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Death in Leamington

 

Leamington-Spa-Parade

 

On Thursday I attended the funeral of an old family friend who had died recently in Leamington at the age of 98. As she had no close family of her own, the task fell to me of organising the funeral. It was the first time in my life I have been so closely involved in the practical arrangements surrounding a death and it made me reflect on that hidden, but most inevitable of, human experiences.

The funeral itself passed off well and I am full of admiration for the undertakers and the vicar whose combination of sympathy, dignity and attention to detail was exemplary. There can be no more difficult work than supporting strangers at a time of bereavement. It is immensely important.

Our friend had died peacefully after a long life. She had gone to university before it was at all common for women to do so, she had been a capable and devoted teacher in a secondary school in the North West. She was a woman of intelligence, of strong values and strong views. On retirement, she had moved back to our roots in Warwickshire where, amongst other acts of kindness, she had supported my great uncle, her former teacher, at the end of his life.

In the last couple of years her health had declined, and she had had to leave her own home and move into a nursing home. Like an increasing number of people surviving to a great age, she had lived out a tail to her life marked by physical frailty, some psychological distress and a growing withdrawal from the world. There was some sense of relief in her eventual passing from this life.

Reflecting on the funeral, I was struck by how awkward we are with death these days. To start with we have drifted away from a common narrative of what death means and what might be expected to happen after death. There is no right or wrong to this, and maybe behind the front of collective religion, it was more the case in the past than we suspect. However, it means that we have allowed ourselves less space to talk about death and less of a common language in which to express that conversation.

The events of death also used to be something which happened in the heart of communities and which we have now moved to the margins in hospitals or crematoria where they are not visible. Unless we are clinicians, few of us are familiar with the physical patterns and processes of death. When somebody dies we are, unless they are celebrities, less aware of the fact, less drawn into the ritual of marking their parting, which in the past, would have impinged on the whole of the community. Our more rootless existence and the more drawn out nature of life, mean more people are dying in loneliness and isolation.

It has also been interesting to observe the process of drawing someone’s earthly affairs to a conclusion. In a way I am very grateful that it is so straightforward, and, in any case, our friend’s affairs were in very good order. Nonetheless it has been striking to see how simple it is to make the transition.

I was struck, in preparing for the funeral, in looking at a poem by John Betjeman of the same name as this blog. It describes the quiet and lonely death of an elderly women in Leamington and the matter of fact reaction of her nurse, bringing her afternoon tea, and realising that her patient has passed away. It could have been written for our friend.

Death should be higher in our public consciousness. Facilitating a good death should be a more prominent purpose of health and care services, recognising the psychological, practical as well as the medical aspects of this. We should be more bothered about this, at times, than we are about our obsession to lengthen life beyond its natural limits. The circumstances of death of so many people should be a further reminder of the bitter consequences of loneliness and social isolation. Above all else we should make sure, as individuals, we are prepared to look ahead and consider ourselves what constitutes a good death.

It is in the nature of the human condition that it is hard to understand or reconcile ourselves to ultimate ending of our days. It is not helpful though, to ignore the issue.

 

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Breaking news

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Don’t get me wrong news and current affairs are central to the health of democratic life and taking account of what is going on in the wider world is a crucial duty of any citizen of a healthy society. As John Donne famously said, “No man is an island, entire of itself” and as political and social animals we should be open to an interested in what is happening around us.

However, that said, it seems to me we have a problem about the role of news and media in our society, one which has become more challenging with the emergence of the 24 hours news cycle and the rise of social media. These issues are exacerbated by other factors such as the speed and relentlessness of change. In addition, the growth of isolation means that for increasingly large numbers the media, whether television, radio or the internet, has become a dominant form of social contact.

There are four issues, none of them new, which warrant consideration.

The first is the focus of the media on bad news. While the idea that calamity and misfortune are fascinating is not surprising, the quantity of breaking bad news, in particular, when expressed as a competition for attention between news channels adds to a sense of societal anxiety. This is, perhaps, particularly so for those for whom there are few compensatory events from real life.

