Cardiff University Healthy Ageing Conference & Public Lecture The importance of a healthy lifestyle A Conference and a Public Lecture Thursday 30th October 2014 http://medicine.cardiff.ac.uk/event/healthy-ageing-conference-public-lecture/

1. Is the NHS sustainable?
The philosophy of prevention
Marcus Longley
Professor of Applied Health Policy and Director,
Welsh Institute for Health and Social Care, University of South Wales
Vice Chair, Cardiff and Vale University Health Board
marcus.longley@southwales.ac.uk
Cardiff, October 2014

2. The New National Health Service
Text of the public leaflet February 1948
‘Your new National Health Service... It will provide
you with all medical, dental and nursing care.
Everyone – rich or poor, man, woman or child – can
use it or any part of it. There are no charges, except
for a few special items. There are no insurance
qualifications. But it is not a “charity”. You are all
paying for it, mainly as tax payers, and it will relieve
your money worries in time of illness’
Central Office of Information for the Ministry of Health (83077) Wt39168
2/48Hw

4. The argument
Old principles...
1. The NHS is great
• Funding is a red herring
...new world
2. But it must change fundamentally in two ways:
• A new compact between the NHS and the citizen
• A new modus operandi

6. The real funding challenge
Resources are now, have always been, and always
will be, finite and less than perfect. So...
The first question is:
What are our priorities?
‘Socialism in the language of priorities’ - Aneurin Bevan
Then we need to decide:
What’s the best way of delivering them?
Wasting finite resources condemns people to unnecessary suffering

7. FUNDAMENTAL CHANGE IS VITAL

8. The cost of continuing as we are
• The cost of getting older:
– 2009/10: NHS = 8.0% of GDP
– 2039/40: NHS = 10.2% of GDP?
• The cost of abusing ourselves:
– 2008/9: obesity and alcohol in Wales = £140m
– 2038/9: ?

9. Some key universal truths...
1. The NHS is about more than health... and
health is about more than the NHS
2. Health policy is all about tricky choices
3. Services are a long way short of being
‘efficient’
4. Healthcare is dangerous
5. More of the same isn’t good enough

10. The Main Determinants of Health
Agriculture
and food
production
Education
Work
environment
Living
and
working
conditions Employment
Water &
Sanitation
Health care
services
Housing
Age, sex
&
hereditary
factors
Values of a Civil Society

11. Some key universal truths...
1. The NHS is about more than health... and
health is about more than the NHS
2. Health policy is all about tricky choices
3. Services are a long way short of being
‘efficient’
4. Healthcare is dangerous
5. More of the same isn’t good enough

12. You can’t have your cake and eat it
Universal Comprehensive
Affordable

13. Some key universal truths...
1. The NHS is about more than health... and
health is about more than the NHS
2. Health policy is all about tricky choices
3. Services are a long way short of being
‘efficient’
4. Healthcare is dangerous
5. More of the same isn’t good enough

14. 14

15. 15

16. Some key universal truths...
1. The NHS is about more than health... and
health is about more than the NHS
2. Health policy is all about tricky choices
3. Services are a long way short of being
‘efficient’
4. Healthcare is dangerous
5. More of the same isn’t good enough

17. Day of the week: mortality
Crude Mortality Rate by Day of Admission
Health Board Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Abertawe Bro Morgannwg 5.7% 5.8% 5.8% 6.3% 6.2% 6.3% 6.9%
Aneurin Bevan 4.3% 4.7% 4.6% 5.1% 4.8% 5.4% 6.4%
Betsi Cadwaladr 5.9% 5.9% 5.9% 5.6% 5.4% 5.7% 5.8%
Cardiff and Vale 5.5% 5.5% 5.6% 5.5% 5.8% 5.2% 5.8%
Cwm Taf 6.0% 5.7% 5.7% 5.9% 5.7% 6.3% 7.2%
Hywel Dda 6.3% 6.1% 5.3% 6.2% 6.3% 7.1% 6.0%
Powys 19.5% 13.8% 24.8% 30.7% 22.6% 25.9% 6.5%
Velindre 7.6% 4.6% 8.6% 7.3% 6.0% 1.6% 2.3%
Wales Average 5.6% 5.6% 5.5% 5.8% 5.7% 5.9% 6.3%
Source: PEDW - Data subject to further validation
Emergency admissions only – excludes paediatrics, obstetrics and
maternity

