[SIDE CONVERSATION] Hi, everybody. Welcome to another edition of Department of Medicine Grand Rounds. We're very fortunate today to have Dr. Steve Powis here with us. Dr. Powis is the national medical director of the National Health Service in England, and for the NHS Improvement. And in his role, he's the most senior doctor within the NHS in England. 

He got his medical degree from the University of Oxford. He has a PhD in immunogenetics, has an MBA from the University of Warwick, is a Fellow at the Royal College of Physicians of London, an honorary fellow of the Royal College of Physicians and Surgeons in Glasgow. 

Currently underneath his medical directorate he is responsible for commissioning the National Clinical Audit Program, developing professional standards for doctors throughout England, and developing clinical policy for the NHS. 

Prior to his current role, Professor Powis held the Moorhead Chair of Renal Medicine at the University College of London from 1997 to 2017. And his research interests include the human major histocompatibility complex, transplant biology, and the genetics of membranous nephropathy, and currently retains an honorary chair of renal medicine at the University College of London. 

And he's been very generous with his time this week, and all that have met with him have thoroughly enjoyed it. So please join me in welcoming him as he talks about The NHS at 70, Improving the Health of a Nation. 

[APPLAUSE] 

Thank you, [INAUDIBLE]. And thank you, Mitch, for the invitation to come here to Charlottesville at a beautiful time of the year. And thank you to everybody who I've met over the last couple of days, from the residents and the interns through to faculty. It's been a really enjoyable few days, and it's a real honor and privilege to be here. 

So I from time to time visit health systems in the United States. And although, as we will discuss today, some of the fundamentals about how the health system here and the health system in the United Kingdom are very different, I'm always struck by the similarities between health care rather than the differences. 

And again this week, in talking to everybody, I've really been struck with the things that we are doing that are similar, whether it's the challenges that we all face as clinicians and a society, or whether it's the solutions that we are implementing in order to meet those challenges, so as ever, more similarities than differences. 

In my sort of career, my unexpected and probably accidental career, moving from a medical student to an intern resident, through to being a nephrologist, through to being an academic, and then becoming a health care leader and health system manager, it's become really apparent to me, as I'm sure it has to many of you who've taken that journey, that the ability to do good is not just the ability to do good to the patient who's sitting in front of you, which of course, is always the prime basis upon which we as clinicians practice. 

But there is just as great an ability, and perhaps an even bigger ability, to do good at the population level in managing groups of populations, groups of patients, and populations of citizens. 

And so when you start to think about that, and you start to work in a world where you can change things at that level, thinking about how health systems are designed and how health systems operate becomes really important. 

So I've always been interested and increasingly fascinated by how health systems work. And it's my task I think today, to tell you about our health system and how it works, where it came from, what it does well, what it doesn't do so well, and what we need to do to improve the health of our nation over the next 10 years. 

Now, I'm going to assume that none of you know anything about the NHS, even though probably some of you do. And some of you, I know, have worked in it. But I usually say to people when they're telling me something, assume I know nothing. It's the safest place to start. 

So my apologies to those of you who know some of this. I'm going to start by assuming that not everybody knows anything about the NHS. I have no disclosures, other than I work for NHS England and NHS Improvement. 

So to start off, I'm going to take you home. I'm going to take you to London where I live. And I'm actually going to take you to my home, because this, on the left, is the back of my house where I live. 

It's a terraced house, three-story townhouse, built around 1905, 1906, just in the change between the Victorian and Edwardian eras, in a street where there are lots of-- in a part of London where there are lots of houses like this, when London was going through its big population expansion, and the suburbs were being created for the middle class, who were increasingly being drawn into London. 

And what you will notice about it is that the brickwork at the top of the back of the house is different and is newer than the Victorian and Edwardian brickwork at the bottom of the house. And that's the third story at the back. 

And the reason it's different is because-- we believe, we don't have the documentation-- that when the Luftwaffe dropped a bomb on the houses next door, which completely destroyed the next three houses, the bomb also damaged that bit of our house. 

And in fact, if I photograph the house next to it and the one next to it, you would see similar parts of the house that were blown away and reconstructed. And the further you got from the bomb damage, the smaller. 

So I'm very aware, because it's right on my doorstep, of the effects of the Second World War on Londoners. And on the right, you will see the plaque that's in Balham tube station. So that's the underground station a few minutes walk from where I live, that I get on every day to go seven stops to my work in central London. 