The second is the tendency to narrate events through a series of polarised stereotypes. I know from my campaigning work in mental health how difficult these are to shift whether the stereotype of the “mad axeman” or that of “real men don’t get depression”. When views and attitudes are grounded in media stereotypes, rather than real life experience, they tend to be less positive. The success of Time to Change and other initiatives to improve attitudes towards mental health has been based on reconnecting people with the lived experience of mental health problems amongst their friends, family and colleagues.

The third disturbing feature is the narrow focus of the media both in terms of geography and issues. Important though President Trump is and distressing though some of his tweets are, I sense, at times, that they can attract a disproportionate level of attention when there are issues, in many parts of the world, which will struggle to secure the coverage they deserve. In this country our media continues to be London centric. This has always been obvious to someone of Welsh origin, but it also explains the level of shock represented by the Brexit vote which brought to surface many longstanding issues of concern and disillusionment which had been registering in many part of the country over a long period of time.

Finally, there is the phenomenon of fake news. Again, this is not new but, in an era, where there are so many sources of formal and informal news the scale of what is possible has grown. There are two manifestations of fake news. First the actual propagation of false information. Second the ritual denial of information on the basis of the source without a further thought about its veracity.

Looking at society, our presentation and consumption of media is fuelling both our sense of collective anxiety and the polarisation of society. The problem is exacerbated by the decline of traditional media which has to shock and shout ever more loudly to attract our attention and our collective ambivalence about the impact of social media and other online communication. They also speak loudly about the decline of some intellectual traditions in our society.

Are there remedies? I will make a couple of points about how our own actions can help.

The first is to extol the virtues of slow news. For several years we have taken “The Week”, a very good publication in many ways, but best of all for presenting the news through the lens of 7 days rather than that of the breaking headline. It is striking how often, even over a week, the focus of a story will change. History encourages us to always look at the longer term rather than just the froth of current affairs. The less rapidly we leap to conclusions the better.

The second is to be bold enough to listen to the views of those we don’t agree with our and to take the time to engage with opinions which are different from our own and about places and issues which are not the usual focus of one’s interests. Our own stereotypes can just be as destructive as those of others. The willingness to change one’s mind and modify one’s views is an underrated quality and one, which, these days requires some bravery. Above all we must be willing to avoid simple binary paradigms, real life is never as simple.

The third is to privilege the stories of real life over the media stereotypes. The complexity and genuineness of lived experience can always make it possible to think again, and, in particular, evoke in us the sense of human empathy which connects us to our fellow humans.

Finally, as someone who took a deliberate view, a couple of years ago, that starting my day with Radio 3 was better for my sense of wellbeing, I think there are times when we should force ourselves to take a break from the news and enjoy the more timeless things of life.

Investing in the Future

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It’s the end of March so the streets are full of roadworks and Finance Directors, across the public sector, are scratching their heads about how to manage end of year underspends. The constraints of annuality remain one of the striking examples of how the rules of public sector finance can provide obstacles to taking the most prudent decisions about spending and investment. While always frustrating, those constraints have a particularly negative impact at a time of austerity.

In any endeavour there is always a balance between long and short-term interests but at, the current time, when not only is money tight in the short term but there also major challenges about the long-term sustainability of public services it is particularly difficult. Whether in the NHS, local Government, criminal justice system or any other public service the logic is that we should be doing everything we can to invest in prevention and early intervention with the aim of reducing long term demand pressures. In reality, the system is forced, when resources are tight, to focus disproportionately on the management of short term financial pressures and concentrate spending on the most expensive parts of the system where demand cannot, in the short term, be, easily avoided.

These issues are not new and, to be fair, the system is nothing like as limited as it was when I started my career in the public service when, even budgets for Government Departments, were set on an annual basis in the Autumn Statement. The Comprehensive Spending Review and the introduction of 3 years spending settlements have been positive developments as have been aspects of the new financial regimes for bodies such as Foundation Trusts.

However, three aspects of the overall regime for public sector finance still stand in the way of the best overall use of public resources and the most effective (and efficient) deployment of public services.

