This article discusses whether the National Health Service (NHS) established by Aneurin Bevan is under threat. It notes that over the decades since its founding, the NHS has undergone numerous top-down reforms introduced by successive governments often without strong evidence bases and focused more on short-term political goals than long-term sustainability. While policies and guidelines have proliferated, core clinical practices like temperature charts have remained the same. The article questions whether constant reforms have undermined the NHS without improving patient care.

1.
Is
Bevan’s
NHS
under
threat?
"fair
trade
in
knowledge
for
health"
APGD
2015

2. 1
Albert
Persaud
(AP)
1
and
Geraint
Day
(GD)
2
This
article
is
a
revised
and
expanded
version
of
written
evidence
submitted
by
Albert
Persaud
to
the
All
Party
Parliamentary
Group
on
Primary
Care
&
Public
Health
–
of
the
United
Kingdom
Parliament
–
in
2013
for
its
inquiry
into
‘The
sustainability
of
the
National
Health
Service
(NHS):
Is
Bevan’s
NHS
under
threat?’
Preamble
For
many
people
there
may
be
three
important
pillars
of
British
society:
the
weather,
the
monarchy
and
the
NHS.
Politicians
can
do
little
about
the
weather
and
even
less
concerning
the
monarchy,
so
the
NHS
has
become
a
politicians’
playground.
One
of
us
(AP)
joined
25
years
after
the
creation
of
the
NHS
by
the
Welsh
politician
Aneurin
Bevan.
AP
recalls
similar
questions
being
asked
then
as
are
now.
Since
that
era,
there
have
been
numerous
top-­‐down
reforms,
policy
announcements,
policy
changes,
all
politically
driven
with
one
distinctive
feature;
which
is,
all
the
pronouncements
have
been
largely
aimed
at
the
length
of
the
particular
political
party’s
life
in
government
(about
four
to
five
years).∗
Very
few
of
these
changes
have
been
evidence-­‐based,
or
properly
costed,
but
more
importantly,
have
been
deficient
of
seriously
thought
through
implementation
plans
to
bring
about
real
changes.
At
any
given
time
a
busy
NHS
hospital
ward
in
England
may
have
over
ten
kilograms
of
documents,
policies,
guidelines,
‘good
practice’
guidelines
from
its
NHS
trust,
hospital
policies,
and
so
on,
all
on
shelves
covered
in
dust
(with
due
account
taken
of
infection
control
policies,
no
doubt).
Interestingly,
the
Temperature,
Pulse
and
Respiration
(TPR)
chart
used
today
is
basically
the
same
one
that
was
introduced
in
1948.
Also
of
significance,
the
people
–
NHS
workers
-­‐
who
are
meant
to
1
Co-­‐Founder
and
Director
of
the
Centre
for
Applied
Research
and
Evaluation
-­‐
International
Foundation.
(Careif):
www.careif.org
NHS
experience:
Completed
37
years
in
the
NHS
with
the
last
ten
years
at
the
Department
of
Health
(DH).
Started
in
the
NHS
in
1974
as
a
hospital
porter,
then
trained
and
practised
as
a
clinician
in
mental
health
(psychiatry),
at
the
front
end
of
patient
care,
worked
in
public
health
and
then
at
the
DH
and
crafted
some
of
the
most
progressive
mental
health
policies
including
amendments
to
the
Mental
Health
Act.
2007.
He
is
acknowledged
as
one
of
the
top
40
people
of
Asian
origin
to
have
influenced
the
development
and
shape
of
the
NHS;
Nurturing
the
Nation:
The
Asian
Contribution
to
the
NHS
since
1948;
(DH
Runnymede
Trust;
2013:
http://nurturingthenation.org.uk
2
Health
policy
advisor,
NHS
England
Lay
Assessor;
Care
Quality
Commission
Lay
Inspector,
employee
of
a
royal
college,
former
head
of
health
policy
at
the
Institute
of
Directors,
and
former
NHS
public
health
statistician.
He
worked
with
DH
and
others
to
help
create
NHS
foundation
trusts.