And I pass the remembrance plaque there which recognizes those that died in the underground station, when during the blitz it took a direct hit, again, from a German bomb, and killed the staff and those that were sheltering from the blitz in the underground station. And if you ever go to Balham underground station, you will see pictures of that event. 

And I start at the Second World War because the history of the NHS starts with the Second World War. The Second World War, as I'm sure you all know, was a catastrophic and cataclysmic event for the citizens of Britain. It was an event which completely changed the way the population thought about itself. 

So society had been changing up to the 1940s. Those of you that watch Downton Abbey, I'm sure some of you do, will know the story of during the '20s and '30s how society was changing. That's a theme that runs through that series. 

So it wasn't as if there wasn't a direction of travel, but the Second World War really shaped people's thinking for the next 50 years or so. And having gone through that experience, the British Society really felt that the future needed to be very different from the past. Something needed to change. There needed to be a leveling of the old societal boundaries and structures. 

During the war, government asked William Beveridge, an economist and a politician, to think about some of the social security structures that might evolve after the war. And Beveridge, who was quite a radical thinker, produced a report in 1942 for the government called, "Social Security and Allied Services." And that was really the blueprint that established the what we now know as the welfare state in Britain post-war. 

So of course, Churchill won the war, but he lost the election afterwards. And he lost the election immediately after the war because the British people wanted a radical alternative for the future. And they voted in the labor government, the more left-wing government, on a radical agenda of change. 

Beveridge, in his report, talked about the five giants that we need, that the government needed to fight on the road to the reconstruction of Britain. This was 1942, so it wasn't even clear that there would be an end that would end in a future for Britain. But he wanted the government to address these five issues-- want, disease, ignorance, squalor, and idleness. 

So want-- social security and basic social payments; disease-- a national health service; ignorance-- a new education system; squalor-- good housing for everybody, so social housing; and idleness-- employment and unemployment, as a policy for employment and unemployment. 

And if you're interested in how all those five areas were translated into policy, and how over 70 years that policy's developed, then I would recommend the book by Nicholas Timmins, The Five Giants, taken directly from that quote, which beautifully documents the history of the welfare state in the 70 years or so-- 65 years, about 70 years or more since the Beveridge Report. Other histories are available. Not a promotion, but it's a particularly-- it's a long read, but it's a very easy read if you're interested. 

So it fell to the labor government, and it fell to Aneurin Bevan, who's shown here in a hospital in London, to actually take the Beveridge proposals and the proposals that are worked up during the war, and translate that into a national health service. And this is the bill that was put forward by Beveridge to take the proposals through Parliament. 

They were not universally welcomed. The doctors fought it tooth and nail, because the doctors really did not want to introduce a national health system. They saw it as a threat to their private practice, to their way of working. 

The British Medical Association, which is now one of the strongest supporters of the NHS, at that time was one of the strongest opponents of the NHS. But nevertheless, Bevan worked on it and established the NHS as an act of parliament. 

And the founding principles of the NHS are the same principles that remain to this day. It's founded on a principle of universal access to care. Everyone, rich or poor, city, rural, white or black, elderly, young, has equal access to the service. 

It's funded out of general taxation, and is largely free with only a few exceptions at the point of delivery. So no charges made at the point of delivery. And those are the founding principles on which it was built, and the founding principles upon which it still works today. 

Last year in the summer of 2018 on the 5th of July, we celebrated the 70th anniversary of the NHS. We tend to celebrate anniversaries every 10 years in the NHS. Some of them have been big celebrations, some of them smaller. 

Last year we had a big celebration around the 70th year. And of course, whenever you have a anniversary, it's a really good time to reflect on what you've achieved, what you haven't achieved, and what you need to do going forward. 

And of course, in the 70 years of the NHS, an awful lot has changed. It has changed here in the States in the same way it's changed in the UK. 

So we're living longer-- 14 years on average than we were in 1948. But of course, we are living longer with much more multimorbidity and much more chronic disease. So a service that was set up to deal with episodic illness, now has had to evolve to deal with complex illness and longevity. 

You all know that medical knowledge is very much advanced. So in 1948, medical knowledge doubled every 50 years. There's an estimate, whether it will be true or not, that by 2020, medical knowledge will double every 73 days. And of course, all the technological advances that go with that increase in knowledge are increasingly a challenge for any health service. 