The first, which I have already alluded to, is the restrictions in carrying money forward from one financial year to another. This causes artificial pressures on how resources are used, in particular in cases where the purpose of resources has been clearly decided in advance, for instance as part of an agreed project plan. Great flexibility here would promote better use of resources by removing the pressure to rush important decisions about the design of initiatives or sub-optimal decisions to spend in haste so the money is not lost. It would allow precious management attention to be focused on the task in hand rather than being wasted on the management of financial rules.

The second issue is more fundamental and is the perennial challenge of programmes focused on investing to save. Across public services there is good evidence for how investment in one sector or organisations can liberate savings in another sector. The structures of public sector finance, however, stand in the way of realising benefits for the system as a whole. It appears we are working on solutions. Placed based budgets and integrated care systems are examples of trying to facilitate the joined-up commissioning of services.

The third challenge relates to funding longer term interventions. Often such interventions relate to upstream and preventative initiatives, many of which can demonstrate an excellent return on investment, I heard, this week, about anti-bullying initiatives which can demonstrate lifetime savings of £146 for every £1 spent on the programmes. There is a case for trying to separate such programmes from the mainstream of public spending. There would, for instance, be a case for totally separating public health from other spending to ensure that investment in the future health of the nation continued, whatever the vagaries of the economic cycle and short term pressures on other health and local government services. If that was not possible, there could be an argument for funding public health and other long-term initiatives on a capitalised basis (as we do for buildings, IT and other public assets) which would allow upfront investment against an evidenced stream of longer term benefits.

The same argument would apply to the costs of transformation where an element of upfront investment or double running costs are an inevitable part of any plan to reshape services and moving from one service model to another. Such transformation investment was, eventually, permitted with the closure of the long stay hospitals, in that case set against the anticipated capital receipts from the sale of prime real estate.

There are many reasons why the Treasury and others are reluctant to embrace the risks of more innovative models of financing. In a complex and dispersed financial system one can appreciate the nervousness of losing financial control. On the eve of nearly going broke in the 1970s the administration of New York had capitalised a quarter of its overall expenditure as a means of living beyond its means.

However, by its nature, public finances are long term. National debt and the security of future tax receipts should allow the State to take a level of risk in making investments which smaller institutions are unable to do so. It was only in the early 2000s that we paid off the last of the debts accumulated in the two World Wars.

My argument is not to let go of overall control of public finances but to consider, in an open way, a range of innovative solutions, which facilitate well-constructed and evidenced base investment in initiatives which can help deliver a sustainable future shape to public services. Such initiatives need to have clear burdens of proof and clear lines of accountability for the delivery. However, the biggest lesson of austerity for me is the need to think about the long term. In the short-term services may be under pressure. In the long term, if we don’t do something different they won’t be there at all.

A little Latin (and Greek) is not a bad thing

 

 

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I am aware that Boris Johnson and Jacob Rees-Mogg have recently given Latin a bad name as an elitist pursuit, irrelevant to the 21st century. I would argue, though, that there are many things to be gained from the study of the ancient world and its languages. Certainly, I feel enormously privileged to have had the chance to study Greek and Latin and ancient history at school and University. That experience has provided me, and continues to provide me, with many powerful insights into the modern world and the underlying dilemmas of the human condition. In this blog I would like to set out why.

The first thing I gained from a classical education was a better command of my own language. Studying Latin led to a significant development in my skills with English, broadening my vocabulary, improving my spelling, and making me much more aware of the structure and sound of the language. It also helped give me my wider love of languages and facilitated learning romance languages such as French and Italian. As a non-clinician working in healthcare, a knowledge of Greek has been pretty handy in understanding medical terminology.

Making sense of the classical world also brings a particular set of intellectual challenges. Bits of it we know a lot about, bits of it we know very little about. As direct ancestors of our own culture the classical worlds show many things which are very familiar, whether they are stories and dramas, political concepts, forms of art and architecture. At the same time the ancient world can seem very different and distant. It is endlessly fascinating to try to patch together a fuller understanding from partial sources and classical scholarship has been enriched by a widening set of information sources, in particular, the results of archaeological investigation which has cast a much richer light on the lives of the poorer Romans and Greeks.