He
is
a
branch
committee
member
of
a
healthcare
friendly
society
and
worked
with
Albert
Persaud
in
both
Wiltshire
and
Swindon
Health
Authorities
in
the
1990s.
www.linkedin.com/in/geraintday.
Writing
here
in
a
personal
capacity.
∗
From
May
2010
the
UK
Government
has
been
formed
by
a
coalition
of
two
political
parties
and
with
a
parliamentary
term
fixed
at
five
years,
but
the
same
principle
applies,
we
assert.

3. 2
use
or
observe
the
advice
or
edicts
of
these
documents,
have
for
the
most
part
since
1948,
hardly
ever
been
involved
in
their
drafting
let
alone
assessed
them
for
their
relevance
to
them,
their
work
and
the
patients
they
care
for.
With
every
new
policy
change
or
pronouncement,
what
seems
to
have
invariably
emerged
has
been
a
plethora
of
NHS
experts
in
England
in
particular
(where
most
of
the
recent
changes
have
been
occurring)
-­‐
some
self-­‐appointed
critics,
jargon
inventors
who
always
give
the
impression
of
wisdom
-­‐
they
know
what
is
right
and
what
is
wrong
with
the
NHS
and
to
those
who
work
in
it.
What
tends
to
follow
is
a
series
of
‘word
salads’
–
a
group
of
words,
phrases
and
sentences
put
together,
that
do
not,
however,
make
a
lot
of
sense.
(Note:
such
behaviour
is
similar
to
symptoms
sometimes
found
in
people
with
a
serious
mental
illness
like
schizophrenia
that
sometimes
requires
medication).
There
is
now
an
industry
of
such
people
and
consultants
(of
the
non-­‐clinical
variety,
usually)
whose
voice
and
ability
to
lobby
may
become
the
story;
instead
of
that
of
the
patients,
their
families
and
NHS
workers.
The
NHS
is
unique
and
a
precious
pillar
of
UK
life.
What
is
never
discussed
or
indeed
recognised
is
how
it
has
moved
and
progressed
since
its
inception;
this
is
sadly
very
often
true
of
politicians
including
prime
ministers,
experts,
economists,
vested
interests,
patient
groups
and
others.
The
UK’s
NHS
has
long
depended
on
overseas
people
and
nations,
however,
what
is
and
has
never
been
adequately
recognised,
is
the
contribution
made
by
migrants.
People
came
to
the
UK
in
the
1950s
and
1960s
and
in
subsequent
years,
to
build
the
backbone
of
the
NHS.
They
came
from
the
Caribbean,
India,
Pakistan,
Malaysia,
and
Mauritius
and
elsewhere
to
add
to
those
from
England,
Scotland,
Wales
and
Northern
Ireland.
It
is
time
that
this
fact
be
truly
taken
into
account
and
openly
acknowledged.
Is
‘Bevan’s
NHS’
under
threat?
The
All
Party
Parliamentary
Group
(APPG)
on
Primary
Care
&
Public
Health
posed
a
number
of
relevant
questions:
on
how
the
NHS
was
delivered,
its
scope,
costs,
current
structures
and
the
future
of
the
NHS.
In
what
is
written
here
we
attempt
to
go
to
the
centre
of
the
crossroads
at
which
the
NHS
finds
itself.
In
a
way
it
moves
away
from
a
certain
mindset
in
parts
of
the
NHS
that
cuts
(or
‘efficiency
savings’,
if
you
care
to
adopt
a
particular
politically
driven
management
term)
means
fewer
‘tea
bags
and
papers
clips’∗
.
The
same
thinking
continues
that
those
with
‘vested
interests’
[doctors,
nurses,
royal
colleges,
the
British
Medical
Association
(BMA),
NHS
trusts,
chief
executive
officers
(CEOs),
some
patient
groups
and
organisations
and
increasingly
the
voluntary
sector
now
supposedly
wearing
the
mantle
of
the
Big
Society]
must
be
obeyed
and
venerated;
and
that,
if
you
make
‘cheap
shots’
at
the
frontline
staff
-­‐
those
who
provide
the
care
–
that
they
must
‘work
smarter’
–
a
concept
that
seems
to
presuppose
that
these
same
workers
have
to
accept
that
they
∗
There
is
at
least
one
-­‐
and
probably
more
-­‐
than
one
large
NHS
trust
in
England
at
which
the
staff
have
been
told
that
they
had
to
provide
much
of
their
own
stationery,
including
pens.
