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A follower of things historical

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My love of history started very young with the Ladybird book of Julius Caesar and Roman Britain. It has been a lifelong pursuit, the subject I studied at university and a major source of ongoing interest ever since.  Furthermore, it has been, I would argue an immensely practical training for the career I have pursued.  For how can one plan for the future without what, and just as importantly, why and how things happened in the past?

History, our ability to develop a collective understanding of who we are as individuals and groups and how we have been shaped by what has happened to us is at the heart of what makes us human. It is a crucial intellectual discipline in itself but also a critical part of understanding many other issues, medicine and healthcare to give but one example.

History operates at two levels. The first is the process of research: the discovery and analysis of records and other sources of evidence; the sifting of truth from falsehood; the piecing together of a story from disparate facts.  Historical periods come in two varieties.  Those like the ones I studied at niversity where sources and data are thin on the ground and where the process of reconstruction can, at the best, be only partial.  Those like our own times where there is too much information and the challenge is to spot the wood for the trees.

The other level of history is broader and more strategic. The task here is to draw together evidence to construct a wider narrative about what has happened in the past and what it means for us in the present.  This can involve, at times, opening up new aspects of inquiry or recasting the traditional interpretations of events or bringing new models of thinking to the task of how we look at the past.

All subjects are, in their own way, ideological but history is explicitly so. George Orwell’s adage that “He who controls the past controls the future” is highly relevant and has often been at the heart of the motivations of those who have written or commissioned history.  Ideological bias has always to recognised but, I would argue, it has not always been a bad thing.  Marxist historians have brought many prejudices to the history they have written but they have also been responsible for a healthy willingness to broaden the focus of historical enquiry away from the rich and powerful to include the lives of ordinary people.

To finish this blog I wanted to share six of the historians whose work I have most appreciated. It was hard to stop at six but here goes.

My first choice has to be the Greek historian Thucydides whose account of the “History of the Peloponnese War” is one of the first pieces of serious historical writing which attempts to describe events and their causes. It remains gripping history two and a half millennia later.   The description of Pericles’ famous Funeral Oration provides a fascinating and powerful insight into the values and tensions of the first democratic society.

My second historian is Eric Hobsbawn whose four volume of the rise of industrial capitalism and modern society in the two centuries between 1789 and 1989 is monumental in the sweep and depth of its historical perspective. The last volume “The Age of Extremes” is a fascinating account of the last century, the scale of change in human life it entailed and the brutality it unleashed as part of those changes.

Third up is Roy Porter, originally a historian of the 18th century but one whose reputation is based on his work in describing the history of medicine and significantly that of mental illness.  His landmark book “The Greatest Benefit to Mankind” is a fascinating account of the history of medicine, both in terms of the tracking the scientific progress made by medicine but also the also the social role and motivations of those who have practiced medicine.  His extensive writings on mental illness are well worth reading, in particular for its determination to create a place for the lost voices of those who have been affected by mental illness in the past.

My next choice is the American historian Barbara Tuchman, one of the best historical narrators I have come across, whether in “August 1914”, her brilliant account of the first month of World War 1, “A Distant Mirror” an account of the 14th century and the Hundred Years’ War through the lens of the life of the French nobleman Enguerrand de Coucy of “The March of Folly”, a set of essays which prove Voltaire’s dictum “History does not repeat itself, men do.”

“Montaillou”, by the French historian Emmanuel le Roy La Durie remains one of the most fascinating historical bookds I have ever read. Due to the survival of the amazingly detailed records of the Inquisition, La Durie is able to reconstruct, in microscopic detail, the life and beliefs of a 13th century village in the Pyrenees which is gripped by the Cathar heresy. Such an insight into the daily lives, let alone thoughts and beliefs of past generations is rarely possible.  The past is indeed “a foreign country”.

It would be unsurprising for me to finish with a Welsh historian, John Davies. His “Hanes Cymru”, written in Welsh but available also in England provides the best and most integrated account of the history of my own nation.  As this blog has tried to argue, history is essential to all sense of identity, particularly the identity of nations, however small.

Others will have their choices but all the six I have chosen I value not just for what they have to say about the past but what they can contribute to an understanding of the present.

We live in an uncertain times and that makes history, for me, an ever more essential area of study. For if we do not know where we have come from, how can we judge where we are going?

