Matthew Taylor's speech to the RSM's Stevens lecture 2023

Thank you for inviting me to give this lecture. Edwin Stevens, who so kindly founded this series in 1970, was as well as a philanthropist, an inventor responsible for manufacturing the world’s first wearable electric hearing aid. Something that must have made a huge difference to the quality of many people’s lives.

Looking back over the dauntingly impressive list of previous speakers in this series I notice how agenda-setting it has been: Patrick Lawther on air pollution back in 1975; Crispin Tickell on climate change in 1991; Rannan Gillan on reproductive cloning in 1998. But you have also been happy to court controversy, whether it was Ludovik Kennedy on assisted dying in 1993, or Princess Anne opining on what she described as medical ‘mumbo jumbo’.

I look forward to answering questions later, but these associations with Edwin Stevens and past lectures put me in mind of another Q and A session, when I was chief executive of the RSA. It was the annual president’s lecture chaired by the redoubtable Prince Philip and that year given by Sir David Attenborough. When the speech was over, two problems became apparent: On the one hand, Prince Philip, in the chair, was not someone to suffer fools gladly. So if he didn’t like the question from the floor he would either ignore or substantially edit it before relaying it to Sir David. But also, either due to the acoustics or perhaps a resistance to wearing a hearing aid, the Prince only caught some parts of the questions that were asked. And Sir David in turn only caught some parts of the question after it had been reinterpreted by Prince Philip.

Those members of the audience selected by the Duke were in equal measure honoured to be addressing these two great figures and nonplussed by the almost complete lack of correspondence between the content of their inquiry and Sir David’s answer.

It is hard not to see a parallel here with what can often happen when well-intentioned instructions from the top of the NHS finally reach the front line. 

Tonight I will propose we use the occasion of the NHS’s 75th birthday to develop a more ambitious national social contract for healthcare. This is more practical and more achievable than it might sound

Tonight I will propose we use the occasion of the NHS’s 75th birthday to develop a more ambitious national social contract for healthcare. This is more practical and more achievable than it might sound. In some places some elements of it already exist and the potential is evident. But to achieve it for the nation, will require us to make a more profound commitment and to rise to two sets of challenges. Firstly, the need to re-set relationships: between the public and our own health; between the centre and the NHS; and between all organisations involved in health and care. And secondly, the urgent demand for investment – not just the amount, but also where we invest.

Firstly, the challenge of re-setting the relationships with each other: who is responsible, in charge, accountable, empowered to improve our health?

For a start, we need to recognise that health policy is about a lot more than NHS.

From the beginning of the industrial revolution to the start of the 20th century, major advances in life expectancy were the result of improvements in nutrition, hygiene, housing, sanitation and other public health measures. As we progressed through the 20th century, vaccination for many infectious diseases in the 1950s and 1960s, and reductions in smoking rates from the mid-1970s continued to make a positive impact on our life expectancy. It is only in the most recent period of history that the treatment of disease has been amongst the main factors in driving our average life expectancy higher – particularly with improving heart disease and cancer outcomes.

But over recent years, average life expectancy has levelled off and since Covid has fallen. This levelling off has happened in other countries but the trend appears stronger here. The pre-Covid levelling off was worse for people in the most deprived areas and life expectancy actually decreased for women in those areas.

The inverse care law and the higher degree of strain on care we see in disadvantaged areas contribute to unequal outcomes

Access to healthcare does make a difference to life expectancy and countries with universal coverage do significantly better than those without. The inverse care law and the higher degree of strain on care we see in disadvantaged areas contribute to unequal outcomes. However, the actions of the NHS itself are much less significant in both determining life expectancy, healthy life expectancy, and the differences between people and places than other factors - particularly social determinants.

It is now 13 years since the publication of the Marmot review, Fair Society Healthy Lives. Marmot and his distinguished team of commissioners recommended six areas of action to address health inequalities. These included early years education and support, good work and adequate living standards as well as investment in prevention and community capacity.