That
sort
of
management
and
leadership
seems
entirely
arbitrary
and
unlikely
to
contribute
much
towards
the
‘efficiency’
savings
averaging
millions
of
pounds
per
trust
being
demanded
of
the
NHS
in
England
by
the
UK
Government.

4. 3
are
deficient
in
intellect
(stupid)
in
the
first
place!
Similarly
a
good
case
could
be
made
that
the
current
problems
of
the
NHS
are
inherently
caused
by
politics
and
politicians
where
ideology
often
gets
confused
with
common
sense,
choice
gets
confused
with
preference
and
evidence,
facts
and
reality
get
confused
with
opinion,
folklore
and
myths.
As
far
as
England
is
concerned,
the
NHS
should
sit
alongside
the
Home
Office
and
HM
Treasury
as
primary
functions
of
the
UK
Government
rather
than
as
it
stands
number
nine
or
so
in
the
list
of
Government
relevance
and
importance.
In
England
the
Secretary
of
State
for
Health
needs
to
be
a
person
who
commands
the
respect
of
NHS
staff,
professionals
and
the
public;
capable
of
putting
the
NHS
first
rather
than
purely
party
politics,
respect
the
NHS
and
maybe
performing
the
role
of
an
advocate
rather
than,
in
some
cases,
giving
the
impression
that
the
NHS
is
some
sort
of
backwater
of
the
former
British
Empire.
New
NHS
Model
The
most
important
aspect
of
the
APPG’s
inquiry
was
the
notion
of
the
survival
of
the
NHS.
Here
we
propose
a
model
for
the
next
50
years
that
should
be
built
on
these
three
pillars:
creating
a
modern
NHS,
safeguarding
Bevan’s
values
and
founding
principles.
(1) NHS
Statute
Board
The
Government
should
establish
in
statute
a
board
to
direct
the
NHS;
similar
to
the
Bank
of
England’s
Monetary
Policy
Committee
but
not
the
current
commissioning
board
[which
has,
to
be
said,
gone
through
two
changes
of
name,
having
been
born
as
the
NHS
Commissioning
Board
Authority,
shortened
its
title
to
the
NHS
Commissioning
Board
and
now
lives
its
life
under
the
title
of
NHS
England
–
which
one
of
the
authors
(GD)
noticed
recently
may
abbreviate
to
NHSE
–
like
that
for
the
former
NHS
Executive,
which
was
abolished
in
the
year
2000,
not
having
reached
its
teenage
years].
This
board
would
oversee
and
direct
the
NHS
in
England
–
looking
at
the
NHS
as
a
long-­‐term
national
investment,
evidence
based,
focused
on
outcomes
and
the
patient,
staff
and
public
experiences.
The
board
would
set
the
policies,
cost
its
effects
and
set
out
clear
implementation
actions
and
timescales.
It
could
perhaps
be
chaired
by
a
judge
and
have
strong
legal
powers.
Although
other
options
could
of
course
be
possible.
The
board
could
set
out
in
clear
language
what
it
is
that
the
NHS
in
England
would
be
responsible
for
and
would
treat
-­‐
for
example:
• Category
A
(must
do):
for
example
dealing
with
strokes,
myocardial
infarctions
(MIs),
coronary
heart
disease
(CHD)
and
the
results
of
road
traffic
accidents,
maternity
services,
immunisations,
depression,
organ
donation
and
transplants,
and
blood
transfusion,
etc.
• Category
B
(would
do
after
serious
considerations
given
to
judicious
and
equitable
application
of
a
new
social
or
health
insurance
policy)
-­‐
long
term
and
residential
care,
and
rehabilitation,
etc.

