Lord Crisp – Written evidence (NHS0176)

1. Overview

Thank you for the opportunity to provide evidence for the committee.

The Committee has a unique opportunity to re-shape thinking about the NHS. I suggest here that this re-thinking needs to be based on:

• the economic role that the NHS plays in the UK and its contribution to future prosperity
• the NHS’s intimate links with the wider social sector and its role in society
• The need for major changes in the way the NHS operates and services are delivered to make it fit for purpose in the future
• The necessity of involving all sectors – employers, educators and designers as well as citizens, government and health bodies – in supporting healthy and resilient communities and individuals

This paper describes the conditions needed for sustainability and draws on research and examples from around the world. Whilst it is critical of the NHS, we should remember that the NHS is one of the highest performing and cheapest health systems in richer countries - and that its problems are very similar to those elsewhere. There are no models to copy or easy answers to find. 

2. The transition underway in health and social care

The pressures in the health and care system and the uncertainties of Brexit point to the need for change. Even more important, however, is the need to recognise that the current hospital and illness-based model of service provision – which has served us so well in the past – is simply no longer fit for purpose.

Put simply, the UK, like every other western country, suffers from using a 20th century model of service provision to deal with the needs and opportunities of the 21st century. This is inherently inefficient and ineffective - as can be seen every day in hospitals and communities around the country.

Report after report in the UK and other western countries have described how the nature of the illnesses we suffer from has changed and that services need to change too, so that many more are provided in communities and homes and there is far greater emphasis on disease prevention and health promotion. These reports have all in their different ways described the need to transition to a health–based and person-centred system where patients and communities are fully engaged as partners and where full use is made of modern science and new technologies.

This transition is already underway in the UK with new practices and services being developed but it is slow, patchy and disjointed and doesn’t capitalise on the UK’s world class capabilities in research, science and technology. This transition needs to be given new impetus and accelerated.

It is the new and emerging NHS that needs to be sustained not the current one.

3. Sustainability

The sustainability of a health system is a health problem and cannot be reduced, as sometimes happens, to being a purely financial or economic problem. Moreover, it is a systems issue where changes in one part of the system impact, in often unintended ways, on all other parts. Recent experience in the Netherlands provides a salutary example, where finance and insurance-based reforms designed to manage costs and improve services led to improved access but also had the unintended consequence of producing far higher overall costs. [1]

In 2014 I was privileged to chair a Commission on the Portuguese health system “to look forward 25 years to create a new vision for health and health care in Portugal, describe what this would mean in practice and set out how it might be achieved and sustained.” [2] Its main recommendations have since been accepted as Portuguese Government policy.

That Commission concluded that achieving sustainability was dependent on 3 factors internal to the system itself (how the system operated; the availability of sufficient numbers of well-trained health workers; and the costs and economic implications of the system) and 3 external ones (building the health and resilience of the population, having strong informal caring and informal networks of care; and integrating health policy and practice with other sectors.)

Underpinning all these other factors is the need for any health system to have public and political acceptability and support. The Commission understood that the changes needed in Portugal would only be achieved with sustained political will and good public support. There are many international examples of how political will has produced change including post war Europe’s establishment of welfare states and, elsewhere, the massive improvements in current day Iran and Rwanda. President Obama’s struggles in the US show just how difficult this can be. These 7 factors are shown in Box 1 and discussed very briefly in turn in the following sections.

Box 1: The conditions for the sustainability of a health system

4. The NHS - internal factors for sustainability

4.1 The efficiency and effectiveness of health care provision.

As already noted, the NHS operates a service model largely based on the health and service needs of the last century. The biggest single issue affecting its efficiency and effectiveness is how well chronic diseases are managed. These diseases (also called non-communicable diseases or long–term conditions) are now the greatest burden on the NHS and a small percentage of the population – mostly older people with more than three chronic diseases - use a very large proportion of the overall budget. In most western countries the figures are in the order of 5% of the populations using 40% of resources or 10% using 70%. 