 

 

 

 

No alternative – next steps on the Five Year Forward View

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The refresh of the Five Year Forward View, published on Friday, gave all of us in the NHS our marching orders for the priorities in navigating the next two crucial years in the service’s history. The original 5 Year Forward View was one of those rare genuinely strategic moments, inevitably Friday’s publication was tactics.  Like most of the key pronouncements in the Stevens’ era it was worth reading and, in my view, made the most of a difficult hand.

The abiding message was more of the same and quite right too. The original Five Year Forward View prompted an unprecedented level of consensus on what needed to change if we were to deliver a sustainable health and care system which could withstand the demographic and other pressure of the next 20 years.  Some progress has been made in delivering that vision and, however difficult the current circumstances, now is not the time to draw back.  However, given the scale of financial and workforce pressure in the system, delivery is not straightforward.

The Refresh is clear about the givens. Brexit is Brexit and the money is the money.  Whatever happens will happen within the funding committed in the Comprehensive Spending Review and the next two years are the toughest ones in the settlement.  There is little room for investment in the double running of services and activities which would smooth the process of transforming services, very little room to deal with anything new or unexpected such as a genuine flu epidemic, very little scope to address the financial pressure on NHS staff, especially at the time when Brexit will exacerbate staffing pressures, and very little room to get anything wrong.  It’s not impossible but the margins are immensely tight, as anyone of us involved in driving a STP delivery plan is more than aware.

However that is the hand which Simon Stevens has been dealt and which he, in turn, has to get the NHS to operate within.  Unless political pressure plays out with a different dynamic than it has over the last 6 months, and something did shift on social care, then the chances of new money remain very low.  There are, though, some important commitments which might make a difference.

First there is a clear and consistent set of priorities: finance, A&E, primary care, mental health and cancer.  In the circumstances these make sense and I am pleased to see the commitment to mental health followed through again although there is still much to do to make the funding flows required to deliver the Mental Health Five Year Forward View objectives clear and transparent.

Second there is a recognition that something else has to give in the form of waiting time targets for some routine surgery and treatment. This will not be without cost for individuals who will face longer periods of distress and anxiety as they wait for treatment, something which in mental health, without historic waiting time guarantees, we are all too familiar with.  There must also be a concern that this is the beginning of a process by which the NHS consolidates as a universal service around urgent care.  Nonetheless in the circumstances it may be the least bad thing to do.

Third there is the commitment for budget flexibility in relation to the rollout of new drug treatments. This will again not be without cost but I have long felt that it was unjust that new drug treatments and the commercial interests of the pharmaceutical industry trumped basic access to care in areas such as psychological therapies.  Unless we see substantial new growth in future funding for the NHS we will need, in any case, to see a radical overhaul of thresholds for approving new drugs and treatments with a much greater emphasis on those with a genuinely transformational impact and less space for “Me toos”.

Finally it was interesting to read the intention to put the nail in the coffin of QoF which the Refresh describes tactfully  “as an approach which has run its course”. As I remember from the time, its intentions were well meant but as a mechanism for driving genuinely health improvement it has become discredited. Hopefully there will be better ways of spending £700 million.

It takes until Chapter 8 until we reach the issue of Workforce and yet nothing could be more significant, both to managing short term pressures and to longer term hopes of transformation. Workforce pressures and issues have been central to some of the biggest financial and quality challenges over the last couple of years, epitomised by agency staffing.  They perhaps have a bigger profile in the Refresh than they did in the original Five Year Forward View but the NHS has a consistent record of not giving workforce the attention it is due.  That cannot be the case over the next couple of years.

There are three challenges. Keeping the numbers on track at a time when retention may be difficult with ongoing pay restraint and the impact of Brexit.  Reskilling the existing workforce to work in the very different ways required by new models of care, perhaps the part of service transformation which mental health took longest to get right in respect of the closure of the long stay hospitals.  Finally the challenge of maintaining staff morale and wellbeing when anxiety is high, pressures are increasing and pay restraint likely to continue.

