Ruminations from the Bevan Commission

Abstract

The President: Ladies and gentlemen, this evening’s lecture is the annual Minty Lecture in honour of the late Leonard le Marchant Minty, who was a barrister. He died in July 1985, leaving the Society the benefit of a trust fund, which has helped us greatly. Many of us remember with much pleasure the early years of the National Health Service. We thought there would be a tax-funded comprehensive health service providing all the necessary healthcare for our population free at the point of access. Over about 20 years it became apparent that the cost of this was spiralling and access had to be rationed to some extent, mainly by waiting lists. More and more advanced and very expensive techniques were being developed. It is now probably the case, some people feel, that if we were to provide ideal healthcare to our whole population it would cost more than our gross national product. Rationing has been necessary, but it is a word that is prohibited by politicians. So we are delighted to have Professor Sir Mansel with us tonight to tell us about the Bevan Commission and how our limited resources can best be used. Professor Sir Mansel Aylward. (Applause)

Professor Sir Mansel Aylward: Good evening everyone. It is an honour and pleasure to give an important lecture in here to you. Your introduction sets the scene precisely and although I will be focusing particularly upon Wales, the tales I tell about Wales are based upon data which is equally important for England and Scotland and Northern Ireland. But we are all looking at it in a different way, and you have given a very good example of, shall I say, the taboos that exist at the time. We don’t use the word ‘rationing’, but we ration as much as we did during the Second World War in some cases in health. We talk about ‘comprehensive’ and ‘universal’ (and I will come back to that) as if they were sacred, not just taboo words but sacred words, but they are not, because within a couple of years Aneurin Bevan resigned from the Government because people had to pay for their dental services; they had to pay for their false teeth and they had to pay for having all their teeth out, because that is the way dentists worked, understandably, in those days; and they had to pay for their spectacles, or some part of it. So it was never comprehensive and universal in a sort of very pure way. Moreover, if we look at the NHS today in all of the UK, let us not forget that in Wales we talk about health and care. We consider both of them equally important. If you look at the care part of that health and care system, the comprehensive system, 80% of care homes are owned by the private sector. So we have got to be rational in the way we judge the words that are used and we have got to realise that Aneurin Bevan was living in a different age to ours now.

So let us begin by giving you a little bit of background to the Bevan Commission. As I say, it is in Wales. It is made up of international celebrities and experts and it is looking at the question that is not just affecting Wales or England and Scotland and Northern Ireland but also New Zealand, Australia, South Africa, Canada, particularly Vancouver, which has similar problems to ours: but not in the United States. But, our dear friend, the President of the United States, hasn’t yet succeeded in removing Obama Care.

So let’s go on to what I am here to talk about, and that first is the Bevan Commission.

Here we have a photograph (though not all of us) of the Bevan Commission. Let me make it quite clear: we are not political. Because we are called ‘Bevan’ it does not mean that all of us are to the left of centre. That is not so; we are all apolitical. As Bevan Commissioners we are not committed to any particular party and most of us are floating voters only committed to voting for the people that we think or the party that we think is appropriate at that particular time. So we are impartial and we are independent. We were funded initially by the Welsh Government, but we have been and remain an independent think tank. We are funded by the Welsh Government to undertake the commissions that they ask of us. As it says in the slide, we are helping to a create a health and care system altogether fit for the future. Around 52% of the budget in Wales is spent on health and care. In Wales and indeed in the UK if we were to address every single thing that is desired by some people in the provision of healthcare, we would be unable to do so within the total budget that we are assigned to spend in the UK, but we come very close to meeting the health needs of the great majority. But to meet all wants, of course, is impossible, and I want to tell you how we may actually do something about that and change the way people think and the behaviours some people have to ensure that we don’t have to spend as much as we do now. Nevertheless, in Wales, we still are prepared to spend around 52% of our budget, but not solely on the delivery of healthcare in NHS. We also spend a portion of that budget on care in the community. Local government suffers with cuts, but to my mind local government has not been affected to the same extent in Wales as elsewhere in that some funding of local authorities is available for them to deliver an equally important part of the health and care system, notably in social care and care in the community.