Figure 1 below shows the health care needs of the entire population of the Basque country as estimated by the Regional Government in 2010. A small number, here under 2%, need very intensive case management while another 8% need specialist disease management. The Basque government has attempted to orientate its entire health system around these needs. Similar stratifications of need and risk have been done in the UK with local health organisations seeking to implement similar changes. 

Figure 1: Chronic disease management in the Basque country 2010 [3]

Many of these high-burden patients need care from different specialists and services and the traditional linear model of GP- hospital specialist–tertiary centre doesn’t work efficiently for patients with complex needs and multiple morbidities. New models for dealing with Parkinson’s disease, mental health and the deployment of home nursing for dementia are described in section 5

All these new services use resources and knowledge in new ways. There is good access to evidence and protocols, technology is used (biological, engineering and ICT), people – both professionals and patients – take on new roles, community assets are used (as in the developing field of asset-based health care), methodologies for continuous quality improvement are employed, and funding is used to reinforce good practice.

These changes all require flexibility and are difficult to make in the current system which is beset by rigidities. There are, for example, difficulties in funding new services that use telephone or video consultations. There are even greater rigidities in how health workers are deployed with big differences in how consultants and GPS work and even greater demarcations between the professions.

This same lack of flexibility applies to acute services. Leading examples globally as described in section 5 include Aravindh and Naryana in India where inspirational innovators without our resources – and crucially without our baggage and vested interests - are “breaking the rules” and inventing new practice. The Government and the NHS need to find ways of doing this in order to accelerate the transition that is underway.

These criticisms of the NHS should not obscure the fact that it is a leader globally. It has many features from NICE to Public Health England to being a single-payer system which put it ahead of its competitors and mean that it regularly tops the Commonwealth Fund’s league table of countries. Moreover, like any incumbent - rather than disruptive incomers - it has to continue to run the current service whilst introducing changes. This double running of the old services while introducing the new saps energy as well as increasing costs.

4.2 The availability of well-trained health workers

There is a global shortage of health workers which is getting worse as middle income countries and emerging economies build up their health services.[4] This is a major challenge to the sustainability of the NHS particularly if Brexit makes it harder to retain health workers from outside the UK and/or encourages a “brain drain”. Health workers are the largest element of costs for any health system and in the NHS amount to more than 60% of the total.

These shortages need to be tackled globally by a combination of  training more health workers, extending their roles with technology, “task shifting” so that less trained workers can take on work previously only done by professionals with higher skills (and at a higher cost), and enabling or “activating” patients and communities to take on more themselves.

The examples given in section 5 illustrate all these approaches. All are important but I will only look at one here – the way in which health worker roles need to change. The Lancet Commission on the future education of health professionals advocated an approach in which professionals were “agents of change” leading teams to accomplish tasks and always seeking to improve. In this model health professionals do not need to do everything themselves but are responsible for quality and improvement. [5]

At the same time there have been important developments in “task shifting” or “skill mix change”  with, for example, Lord Willis’s review for Health Education England Raising the Bar, review of the future education of registered nurses and care assistants showing how this could be achieved in nursing. [6] Similarly the APPG on Global Health has advocated a greater role for nurses which allowed them to work to the full extent of their competences. [7]

In an earlier study on skill-mix change the APPG identified the success factors which led to successful change. These are shown in figure 2. The way that nurse prescribing was introduced in England in 2003 was an excellent example of successful change; however, the widespread introduction of health care assistants without adequate training, support and supervision in many UK hospitals more recently has, sadly, been an example of failure to apply these factors and led to failures in patient care.

Figure 2: Success factors in skill-mix change [8]

There are similarly examples of good and bad programmes of patient engagement which I have not described here.

4.3 Costs and economic implications

I touch briefly here only on 4 major areas and try to pull out some of the key points – and I am sure that the Committee will be exploring all of them in far greater detail.