As we enter the new financial year it is a good time to take stock on where we’ve got to. The Refresh deliberately accentuates the positives and, despite the pressures which most of us can feel trying to manage the system, it is right to celebrate some of the significant achievements of the last year including the introduction of the first waiting time targets for mental health.  In the last year the NHS and its staff have shown great strength, commitment and resilience to achieve what they have in such difficult times.  While the direction of travel still remains the right one it will take a lot more hard work and resilience to get to the final destination.

 

Don’t roll over Beethoven

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Serious music started for me with Beethoven. I remember listening with wonder to the record of Fifth Emperor Piano Concerto I was given as a Christmas present in 1974.  Shortly afterwards came the symphonies which remain some of my favourite works and which kindled a lifelong interest in and passion for classical music.   However many times I have listened to them they remain works which never fail to move me.

It is only more recently, however, that I have got know very much about Beethoven the man and the details of his life, most significantly in reading Jan Swafford’s superb biography and visiting over the last couple of summers some of the places most associated with the composer.

The story of Beethoven’s life is a story of the sublime and the ridiculous and a story of how some of the most moving and majestic artistic creations of all time were born in the midst of much personal sadness and distress.

He was born in 1770 in Bonn, the son and grandson of a musician. It is still possible to visit his birthplace, full of fascinating artefacts from his life. His family was Flemish in origin hence the “van” rather than “von” in his name.  He had a youthful talent although one which was not promoted with the success of Mozart.  Nonetheless he gave his first public concert at the age of 7 and was heavily involved as a teenager in the music of the court of the Elector of Cologne.  The Bonn in which Beethoven grew up in the 1780s was a centre for Enlightenment (Aufklärung) and the values of the Enlightenment are a lodestar for Beethoven’s view of the world.  Nowhere is that more in evidence than in the famous Ode to Joy in his 9th Symphony.

In 1792 he left Bonn for Vienna, never to return. Vienna home to Haydn and, until the year before Mozart, was the centre of the musical world and the most likely place where a budding talent such as Beethoven would find opportunities for performance and patronage.  However, while it was his home for the rest of his life Beethoven never developed a love for the city or its inhabitants, commenting “from the Emperor to the bootblack the Viennese are worthless.”

Beethoven was relatively successful first as a piano virtuoso and increasingly as a composer, attracting the interest and the financial support of a number of wealthy patrons. His talent, unlike that of some composers, was recognised in his own lifetime although it never made him a wealthy man, especially later on in life when he was supporting his nephew Carl.

It was in the first decade of the 19th century, in the midst of the Napoleonic Wars that Beethoven started writing the works which changed the shape of music and established his reputation as one of the greats.  The seminal work was probably his Eroica Symphony, premiered publicly in 1805, a symphony initially meant to have been dedicated to Napoleon and unlike any orchestral music which had come before conveying an unique sense of power and tension.   In a remarkable period of creativity over the next decade he followed it with many other signature works in many different musical forms, orchestral symphonies, an opera, piano sonatas, string quartets all of which remain some of the most significant works in the whole of the classical repertoire.

DSC_0044It was as well that Beethoven was a successful musician because in few other ways was he a happy or fortunate man. His mother, to whom he was devoted, had died before he left Bonn after a long and painful illness.  His father, a mediocre musician who took out his disappointment and a fair amount of the family income in drink, died shortly afterwards.  He remained close to his brothers, but his relationships with them and their families, as with many of his friends and associates were difficult, full of misunderstandings and fallings out. Beethoven, who remains one of the greatest exponents of the idea of humanity, struggled with the day to day challenges of human relationships.  He never married.  Finally the adoption of his nephew Carl, the wrangling for custody with his sister-in-law and Carl’s eventual attempted suicide provided the ultimate tragedy of his life.

He suffered too from bad physical and mental health for much of his life and from the early 1800s began to lose his hearing. Beethoven frequently suffered from depression and in a remarkable surviving document, the Heiligenstadt Testament, addressed to his brothers but never sent, he hints at a desire to take his own life but ends with a commitment to live with suffering for the sake of his art.

In his later years Beethoven was for various reasons less prolific but there stand out a number of works which are amongst the greatest masterpieces of the western canon. His 9th Symphony is perhaps the most famous with its choral finale based on Schiller’s “Ode to Joy.” When it was first performed in Vienna the totally deaf Beethoven had to be turned to see the audience applauding his creation.

