These then are the main issues for a new NHS compact with the public (plus or minus a couple over the summer).

In last Wednesday’s HSJ Simon Stevens gave us his first take on the issues the NHS needs to address with the extra money the public will be giving it from November. (Yes, many in the NHS will say that it’s not enough and others will say it will all be swallowed up by backlogs from the last few years. But it is extra money).

To reiterate my point (passim). The money is likely to come from extra taxes (We know it’s not coming from the magic money tree called “the Brexit dividend”) and that means many people will have less disposable income than they would have had. There’s a lot of evidence that the public are prepared to pay these extra taxes but, let’s be clear, providing extra money for the NHS requires that the public have less. So, if the NHS wants a lot more the public will have a lot less.

The point I am making is that, so far as the public is concerned, it will be seen it as extra money (because it is). And they will therefore expect extra for it.

So let’s examine Simon Steven’s proposed extra activities for the new compact one by one.

First is mental health – especially services for children and young people. A couple of weeks ago, in a post I found the most difficult to write, I compared my safe (though boring) childhood and teenage years in the 50s and early 60s with today. It does seem to me that mental well-being for younger people is harder to achieve today. A concomitant of this belief must be that there are more children and young people who likely to face both acute and chronic mental ill health. Society must respond to a larger number of children and young people losing mental well-being and our NHS mental health services must respond to those that fall into mental ill health.

Simon makes the point that obtaining the numbers of professionally qualified staff to work with these young people is not going to be easy or even likely. (Likewise for the  old and frail – essentially my point is there won’t be enough professional staff in the world). Some of our existing physically-orientated professional staff are going to have to retrain in mental health work. Some of them – for example those in primary care or Emergency Departments – will be working in the same locations as before but are going to have to gain mental health expertise to be able to meet increasing demands.

Simon Stevens is right to caution that if we are being realistic about getting new staff, these new services will probably need to be delivered in imaginative and novel ways.

Second on his list he highlighted importance of cancer – in particular the way we think about screening. Every year we are learning more about the relationship between DNA and cancer which precludes the necessity for blanket screening. But it’s also the case that what we call ‘universal screening’ never is. For a variety of important reasons some people don’t get covered by it – so it is not working for all the population. The majority of our worse than other countries’ cancer survival rates are caused by late presentation and diagnosis. It follows that this is where we need to develop a new relationship with members of the public who should present but don’t – often older working-class men. And change the behaviours of those that don’t diagnose (usually the primary care team) and should. Some primary care teams just do not send enough people for diagnostic tests – so any advance here will also require many more tests to be done.

Third item – we need to improve early warning on cardiovascular disease – and as I mentioned last week with work in Dudley this needs much more proactive reaching out by primary care to people in their late 40s and 50s.

Fourth – we need to refocus on children. A part of this problem has been the long-term decline of the relationship between schools and the NHS. Schools are not only very nearly universal but they are also very nearly a constant for children over an 11 year period. Again, without over-romanticising my ancient past, in every term at my primary school the nurse would not only weigh us but would (yes I am that old) check us for rickets with the high-tech diagnostic test of putting a penny between our knees to see if it fell out (rickets causes bowing of the legs. I won’t revisit the shame of my chubby thighs making that difficult…).

I also remember joining a crocodile of children being led to the school playground where the mobile x-ray machine examined us for TB. “Today we’ve got the school nurse” was as routine as “today we’ve got PE”. These days we will need higher tech than pennies and fewer numbers of highly qualified staff than before, but children must be a focus.

Fifth point, and personally very pleasing to me, Simon Stevens talked about reducing health inequalities. He focused on the inequalities of access for different groups of people and recently I have been looking at the inequalities of life expectancy. (Incidentally this was picked up by the BBC last Thursday. They highlighted the moral problem of where you are born playing such a key role in the number of years you live.


Poorer people die of the same diseases as everyone else, but they die earlier. So while the better-off do die of strokes, heart attacks, COPD, and diabetes concentrating on them in poorer areas would save a lot of lives.

Simon Stevens also mentions homelessness and I will be explaining a little more about that on Wednesday. Tomorrow I want to look at health and domestic violence.

He also mentions two more issues. Maintaining the push from the 5 Year Forward View for the care redesign agenda. Unless there is much more coordinated person-centred care for people in 5 years’ time, the NHS will not be able to meet all the new and different demands for health care. I would be surprised if there were even a million people receiving such care at the moment, which indicates the need for a very sharp increase in the roll-out of new care models if we are to grow with sufficient speed to meet demand.

He also talked about developing the four-hour waiting time target in A and E. This is an important issue. When this target was reintroduced to the NHS Plan, there were two almost universal responses. Firstly it was ridiculous and would be bad for patients and secondly it was impossible. Over the years those objections fell away. Those involved in A and E recognised that it was only through this target that A and E got the attention and resources from the NHS that the public demanded kit have. So as someone involved in its inception I am proud of its outcomes.

However, in conversations I’ve had with A and E doctors they make two interesting points. First they ask that the target is not completely removed. They know that without the very public pressure of this issue, resources and attention will ebb away. The second point they raise has certainly had me thinking. Some have said to me that the A and E target is primarily about geography. It is not about all accidents or all emergencies. It is simply about those accidents and emergency that turn up at A and E departments. If you can divert people who see their problem as an emergency to places where there is not an A and E entrance, then those ‘emergencies’ won’t count as part of the target.

So at the moment we have an important target about the public being seen when they have an emergency that is counted in some geographies (A and E departments) and not in others. That’s more than a bit daft.

And for those with mental illness emergencies this particular geography leads to a very bad outcome. If you want your mental health emergency to be treated as such within the 4 hour target then you have to go to an A and E department. But I find it hard to think of a worse place to be when you have a mental health crisis than an A and E department.

So we do have an important target – but it should not be defined by geographic boundaries but by experience. This will not be an easy issue to work through. I think for the time being we need to maintain this target, and spend some time working through a new one.