There is a close two way relationship between health and the economy

As countries grow richer they spend more on health. In recent decades roughly every 1% increase in GDP in a country has led to a 1.1% increase in health expenditures. Moreover, public expenditure almost always increases as a proportion of total health expenditure as countries grow richer. This means that several rich countries including the US subsidise their health systems from public sources to a far higher extent than the NHS does. In 2015 the OECD recorded that the UK spent 7.8% on health from public sources while Germany spent 9.4%, France 8.6%, Sweden 9.3%, Japan 9.5% and the US 8.3%. [9]

Not only is total health expenditure in all these countries far higher than in the UK but public expenditure is also far higher. In the UK this is simply – and cheaply – funded through tax and national insurance contributions but in the US it comes from many different subsidies, for example for medical education, and separate provision for different groups.

Expenditure on improving the health of the population is not simply a cost, however, but contributes to a healthy workforce and its productivity. Many studies have estimated the value to western economies of improved health in the workforce and, conversely, the costs of ill health and epidemics. Southern Africa, for example, has grown by at least 1% per annum slower due to HIV/AIDS. This year the UN’s High Level Commission on Health Employment and Economic Growth set out the evidence for the impact of improved health on the economy and argued further that employing people in the health sector had a positive impact on the economy through a variety of different mechanisms. [10]

One of the routes for beneficial economic impact is through the way in which research in the bio-medical and life sciences and associated technology benefits from a good health service and contributes to the strength of the economy. As noted in section 10 the UK could do more to capitalise on the comparative advantage it has in this area because of its access to the NHS, the largest integrated health system in the world.

Cost pressures

Costs have been driven up in OECD countries for many years due to ageing populations, the availability of new treatments and changing government policies but have slowed recently. The OECD’s report on projected health and long term care expenditures to 2060 sets out different scenarios and suggests expenditure on average for OECD countries will rise by between 3.3% and 7.7% of GDP between 2010 and 2060. [11]

The financial crisis of 2009, however, led to a slowing of growth in expenditure as countries took action to reduce costs. Some of this reduction came from short-term one-off measures such as pay-cuts or freezes, changing stock levels and restricting price rises and some from service cuts but others provided long-term recurring benefits.  As well as looking at this report, the Committee may wish to consider how these reductions were managed and what can be learned from this period.

New approaches to cost control and payments systems

New approaches to cost control, financial management and payment systems are important. Here again, there are no simple and universal answers and changing financial flows can lead to increased transaction costs and to unintended consequences as noted earlier in the case of the Netherlands.

Competition has a place. Several studies have shown that introducing an element of managed competition into the English NHS not only improved efficiency but also improved quality. A 2010 LSE report, for example, concluded that. “Using AMI mortality as a quality indicator, we find that mortality fell more quickly (i.e. quality improved) for patients living in more competitive markets after the introduction of hospital competition in January 2006. Our results suggest that hospital competition in markets with fixed prices can lead to improvements in clinical quality.” [12] The position is, however, less clear-cut with primary and community care services or in dealing with chronic disease management and the problems of managing patients with complex co-morbidities. Moreover, competition in markets without fixed prices can lead to a race to the bottom in quality terms.

Fee-for-service payments have been largely discredited in health care and identified as major cost drivers in many systems. Payment systems such as PROMS which take account of patient reported experience and others which pay uplifts for implementing best practice protocols, however, seem to have their place as systems try to move towards outcome costing and pricing. Similarly, approaches which make payments for a whole package of care which may last over several different episodes and involve different providers, are more effective and efficient that payments per episode or activity. Personal budgets and direct payments particularly for people with long-term conditions have an important part to play here as well – and, I understand, are likely to be extended in England.

The Portuguese Commission looked at these sorts of examples in some detail, as I am sure the Committee will, and concluded that it was important for a health system to keep developing these methodologies. However, it also noted that more often than not these systems lagged behind service developments so, for example, inflexible payment systems got in the way of innovation rather than payment systems promoting service innovation. It considered that for the foreseeable future at least policy-led changes in service design were likely to have a much more significant effect on overall costs and quality than innovation in financial flows and payment methods.