The 9th Symphony was composed in Baden, a picturesque little town, just outside Vienna where Beethoven went for a number of summers to compose.  We visited Baden last summer and the beautiful Helenental along which Beethoven himself would walk his mind full of the music, which he could only hear in his head.  It was a very moving day to follow in the footsteps of a musical genius and hero.

Franz Schubert, himself no slouch as a composer, said “Who can do anything after Beethoven?” In literature it is probably Shakespeare who most sublimely captures the essence of the human character and condition. In music, without a doubt, it is Beethoven.

Paying the piper Calling the tune

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In the midst of challenges we are facing as a society today, is a sense that the model of 20th century capitalism which did so much to generate the prosperity which we have enjoyed since the end of the Second World War, is no longer working to our interests. Inequality is growing, wealth is becoming ever more concentrated and economic growth is no longer able to deliver a sense of benefit for all.  Multinationals seem able to outmuscle national Governments and dictate the terms on which they contribute to society through taxation.  Capital is mobile and business models shift relentlessly to create increasingly insecure forms of employment.  And, as I highlighted in my last blog We Robots, if we are concerned now wait until we see the impact of mass automation on both unskilled, and increasingly skilled, jobs.

It is hard to see where these changes will lead to. Socialism remains discredited and, as events in the last year illustrate, the wider public, and in particular those from communities most left behind by processes of economic change, are increasingly dissatisfied with what the traditional political system has to offer by way of solutions.  While, personally, I believe that popularism and protectionism have nothing to offer to those on whom they most target their enticements, there is very clearly an issues to address.

In all of this there is an important question of agency. If believe the world needs to change, to what extent are we prepared to modify our own actions to contribute to that goal? Political actions are important, but we also have an important role as consumers, in particular if we act in sufficient numbers.

There are important precedents. The intellectual argument to abolish slavery in British dominions was won a long time before measures were passed to end it.  Political pressure and the work of campaigners such as William Wilberforce  were crucial but so were the actions of many individuals prepared to boycott sugar, demand for which had been the engine house in the growth of slavery.  Nelson Mandela was vital to the end of Apartheid in South Africa but so was the boycott of South African goods.  Fairtrade, initially a fringe movement aimed at offering the producers of tea and coffee a fair return for their products, has now become a mainstream economic activity with its distinctive logo visible all across our supermarkets.  Where consumers come together capitalism does listen, perhaps at times quicker than politicians and Governments.

With at times some resentment or, more often, gentle mockery from my family I have tried to align my decisions as a consumer with my beliefs. At times, such as with Fairtrade, it has been gratifying to be part of a growing movement for change.  On other issues, such as boycotting Amazon, on the grounds of not paying tax in the UK and their exploitative employment practices it has felt harder work.  In all the cases, however, I have felt it has been the right thing to do, however many others are prepared to act in a similar way.

I am not claiming that consumer power, in itself, can solve all the problems in the world but it can make a contribution and it provides an important statement that people are prepared to make some sacrifices on behalf of their moral and political beliefs.

Individuals will vary in what they think is most important to try to influence in their actions as consumers. For me there are three general priorities.  First is an assurance that companies I buy from are prepared to make their contribution to society through corporate taxation.  Second is a desire to support companies which treat their workers fairly in terms of both pay and working and conditions.  Linked to that is, increasingly, a desire to support those activities which value human labour and to avoid unnecessary automation and self-service.  Finally has been a desire to support activities and goods which respect the environment, either because they are produced locally or because they are, in others ways, environmentally sensitive in the way they are produced, distributed or delivered.

I recognise my principles are not the same as those of others. I am not a vegetarian or vegan but I respect those who do not buy meat or other animal products for reasons of principle.  Similarly I was prepared to pay for my children’s education, initially because it was clear to me that state system was seriously failing one of my sons. I know others would feel strongly that private education reinforces inequality.

Some will argue that such choices of principle are easy for someone like me, who is pretty well off, to make. I am sure that is a valid point and I would not wish to be critical of those for whom price has to be the sole determinant of their purchasing decisions because they do not have the income to do otherwise.  I would, however, be more critical of those who have the income to make choices which align with their principles but still choose not to.