The Bevan Commission was established in 2008, on the 60th anniversary of the advent of the NHS, and we are now celebrating our 10th anniversary next year, on the 70th anniversary of the birth of NHS. The Commission was tasked to observe, analyse, interpret, comment, provide data and do research on health-related matters in Wales and beyond. We have links with Australia and Canada; we are co-operating on health-related work in New Zealand; but we are primarily focusing on Wales, and when Rhodri Morgan, who sadly died a few months ago, was then the First Minister of Wales he encapsulated what the Bevan Commission was all about when he said to me and said publicly, “What I want you to do is put together a team of international experts, who would be well recognised by their peers and others, who will look at the reforms of the NHS that are taking place in Wales, in England and Scotland but primarily in Wales, and I want the Commission to make sure that the reformed NHS in Wales still remains recognisable to the architect of the NHS, Aneurin Bevan.” So this is the mantra that underpins all that we have done and continue to do. I think you will get a flavour of what, therefore, we are about. Because we are called ‘Bevan’ people think that we are part of the Labour Party. We are not. I re-emphasise that we are independent in thought, mind, deed, politics and religion.

Supported by the Welsh Government, as I said, we are there for Cabinet Secretaries to draw upon the expertise and advice of the commissioners, and these are not drawn just from people with backgrounds in health and care. Health is not just about the Health Service. If we look at the contribution the National Health Service makes to the health of a population, how much do you think it is? How much do you think a population’s health is contributed to by the National Health Service?

A member of the audience: Is it around 10%?

Professor Sir Mansel Aylward: You were just a bit under. 15% is generally taken to be the contribution. The rest is contributed to by all the other areas, factors and influences that have a major effect on population health besides the provision of healthcare. Education, housing, traffic, safe environments, green spaces, freedom, locus of control; all those things contribute to 85% of a person’s health, so we have got to remember that. We are spending in Wales nearly half of our money on healthcare. We are not spending as much as we should be spending on public health and on these other areas that contribute to securing the health of the people.

These are the people. Some names you may know. I notice the name of Lt. General Louis Lillywhite, as a former President of the Medical Society of London, is up on the wall over there. I didn’t know that. Louis is a long-time Bevan Commissioner. The list of the names of Commissioners on this slide illustrate how many are drawn not just from health and care: they represent housing, local government, education, third sector, academia – they represent a whole realm of expertise and knowledge that are important to ensuring the people’s health. More and more we feel that we need to involve the Third Sector and charities and the people themselves and those that are working in communities whose expertise and experience have been unexploited. You will see the name there of Nygaire Bevan, a descendant of Aneurin Bevan, and she is a Commissioner not because of her Bevan family connections but because of her nursing and other experience and expertise.

What makes up the Bevan Commission? In addition to the Bevan Commission itself we now have the Bevan Academy. We are the think tank, but the Bevan Academy are those people who actually turn our thoughts and our concepts and our proposals into reality. This Bevan Academy is located in Swansea University and is made up of Fellows, Exemplars, Innovators and general public Advocates. They work together to develop new ways of thinking in the areas of population health, health and social care, try out and experiment and further develop ideas which bring benefits to patients, professionals and carers. These innovative approaches are brought to the attention of those managing and working in NHS Wales so that they may be further tested, implemented, ultimately mainstreamed. They are bridging the gap between disruptive thinking, new concepts, theory and practice. These are the Innovators: people that bring flesh to ideas; Advocates are the people who go out into the street and talk about the work that we do and the work that they want done; and, thirdly, Fellows, who are primarily people who are specialists in healthcare. We are now moving towards creating Fellows and the range of Exemplars from local government and other areas as well; and translate thinking into change across the NHS. We are developing Innovation Hubs in each of the seven Health Boards and three Trusts in Wales. These are progressing ideas into practice in the field and into the hospital, into the ward and into the community. So the Commission is not just a think tank. It is no good having a think tank if you don’t actually exploit the results of conceptual and, indeed, thinking, research, informed opinion and a growing evidence base.

The time for diagnosis in this area of health and care is past. We all know what needs to be done, we all understand the diagnosis, but unfortunately we ain’t done the treatment. We know what we need to do, but nobody has actually really done it well as yet. And it is knowing in part what the treatment might be, but nobody is fully embarking upon fully developing the treatment pathways, not just in the UK but elsewhere. Because we know what the cure might well be, we need to make way on that path by translating these concepts and ideas into real action and seeing the results and examining them in a very research orientated and evidenced-based way.

These are just a small sample of the work that we have done since 2011. I shan’t list all the papers and submissions we have completed since 2008. These are the principal papers:

Creating a “Social Movement for Change” which we have called “A Prudent Approach”, and I will tell you about that. Be mindful that in its early years the NHS was a social movement. It should have remained a social movement, but it has lost some pace and vigour, and one of the things that we want to do is to get that social movement back on track.