5. 4
• Category
C
(not
delivered
through
the
NHS
but
done
through
social
or
health
Insurance):
including
in-­‐vitro
fertilisation
(IVF),
tattoo
removal,
circumcision,
hair
transplants,
etc.
The
board
would
produce
policies
that
join
up
health
alongside
physical
health
policies
(for
instance
around
CHD
and
diabetes)
with
mental
health
policies
(covering
self-­‐harm,
depression
and
so
on)
so
that
the
whole-­‐person
concept
is
considered
and
delivered
through
a
more
holistic,
preventative
and
whole
care
system
delivery.
Greater
use
of
the
evidence
that
links
physical
ill
health
and
mental
health
should
be
utilised.
For
example,
factors
leading
to
perceived
stress,
which
may
itself
be
a
causative
factor
in
occurrence
of
strokes
and
other
physical
illness.
The
board
would
go
further
by
producing
policies
that
join
up
government
departments,
such
as
those
dealing
with
drug
misuse
and
crime;
treatment
may
need
many
departments
and
other
agencies
to
be
fully
implemented
(such
as
the
Home
Office,
DH,
social
services,
education
and
the
voluntary
sector).
That
could
in
the
end
lead
to
better
outcomes.
Every
quango
including
the
National
Institute
for
Health
and
Care
Excellence
(NICE)
and
the
Care
Quality
Commission
(CQC)
would
come
under
the
jurisdiction
of
this
board.
It
would
direct
and
advise
DH
ministers
and
itself
answer
to
the
UK
Parliament.
This
would
be
a
remarkable
model
of
governance
that
many
might
argue
would
threaten
democracy;
but
the
NHS
is
a
remarkable
institution
Economic
Impacts
of
mental
disorder
in
England
• To
the
economy:
about
£105
billion
annual
cost
of
mental
illness;
• To
the
NHS:
~£12
billion
or
11%
of
the
NHS
annual
budget
spent
on
mental
illness
(and
the
biggest
single
item
of
the
NHS
budget
when
considered
by
disease
condition);
• Proportion
of
the
total
burden
of
disease:
nearly
23%
of
the
total
burden
of
disease
• To
employers:
£23
billion
annually;
• Crime:
~
£60
billion
annual
cost
of
crime
in
England
and
Wales
by
adults
who
had
conduct
problems
during
childhood
and
adolescence.
No
other
health
condition
matches
mental
ill
health
in
its
combined
extent
of
prevalence,
persistence
and
breadth
of
impact.
(2) Local
levy
A
local
levy
could
be
charged
and
collected
through
the
council
tax
and
ring-­‐fenced
to
be
spent
to
support
the
local
NHS
in
England.
This
would
be
based
on
local
needs
and
demands;
for
example
maternity
care
could
be
supported
with
this
type
of
funding,
if
for
example,
extra
resources
were
needed
to
meet
an
increased
child
bearing
age
population.
Funding
for
specialised
services
(such
as
burns
units
and
trauma
networks)
would
need
to
be
considered
out
of
an
England-­‐wide
budget.
(3) Elected
not
appointed
Local
NHS
non–executive
directors
(NEDs)
should
be
locally
elected
(perhaps
every
three
years).
By
submitting
to
such
a
process,
the
candidates
would
be
able
to
provide
their
own
manifesto
for
improvements
of
the
local
population’s
health.
Healthcare
and
health
services
would
have
more

6. 5
local
ownership
and
participation
–
and
accountability.
This
model
is
totally
compatible
and
would
be consistent with
pursuance
of
a
merger
with
health
and
social
care
services
and
budgets
Some
other
considerations
in
support
of
the
three
pillars
above
are:
Some
of
these
points
are
offered
in
some
ways
at
present
by
policy
makers,
but
need
to
be
pursued
with
much
more
vigour:
• Perhaps
90%
of
the
public’s
healthcare
is
delivered
by
the
public
themselves;
yet
the
public,
like
most
NHS
workers
–
as
taxpayers
and
NHS
funders-­‐
have
little
or
no
say
on
how
the
NHS
is
run,
let
alone
reformed.