The Health Foundation’s follow-up report, Marmot Ten Years On, published just before Covid hit and before the cost-of-living crisis, found that most of these factors had deteriorated over the decade with, for example, rising child poverty, poorer quality of work, declining youth and other public services. Of course, Covid itself shone a very unforgiving light on our deep health inequalities.

The shocking healthy life expectancy gap of 19 years between our most and least deprived areas in part reflects another gap. This is between the government’s stated intentions on public health and the reality of inaction. Last year the government published its Levelling Up White Paper. It included the commendable target of increasing average healthy life expectancy by five years. The Health Foundation has explored what it would take to reach this target based on current policies and trajectories and reached a figure of 192 years. A date which could clash with the publication of the government’s workforce plan.

Any serious attempt to improve life expectancies and reduce health inequalities has to involve action across Whitehall, backed by commitment from Downing Street. As Patricia Hewitt argued in her recent report, to get back on track to rising healthy life expectancies we need a national mission, not just an NHS mission.  Unfortunately, the government has been going in the reverse direction. The Health Disparities White Paper was binned, a ministerial Cabinet committee on public health was closed down and the promised cross-departmental mental health strategy has been subsumed into the DHSC-led major conditions strategy.

…just as economists have recognised the need to factor in the costs of a failure to tackle climate change, so we must understand and acknowledge more fully the economic consequences of poor public health

Just as government departments and large corporations accept the necessity to consider the climate impacts of their actions, so too policy makers need to consider and be held to account for the likely consequences of their action and inaction for health and for health inequalities. And just as economists have recognised the need to factor in the costs of a failure to tackle climate change, so we must understand and acknowledge more fully the economic consequences of poor public health.

So, we need to widen the way we approach health policy. But also we need to upend it.

When most people think about the NHS they conceptualise a hierarchy that starts in Whitehall and ends in the waiting room of a GP practice. The centre tells leaders of systems and trusts what to do, then through command and commissioning these leaders tell clinicians and other staff what to do and then the public does its best to navigate what can be a complex and patchy architecture of available services.

There is inevitably a hierarchy in the NHS as a publicly funded, politically overseen system and there are of course some things that are best defined and delivered by the centre. NHS England plays a vital leadership role, and it is to be commended not only for doing its best to resist ministerial micromanagement but also for being willing to make difficult choices about its own scope and role.

But the current model of accountability is still overwhelmingly about what each level owes upwards to the layer above. Instead, we need so see accountability as something we owe outward and downwards just as much as upwards.

As a number of leaders – including as Kathy McLean, chair of Nottingham and Nottinghamshire ICS - have argued, we need to invert the pyramid of accountability.

That means a centre that ultimately judges itself by whether it empowers and enables health and care leaders, it means leaders who in turn empower and enable their partners, clinical and managerial colleagues and ultimately it means a service that is oriented to empowering and enabling patients and communities to manage and improve their health and wellbeing.

And the evidence is growing that patients who feel they are being seen, listened to and given agency will not only get better outcomes but will feel better about those outcomes too

This question of accountability may seem secondary in the face of our pressing day-to-day challenges. Yet, research demonstrates that decentralised organisations, in which the leaders of cost centres have autonomy, perform better than those that are centralised and tightly controlled. Equally, staff who feel they are trusted to make choices, to show initiative and to speak up about problems are more productive and contented. And the evidence is growing that patients who feel they are being seen, listened to and given agency will not only get better outcomes but will feel better about those outcomes too. It should be obvious that many initiatives that are vital to the success and sustainability of health services from hospital at home to anticipatory care, and from medicines adherence to the take up of new diagnostics, rely on patients feeling trusted and engaged.

The long-standing argument for decentralised systems has now tilted significantly, something we at the Confed underlined back in 2021 when we commissioned Sir Chris Ham to write a report on the changing role of the centre. By establishing integrated care systems on a legal basis , the 2022 Health and Care Act introduced important and widely welcomed changes in the way we work. But it is not clear that the NHS has adapted to this new reality.