The Report that achieved substantial support and change was “The Report of the Bevan Commission 2011”. It wouldn’t be wrong for me to say that the NHS in Wales and in the other UK nations was in a parlous state at the time we prepared that report, when perhaps we didn’t know which way to turn with the recession, financial stringency, impending austerity and failures to keep within budgetary limits. Many expected that we would not be able to meet the costs of the NHS at all, and what the Bevan Commission did was to suggest various ways in which that environment could be tempered but not completely eliminated. The report of the Bevan Commission provided the basis for what the Welsh Government called “Together for Health”, which was the strategy for Wales, and several other countries have picked up on that strategy. This is an example of the way in which the thinking and advice of the Commission has achieved tangible actions.

The NHS Wales faces the challenge I have already mentioned about providing high-quality care in a time of diminishing resources. We in the United Kingdom, and also in NHS systems elsewhere, must do more with less. The success of science, which has been referred to, and technology has driven huge increases in the costs of delivering health and care, but both science and technology have already improved the way we deliver our services and our understanding of health and disease in populations: people are living longer and in general are healthier and spend longer periods of their life free of disabling illnesses and chronic diseases; but the pressure on public services is massive. Do you know that in 30 years’ time there will be around a 40% increase in the number of people over the age of 65, and by comparison there will be a very small increase in the number of people who are of working age, so that means less money will be available from tax etc. to fund a huge increase in the population, and even if that population were much healthier because of the work we are doing now, there is a very substantial burden of illness and disease to tackle. So even if there were a 20% to 30% improvement in the health of elderly people, we still would have a huge demand upon the service. Older people (and I am one of them) sometimes say to me “Why are you blaming us for the problem?” We are not to blame, are we? Of course no blame falls on them. The problem arises because of the success of the NHS in that people are living longer. We are not blaming the people that are living longer, we are just stating the facts. As we age, we are more prone to illness and disease and so we have to spend more money to tackle this financial burden and to do so we have to reduce waste, harm and variation in the delivery of health and care.

So we have:

Ageing patients and citizens; Rise of chronic diseases

There have been dramatic increases in, for example, diabetes, obesity and mental health problems – worrying increases. As regards heart disease, that’s getting better, in the sense that we are both preventing it and managing it much better, but with that increase in obesity and diabetes, the prevalence of cardiovascular disease is expected to increase. No matter how well we are managing cardiovascular diseases that is not going to be enough, we have got to prevent it happening in the first place.

Finite resources

You know quite well that we only have a finite resource for our national budgets, without reducing the demand on NHS resources the spend could escalate well beyond the finite resources we have. There is no realistic promise that those resources will be increased in a significant way. Moreover, if more were spent on the NHS, then other public services are bound to suffer. This is already happening.

Inefficient use of skills and resources

Now, we can do something about that, and I shall say more about that.

Risk averse/blame culture

Personally, I think the NHS is the most risk-averse organisation I have ever worked for and there are understandable reasons for that being so. Innovation is something they are afraid to do because it might not work. If you don’t take risks and look for innovation and be disruptive, then you are not going to get anywhere. If we keep doing the same thing as we have always done, we will just keep getting the same results as we always have. Fortunately, in Wales, we are now moving, albeit slowly but discernibly, to a system which embraces innovation whereby we are beginning to take well thought through risks to improve the quality and safety of the health and care systems, but there remain some people who are so risk averse that they shouldn’t be in the jobs they hold. Failure to take well-judged risks flourishes in a blame culture: “It’s not my fault, it’s somebody else’s fault” and “Don’t do that, because if you do, something will go wrong and I’ll be blamed!”

Medical model

And we still remain largely driven by a medical model of illness and disease. The medical model is one that rests on the premise that the body is a machine. It breaks down as we get older; disease and illness break it down; but it is only a machine and we can mend it and put it back together again. Well, of course it isn’t a machine. We should be applying a much wider more holistic model that takes account of biological, personal and social factors that influence health, illness and disease in an integrated way. Around 85% of the factors in life which actually determine the health of the population and are responsible for the health inequalities that we have now are beyond the scope of what the healthcare system can fully address. So the medical model still has a place in certain contexts but we need to focus more on social models.

Advances in technology and science

So we have to have a system which unfortunately must address the question: “How much good life are we giving to this person by spending this much money?” That may be offset by: “How many other people could we improve the lives of to the same extent than just the one person who needs that particular intervention?” It is a moral dilemma and I have been involved in that and it is so difficult to make a decision, but there are only finite resources. Even if we were a far wealthier country free of economic stringency, we would still have to make these nasty rationing choices.