The study of the ancient world, itself an ancient tradition, has also been enlivened by the interpretation and reinterpretation of the same sources over the centuries in the light of wider developments in scholarship and in ways which reflect the preoccupations of different generations. History, and its interpretation, is never an absolute truth but always carries an image of those who write the history and their concerns. In the age of globalisation, Brexit and its resulting uncertainties there is a plenty of scope to plant our own story on the template of the classical tradition.

A great fascination with so many things in the classical world is that they hold the origins and first examples of some many constructs which are so fundamental to the modern world. Whether it is the democracy or political science, natural science or philosophy, theatre and drama, Rome as the world’s first metropolis, roads or central heating, Greek and Roman civilisations transformed human thought and political organisation in ways which later generations have built on but, not necessarily, fundamentally changed. The intellectual revolution which, in particular, seized the Greek world between the 7th and 4th centuries BC remains one of the most amazing leap forwards in human development. It is humbling that it is still possible for us to appreciate it.

There is also something very significant in studying a world and set of civilisations which came to an end. Views of the end of the Western Roman Empire in the 5th century AD have changed and there is much more emphasis in modern scholarship on those areas of continuity which survived into the early modern era. Nonetheless the end of the ancient world remains one of the most significant and fascinating discontinuities in the whole of our history. Nowhere is that more evident than in the city where I am writing this blog. In the middle of the 4th century London was the thriving capital of Roman Britain, by the middle of the 5th it had been abandoned, not to be properly settled again until the 9th century. As I have argued in a previous blog  the end of the Roman Empire has some lessons for modern Europe and the issues it is facing.

Finally, the classical world casts some brilliant insights into the human condition. Nowhere is this more evident than in Homer’s Iliad and Odyssey, the oldest works of western literature, written down in the 8th century BC but built on an oral tradition which goes back much further. Despite that antiquity, these poems contain a rich and moving understanding of what is like to be human, our battle with mortality and our desire to leave a small mark on the tapestry of life.

Classics will never regain the place it had as the universal basis of western education, but it deserves not to be despised as old fashioned and irrelevant. It needs to adapt to the character of modern world in ways which recognise the significance of a much wider group of ancient civilisations, not just those which have contributed most directly to western Europe. Classics also needs to reach out beyond the bastions of independent schools where it has, to some extent, ended up, to offer programmes and forms of study which can appeal more widely. It needs champions like Mary Beard who can make the ancient world exciting and accessible to modern audiences.

That said, as our greatest poet and playwright, acknowledged, let’s recognise the value of a little Latin and even less Greek.

Some progress, so much more to do

 

Abandoned Illness

It was good this week to return to the issues affecting people with schizophrenia and psychosis when I joined colleagues at Rethink Mental Illness to mark the 5th anniversary of the publication “The Abandoned Illness” the report of the Schizophrenia Commission. The Commission remains one of the most interesting, and fulfilling, pieces of work I have been involved in, in the course of my career. 5 years is a good perspective from which to judge the impact it has had and how the cause of those affected by severe mental illnesses such as schizophrenia has fared given 5 years of priority for mental health but also 5 years of austerity. Rethink Mental Illness published an assessment of the key developments.

The picture is inevitably mixed. There are some areas of clear progress. Not surprisingly top of the list is the impact of a reducing level of stigma towards mental illness and those affected by it. When we started on the journey with Time to Change and other action to tackle stigma and discrimination there was a fear that, while it might be possible to reduce stigma to more common conditions such as depression, the prejudice towards people with schizophrenia and other more severe mental health problems would be untouchable. This has not turned out to be the case and brings benefit in helping people affected by these conditions to engage, where possible, with work and with other social activities.

