Delivering big outcomes requires big money – and a lot of help from us.

This week I’m exploring what a new contract between the NHS and the public might look like.

On Monday I suggested, drawing on my own experience in 2002, that it is politically and morally important for the NHS to contract the delivery of new achievements for the new money. Today and tomorrow I want to explore what might, and might not, go into such a contract.

It seems rational to assume that any discussion of what the NHS can achieve should include an examination of ways of improving the nation’s health over the next ten years, such as –

What can be done to improve mental well-being?

We must surely reduce obesity?

We must be able to reduce the number of years that older people spend suffering with long term conditions?

Why are there still such shocking inequalities of life expectancy in different parts of the country?

Why is social care so threadbare in England and how can it better coordinate with the NHS?

All of these – and many more – are important social and political tasks for society to tackle. And since the NHS is an important and (given the extra money) growing part of our society then it must have a role in solving them.

But on its own it can’t solve any of them. Let’s look at a couple of examples to demonstrate what the NHS can and cannot achieve.

One of the most important elements in fostering mental well-being is security.  Feeling secure doesn’t guarantee good mental health but being insecure endangers it. Current economic forces in our society have significantly increased economic insecurity compared to a few years ago. This is true for a great number of people in and out of work; true for people renting in the private sector; and true for people in certain forms of debt.

Our society and economy is built on debt.

At various times of my life I have owed tens of thousands of pounds – but these debts have been incurred through mortgages and no-one was threatening to send the bailiffs into my house to take the telly away at the end of the week. There are some forms of debt that are part of our society but which don’t add to personal insecurity very much.

But there are others that do. If you look at adverts for payday loans nowadays they are being made for everyday things. The boiler needs mending; the car needs repairing – so take out a loan at more than 1000% and that will sort it. But then, as interest increases, payments become harder and harder and it’s a big worry. They create deep insecurity in people’s lives.

So in our modern world certain forms of debt create more insecurity, and that insecurity – compounded with others – will, for some, have an impact on their mental health.

It’s not debt per se that’s wrong – it’s the latest instruments that we have constructed to encourage certain forms of it.

So at the moment when our society is pledging itself to once more expand the NHS there is something very perverse happening. We are living in a society which prides itself on its socialised health care system, yet that same society creates conditions under which socialised medicine system has too many demands placed upon it to work. If English society loves the NHS so much, why does it make its life so difficult by creating so much insecurity?

Day after day health care professionals express this same frustration – as GP’s surgeries become half-filled with people whose life experiences drive their ill health beyond the extent to which medicine alone can cope. Nurses, GPs and receptionists all know that they are having to work against social forces that fill their reception rooms and cause ill health and misery. Of course NHS staff don’t give up, but there is something very frustrating about working in a socialised medicine system helping sick people when their ill health is so obviously caused by other elements of the same society that, at the same time, celebrate socialised medicine.

So in terms of any pledges on mental health, the NHS can and should do much better in helping people to develop and maintain mental well-being. But it would be wrong to assume that the NHS can achieve this on its own.

The same is true for obesity. The other week I was in a seminar where we were discussing the likely response of the government to the obesity crisis. If it all happens this will consist of a ban on certain adverts aimed at children, colour coding of goods in supermarkets and a request to manufacturers to limit the amount of sugar in their products. Under discussion was a recent Times editorial with the headline “War on Obesity and an outline of the above measures.

I’m not saying those measures don’t matter at all  – but they are not a war. They are not even a skirmish.

We live in a society where the main fear about obesity is body image, not an early death. Yet the NHS must cope with the very bad ill health that comes from obesity – all the time living in an obesogenic culture. So the NHS can and it should help to motivate patients, when they need to, to lose weight.

But on its own it can’t promise to solve the problem of obesity. That is going to need almost every element of our society to bend its will and organisation in that direction.   It will need a total war, but we are a long way away from declaring that war.

So in return for the extra money over the next few weeks, and as the NHS constructs a new compact with the public, it needs to promise what IT can deliver and not what the whole of society needs to take on board.