Not enough public ownership

“Well,” people say, “we’ve got a free NHS.” No, we haven’t got a free NHS! All of us pay a substantial sum in our taxes and other social payments to fund the NHS. It’s not free and it shouldn’t be spoken of as being free. We own the NHS, we do, and we should be members of the club. When the NHS was formed, it was conceived as everyone working together to support it, pay for it, own it and benefit from it. But currently there is not enough sense of public ownership; there is not enough public passion about the NHS. There may not be as much compassion nowadays. Nonetheless, the results of independent surveys on what people think of the NHS always demonstrate that it is rated it very highly. That is good. When I come back from abroad, when I’ve witnessed other systems, I come back and I realise much more strongly that our NHS is the jewel in our crown. Despite all the warts and everything, it is still the jewel in our crown, but, to my mind, not enough people value it to the extent that they did in 1948 and in its early years. We want to drive once again for that sense of public ownership, pride in our NHS by those who work in, by those who pay their taxes to fund it and by those who benefit from it. Getting the people to participate, getting involved in designing it with the healthcare professionals and those that work in it, decide commonly together where hospitals should be based, what interventions should be undertaken, what if any cuts need to be taken. That is all of us being part of the club which is the NHS. If you are in a club and you are all working together, you are all equally responsible. That is what we want in Wales and elsewhere.

The NHS was there “to provide best care for all citizens and, wherever possible, prevent ill health”. We know much more now about how to prevent ill health than we ever have in the past. I draw attention to adverse childhood experiences. The impact that adverse childhood experiences have on subsequent life, happiness, mental illness and chronic disease is immense, and the more time that the child is submitted to an adverse experience the greater the likelihood of the adverse effect in later life. We know that even in pregnancy in dysfunctional families the child actually may grow up to be less healthy and take longer to achieve health developmental milestones than a child that is not in a dysfunctional family, and it is not just because that dysfunctional family may be using drugs or may be drinking alcohol or smoking cigarettes which we know will likely cause adverse effects; but even discounting all that, a child exposed to violence, threats, perhaps just shouting and screaming is at greater risk of subsequent health, mental and dysfunctional problems and behaviours in later life. Maybe it is because the mother is producing excessive stress hormones which have adverse effects on the embryo in utero. Further research is much needed here.

Remember too, that the NHS treats many more patients every year and introduces many new treatments within these limited resources. Indeed, as I have said already, the NHS is a victim of its own success.

The total Welsh budget is around £14 billion a year, right, and the cost of the Health Service is about £7.8 billion a year, and the NHS Wales must deliver at least £700 million of efficiency savings to close the projected funding gap by 2019/20, which amounts to almost 10% of current NHS spending. It’s impossible. No society in the world with a comparable health service has ever been able to do that. Indeed, without radical change it is inconceivable. The report suggests that if we even just met the costs of 2.2% above inflation every year that may keep the situation steady, but it wouldn’t allow any further improvements and some services would have to be cut. It is a desperate situation and is equally applicable to England, Scotland and Northern Ireland.

The Health Foundation Report stated that fiscal sustainability will also require adapting services so that they must meet the needs of the future population, which I was speaking about earlier. The Bevan Commission believes that adopting the concept and the design principles of Prudent Healthcare will contribute substantially to tackling meaningfully several of the challenges I have mentioned earlier. Moreover, the Health Foundation Report suggests that this approach would not increase the total cost pressures for the NHS. It would actually bring down or tackle the costs which are not included in inflation, the actual costs themselves, and this would result in sustainability.

The Bevan Commission spent about three months thinking of and formulating the Prudent Healthcare Principles and another year perfecting them and testing them. Now they are being applied and mainstreamed across the NHS in Wales, and hopefully we will be able to export the concept and design principles to other parts of the world, including England, Scotland and Northern Ireland.

In response to these challenges, the Bevan Commission outlined its approach and thinking through Prudent Healthcare, and I will tell you how that came about. I had a meeting with the Welsh Health Minister at the time and we talked about what in the USA is known as Parsimonious Medicine. We rejected that term. It made one think of Scrooge and Marley. In America, it seems, they use parsimony in a different way. Moreover, our conversation was not about the money spent on the NHS but rather on improving quality and patient safety in NHS Wales and redrawing the relationship between patients and the NHS in Wales. When I was driving home, as a Beatles fan, that’s my age, I was playing the White Album. The Beatles’ fans here must know ‘Dear Prudence’? “Dear Prudence, won’t you come out to play?” I thought “What does prudence mean?” I looked it up, the concept of Prudent Healthcare was conceived and articulated by the Bevan Commission as:
Healthcare which is conceived, managed and delivered in a cautious and wise characterised by forethought, vigilance and careful budgeting which achieves tangible benefits and quality outcomes for patients.
That definition is what we mean by Prudent Healthcare, and you can see all the parts fit together. It is common sense, isn’t it? When anybody says to me “Oh, that’s common sense” I know that we are on to a winner, because actually “If it is common sense, why didn’t you think of it earlier?” That is the only answer you can give. But it is no good having all this if you don’t do something about it.