An
exception,
so
far
limited
in
its
scope,
is
the
NHS
foundation
trust
model
in
which
local
people
may
have
a
vote
in
electing
some
of
the
‘governors’
who
in
turn
appoint
the
NEDs.
Other
models
of
engagement
and
participation
must
be
considered.
NHS
England
has
been
working
on
a
range
of
possibilities
but
there
is
a
very
long
way
to
go.
• The
NHS
must
stop
the
constant
recycling
of
the
golden
cabal
of
failures
(individuals)
who
move
from
one
top
job
to
another.
Most
of
these
individuals
seem
to
go
on
to
anoint
themselves
a
level
of
importance
that
any
attempt
by
the
public,
or
indeed
NHS
staff,
to
understand
this,
is
quickly
met
with
contempt
and
disbelief
by
the
public.
The
Secretary
of
State
for
Health
should
stick
to
his
quite
recent
and
very
timely
promise
made
in
the
UK
Parliament
that
no
managers
in
the
English
NHS
who
had
failed
in
their
job
should
be
allowed
to
move
to
another
similar
one,
as
has
very
often
been
done
up
to
now∗
.
To
do
that
will
require
determination
and
negotiation
with
the
plethora
of
NHS
employing
organisations.
Yet
carried
through
it
must
be,
if
for
one
other
additional
reason
of
producing
equity
alongside
NHS
clinical
staff,
who
all
run
the
risk
of
dismissal
and
sanction
by
their
professional
bodies,
while
NHS
senior
managers
(or
‘Very
Senior
Managers’,
to
use
a
term
that
has
crept
in
along
with
some
huge
salaries
in
the
last
few
years)
seem
to
operate
according
to
not
only
an
entirely
different
set
of
ethics
but
a
grossly
different
disciplinary
procedure.
• A
vibrant
NHS
needs
a
strong
and
emerging
voluntary
sector,
an
engaging
private
sector,
a
creative
and
accountable
social
enterprise
sector
and
an
engaged
public.
It
also
needs
a
much
stronger
and
transparent
partnership
with
local
authorities,
social
care,
business,
environmental
agencies,
education,
community
groups,
religious
groups,
young
people
and
entrepreneurs
of
various
sorts.
The
Labour
Party
set
out
∗
The
CQC
has
recently
published
a
regulation
to
deal
with
‘fit
and
proper’
persons
at
director
level
in
the
NHS
in
England.
Alongside
that,
be
aware
of
a
senior
clinician,
who,
having
heard
that
the
chair
and
chief
executive
of
a
NHS
foundation
trust
had
resigned,
asked
the
question,
“I
wonder
where
they
will
pop
up
next”.
(A
luxury
denied
to
doctors
and
nurses,
for
example,
who
are
liable
to
the
risk
of
being
struck
off
their
professional
register,
it
must
be
stated.)
It
is
hoped
that
the
new
regulation
will
help
level
the
playing
field
at
least.

7. 6
its
stall
on
a
new
approach
to
NHS
policy,
in
February
2014.
That
review
(by
the
Oldham
Commission)
included
a
recommendation
to
better
join
up
health
and
social
care.
That
is
something
that
is
surely
needed.
It
also
explicitly
mentions
the
importance
of
housing.
Yet
it
is
also
a
case
of
history
repeating
itself.
Go
back
to
1945
to
realise
that
Aneurin
Bevan
was
actually
appointed
as
Minister
of
Health
role
with
a
remit
also
covering
housing.
• An
even
better
NHS
would
look
at
how
other
countries
do
healthcare;
promote
more
international
collaborations
and
see
technology,
evidence,
research
and
exchange
as
progressive
and
positive
thinking,
instead
of
a
host
of
often
disregarded
‘pilot
initiatives’
which
may
often
seem
to
demonstrate
that
‘not
in
my
backyard’
is
a
concept
alive
and
vociferous
in
the
world
of
the
NHS+
.