It was also good to celebrate the impact of the waiting time standard for early intervention. The model of early intervention remains, for me, one of the most positive developments in mental health care in recent times and it has a clear evidence base both for delivering better outcomes but also for reducing the costs of future care.  At the time of the Commission there seemed to be a threat that early intervention would be diluted under the financial pressure faced by Mental Health Trusts. Norman Lamb, the Minister for Mental Health at the time, deserves an enormous amount of credit for making early intervention one of the first standards for mental health.

There are areas of mixed achievement. The poor physical health of people with severe mental illness is now widely recognised and a lot of effort is being made to build more integrated models of service delivery. There is, however, a long way to go to provide the level of input and support which will make a real difference to such a deep-seated problem. The pressure on primary care services does not help but there is no doubt that further investment here would have a real pay back, not only in terms of years of life for people affected by severe mental illnesses but also in terms of savings for physical health services.

Inpatient care remains a point of concern with levels of occupancy across the system well above the level of 85% recommended by the Royal College of Psychiatrists and too many patients having to be placed out of area to secure a bed. I am pleased that there is a national focus on reducing out of area of placements and I welcome developments, which were called for in the Schizophrenia Commission, to facilitate a transfer of resources from secure care to strengthen community services. However, there is a need to face up to the fact that there in many places there are insufficient resources to create an effective acute care pathway with the right balance of beds and community resources. As this week’s report from the King’s Fund confirmed such a situation is inevitable in world where parity of esteem for mental health still comes second to the pressures in the acute physical care hospitals. A system under strain like this, inevitably, has its impact on the staff working in it and there is a danger we have created a vicious circle where the pressure of the environments we ask staff to work in has a negative impact on recruitment and retention, perhaps most worryingly for new trainees.

The most depressing part of the piece though must be the impact of austerity on areas such as housing, benefits and community services which provide the underpinnings for people with severe mental illness remaining well in the community. There is no doubt for me that this is having an impact in increasing the demand for mental health services and it was sad to hear from carers and others at Rethink Mental Illness the traumatic effect of the work capability assessment amongst other things. This remains the most blatant area of discrimination in society against people affected by mental health problems. While I, of course, welcome the current review of the Mental Health Act, a far more urgent requirement is to make a serious commitment to tackling the injustices which people with mental health problems face in the social security system.

So, 5 years on there are definite areas of progress but still so much to do. However, I was also struck by what Sir Robin Murray who chaired the Schizophrenia Commission had to say at the event this week about hope. For him, one of the biggest learnings from the work of the Commission was the importance of a message of hope in supporting people with a diagnosis of schizophrenia or other severe mental illness. This has a lot of resonance. Hope is not necessarily the same as optimism but hope inspires the will to try and to fight and that for individuals and for society battling with the issue of mental health is what we need more than anything else.

 

Howards End – not just a pretty period drama

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In the end I thought the recent television adaptation Howards End did a pretty good job. Best of all, though, it tempted me to re-read the original novel, reminding me of just how good a writer Forster is and how valid this novel still is in its analysis of human character and psychology.

I have always had a fascination with the Edwardian Age, the period when my grandparents entered adulthood. I read Howards End for the first time at a time when the last of that generation was still alive. Nearly 35 years later it remains just as vibrant as when I first read it and indeed Forster’s reflections on the foibles and anxieties of that age seemed if, anything, more relevant to those we face in 2018 than to that of 1983.

The television version stayed very true to the original plot and the dialogue was often based on that of the novel. In re-reading the novel I was struck that the screen adaptation missed one very powerful ingredient, Forster’s own authorial voice through which he delivers much of the interpretation of the characters he is portraying as well as a fascinating commentary on the times in which the novel is set.

The novel takes place just before the First World War, the most catastrophic event in European history and the growing political tension which led to it is part of its background. This is played out in the relationships between two families: the Schlegels, half-German, intellectual, cosmopolitan and edging to socialist and the Wilcoxes, classically English, insular in attitudes, immensely practical in outlook and conservative in politics. Translated to today one family would be staunchly Remainers, the other, hard line Brexiters (Of Mr Wilcox “My husband has very little faith in the continent, and our childrten have taken after him”).Foster brilliantly brings out the mutual incomprehensibility of outlook between the two families. At the extreme they “had nothing in common but the English language.”