So the prudent approach was:
Conceived in a crucible of economic stringency and the threat of under-funding

But it is not all about money. It is not all about cuts. It is about doing things more effectively and efficiently and therefore making savings which can be spent elsewhere, not just in the NHS but outside of the NHS in local government. That is the approach. It is not a cost-cutting exercise. If it was a cost-cutting exercise, it would not have gained acceptance at all. It is not. It is being more frugal, more efficient, delivering better correct care, better quality care to many more people and bringing in innovation to cut the costs.
It was born to improve the quality and safety of healthcare which fits the needs and circumstances of patients and actively avoids wasteful care; and

it grows to redraw the relationship between the patient and the NHS and the citizens and the state in Wales.

So I have used the sort of growing up analogy/metaphor there – conception, birth and growth.

The concept of Prudent Healthcare was developed and championed, as I have said, by the Bevan Commission and is now a cornerstone, a plank of the Welsh Government’s health policy, and it chimes with the Wellbeing of Future Generations Act (Wales) placing Wales as the first country in the world to put wellbeing at the centre of its policy. That is a huge revolutionary step.

Achieving health and wellbeing with everyone as equal partners through co-production

I don’t like the word ‘co-production’, it reminds me of factories, but it means everybody working together, co-design, co-conceive, co-produce, co-own, working together to a common goal. That is so attractive, and the challenge is getting people to believe in that. Once the do believe this does have an effect on changing people’s behaviour, it changes the way people think about the NHS.

Caring for those with the greatest health needs first, making best use of all skills and resources

Now, we are not doing that. People say to me “Ah, well, who makes the decision about who is the most needy?” Well, it should apply on an individual patient basis where the healthcare professional should make that judgement based on their knowledge, expertise and taking into account the medical, personal and social circumstances of their patient – but it works with populations as well. We know that there are areas of the country where health and social inequalities are very high especially in deprived and disadvantaged communities. We should adopt Proportionate Universalism which is the resourcing and delivering of universal services at a scale and intensity proportionate to the degree of need. Services are therefore universally available, not only for the most disadvantaged, and are able to respond to the level of presenting need. That is, you give everybody the same improvement and help but you focus more on those who need it more and those who have got the highest level of disease and the highest level of disadvantage, and when it comes to the individual patient, it should be a mantra in every healthcare practitioner’s mind that if I accept the Prudent Healthcare principles, then when I make my decision I have to make that myself, because it must be my own clinical judgment, but I have to share that decision making with the patient and be able to explain to the patient why I am making my decision taking all the relevant issues into account.

Doing only what is needed, no more, no less and do no harm

This goes further than the Hippocratic Oath. The Hippocratic Oath, of course, is “First do no harm”; primum non nocere. Well, he didn’t say that, because he was Greek and that is Latin, as you well know. But it goes beyond that. It says not just do no harm but do some good, when you are thinking of the patient and you are thinking of the population and intervention, and do only what is needed. In other words: Only do what only you can do.

Reduce inappropriate variation using evidence-based practices

NICE has pointed out that there are scores of interventions, therapies, medications, remedies and treatments for which there is evidence that they don’t work, yet they are still being used. Fortunately, this advice is being given publicity and attention which it merits. Do not do use them because there is no evidence that they work!

Why is it that in some hospitals the death or complications rates from certain operations is several times that of others? Why do people stay in hospital for six or seven weeks in some hospitals and only three weeks or three days in others? Why do people get bed sores in 30% of cases in some wards in some hospitals and other wards don’t get any bed sores at all? It is because of variation and we have got to pounce on that and ask why this happens and do something about it. The Bevan Commission published a paper entitled the ‘Visible Hand’. We would welcome publishing this information. It can be done without naming names. They will now who they are and hopefully take remedial actions.

We must move away from the traditional model of care which places power with the professionals to a social model which involves the patients and recognises the shared responsibility of society; starting with the individual, a model which places the responsibility of improving health and wellbeing across society as a whole and does not confine itself solely to the medical and allied professions.

The challenge therefore remains as to how we ensure we effectively do that and rebalance this relationship, which we are moving forward in Wales, between people and the state in a meaningful and prudent way. We have to help people to be proud of and understand the Health Service and people working in the Health Service to be proud of what they do.