Alternative financing systems

Broadly speaking there are three main ways of paying for health care globally:

• Out of pocket – as happens in most poorer countries
• Through tax and compulsory national insurance programmes which may have elements of direct patient charges or co-pays
• Through private insurance with direct patient charges or co-pays

Most high income countries employ their own mix of these three. There are others such as the Singapore system with its personal budgets which are probably too culturally specific to be of direct interest to the UK.

The UK system with its reliance on general taxation is the simplest and cheapest method with very low overheads. Competing private finance systems as in the US have the highest overheads.

The introduction of “co-pays” or patient charges into systems is often promoted as a way of increasing funding and improving efficiency but has some serious limitations. Studies such as the RAND one of 1983 show that increased charges reduce patient use of effective and ineffective health care in equal proportions, reminding us of the problems of market failure in health.[13]  Reducing usage of health services for richer parts of the population in the US, where there is over-use, may be good for their health. However, poorer people who in the US make far lower use of services may miss out on services they need.

The problem as others have subsequently argued is that introducing exemptions for poorer and older people who are the biggest users of the service in the UK – as we do for prescription charges – mean that the charges on the remainder of the population have to be very high in order in order to generate any material amount of extra money.

These arguments don’t apply in quite the same way to proposals to raise extra funding through the types of compulsory social insurance scheme used in much of Europe. These are generally progressive rather than regressive and can raise significant amounts by being in effect an additional tax. They also maintain the important principle of pre-payment for health care so that it remains free at the point of need.

A hypothecated NHS tax is often proposed as a way of securing extra funding for the NHS and showing people how much they are paying for the NHS and thereby making a link between payment and services. Critics, however, argue that funding from general taxation is more flexible and better able to reflect changing levels of need.

There is more consensus about the need to bring health and local authority budgets together, particularly in social services but also in housing and other areas to achieve synergies and improve overall usage of public funding. Experience in Northern Ireland shows that whilst this is a useful measure it is not in itself enough to secure better efficiency and quality but needs to be accompanied by other policy and management measures.

New sources of funding need to be considered particularly in raising capital and there are powerful arguments advanced both for local authorities being able to raise local taxes for health and care services and for public bonds of different sorts. 

Another approach which has some promise but would involve a radical change in the UK is the example of the Accident Compensation Corporation of New Zealand. This is a public body, funded through government and from levies on employers, which pays for the health cost of anyone who has an accident of any sort – on the roads, for example, at work or as a consequence of health care itself. It provides about 14% of the funding of the New Zealand health system and has become over time an active proponent of better health promotion and more interventionist in demanding efficient and effective health care. It is another way of making a direct link between those who use the service and its funding.

5. Examples of leading practice internationally in health service provision

The examples described briefly here are only a few of many from around the world which give an insight into what future service provision might look like.

Parkinsonnet.org is an excellent and innovative example of chronic disease management. [14] It brings together over 2,700 health professionals into regional networks with patients and carers to provide information and services throughout the Netherlands and into neighbouring countries.  They are supported by a coordination centre and academic specialists at the Radboud University Nijmegen Medical Centre.

Parkinson's syndrome is a generic term for a very complex disorder which may lead to a wide range of different problems needing attention from different carers. This network ensures that patients are able to reach the appropriate professionals and, by having access to all the information and protocols in the network, to play a full role in their own care.

The model breaks down all the rigidities of the traditional system described earlier with new roles for professionals and patients, home and community based care and extensive use of IT. Figure 3 shows the main components. Similar model could be developed for other chronic diseases.