Crucially, integrated care systems, and particularly the integrated care partnerships that set the overall strategy, are collaborative bodies looking at health and care in the round, promoting integration and mutual accountability with elected local authorities but also other parts of the public, voluntary and private sectors.

As it is for systems, so it is for place bodies, generally led by local government. And building on the  excellent review by Dr Claire Fuller, we are seeing the development of integrated neighbourhood teams. Innovation in the health service is often portrayed as something largely technological and top-down. But the most exciting glimpses of the future I have seen have been local and human.

In the face of public worries about access and the shortage of GPs, there is understandably much concern about the state of primary care, but in recent months I have seen fantastic practice led by inspirational GPs and primary care managers in Gloucestershire, in Peterborough, and in Sheffield. Standing out in this work is a commitment, on the one hand, to improve population health and reduce health inequalities and, on the other, to work with partners in the health service and beyond and with community organisations. Through the work of social prescribers, health coaches and navigators, mental health peer counsellors and many others, these primary care innovators are seeing neighbourhoods not just as the places patients live, but as connected communities with assets to be drawn on and developed.

The most inspiring primary leaders don’t see themselves as the furthest reaches of a national bureaucracy, but as street-level entrepreneurs knitting together networks, services and bits of funding, focused always on working with others to improve the health and wellbeing of communities.

Another challenge is obvious to all of us who work in around the health and care system: investment in health

Improving health outcomes relies on the NHS working in collaboration. Local government and other partners share our goals and are enthusiastic about working more closely with us, but often they wonder how much value there is in partnership with NHS bodies that have such limited discretion, who seem to be pulled from pillar to post by an ever-changing set of national priorities and who have so little scope to question the underlying value for money of NHS interventions.

Another challenge is obvious to all of us who work in around the health and care system: investment in health.

Not just increasing the amount, but reconsidering how and where we invest. The debate about the resourcing of the NHS is complicated and contested but the key points for me are thus:

The trend rate of growth in NHS spending over the last 75 years has been 3.6 per cent. This is broadly in line with the growth that health economists say is necessary to respond to population ageing, rising expectations and more expensive forms of treatment.

While inflation-adjusted spending on the NHS has risen by about ten times since its creation 75 years ago, it is worth reflecting that the number of people over 75 has increased by six times and the number over 85 by around eight times. Those numbers will continue to rise, but perhaps most tellingly, given that we tend to consume the highest proportion of health and care resources in our final year of life, is that it is projected that the number of people dying each year in the UK will increase by 12 per cent over the next ten years and by nearly a quarter by 2043.

Cancer treatment exemplifies trends in the standards, expectations and costs of the care we are able to deliver. Although the UK lags behind too many other countries in cancer outcomes, over 54 per cent of adults diagnosed with cancer in England and Wales will now survive for five years or more. Increasing from 29.7 per cent in 1971. Most of those kept alive will rely on close monitoring and frequent treatment.

New developments in cancer treatment are exciting but they can also be very expensive. Nowhere is this truer than the developments of immunotherapies. When, in April this year, NICE and NHS England approved the addition of two new indications for CAR-T therapies to the Cancer Drugs Fund it represented an opportunity to provide these treatments to hundreds more patients every year. However, the journey to this point has been long and expensive and as a result the cost of a single course of Yescarta treatment without the NHS’s significant discount, is £300,000. A  study from the US found that the median cost of developing a cancer drug was $648 million.

But in recent times the NHS has not kept up with demand, expectation and potential. Analysis from the Health Foundation suggests that if UK spending per person had matched the average across the EU-14 countries between 2010-2019, UK total spending per year would have been £40 billion higher.

This means that we have been forced to make hard choices about what parts of the system are prioritised. We went into Covid with 100,000 NHS vacancies and that figure is now 124,000. Our profound challenges with workforce have been highlighted by industrial action, staff survey findings and worrying retention rates.

Some areas of spending have suffered particularly badly. The fondness of ministers for talking about prevention is cast in a dim light by the fact that the public health grant has been cut by 26 per cent in real terms since 2015/16 and that these cuts have fallen disproportionately on the most deprived local authority areas.