Consumer action needs support, most significantly in terms of information and signposting. The media and campaigning groups have an important role to play in exposing the actions of companies and explaining how things really work.  The tax affairs and employment practices of multinational companies is scarcely general knowledge and my own judgements and actions have been helped by those in the media, and increasingly on social media, who have set out the facts on particular issues.   Good branding can also help, something which the Fairtrade movement has exemplified.

The Germans have an expression “Man ist was man isst”, “One is what one eats.” If we believe in agency then we have to believe that our actions are important and our principles are worth some sacrifice when required.   On our own we are powerless but with others we can make a difference.  However someone has to make the first move and others have to follow.

 

We Robots

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It seems to be a good time for dystopic novels. Sales of 1984 are booming in the wake of the election of Donald Trump and, in a wider sense, contemporary events shake us into remembering the worlds we were happy to believe only existed in fiction.

One of the most disturbing pieces of fiction I have ever read is Isaac Asimov’s “I Robot”, a chilling and very well told set of stories tracking a possible future of robots taking over from humans. The 2004 film of the same name explored some of the same issues, but, of course, with a Hollywood happy ending.

In recent weeks robots have been back in the news in various guises. Automation and the replacement of human labour and intelligence with robots is ever more regularly discussed as the key to improving productivity and even to squaring the circle in terms of the cost of public services.  Only last week a report from the think tank Reform “Work in Progress:  Towards a leaner, smarter, public sector workforce.” suggested that it might be possible, amongst other things, to replace both school receptionists and 90% of Department of Education administrators with robots.  It was n’t just because I have been a civil servant which made me stand back in shock at the scale and implications of this change.

The arguments about automation are not new and, as a historian, I know that in the long term the Luddites and saboteurs (their French equivalent) have usually been on the wrong side of the argument. Whatever the trauma experienced by the generation and groups most directly affected, we have, in the longer term, replaced the roles we have lost with new ones and automation has generally contributed to a net increase in wealth (whether or not that wealth has been evenly distributed).  Why should it be different this time?

I have a number of concerns that warrant, I believe, society considering more deeply the implications of the kind of changes which are being proposed here.

The first relates to scale. The number and breadth of roles which could be automated implies an enormous change in both the world of work and the structure of society.  Given the importance of work both as a means of distributing wealth but also of providing individuals with purpose and a sense of identity, can we successfully manage this level of change without creating a level of economic and social dislocation which would dwarf the issues we are already struggling to manage?

The second is the danger of myopic focus on technical efficiency rather than wider social functions which are embedded in many of the roles which might be automated. I know, for instance, how important receptionists are in my own NHS organisation.  On one level their role may be seen narrowly as administrators but often they can be a crucial source of welcome and support for anxious patients and families coming to our Clinic for treatment.  We neglect those intangible but crucial social aspects at our peril.

My third concern relates to arguments about who the beneficiaries of such change might be. It is possible to argue that if more work was automated we could all have more leisure.  That argument assumes however that, as individuals, we have the income to enjoy that leisure.  The disturbing trends towards the ever greater concentration of wealth would be at risk of being exacerbated by wholesale automation.  With declining commitment to individual and corporate taxation, employment remains one of the few ways in which wealth can be successfully distributed across society.  We may create, as a result of automation, more interesting roles for those who remain in employment, but what of those who do not have the skills or attributes to get the new roles? The dangers of expanding an underclass of the workless is concerning, even more so in the turbulent political times in which we are living.

My final concern is what I would call the Frankenstein argument. I am no expert but it strikes me that some of what we are now able to do with technology is of such a level of sophistication that it is changing the relationship between humans as creators and that which we create.  There are dangers here which we need to be more wary of before committing to the next generation of automation across all aspects of our activity.

Some automation is good and will inevitably happen. My plea in writing this blog is not to  rubbish all technological innovation but rather to reassert a moral and ethical framework around which we decide what is best us for us as a society.  The danger is that we become the slave not the master of our technological genius and if you want to know where that might lead buy a copy of I Robot.

A Long Shadow – the events of 1917

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We are living in interesting times. With the political convulsions of Brexit and the election of President Trump there is a sense of losing some of the bearings against which I have judged political and other events for most of my lifetime.  I have long argued that, at a time when it is difficult to look forwards with any certainty, there is a value in looking backwards at what history can tell us about the impact of major change.