We are currently preparing a series of linked papers, the first of which is entitled, ‘Exploiting the Welsh Health Legacy’, building on the original concept that Aneurin Bevan had and getting back to that. It is not a political thing. This is a community endeavour. Let’s all work together. “A New Way of Thinking: The Need for a Prudent Model of Health & Care”. And there will be others in the series: “A New Way of Doing: Developing a Prudent Model of Health & Care”, and ‘A New Way of Living: Delivering a Prudent Model of Health & Care

Now, the NHS, as it says up there, didn’t spring from the mind of one person, nor was it conjured up in an office by a team of experts, which is what lots of these interventions are being now – we sit down, look at the evidence, do a literature survey and say “Right, this is what we should be doing”, without even testing them in full. This wasn’t the way in which the Health Service came about.

The model was rooted in the realities of a local community, and that community was a place called Tredegar. Has anybody heard of Tredegar? (Some of the audience indicated in the affirmative.) Not Tredegar, because when I went to Richmond in Virginia they told me that I should go round the iron works which kept the Civil War going for such a long time by arming the South, and I said “Where is that?” and they said “In Tredegar”, and I didn’t know what he meant, and then I said “Oh, Tredegar” and then I discovered, of course, that it was founded by people from Tredegar. It is at the head of the South Wales Valleys, near Merthyr Tydfil and Ebbw Vale.

The NHS – this is the important part of the talk; let’s get back to basics – the NHS emerged from a model which was rooted in the realities and needs of a South Wales community in Tredegar. Every part of the community came together to address their needs and find a solution. There was social capital, there was a community. We are losing that, but we don’t necessarily have to do that. The NHS could be the way in which we actually start building a community and building a raison d’être for coming together again, and that worked in the healthcare service, in the mines, in the steelworks, and of course it was advocated and fought for by Aneurin Bevan. I gather he wasn’t always the best of people to get on with. He was bombastic is some ways with his own ideas, but what he had was passion and compassion, and the passion and commitment was that we should have a free, comprehensive and universal healthcare system for all the people all of the time.

We have got to change the way people think about the NHS and think about how they can best manage themselves but I believe that we can’t say “Ah, well, if we get them to self-manage themselves, that will remove a lot of money because they won’t have to go and see their doctors, and all that”. That is a load of rubbish. People can’t help themselves if the circumstances in which they live don’t allow them to. How can they take exercise in a place that doesn’t have any green spaces and is at the top of the hill, as are many in Wales? How can they go out at night running, or even playing in the street, when there is no lighting there? How can we ensure they have safe places? You cannot just do all the things that are really more important than healthcare unless you change the environment, not the money but the environment, to make it possible for people to do these things that maintain, promote and improve their health and wellbeing for first they have to have a locus of control over the lives they wish to lead.

“Reflect on Bevan’s original vision for the NHS – where every part of the community and society comes together to address needs and find workable solutions.” I know it sounds like pie in the sky but unless people stop talking about this and do something about it and show real improvement happening, as we are showing in Wales, then it won’t happen. It is no good saying “Oh, it’s too altruistic; it’s never going to happen”. If you say that, it never will happen. We have got to take the risk of it not happening, by doing it.

It is a question of priorities. It is a question of complexity – we know that. It is a question of priorities in the NHS – we know that. But we can address these things and we can simplify the complexities a tremendous amount by doing the things I mentioned in the Prudent Healthcare principles. It is a question of changing behaviour and thinking in Government. I am a member of the Panel undertaking the Parliamentary Review of Health and Care in Wales, to which all political parties in the Welsh Assembly have signed up. That is an excellent step in the right direction.

It is after all a question of rights and responsibilities. If you belong to the club, you have got to obey the club's rules. There are far too many people who abuse the Health Service. There are far too many worried well. There are far too many who have an appointment with their GP and the next thing they do after the consultation is go out and automatically make an appointment to see their GP next week. We have got to value and treasure the NHS, and we must not abuse it. We must abide by the rules of the club to which we belong.

So it is everyone’s responsibility for health and care, people, communities and patients; community infrastructure, which I have mentioned; the workplace. I haven’t mentioned the workplace, but of course the workplace is a very important place. Much of my work in the 1990s was to look at health in the workplace, a healthy workplace is so important. The best place to manage mental health is in the workplace. Did you know that I am talking of good work, of course? People stay off work because they have a mental health problem. Actually, they are making themselves worse in that way. People at one time used to go to bed when they had back pain. What happened? They had back pain for the rest of their lives. I am being a bit immodest now, but I worked with a fellow, the late and lamented Professor Gordon Waddell, who was a Professor in Scotland and came to Cardiff as a Professor when I took up my chair at that University, he actually changed the way people thought in the “back pain revolution”, and we said (to paraphrase) “If you go to bed and lie down with a bad back and don’t move and keep on functioning and don’t worry about pain, because pain doesn’t mean harm, you are going to have a bad back all your life”, and that changed the way doctors thought about treating back pain, not in this country, but in the international health arena.