Demand is rising for children’s and young people’s mental health services but only a third of those needing care can access it. We will not get a second chance to support this generation

We are failing our children. Demand is rising for children’s and young people’s mental health services but only a third of those needing care can access it. We will not get a second chance to support this generation.   

And, of course, social care is vital to the health system not just, as commentators may sometimes make it seem, to help us get old people out of hospital beds but because it also plays its own important independent preventative role. Social care shows that devolving control of vital services only works alongside adequate investment. Between 2010/11 and 2021/22, local government spending power, the main source of adult social care funding, decreased by 29 per cent. With spending on adult social care provision falling by 2.9 per cent in real terms between 2009 and 2019.

The gap between us and our comparators is even greater when it comes to capital spending. The OECD finds that UK capital investment in health is around a third lower per head than in comparative EU countries following a decade and a half where capital spending per head was often less than half OECD peers. This is why the NHS capital investment backlog now stands at over £10 billion. The slow and inadequate funding of capital projects is a major impediment to the NHS taking advantage of new developments in technology and treatment

The truth is undeniable. In order to meet rising demands and expectations and to make the most of advances in medicine we need better, more sustained, and more equitable funding for health and social care. But this reality can drive a narrative that sees the NHS – to mix my metaphors – as either a bottomless pit into which public spending is poured, or as a sheet anchor holding back economic dynamism and growth.

This narrative can and should be challenged.

…we need to acknowledge the economic value of health investment and conversely the economic consequences of a failure to invest

First, and fortunately this is an argument that is starting to gain traction, we need to acknowledge the economic value of health investment and conversely the economic consequences of a failure to invest.

The NHS Confederation has commissioned research from Carnall Farrar showing that for every £1 invested per head on the NHS, £4 is returned to the wider economy.

Recent research by IPPR found that experiencing a physical health condition was associated with a drop in annual earnings of between £1,700 and £1,800 and that mental illness was associated with a drop in annual earnings of between £1,700 and £2,200.

Lost earnings have a significant impact on Gross Domestic Product (GDP). IPPR estimates that long-term-sickness-determined loss of earnings cost the UK economy £43 billion in 2021, equivalent to around two per cent of GDP.

Second, health is the fastest growing global marketplace, with the WHO reporting that global healthcare spending reached $9 trillion in 2020. The NHS retains a strong reputation internationally, with health systems across the globe looking to the UK for partnership and collaboration. There is scope of opportunity that encompasses innovations in everything from pharmaceuticals and medical devices to models of care and digital solutions. As well as opportunities for additional revenue to be invested into frontline care, engaging in the global health marketplace opens up the NHS to new insights from our international partners and access to the latest research, ultimately developing a more resilient system.

Third, biomedical, digital, and service innovation gives us scope for major advances in productivity in future years. This could itself be the subject of many speeches but let me pick out some examples. Sometimes progress can mean the effective conquering of a disease as we are on track to do with hepatitis C. Or it may be the development of new services and treatments that mean we can head off illnesses and massively reduce their impact. Using relatively cheap treatment, we have made great progress in relation to preventing cardiovascular disease with mortality rates falling by around a half, although that progress has levelled off in recent years.

Having just watched a close relative achieve remission of type 2 diabetes and at the same time become fitter, happier and more self-confident I, like many of you, have seen the opportunities offered if we identify those at risk and give them the right advice and support to take control of their health.

From wearables to hospital at home, digital healthcare can help us keep people healthier, intervene earlier and offer treatment which is more personalised and humane. As we get better at collecting, analysing and sharing data we can segment the population and make sure services are designed around people’s risks, needs and preferences.

…like trying to use a spoon to bail out an overflowing bath while the taps are still running

Just about every health leader I speak to would like to be spending more time on innovation, improvement and transformation. But in a service that lurches from crisis to crisis, finding the time, money and commitment to innovate is hard. The investment case for intervention requires evidence that it can reduce costs but when demand exceeds capacity it is difficult to show that preventative interventions are having an effect. It is like trying to use a spoon to bail out an overflowing bath while the taps are still running.

