England.  General  practitioners  (GPs)  remained  independent  contractors.   Equity  and  Excellence:  Liberating  the  NHS  [TSO  (The  Stationery  Office)  2010]  removed  Strategic   Health  Authorities  (SHAs)  and  Primary  Care  Trusts  (PCTs),  and  established  a  National  Health  Service   Commissioning  Board,  with  local  commissioning  carried  out  by  consortia  of  GPs.  [DH  (2010),  Equity   and  Excellence:  Liberating  the  NHS,  London:  HMSO.]   Review  into  the  care  and  quality  of  treatment  provided  by  14  hospital  trusts  in  England:  overview   report  and  related  reports  on  the  individual  trusts  (2013),  Professor  Sir  Bruce  Keogh,  DH:  2013,   summarised  the  findings  into  reviews  of  NHS  hospital  trusts  found  to  be  outliers  in  terms  of   mortality  rates.   All  Party  Parliamentary  Group  Primary  Care  &  Public  Health:  Is  Bevan’s  NHS  under  Threat?  (July   2013)   www.pagb.co.uk/appg/inquiryreports/Bevan%27s_NHS_July_2013.pdf     Organisation  for  Economic  Co-­‐operation  and  Development  (OECD)  :  Mental  Health  and  Work:   United  Kingdom,  (OECD  Publishing,  2014)   www.oecd.org/els/emp/mentalhealthandwork-­‐unitedkingdom.htm     Labour  Party:  One  Person  One  Team  One  System,  Report  of  the  Independent  Commission  on  Whole   Person  Care  for  the  Labour  Party  (February  2014)  
• 11.
  10       www.yourbritain.org.uk/agenda-­‐2015/policy-­‐review/whole-­‐person-­‐care                                                                                "fair  trade  in  knowledge  for  health"