Figure 3: The Parkinsonnet.org model

Buurtzorg [15] is a home care provider in the Netherlands which involves teams of front line staff who lead the assessment, planning and coordination of care. The model consists of small self-managing teams of a maximum of 12 professionals (made up of nurses and other allied health professionals). These teams provide co-ordinated care for a specific catchment area, typically caring for between 40 to 60 patients. Overall they now look after 70,000 patients, about half of whom have dementia, and deal with health promotion as well as treatment.

Aravindh and  [16] Naryana Health[17] are two examples of the innovation underway in India. Both use modern production management techniques to streamline and improve specific services – for eye care and cardiac surgery and other specialities respectively. Staff are deployed in different ways – ignoring many traditional western demarcations, patients and carers are co-opted to help and technology is used extensively. Both organisations provide very high quality services.

Sangath, an NGO working on mental health, child development and related services in Southern India, is equally impressive but works in a very different way. [18] It was founded 20 years ago by a small group of highly trained professionals who deliver services in the community by working with community workers and local groups. Using clear protocols and well-organised training and supervision it has been able to run successful randomised clinical trials on delivery methods as well as providing services to large numbers of people who would not otherwise be reached.

In America the Mayo Clinic, a not-for –profit organisation, is one of a number of good examples of organisations which are placing the individual experience at the heart of their services – empowering patients with data, offering choices and explicitly tailoring services to meet the needs and preferences of individual patients. [19]

It is interesting to note that City Health Works based in Harlem has explicitly copied the principles and methods of African community health worker programmes to “bridge the gap between the doctor's office and the everyday lives of patients diagnosed with life-threatening chronic illnesses.” Peer support workers contact and work with people where they live. [20]

It is perhaps not too fanciful to imagine that a combination of the methods employed by Pakinsonnet for chronic diseases, Aravindh and Naryana for acute specialities, Buurtzog and Sangath for community care, and the Mayo for patient-centeredness might replace our current model of GP-hospital-tertiary centre with its multiple rigidities.

6. Health and wider society – external factors for sustainability

“Modern societies actively market unhealthy life styles.” This quotation from WHO Europe sums up the problem which places ever-increasing pressure on the NHS. The NHS will not be sustainable without reversing this current set of trends and, ultimately, building a society that helps create health by supporting healthy and resilient communities and individuals. There is a traditional African saying which equally simply describes the situation: “Health is made at home, hospitals are for repairs”.

The NHS and politicians cannot do this by themselves – all sectors of society need to be involved. This section touches very briefly on some of the key ways this needs to happen.

6.1 The health and resilience of the population

The Government, NHS England, Public Health England and other authorities are beginning to play a stronger role in disease prevention and health promotion and need to do more. Some of this requires legislation in tackling, for example, tobacco, air pollution, sugar, alcohol and road safety. In other areas they can lead on campaigns and by example in how they support their employees to be healthy.

Individuals and their families play the most important role in looking after their own health and adopting healthy lifestyles.There is not yet, however, sufficient recognition in policy and practice of the important role that the social determinants play in health and of the fact that social support, housing, employment, education and many other sectors need to play their part in strengthening the health and resilience of the population – and that government policy needs to be shaped to enable them to do so. There is evidence that recent austerity-inspired policy has damaged health and reduced resilience in the UK and elsewhere. [21] Moreover, it has become more difficult for some disabled people to live independently as benefits systems have changed.

Global policy on the control of non-communicable diseases and the ambitious Sustainable Development Goals both focus heavily on prevention and on recognising and working on the social determinants of health. [22]

6.2 The strength of informal caring and informal networks of care

The importance of a population “fully engaged” in its own health to controlling costs and improving quality was pointed out by Wanless in Securing our Future Health: Taking a long-term View in 2002 and remains true today.

It is equally important to ensure that local informal caring and informal networks of care are strong and effective. It is estimated that the value of individual unpaid carers work alone is £132 billion annually, almost exactly the same as the UK wide spend on the NHS. [23]  Where these carers get weaker the burden falls on the NHS and local authorities; where they are strengthened the NHS becomes more sustainable. [24] Similarly policies that encourage and support local caring networks and voluntary organisations will help take the strain off the statutory services. 