The NHS is currently unable take full advantage of the innovation possibilities emerging almost every day. The public remain deeply committed to the egalitarian principles of the NHS, but those principles are under more pressure than ever before. The decisions we make as a society over the coming period will determine whether technological and biomedical change enables continuous improvement in the offer we make to everyone through the NHS or whether it will divide ever more widely the healthy haves from the unhealthy have nots.

Despite the complexity of its finer details, investment is a problem we in health find it easy to talk about. But there is another aspect of the investment debate. While the overall funding for the NHS may be out of our control, we have more influence over where that money is spent. And it is in relation to this that we need to aim for an upstream or ‘leftwards’ shift of resources.

This means investing proportionately more money into primary, public health, prevention and community-based services. This has been the stated intention of NHS policy for many years yet, as we all know, the reverse has happened. For example, since 2016 the number of full-time GPs has fallen while the number of hospital medical staff, and particularly consultants, has risen substantially. I spoke earlier about the decline in funding for public health and the perilous state of social care provision.

Most health leaders – including those who run acute trusts -  recognise the need for the leftward shift if we are ever to get off the hamster wheel of trying to meet ever more demand for hospital-based care

Part of the reason we have not only failed to achieve the leftward shift of resources but arguably gone in the opposite direction is the central control I discussed earlier. As Malcom X said: ‘it’s the hinge that squeaks that gets the grease’ and in terms of public and media attention it is elective backlogs, waits in accident and emergency and corridor care that get the most attention. The Prime Minister’s health pledge is not to improve health outcomes or bolster prevention but to reduce elective wating lists. Conversations with officials confirm that anything that isn’t immediately relevant to that target are considered pretty much irrelevant.

Most health leaders – including those who run acute trusts -  recognise the need for the leftward shift if we are ever to get off the hamster wheel of trying to meet ever more demand for hospital-based care. System leaders see actioning the shift as one of the most important measures of their medium-term success. The international evidence – from community work in Brazil to HMOs in America – show that such a shift can be achieved and make a difference is growing. Yet, we shouldn’t underestimate how much collaboration, skill and commitment will be required to make this happen.

If we are to make the hard choices then leaders in every part of the health and care system need to be convinced those choices will pay off. The leftward shift should be reasserted as an explicit long-term objective, but as Joe Rafferty Head of Mersey Care and an innovator in the use of population data argues, to get proof of concept we need initiatives that demonstrate fast feedback loops.

Examples of ways in which resourced can be moved upstream come in many forms.

In different parts of the country and in areas ranging from dermatology to mental health I have seen primary and secondary colleagues working together to enable people to access a diagnosis and treatment outside hospital.

Virtual care has been portrayed as a way of accelerating discharge but it can also play a vital role in stopping people needing to go to hospital. In a part of south London, for example, the community trust had been able to persuade social care colleagues to change their eligibility criteria and support patients in virtual wards and their carers. The critical factor was data that showed patients in virtual care were more likely to return to independence than those who got stuck in hospital.

A very different example is a digital hubs in which service managers collaborate to reduce unnecessary ambulance conveyance to A and E. In one example from the south of England, nearly two-thirds of category two calls that were referred to the hub required no rapid onward referral.

…the game changer came when the digital hub team committed to expedite every call that was passed on, only returning to the ambulance service the small proportion of cases that genuinely needed to go to A and E

There were three aspects of this innovation I found particularly interesting. First, the importance of trust and reciprocity. Before the hub was established the ambulance service had made limited use of the directory of service to avoid conveyancing. Too often their calls had gone unanswered or they had been told that a community facility was full. So the game changer came when the digital hub team committed to expedite every call that was passed on, only returning to the ambulance service the small proportion of cases that genuinely needed to go to A and E.

Another aspect was that by working together in the hub, managers from different parts of the system – from the NHS, from social care and from the voluntary sector - saw each other’s services in action, what was working and also what wasn’t. This led to conversations about how to use resources better and reduced the tendency for different organisations to be defensive about their services.