• NHS
changes
and
polices
must
be
unambiguous
about
their
impact
on
rural
communities
and
people
of
ethnic
minorities
and
be
applied
in
practice
as
opposed
to
simply
being
policy
statements
of
intent
around
such
vague
topics
as
‘diversity’.
Thus
they
should
contain
means
of
demonstrating
how
they
are
actually
addressing
and
–
more
to
the
point
-­‐
dealing
with
inequalities.
• In
one
view
of
the
world,
those
with
vested
interests,
doctors,
nurses,
royal
colleges,
the
BMA,
other
trade
unions,
NHS
trusts,
CEOs,
some
patient
groups
and
organisations
and
the
voluntary
sector
might
be
perceived
as
speaking
for
all
but
representing
nobody
in
particular.
It
is
lazy
policy
making
when
a
government
invites
just
these
groups
(and
of
them,
‘the
usual
suspects’
who
with
the
best
will
in
the
world
certainly
cannot
represent
all
needs)
to
meetings
and
discussions.
NHS
England,
for
instance,
has
made
welcome
moves
away
from
that
with
regard
to
use
of
more
individual
patients
and
members
of
the
public
in
recent
years,
it
is
acknowledged.
• Every
citizen,
group
or
set
of
professionals
is
an
owner
or
‘shareholder’
of
the
NHS.
As
taxpayers
they
should
have
every
right
to
disagree
as
much
as
agree
to
what
is
proposed
about
the
NHS.
Engaging
with
the
disagreeable
is
a
sign
of
strength.
That
is
a
trait
that
seems
to
have
gone
out
of
fashion
in
far
too
many
public
bodies
nowadays,
when
it
appears
that
abilities
in
‘good
news’
management
are
more
highly
remunerated
than
having
specialist
caring,
clinical
or
other
skills.
No
doubt
those
of
an
especially
critical
nature
might
prefer
the
term
‘lying’
in
place
of
‘news
management’,
especially
in
the
wake
of
the
prolonged
debacles
over
many
years
at
Mid
Staffordshire
NHS
Foundation
Trust
and
possibly
some
other
NHS
trusts.
• The
NHS
starting
point
must
be
from
+
Although
thankfully
the
principle
of
nimbyism
has
not
been
enshrined
in
the
NHS
Constitution,
which
is
meant
to
guide
NHS
actions
in
England.

8. 7
♦ care
groups:
such
as
children,
mothers,
young
people,
older
people,
men;
♦ settings
(where
the
services
or
care
are
provided):
ranging
from
hospitals,
general
practices,
day
and
sports
centres,
the
independent
sector
to
supermarkets;
♦ conditions
(disease
and
illness):
a
wide
spectrum,
including
depression,
CHD,
measles
and
the
consequences
of
hospital
acquired
infections.
Prevention
considerations
should
be
integrated
with
that
concerning
good
clinical
assessment,
diagnosis,
treatment
and
outcomes.
• The
current
non-­‐statutory
function
and
role
of
public
health
has
in
many
ways
failed
and
may
continue
to
fail.
It
is
not
wise
to
have
an
expensive
system
in
which
doctors
and
others
working
in
public
health
have
no
patient
or
hands-­‐on
contact,
yet
give
advice
and
what
may
come
over
as
imperious
commands
to
those
dealing
with
patients.
Many
frontline
practitioners
despise
this
system.
Public
health
practitioners
should
be
people
with
dual
roles;
both
in
patient
and
community
contacts
and
examining
population
public
health.
Such
duality
could
also
encompass
academics,
researchers,
primary,
secondary
and
social
care
practitioners.
• Who
exactly
runs
the
NHS
in
England?
Is
it
the
politicians;
is
it
the
DH
or
NHS
England?
Is
it
the
NHS
trust
boards?
The
Clinical
Commissioning
Groups?
Health
and
Wellbeing
Boards?
Or
local
councils’
Health
Overview
and
Scrutiny
Committees?
There
are
also
local
education
and
training
boards.
Or
perhaps
the
answer
is
to
be
found
in
Clinical
Senates
or
Quality
Surveillance
Groups?
The
number
of
separate
NHS
bodies
in
England
has
bloomed
under
the
Health
and
Social
Care
Act
2012.