6.3 The integration of health policy and practice with other sectors

Integration of government policy and action across sectors is essential for the reasons given earlier but so, too, is the involvement and leadership of people and organisations outside government.

The creation of Health and Well-being Boards in England and the current development of Sustainability and Transformation Plans are both attempts to achieve integration across sectors. The devolution of health budgets in Manchester and the bringing together of health and social care budgets elsewhere are designed to have the same effect.

These government-led programmes, however, need to be accompanied by employers, educators and others living up to their responsibilities for the health and well-being of the people they employ, teach or otherwise work with. There are some excellent examples where this is starting to happen and others such as the St Paul’s Way transformation project described in Section 7 where wide partnerships have come together to improve neighbourhoods and, inter alia, improve health. They are the exemplars of the health-creating society of the future.

7. Examples of leading practice in health-creation

Effective practice in health-creation is generally less advanced than innovation in service delivery but there are interesting examples – and many low and middle-income countries, with weak health services adopt policies which align poverty elimination with environmental, economic and health improvements.

Finland was the first country explicitly to adopt a Health in All Policies approach by recognising that farming and other practices influenced health and subsequently developing cross-sectoral policies to improve health. [25] This approach emphasises the consequences of public policies on health determinants, and aims to improve the accountability of policy-makers for health impacts at all levels of policy-making. This is now policy in many European countries and advocated by WHO Europe.

The Scottish Government’s Early Years initiative is designed to make Scotland the best place in the world to grow up in. The Early Years Collaborative is the world's first multi-agency, bottom up quality improvement programme to support the transformation of early years. Launched in October 2012, it involves all 32 Community Planning Partnerships and a wide range of third sector partners. Its focus is on strengthening and building on services using quality improvement methodology, enabling local practitioners to test, measure, implement and spread new and different ways of working to improve outcomes for children and families. [26]

Wales, similarly, is developing a new strategy and illustrates the economic argument for its approach with Figure 4.[27] 

Figure 4: the economic argument for investing in Early Years.

The Early Intervention Foundation, an NGO, adopts a similar approach in England but does not have the reach that comes from being a government programme. [28]

Mexico, Brazil and several other low and middle income countries use “conditional cash transfers” – policies which attach conditions such as the requirement to have children vaccinated or attend school to social benefits – to improve health and life chances. The largest programmes, such as Brazil’s Bolsa Família and Mexico’s Oportunidades, cover millions of households. The World Bank has evaluated these and identified the benefits they can bring. [29]

BRAC in Bangladesh works with the ultra-poor providing health services, micro-finance loans and education and thereby breaking down barriers between the sectors and improving health. It is the largest development NGO in the working with 138 million people in Bangladesh, with a turnover of $1 billion and now working in 10 other countries.  [30]

The UK has some very interesting health-creating partnerships at the local level including many who are members of C2, Connecting Communities. [31] The largest is the St Paul’s Way Transformation Project which brings together a wide range of private, public and third sector partners to re-generate an area in east London and has created links between the local school, health facilities, housing and pharmacy as well as with universities and multi-national companies working in the area. Like BRAC, St Paul’s way is not purely or even primarily focussed on health. Some of the partners are shown in Figure 5. 

The lessons from St Paul’s Way are being transferred to 10 towns and cities in the north of England through Well North with support from Public Health England. [32]

Elsewhere in the UK there are many other initiatives some supported by CCGs, others, like the City Mental Health Alliance run by employers, and others run by organisations as diverse as the Royal Horticultural Society, arts organisations and designers.

Figure 5: Some of the partners in the St Paul’s Way Transformation Project

8. Public and political acceptability and support.

In international terms the NHS is both relatively cheap and high performing – and has enjoyed high levels of public support for almost 70 years. The current debates about sustainability are important in themselves but they also mark a wider concern about the future direction of the NHS and its fitness for purpose in the 21st century.