Thirdly, the hubs were generating sharing data which could enable them to start to think about acting more proactively to meet demand earlier and focus secondary prevention.

The leftward shift needs to be seen not as an aspiration but as the way to tackle some of the most pressing operational issues. So, for example, at the Confed we are encouraging conversations now in systems and places about how we build resilience ahead of next winter. One aim in doing so is to encourage the Treasury and health department to invest winter funds in ways that are more aligned to our long-term vision rather than as a last-minute panic measure.

And we need to explore other avenues. At the Confed we are working with partners to explore the scope for models of social investment in which upfront money generates a return through reducing demand. Ultimately, every ICS should aim to have a portfolio of social investment projects.

But there is one more major initiative I think is vital. The 75th birthday of the NHS is an opportunity for a reset and for a new conversation with the public. A public that is less happy with access to NHS services than at any time in the service’s history but still values highly the care it does receive and holds firm to the service’s founding principles.

Could the shifts I have described in this speech provide the basis for a renewed national social contract on health? This is an idea that lay behind the development of the NHS Constitution. It was also central to the fully engaged scenario advocated by Derek Wanless in his 2002 report. We can also learn at the national level from local initiatives like the Wigan Deal for Health and Wellness.

…today may be the time to appreciate and act on the established insight that the quality and depth of the NHS’s relationship with patients and the public has become mission critical

It is often the case in policy and politics that good ideas have to wait until the time is right to become fully mainstream.  Today, as we look out on an NHS in many ways more challenged than ever before yet reaching its 75th birthday still with wide and deep public support for its founding principles; today may be the time to appreciate and act on the established insight that the quality and depth of the NHS’s relationship with patients and the public has become mission critical.

What would be the core tenets of a new social contract? On the one hand, from government, a commitment to sufficient and sustained funding for the health and care system along with a national mission for health improvement, mobilising all parts of government and civil society. That might involve, for example, a practical plan to match the pledge to a five-year uplift in healthy life expectancy, starting with our poorest communities. On the other hand, through inverting the power pyramid and moving investment upstream, can we change the model of healthcare from one in which we incentivise activity levels measured by treatments delivered to patients as largely passive consumers, to one in which health and care outcomes are co-created by the service and the people we serve?

Our health choices have implications not just for us but for everyone else. Compelling people to monitor their health, to follow health advice or adhere to treatment programmes would be counter-productive and unworkable. But social norms and expectations make a difference. Look at drink driving, smoking, and attitudes to sexuality – all areas where law has played a role, but the main driver has been a shift in the public sense of what is right. Right for ourselves and right for each other.

The idea that the public’s attitudes, expectations and behaviours are vital to the sustainability and success of the health service is obvious. Yet it is not something our leaders are often willing to articulate, much less act upon. I spoke to a senior politician about this just recently and his answer was telling: ‘how can I lecture the public when they can’t get a GP appointment or find a dentist for their children?’

…we know that health is the single biggest factor determining people’s sense of wellbeing. Poor health is not just about the physical symptoms, it robs us of control and possibility

Another objection to seeking to raise our expectations of how people approach their health and use health services is that it smacks of authoritarianism, a denial of our personal space and freedom. Yet we know that health is the single biggest factor determining people’s sense of wellbeing. Poor health is not just about the physical symptoms, it robs us of control and possibility.

When we discuss public responsibility and the NHS the focus tends to move to specific, often punitive, measures like charging for missed appointments or denying treatment to people who smoke or overeat access to care. But the conversation we need should be about shared responsibility not blame, about empowerment not punishment. If our future relies in part on people feeling agency and responsibility, how do we enable people to make the choices that are right for them and good for the rest of us?

At the policy level this might involve the greater use of deliberative processes like citizens’ juries and community planning to shape and legitimise choices about service configuration and spending priorities. The NHS is good at evaluating the value for money of individual interventions but much less good at understanding, let alone acting on, the overall relationship between investment and health outcomes. The conversation about priorities and trade-offs is one which can enable the public to see their role in an approach that combines public resources and public action. To take one example, if national government were to host a citizens’ jury on smoking policy I am confident it would lead to the conclusion that we should immediately adopt the advice of the recent Kahn review, follow New Zealand in annually raising the legal age to smoke, while at the same time significantly increasing investment in smoking cessation services.