And
the
Secretary
of
State
for
Health
has
assumed
renewed
importance
in
the
wake
of
the
Keogh
Mortality
Outlier
Rapid
Response
Review
of
14
NHS
acute
hospital
Trusts,
and
the
setting
up
of
the
CQC’s
Chief
Inspectorate
of
Hospitals,
judging
by
some
of
his
recent
UK
Parliament
and
other
statements.
Practitioners
are
responsible
for
the
treatment
of
their
individual
patient,
but
who
exactly
is
responsible
for
providing
the
tools
and
environment
required
for
care?
Recent
press
reports
suggest
that
seven
out
of
ten
members
of
the
public
don’t
seem
to
know.
If
you
are
confused
try
asking
the
staff
who
work
in
the
NHS!
Do
you
think
they
all
know?
• The
underlying
principles
of
the
creation
of
the
‘Bevan
NHS’,
its
journey
and
all
its
historical
values
tends
to
get
lost
in
the
political,
management
and
‘reform’
agenda.
The
anthropological
and
social
conscience
of
Bevan’s
NHS
should
resonate
in
all
undergraduate
and
postgraduate
training
in
health
and
social
care.
(Ideally
it
should
be
a
more
prominent
part
of
the
standard
school
education
curriculum).
• The
emphasis
must
be
on
implementation
to
improve
practice
and
service
delivery.
Thus
a
national
institute
with
a
specific
remit
to
bridge
policies,
practices,
services,
and
good
outcomes
is
a
necessity.
It
must
bring
together
NICE,
CQC,
the

9. 8
practitioners,
other
staff,
patients,
the
public,
undergraduate
and
postgraduate
training,
professional
bodies,
drug
companies,
the
independent
and
business
sectors,
the
legislature
and
many
more,
into
a
functional
and
effective
knowledge
centre.
It
is
recognised
that
the
main
determinants
of
health
encompass
an
enormous
range
of
factors,
as
well
as
how
the
NHS
performs.
These
include
employment
status,
housing,
diet,
exercise,
degree
of
isolation
of
an
individual
and
the
state
of
the
physical
environment
in
which
they
dwell.
The
key
to
dealing
with
these
-­‐
instead
of
simply
talking
about
or
repeatedly
measuring
them
is
to
create
real
action
between
different
departments
of
government,
public
bodies,
voluntary
groups
and
the
private
sector
-­‐
as
well
as
with
individual
people.
That
would
surely
be
preferable
to
many
of
the
'partnerships'
that
often
do
little
more
than
continually
pontificate
Or,
to
be
blunt,
hold
meetings
with
vague
agendas
for
the
sake
of
it
and
never
have
to
account
for
their
successes
or
failures
to
make
practical
achievements.
The
whole
of
the
health
promotion
or
'prevention'
agenda
is
intimately
connected
with
the
state
of
the
nation's
health
and
it
is
probably
time
for
much
tougher
talking
about
some
of
the
constraints
and
calls
upon
the
NHS
as
deliverer
of
healthcare
of
people
falling
ill.
The
addiction
of
governments
to
tobacco
taxation
shows
how
difficult
it
actually
is
to
achieve
reduction
in
harm-­‐inflicting
activities
like
smoking.
Yet
unless
we
are
all
honest
about
that,
then
mere
exhortations
about,
for
example,
changing
lifestyle
will
do
little
or
nothing
to
alter
the
fact
that
people
with
diabetes
need
to
be
treated
because
they
have
that
condition
now.
So
dietary
advice
means
real
dialogue
between
healthcare
personnel
and
food
manufacturers
and
caterers,
for
example,
ideally
with
agreements
at
the
end
of
it.
Concluding
remarks
The
above
views
are
based
on
the
evidence
that
the
current
NHS
is
not
sustainable
with
regard
to
its
structure,
governance,
management,
cost
and
ambitions.