1917 was one of the most significant years of the whole of the last century. Four events, in particular, stand out as having cast an especially long shadow. All those events are set in the context of the First World War and the massive effect that conflict had on the shape of most of the 20th Century.

At the start of 1917 the First World War stood in a position of stalemate. The Somme Offensive, although possibly significant in its impact on German manpower and morale, had failed to make the great breakthrough which British and other commanders had hoped for.  The Battle of Jutland had failed to give other side a definite advantage on the seas.  A half-hearted attempt to broker a peace had not got anywhere.  More than anything there was a deeper understanding of the total and inhuman nature of modern warfare which had extracted an enormous cost from the young men fighting on the Western Front and elsewhere. Furthermore by 1917 the strain imposed by the War had reached well beyond those directly involved in the combat to challenge the very foundations of nations.

The Russian Revolution started in March 1917 (western dates) in the streets of St Petersburg. The economic consequences of the war were the spark for revolt, it turned into revolution when the military refused to put down the disturbances and within days the 300 year old rule of the Romanov dynasty had come to an end.  To start with the Tsar was replaced by a provisional Government of relatively moderate socialist and liberals.  But that was not the end.  A catastrophic decision to continue a war which Russia could neither afford nor win led to a new round of revolution in November.  On this occasion the winners were the Bolshevists led by Lenin who had been cynically allowed by the German authorities to return to Russia in a sealed train.  The first successful communist revolution (brought wonderfully to life in the account of the American journalist John Reed – “Ten days that shocked the world”) left an enormous historical imprint on the rest of 20th century.  It is an interesting historical question whether, without the First World War, it would have come to pass.

The second significant event was the decision on 6th April 1917 of the USA to join the conflict on the side of Britain and the Allies.  While American manpower did not really make a difference until 1918, the US declaration of War on Germany had, both practically and psychologically, a crucial influence on the outcome of the struggle.  It represents America’s coming of age as a world power and its first intervention in European affairs.  That willingness to act as the world’s policeman, both in times of War and, at times, as evidenced by the Marshall Plan, of peace has been another defining feature of the last century.  A more isolationist approach, as America pursued in the 1920s and which Donald Trump appears to be recreating, has a significant impact on events in the rest of the world.

In all sorts of ways the First World War changed the nature of war. One major aspect of this was the involvement of civilians in the conflict through the use of the airpower.  On 13th June the Germans mounted their first daytime air raid on London.  One of its targets was a school in Upper North Street in Poplar, very close to where I used to live when I was first in London.  18 children lost their lives.  Since then civilians and much as soldiers have been the victims of warfare something which recent scenes from Aleppo brutally remind us of.  Back on the Western Front the Battle of Passchendaele in Belgium, which started on 31st July, and in which my great uncle was injured, epitomised the futility of trench warfare as hundreds of thousands of lives were lost in trying to secure several miles of waterlogged ground.  In understanding the events which led up to the Second World War it is worth taking account of the deep psychological trauma which this conflict with its machine like brutality inflicted on a whole generation of men.

The final event does not relate to Europe but to the Middle East. On November 9th the  Balfour Declaration (named after the British Foreign Secretary Arthur Balfour) setting out the support of the British Government to creating a Jewish state in Palestine. Its value at that time was seen, primarily in terms of propaganda, but by the end of the year the British General, Allenby had entered Jerusalem.  While British policy oscillated during the next 30 years of the British mandate in Palestine it set the course for the creation of the State of Israel.  More generally the disintegration of the Ottoman Empire at the end of World War and some of the decisions taken after it by both the British and the French set the scene for a lot of the regional instability which remains a dominant issue in world affairs.

So perhaps more than what happened in 1916 which we marked with the centenary of the Battle of the Somme the events of 1917 are the key to understanding the profound impact which the First World War had on human history. As we face another time of change it is worth remembering what happened a hundred years ago and the long shadow which things which happen today can cast on the lives of those to come.

We need to talk about Kevin

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As often seems to be the case in January, the NHS was back on top of the news agenda this week. At times for good reasons as when Theresa May made a speech promising to end the burning injustices surrounding mental illness, at times for less good reasons as Accident and Emergency Departments struggle to deal with winter pressures.   It is one of those moments when more fundamental questions are again raised about the future of the NHS.