At the service level this is about engaging patients groups as partners with the right to shape services and the responsibility to help those services improve. Take the growing evidence for the power of mental health peer counselling. Not only does support from someone who has themselves experienced mental illness help patients it seems to be therapeutic for the counsellors themselves. My relative is very grateful for the advice and support that enabled her to ward off diabetes – I suspect she would welcome being asked to advocate for and support others who embark on her journey of recovery. Experts by experience can provide valuable insights in service design. I am proud that the deputy chair of the Confed’s Mental Health Network is such an expert and that we have a trustee with a long-term condition as the patient champion on our board. The NHS draws on the work of hundreds of thousands of volunteers, many of whom were inspired by their own experiences of those of their loved ones.

At the individual level we need to offer and expect more. This principle is vital to exploiting the potential of health data

At the individual level we need to offer and expect more. This principle is vital to exploiting the potential of health data. The recent commitment in the Primary Recovery Plan to accelerate and widen the use of the NHS App can help people see the benefits of digital engagement. The Our Future Health UK project is showing both the insights that can be generated by accessing patient data and also the willingness of the public to share when they can see the potential benefits.

A very different example of how we could aim for greater shared responsibility and a more ambitious relationship between clinicians and patients lies in the evidence that if patients have longer initial consultations with members of the primary health team and where there is continuity of care, they are more likely to feel positive and active about their health and to follow advice on behaviour and treatment compliance. Look also at the emerging evidence from experiments in reaching out to members of disadvantaged communities or isolated individuals. Such as one fascinating trial in Westminster, where a service as seemingly simple as community health workers visiting at-risk residents has resulted in these residents being 47 per cent more likely to receive immunisations and 82 per cent more likely to have taken up cancer screening, compared to other areas. Again, the benefit is not only helping people get the right care but encouraging them to look after themselves and use services more effectively.

Already, it feels a long time since everyone was talking about learning the lessons of Covid. We were so determined that our response to the terrible sacrifice and suffering of the pandemic would be to make a world a better place. But time, events, Downing Street parties, lockdown culture wars seem to have sapped our will.

It’s not too late. Shouldn’t we mark the passing of the virus as a global emergency by recommitting to that learning? We learnt that people could respond with responsibility and generosity to the need to protect themselves and each other. We learnt that people would happily undertake regular diagnostic tests on then act on the results even if it meant making tough sacrifices. We learnt that without concerted action, major illness impacts the community unequally and in ways that exacerbate disadvantage and exclusion. But we also learnt that if listened, if we worked in different ways and if we formed different partnerships, for example with voluntary sector and faith groups, we could reach those people and neighbourhoods who had reason to lack agency or trust. And we learnt that with a clear and shared sense of purpose and the right infrastructure, local leaders and organisations could find their own solutions and act on them with speed and creativity.

A new social contact for health can not only memorialise the collective spirit of our Covid response, it can exemplify that spirit, applying it not just to an emergency but to a vision of an NHS renewed.

Despite all the challenges we face I believe the best days of the NHS still lie ahead

In the coming period, bioscience and technology are going to give individuals ever more opportunity to take more control of their health. Clinging on to paternalism is neither honest nor progressive. Unless we address the social conditions that make people sick and rob them of control, unless we build deeper trust and an enduring sense of shared responsibility between the health service and the people and communities it serves, then these opportunities will widen even further the health inequalities from which we already suffer. The NHS needs the support of people just as much as the people need the support of the NHS.

Despite all the challenges we face I believe the best days of the NHS still lie ahead. A universal, equitable service beloved by the public provides the best foundation for the new social contract I have started to outline. Sufficiently funded, properly supported, devolved, preventative, empowering – our health service can be ready to grasp the opportunities offered by science and technology for a transformation in health outcomes. It is future worth fighting for.