And yet Forster’s novel forces those two very different families together for better or for worse. Margaret, the older of the Schlegel sisters, becomes Henry Wilcox’s second wife (to the disgust of most members of both families). Forster brings out wonderfully the psychology of the attraction of opposites, how people can be drawn, unconsciously, to what, consciously, they could never admit to liking and the compromises that people inevitably make in the cauldron of real life and real relationships.  This is expressed beautifully by Margaret as she chides the rest of her family for their reaction to her relationship with Henry Wilcox, “How dare Schlegels despise Wilcoxes when it takes all sorts to make a world.”

Gender is a key theme of the novel, written, as it is, during the Suffragette campaign for votes for women. While some of the attitudes captured in the novel are historical Foster’s description of gender battles have a contemporary ring to them. In this, as in all things, Forster is most judgemental of hypocrisy and of men who assert that different standards apply to women than to their own conduct.

As is appropriate for an English novel the biggest issue is that of class. In the midst of the dance between the Schlegels and the Wilcoxes comes Leonard Bast, a working-class autodidact, who wishes to better himself through books and music whom the Schlegels attempt, somewhat ineptly, to support and help. They are enchanted by him and his authentic love of culture but cannot bridge the division of class and wealth that stands between them. Forster, affectionately but nonetheless ruthlessly, dissects the conundrums of Bloomsbury socialists and middle-class do-gooders. Again, such issues feel vividly relevant to current times.

Later in the novel the plot thickens as it emerges that Leonard’s wife was formerly Henry Wilcox’s mistress. The younger Schlegel sister, Helen, is drawn, almost in an act of revenge against the Wilcoxes, into a liaison with Leonard which leaves her pregnant. In an act of cruel double standards Charles Wilcox the son sets out to beat Leonard to an inch of his life and in fact kills him. Charles has to serve a term in prison for manslaughter but the rest of the Wilcoxes and Schlegel manage, in an uneasy way, to come together in the wake of the terrible event.

The final captivating aspect of the novel is Forster’s eye for place. This is central to the  novel in the form of the eponymous Howard’s End, based on Forsters childhood home Rooksnest (pictured at the top of the blog) which was then just outside Stevenage. The house, which acts almost as a character in the novel, casts a powerful beam of nostalgia for the values of an English past fading under the strains of technological change and political and social uncertainty.

By contrast Forster comments on the constant change of London in terms which are fully comprehensible to a modern resident of the city “It was the kind of scene that may be observed all over London whatever the locality, bricks and mortar rising and falling with the restlessness of the water in a fountain.” He also has a telling eye for the mores of London life commenting on Margaret “with a Londoner’s impatience she wanted everything to be settled immediately.”

Next to Shakespeare, Forster is one of the writers who, in my view, most captures the conscious and unconscious movements of the human soul and who brings a deep psychological insight into the portrayal of his characters, none of whom are perfect but all of whom are eminently believable.

Howards End is set more than a hundred years ago but is scarcely a dry period drama. It speaks of some of the dilemmas of Britain’s place in the world, of gender, class and human relationships in ways which are just as relevant in 2018 as they were 110 years ago and were just as vivid for me as when I first read the novel as a twenty year old.

The NHS at 70 – time for an honest debate about the future

 

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5th July 2018 will mark the 70th anniversary of the establishment of the NHS. It remains the most enduring testament of the collective will of the people of this country to tackle the need and suffering of their fellow citizens. As such it will be an occasion which deserves celebration, but I hope it is also an anniversary which provides a focal point for some critical debate about its future.

By this I do not mean challenging the basic principles of the NHS. Britain is not unique in providing universal access to healthcare but it’s system is distinctive and, on the whole, is relatively efficient and fit for purpose. However, the last 8 years of austerity have highlighted weaknesses which, if not addressed, will undermine the sustainability of what is able to be offered for future generations given an inevitable increase in demand with an ageing population and advances in medical technology.

I would highlight five priorities for the New Year.