We know the NHS is much loved and cherished by the public, the nearest thing the English have to a religion as Nigel Lawson’s oft quoted quip would have it, but it is also something we find, as a nation, difficult to talk about in all but the most banal platitudes. If put to the test, an overwhelming majority of the public would vote to keep the NHS but what sort of health service do we want and at what price?

The next couple of years are a critical time for the NHS as it faces the simultaneous challenges of growing demand, the consequences of austerity and the uncertainties flowing form Brexit.   For one I believe it’s time we took a more fundamental look at some of the key questions which face the service and its development to ensure that there is a genuine consensus across the political spectrum which can ensure we have a sustainable NHS which is fit for purpose in the 21st century.

There are a number of key questions which should be part of such a long term review.

The first, and most pressing, is to look again at the 1948 settlement so as to bring health and social care together as part of an integrated system of funding and delivery. Social care is fundamental to the care of some of the most vulnerable people in society, whether frail elderly people or looked after young people.   When it is not there, inevitably demand on the NHS increases, often at greater cost.   The issue is, at last, on the policy agenda and there is a wealth of work to draw on how this might be achieved, including the report of the Kings Fund’s excellent Barker Commission.

Secondly it is time to institutionalise the commitment to give parity of esteem to mental health. I, like others, was happy to welcome the Prime Minister’s speech on Monday on mental health but the laudable objectives she set out cannot be achieved if the underlying inequity in funding is not addressed.  As the LSE highlighted in their 2012 report “How Mental illness loses out in the NHS” the treatment of mental health problems accounts for 23% of demand on the NHS but receive only 11% of the funding.  I would accept that such a shortfall cannot be tackled overnight but a longer term settlement for the NHS might commit, for instance, to eliminating this differential over a ten year period with a fixed additional uplift for mental health in each year of that period.

The third issue relates to the shape and balance of services. The 5 Year Forward View, still a valid road map for the future of health and care services whatever operational difficulties the NHS is currently facing, is predicated on a vision of community care with hospitals playing a less significant role than at present. This is, of course, a journey which mental health has already been down and is, for me, the direction of travel which we must follow to deliver a sustainable NHS.  Whatever we think are the causes of the current pressures on A&E and other parts of the acute sector the one incontrovertible fact is that a year on year growth of 3% for hospital services is unaffordable.  While an adequately resourced and well explained model of care closer to home can be popular with the public, that support can be lost easily if community care is seen as care on the cheap and essential services are not available when they are needed.  This change needs long term and unambiguous political commitment and adequate transitional funding if it is to happen properly.  However, without it, our chances of sustaining the NHS for next 20 years are slight.

My fourth question relates to how we define the mission of the NHS. It might be thought that there was an obvious answer to that question but health care need is not an absolute quantum.  There are always choices to be made about priorities.  Beneath the surface warmth we all feel about the NHS there is a more complicated reality and some hard choices, often made now by default, about priorities against finite resources.  Of course the NHS is there to save lives but, for me, I would like to see a greater emphasis on improving life chances (for instance through increased investment in children and young people’s mental health services)  and relieving suffering in the decisions we make about the development of services.  When much of what we can do to improve lives, in particular in the area of mental health, remains unfunded we should not assume that all future medical developments can necessarily be supported.  I believe NICE has been, in general, a positive development in our health care system but I think there is a case for revisiting the basis it is given for making some its judgements.

The last point, of course, relates to funding. Just as health care need is not an absolute quantum there is no right answer for what level of funding the NHS should receive.  However there is a case for taking it out of the realm of day to day political decisions and linking the decision to an external benchmark such as the average spend for comparable European or OECD countries.  The NHS is, in relative terms, a cost effective system but it is striking that, over recent years, the spend as a proportion of GDP has been falling and the gap broadening in comparison to other developed economies.  In such circumstances something has to give.

Day in, day out NHS staff do some brilliant work supporting the millions of patients who seek its help.  However it is a system under strain.  Positive change, of the kind outlined in the 5 Year Forward view, is possible but it needs a broad political consensus with the proper engagement of the public and adequate transitional funding if we are to deliver a model of health and care which is sustainable.  How we do that is challenging in an era where politics has become so polarised.  A Royal Commission, as some have called for, might be one route but only if there is an absolute commitment across the political spectrum to implement its findings.

We do need to talk about Kevin.