We are all members of this special club, a true co-operative, not meaning it in any political way. We all have our own NHS number. Does anyone know their NHS number? I haven’t got a clue what it is. But we have got it: we are a member of the club. It is owned by everyone. We have all the rights and all the responsibilities; that is the most important message I want to get across.

We must remember Bevan’s vision, passion and appetite for change, real change, because he had a hell of a lot of problems to challenge. The night before, when people asked him “What is this NHS of yours going to do?” he said “I am going to Tredegar-ise Great Britain”. People didn’t know what he was talking about. They thought he was using a Welsh word, or something, although he didn’t speak Welsh, but he was going to Tredegar-ise those principles as being part of the NHS, and when he was asked “How are you going to get the doctors on board?” Do you know what his answer was? Come on, you must know this.

A member of the audience: Stuff their mouths with gold.

Professor Sir Mansel Aylward: Ladle... Ladle their mouths.... or something like that, fill their mouths with gold, which he did, and dentists benefited too.

We must “Re-Tredegar-ise” Wales in order to create health and care fit for the future.

Again, what needs to happen next is very, very complex.
Strong collective leadership and commitment

We don’t have leadership. I rarely find leadership and direction which is as prominent and passionate as it should be.
Actively support innovation

Use the skills of professionals and the public

The Third Sector are able to do a lot of the work that is being done by the Health Service now, and they do it largely for nothing, and they have got huge skills, expertise and social resources and we should more fully involve them and find solutions together and have a very different conversation about the Health Service.

Bevan said “The purpose of getting power is to be able to give it away”. It is not the end yet. There is somebody else better than I who is going to speak shortly, and that is this person. These are the words of Aneurin Bevan when he brought in the NHS. Now, I am not being political, but just listen to these words, and that will be the end of my lecture.

(A video was then played)

Thank you very much. (Applause)

Discussion

The President: If you ask a question please could you announce your name and your speciality and your status.

Mrs Diana Brahams: Thank you very much for your talk; I found it very interesting. I am a lawyer, now retired. I did a lot of medico-legal work. I saw a lot mistakes. Some of them were denied. I want to ask three questions. First of all, do you think that we should apply more strongly ‘the greatest good for the greatest number’, because at the moment there is rather a cult of individuality and what is a person’s rights and maybe the community’s rights are less than that one loud person who is talking at the time, a pressure group perhaps, something like that. That is one. The second thing is am I right in thinking that Wales has the largest proportion of people who are out of work for health reasons and is your Commission thinking about how to tackle that? And the third point is do you think, in terms of rationing, that from the State’s point of view it would be more sensible to prioritise the young and those in work who contribute to the cost of running the Health Service rather than people who don’t now pay for it but have paid into the system over the years and are now entitled to benefit from it?

Professor Sir Mansel Aylward: I got the first part, rationing from the State, would it be right, and then you said about the young people, and I didn’t get the rest of it.

Professor Sir Mansel Aylward: Yes, okay. Number one, I think, is “Do you think we should be adopting the principle ‘the greatest good for the greatest number?' Yes. That is what I mean when I say that there is an inadequate spend of money on public health and I think community health is extremely important. So my answer is, of course, yes. However, one cannot divorce oneself completely from ‘not the person who makes the most noise’. No, I am very much against that and I think we should have a big stand against that and we should be tackling that issue, people saying “I want” rather than “I need”. I think we should stand up and be counted in that way in the club. On the other hand, where there are people who are in great need and who by treating them in a better way, in a more effective way, and perhaps in a more costly way, you actually return them into work, return them into society, get rid of the overlying depression that surrounds that and make them equal partners of the community who contribute to that community, then I think it is worthwhile. But in general, I am on the side of public health. We have got to spend less on healthcare and more on ‘prevention’. This is the word. I haven’t used it, but prevention is something that hasn’t got to be, as people often say as public health people, “Oh, I’ll never see that happen in my lifetime”. You can now, because if you actually manage the pregnancy better, if you actually manage the family problems and the adverse child experiences, you will see developments within two or three years, not in a lifetime. So that is where money can be spent and be shown to give us an early outcome.