Parts
of
it
are
decaying
(think
of
agency
or
locum
staffing,
and
some
poorly
provisioned
maternity
services
in
decaying
buildings),
parts
are
wasting
money
(ponder
the
information
and
communications
‘links’
between
social
services,
primary
care
and
secondary
care∗
,
NHS
infomation
and
communications
technology
system)
and
others
that
have
been
proven
to
have
a
record
of
inefficiency,
incompetence
or
worse
(of
the
which
the
CQC
was
until
not
so
long
ago,
a
well-­‐publicised
example,
it
has
to
be
said).
The
cumulative
effect
of
these
and
other
factors
is
blunting
motivation
and
inspiration
among
very
many
of
those
who
work
in
the
NHS.
“Change comes about because people are activated. People are involved."
Barack Obama, President of the United States of America.
∗
That
is
without
mentioning
the
late
Connecting
for
Health
white
and
cost-­‐burdened
elephant.

10. 9
Many
of
us
came
to
the
NHS
because
we
wanted
to
care,
a
vocation
of
choice.
Healthcare
is
an
art;
professional
artistry
and
the
science
of
medical
advances
require
that
the
NHS
itself
be
fit
and
healthy
for
purpose.
If
you
would
like
to
contribute
to
the
construction
of
these
ideas;
email
to;
BevanNHS@healthfootprints.co.uk
Some
historical
and
most
recent
reference
points:
The
National
Health
Service
Act
1946
came
into
effect
on
5
July
1948
and
created
the
National
Health
Service
in
England
and
Wales.
Similar
pieces
of
legislation
created
the
NHS
in
Scotland
and
in
Northern
Ireland
on
the
same
day.
The
Cogwheel
Report
encouraged
the
involvement
of
clinicians
in
management
[Ministry
of
Health
(1967),
First
Report
of
the
Joint
Working
Party
on
the
Organisation
of
Medical
Work
in
Hospitals’
(the
Cogwheel
Report),
London:
HMSO.]
The
Salmon
Report
aimed
to
raise
the
profile
of
the
nursing
profession
in
hospital
management
[Ministry
of
Health
and
Scottish
Home
and
Health
Departments
(1966),
`Report
of
the
Committee
on
Senior
Nursing
Staff
Structure’
(the
Salmon
Report),
London:
HMSO.]
The
NHS
Reorganisation
Act
1973
created
14
regional
health
authorities
(RHAs)
90
area
health
authorities
(AHAs)
in
England.
General
practitioners
(GPs)
remained
independent
contractors.
Equity
and
Excellence:
Liberating
the
NHS
[TSO
(The
Stationery
Office)
2010]
removed
Strategic
Health
Authorities
(SHAs)
and
Primary
Care
Trusts
(PCTs),
and
established
a
National
Health
Service
Commissioning
Board,
with
local
commissioning
carried
out
by
consortia
of
GPs.
[DH
(2010),
Equity
and
Excellence:
Liberating
the
NHS,
London:
HMSO.]
Review
into
the
care
and
quality
of
treatment
provided
by
14
hospital
trusts
in
England:
overview
report
and
related
reports
on
the
individual
trusts
(2013),
Professor
Sir
Bruce
Keogh,
DH:
2013,
summarised
the
findings
into
reviews
of
NHS
hospital
trusts
found
to
be
outliers
in
terms
of
mortality
rates.
All
Party
Parliamentary
Group
Primary
Care
&
Public
Health:
Is
Bevan’s
NHS
under
Threat?
(July
2013)
www.pagb.co.uk/appg/inquiryreports/Bevan%27s_NHS_July_2013.pdf
Organisation
for
Economic
Co-­‐operation
and
Development
(OECD)
:
Mental
Health
and
Work:
United
Kingdom,
(OECD
Publishing,
2014)
www.oecd.org/els/emp/mentalhealthandwork-­‐unitedkingdom.htm
Labour
Party:
One
Person
One
Team
One
System,
Report
of
the
Independent
Commission
on
Whole
Person
Care
for
the
Labour
Party
(February
2014)

11. 10
www.yourbritain.org.uk/agenda-­‐2015/policy-­‐review/whole-­‐person-­‐care
"fair
trade
in
knowledge
for
health"