The first is workforce where we have now woken up to the scale of the short and long-term challenges we face. In the short term the big pressure is numbers, for instance, in mental health, we need 19,000 extra members of staff by 2020/1 to replace staff we are losing and to meet the extra demands of the Five Year Forward View for Mental Health. In the long term there are bigger challenges about reenvisaging the health and care workforce and rethinking career pathways along the more flexible lines which will appeal to a younger workforce less likely to buy the old paradigm of a profession for life.

We also need to be much smarter at looking after the workforce we have got. The recent Farmer/Stevenson report on mental health at work positioned the NHS as one of the sectors of the economy with the highest annual costs of poor mental health at work (estimated at between £2,028 and £2,174 per head). We need more than a sticking plaster approach to addressing this, taking account of the fundamentally traumatic nature of working in healthcare and any remedy must be a fundamental part of the calculations make about efficiency and productivity in the NHS.

The second priority is to be honest about the money. All I have seen in the last couple of years is of a system, which despite some heroic efforts from providers and commissioners, is seriously struggling to keep up with the demand it is facing within the resources available, let alone being able to address key priorities for development and transformation such as those for mental health. I am, of course, not alone in that view with similar opinions being voiced by the Kings Fund and most of the leading health think tanks. While I accept that there are no easy answers to the pressures on public finances there are major consequences of the current position. First there is stress of dealing with the fallout on the frontline staff and who can often feel held personally responsible for the failings of the system. Second a constant focus on short term efficiency distorts priorities, making it harder to make investments in new models of care which often require some element of double running but which, in the long term, are central to the delivery of a sustainable system of care.

These dilemmas have made me a supporter of proposals to take decisions about the long-term funding of the NHS and social care out of day to day political decision making with funding pegged to an agreed proportion of GDP. There would still be difficult choices to be made but, at least, the basis for those choices would be less arbitrary.

My third priority is prevention in its wider sense. It is the most obvious economics that intervening early is less expensive than waiting to deal with issues when they have reached crisis point. However again and again in the years of austerity we have cut those services which prevent demand or help to seriously reduce its impact. Some of this recognises the limited role which health services play, on their own, in improving health outcomes. It also reflects the distortion caused by the short-term nature of funding which can lead to the exclusion of initiatives which deliver a very robust return on investment but where payback will be over years if not in some cases, decades. From my perspective there would be very powerful case for treating elements of public health spending as capital investment with upfront investment justified in terms of its longer-term impact on health outcomes and utilisation.

Linked to this is the need for a much greater sense of urgency in tackling health inequalities which needs to be a much greater focus of national policy making and local commissioning decision. In an era where what we can do is being rationed, either explicitly or implicitly, the impact on health inequalities should be a key criterion for any assessment made by NICE of new treatments.

My fourth point is the need to continue to resist the temptation to default to organisational change as a kind of “magic thinking” to address the problems of funding. I think STPs have, in general, been helpful and the principles of Accountable Care provides opportunity to take a paradigm of integrated care further. But let’s not again make the old mistake of putting form before function. From my experience organisational development is best as a means of supporting and extending those areas which are already well on a journey towards more integrated working and any wider roll out must be justified in terms of clear evidence of benefit in a UK setting. We must also be bold in constructing approaches which go beyond the traditional boundaries of the NHS and ensure social care, housing and the voluntary a key seat at the table.

My final point relates to culture. The NHS has many strengths and it is full of many very committed and inspiring individuals. The way it works together as a system can, sometimes, leave something to be desired.  Part of the problem is the public and political nature of the service and to the way in which it is portrayed in parts of the media, some of it relates to the way in which different constituencies, especially when under external pressure, react to each other.  We need a culture which is tough on problems and supportive of individuals and when things go wrong does not automatically try to find someone to blame.  We need to call time on aspects of the persecution and bullying of staff which sadly remain all too visible in the way the NHS, at times, goes about its business.

So, 2018 will be the time to celebrate the 70th birthday of a remarkable British institution. Its remarkableness, however, will be even more reason for an honest debate about its future.