18. ‘In the next room you could hear the
buzzers sounding. After about 20
minutes you could hear the men
shouting for the nurse, “Nurse, nurse”,
and it just went on and on. And then
very often it would be two people
calling at the same time, and then you
would hear them crying, like shouting
“Nurse” louder, and then you would
hear them just crying, just sobbing, they
would just sob and you just presumed
that they had had to wet the bed’
Independent Inquiry into care provided by Mid
Staffordshire NHS Foundation Trust p53

19. …and in Wales?
‘She leant forward only inches from my mother’s face
and said… “Listen, love, I have 38 other patients to
see to, you’ll have to wait”’
‘When asked if her pad could be changed as it was wet
we were told that they could only change them after
they have been wet five times as they were very
expensive and were designed for this’
Older People’s Commissioner for Wales (2011) Dignified Care?

20. Some key universal truths...
1. The NHS is about more than health... and
health is about more than the NHS
2. Health policy is all about tricky choices
3. Services are a long way short of being
‘efficient’
4. Healthcare is dangerous
5. More of the same isn’t good enough

21. Some key universal truths...
1. The NHS is about more than health... and
health is about more than the NHS
2. Health policy is all about tricky choices
3. Services are a long way short of being
‘efficient’
4. Healthcare is dangerous
5. More of the same isn’t good enough

22. 22

23. Shifting the paradigm...
From
• Cure with Care = transactional
To
• Cope with Care = relational
1948
• Illness, diagnosis, cure, rehabilitation, back to fitness
2014
• Supported to cope, predictable threat, minimum
intervention, back to coping

24. Integration and funding
‘The prize of our new settlement is huge: a more integrated
service, a simpler path through it, more equal treatment for
more equal need, and a far less distressing experience for those
trapped in the confusions of today’s arrangements’ - Kate Barker
• Single, ring-fenced budget for NHS and social care; single
commissioner for local services
• New care and support allowance for people with low to
moderate needs
• Much simpler path through health and social care system
to reflect changing levels of need
• Much more social care free at the point of use
• Public funding (generational adjustments, wealth tax + NI)
not charges/insurance

25. Partnership and choices
‘Generate a culture of care built on more
creative public involvement in the setting and
monitoring of standards, and in the resolution of
ethical issues and practical choices that arise
from the need to make decisions within limited
resources’

26. Obesity:
A ‘more wicked’ problem than smoking
‘Of course, there is no good tobacco smoke but we all
need food. So we can't solve the problem by saying 'no
food' or 'don't eat'. It's a more complicated set of
behaviours that need to be considered... we are
building up impossible demands for the health service
within the next 20 to 30 years’
Mike Kelly, NICE

27. Environmental change vs. evolution
Problem
Calories in > calories out
Obese people need more healthcare
Solution?
 Educate people more/better
 Ban fast food outlets
 Make school dinners compulsory
 More PE in schools
 Tax sugar
 Punish parents
 Sue your parents
 Tackle social inequalities
 Make communities ‘play friendly’
 Industry innovation

28. Shared responsibility?

29. The Holy Trinity for Wales
Co-Production, Prudence and Integration
A system which ensures:
1. Prevention: targeted, individual, coordinated
2. Partnership: clinicians/patients/citizens as partners
3. Integration: NHS, social care, 3rd sector, for-profits
4. Outcomes: co-defined and co-measured
5. Coping as important as curing
6. Proportionality: More is not necessarily better
7. Intelligence: Doing the right thing, as well as doing
things right
29

30. Key challenge
Stop fire-fighting…
…and reduce the risk of fires

31. But beware...
‘We said last year that reconfiguration and radical
service changes offer the best opportunity to put the
NHS on a sustainable footing. NHS Wales now needs to
markedly increase the pace of progress if it is to make
its aspirations for sustainable services a reality. But it is
hard to see how this change can be achieved without a
greater degree of political consensus’
– Auditor General for Wales

32. A proposition…
1. The NHS is great
2. Funding is largely a red herring
– it will always be ‘underfunded’
3. But its modus operandi must change
dramatically
– co-production, prudence, integration
4. And most important of all: we need to re-
think the compact between the NHS and the
citizen