Wales did used to have the largest population, but it hasn’t any more. North-east England. You have got to compare like with like. Wales has only got 3.2 million people. Look at areas in England where there are 3.2 million people and the same level of deprivation and social class inequity, and in Scotland, and you will find that actually the level is the same. The Nuffield Foundation actually did that and they said “Yes, but Wales looked as if it had the most because it is a small country and it is a big percentage of a small amount, but when you compare it with equal parts of England Wales it is the same”. But that is no excuse. We do have, and it is not just now due to the old adage of ‘it’s due to the industrial problems’. It is not due to industrial problems, we have cured them. It is due to deprivation and poverty and transgenerational unhappiness with systems because they weren’t tackled well in the first place.

Last of all “Is rationing from the State....” There should be universal proportionalism, and that is saying you should give the same amount of resource and emphasis and energy and commitment to everyone in the community, but if there are particular points in that community, such as with young people who are having problems, particularly mental health nowadays, people in the workplace who are having problems with equal stress and coping with stress, and old people who are coping with old age, then we can actually focus on them without depriving the whole community. So it is a universal approach.

Ms Szelepet: My name is Emma Szelepet, a lawyer. Thank you very much for a really interesting talk which I very much enjoyed. I just wondered how you would see the delegation of NHS services to private providers, going into the concepts of joint ownership and universal membership of the NHS that you outlined, the model of a co-operative. I am interested in just what the position is on that in Wales currently. Thank you.

Professor Sir Mansel Aylward: Well, up until quite recently the position was very simple, anathema; private involvement, anathema, and in fact, if you go back to Aneurin Bevan, he didn’t actually talk about that, did he? He didn’t actually say “free at the point of access”. He said no-one who was unable to pay for their healthcare should be deprived of it. That is what he said. So when we say ‘comprehensive’, ‘universal’, ‘free at point of access’, those have been derived from what he said, and particularly with regard to private ownership. I understand the problem there is, but I think the situation is changing. My own view is that we already have large segments of the healthcare population being taken care of by the private sector, whether we like it or not. We are moving to a point where we can’t afford always to invest in more interventions and innovations, but perhaps the private sector could. My new job is as Chair of the Life Sciences Hub Wales Limited. It is a limited company owned by the Welsh Government and my job is to encourage the private sector to move into Wales to work more closely with the NHS. Now, that says much more than any words, and actually if those people are working in the NHS club are full partners, then I see no reason why it should not happen.

Mr Samuels: Alec Samuels, lawyer. It is said that the medical profession are very highly regarded by the public and they know that and they have a tendency to exploit it. They believe their speciality is more important than anything else, that their demands for more resources must be met, and that they have a tendency to alarm the public, because every day we are told the NHS is on the point of breakdown. Is there any substance in that criticism?

Professor Sir Mansel Aylward: I view it as mental pressure. Yes, there is substance in that criticism. I am a physician really. A lady here was in the same medical school as me, so, so is she. I would like to ask the other physicians and doctors and healthcare people in the audience. How many of you are in the audience here? (There was a show of hands) Okay. Yes, I do think so. Unfortunately, it is the silent majority that is the problem. It is not the majority of clinicians and healthcare workers that believe this at all, and, not only that, they work damn hard to make sure that there that there is a real attempt to have a more efficient Health Service. But there are, unfortunately, parts of the society among clinicians and doctors who do spread that language and who do actually upset people in their view of the particular situation that is their own agenda. I am making this example up now. Let's say I am someone who is very, very adept at putting in new eyeballs made of a particular substance, which is an innovation, but it is going to cost a lot. If I want to get that money I must get the people to believe that that is a wonderful breakthrough and I deserve all the money I can get. That is not common, but it happens, and that gets into the Press, because the Press are readily wanting to have adverse comments on the NHS. So it is not just the clinicians, there are other people who do the same sort of thing. So, yes, I do agree with you and I think that the silent majority of clinicians and physicians and surgeons should stand up and say “Look, we are the people delivering this work. We are doing it without having had a rise in salary for the last ten years”, or whatever it is. “We are not getting money from private practice. We are prepared to work together with everyone else to make this work and we do not believe that the NHS is heading for disaster, because we are the people who have been in it to prevent that happening.” So I do agree with you, but I think it is because the silent majority … You know, there is that famous statement by Edmund Burke: “It is enough that good men remain silent for evil to flourish”.

The President: This has been one of the most interesting and most politically sensitive talks I have heard in the Society in many years, and I say on behalf of all of us, thank you very much indeed, sir.

Professor Sir Mansel Aylward: Thank you, sir. (Applause)