It seems to me imperative that health and political leaders in the UK set out clearly the future direction for the NHS and commit to making the necessary changes to improve it and, at the same time, help it to become more sustainable.

Change as noted earlier needs sustained political will but also need a clear narrative and direction of travel.

9. The way forward

This brief survey has shown that the sustainability of the NHS is not a simple issue nor is the NHS simply a deliverer of health services. Moreover the NHS needs major change to be fit for service for the future. There are examples in the UK and elsewhere which show the ways in which the NHS could develop both in service terms and as a partner with others in health-creation.

Fundamentally, the NHS needs to be seen as having important roles both in underpinning the economy – and the future prosperity of the country – and in supporting the development of a healthy and resilient society in the UK.

This paper ends with a manifesto written by some of the leading clinicians and health scientists in the country as well as a number of social entrepreneurs and members of the cross-benches. It is an attempt to spell out the direction that the NHS and the wider health and care sector needs to take in this country and to start the creation of a future narrative for a sustainable and high quality NHS.

10. A Manifesto for a healthy and health-creating society

The manifesto has 4 aims and sets out actions that follow from them. The aims are described here and the full document can be accessed from the Lancet online for 7 October 2016.

Aim 1. The UK should strengthen its role as a global centre for health and the bio-medical and life sciences.

Health, bio-medical and life sciences need to be at the centre of the UK’s industrial strategy and vision for the future as an outward facing country, networked globally, building on the country’s great traditions and values – and helping shape the future health, prosperity and security of the UK and the world. This will require all sectors: the commercial life and bio-medical sciences as well as the NHS, academia, government and voluntary organisations to build closer and more productive links to achieve synergy and impact.

The UK has the enormous comparative advantage that the HNS is the largest integrated health system in the world and is the ideal platform for developing still further the science and technology vital to health and to the country’s economy.

At the same, time, however, as described in Aim 2, the NHS needs to modernise – with the help of the UK’s science and technology based industries.

Aim 2. The transformation of the health and care system from a hospital-centred and illness-based system to a person-centred and health based system needs to be accelerated and funded.

This will require a massive increase in services in homes and communities and new ways to empower front-line staff, enabled by technology, to manage the complex needs of patients across different services and organisations. It will also require the involvement of many different partners and providers and the development of new infrastructure. Above all, however, there needs to be the far greater engagement of patients and carers in decision making and care – and enabling them to live as independently as possible.

The NHS, however, cannot do it by itself but needs every sector of the community as described in Aim 3 to fulfil their responsibility for improving – and not damaging – health.

Aim 3. The UK needs to develop and implement a plan for building a health-creating society – supported by all sectors of the economy and the wider population – and which addresses health inequalities.

Current plans for health promotion and disease prevention are too small scale and fragmented and need to be replaced by a much larger-scale and society wide effort. The NHS spends very little on prevention and while there are calls to increase it, it is clear that this cannot be done by the NHS, health professionals and politicians alone. Achieving real impact on the health of people throughout society requires leadership and action from all sectors.

The founding of the NHS in 1948 was a great national coming together around the shared purpose of providing health services for everyone. An equally bold initiative is needed today to bring together the expertise and resources of all the parts of society which impact on health – employers, teachers, designers, manufacturers as well as citizens, community groups and government - to improve health for all and build a health creating society.

A health creating society can only be built in a society which itself is healthy and health and science institutions as described in Aim 4 have a role to play in this.

Aim 4. Health, care and scientific institutions should help develop and restore a healthy society in the UK.

The UK's health, care, science and broader academic communities embody values of social solidarity and have a crucial part to play in developing and restoring a healthy society in the UK. They are smaller versions of UK society with the same diversity of population, culture and skills. Tackling racism, promoting equality in all its forms and celebrating innovation and creativity are vital to the sector - and to the country as a whole.

2 November 2016