Many great medical advances have been made over the 70 years, from the DNA-- identification of the structure of DNA, through to the sequencing of the human genome, through to heart transplants and scanning and all sorts that would be far too many to cram onto a timeline. 

But it's also true that the NHS has also evolved over the 70 years, and those that worked in it on the 5th of July, 1948 would recognize some of it, but not all of it, on the 5th of July, 2018. 

So for instance, first prescription charges were introduced. So that promise that it would be free at the point of delivery only lasted a few years in its full promise, and prescription charges were introduced. In fact, Bevan resigned over that because he saw it as a breach of principle. 

Actually, there haven't been many other charges introduced over the years. But there has been a constant debate as to whether general taxation should be supplemented by other income direct at the point of care. 

In the 1980s, we introduced an internal market. So I often hear, and I've heard this week, that one of the differences is the fee-for-service model. But actually, a lot of our transactions in the NHS are essentially on a fee-for-service basis, even though it's within organizations within the NHS. So we pay NHS providers, hospitals, on the basis of a tariff, i.e., a price per activity. 

So what you can see here sometimes, which is you drive up activity because you pay for it. Actually, we see the same in our model. And the internal market was introduced during Margaret Thatcher's government, at a time where there was a very different approach to monopolistic state industries, such as utilities, electricity, the railways. We'll come back to whether that's worked a bit later. 

And in 2012, the NHS introduced, or the government introduced, the very latest in a series of legislative changes-- the 2012 Health and Social Care Bill. So the way the NHS works today is fundamentally based on the changes of the 2012 Act. And the 2012 Act was set up really to drive the internal market further forward. 

So the NHS today-- 1.2 million employees, one of the largest employers in the world. Although, in practice, people are employed by individual organizations. 1 million patients every 36 hours, 123 billion pound budget a year. 

In fact, earlier this year I had the probably once in a lifetime opportunity on the board of NHS England. We signed off five years worth of funding to our providers. I'll probably never sign off half a trillion pounds worth of funding again. That's probably a once in a lifetime experience. 340 million visits to primary care every year. 

But we have challenges. And these are challenges that you will recognize because they're exactly the challenges you have. We talked about the aging population with multimorbidity. We have 100,000 vacant positions, 40,000 vacant nursing posts, shortage of doctors. Sound familiar? 

And that's not just an issue for the UK. It's a global issue. As health care expands, many countries are beginning to face shortages. And we need to work together to work out how we solve those. 

Social care in the UK is provided by local governments, not by the NHS. And of course, there is a very, very big interaction between social care and health care-- so nursing homes, care provision. And that's under severe financial strain. And it has been since the financial crisis in 2008. 

And of course, as the population gets older, their requirements around long-term nursing care increase, and the funding for that is something that we have not solved. In the Queen's Speech, which opened Parliament on Monday of this week, there was, again, a clause in the Queen's Speech which sets out the legislative program for the government around addressing the issue of how we fund social care. 

Technology, buildings-- always a requirement to build new buildings, keep up to date new technology. So capital expenditure is always lagging behind. And certainly, over the last few years when we've been in a period of austerity in the UK, public funding has been cut. We are playing catch-up in terms of some of our equipment and some of our buildings. 

And of course, I'm only going to mention it once, but we are probably about to leave the European Union. And that is not a trivial thing to do, to leave a trading bloc. That has consequences for the way health care is delivered. It has consequences for our supply chain, which is a very sophisticated supply chain for drugs and devices. 

It has implications for our workforce. A significant proportion of our staff in the NHS come from the European Union. It has consequences for UK citizens who get health care overseas in the EU and vice versa. So all of that's being worked through at the moment. 

So that's a more immediate issue. But of course, even if we do exit from the EU two weeks today, it will still take us years to negotiate our longstanding agreement, so another issue for us to think about. 

Now, I don't expect you to look at this and take it all in, because this is a diagram, a cartoon of how the NHS in England works. Now, I should say at this point that I predominantly talk about the NHS in England. 

There is a National Health Service in Scotland, Wales, and Northern Ireland. But because of the way those devolved administrations work in the UK, they have organized themselves a little bit differently. So this is mainly England. Once we're asking questions, we can say a little bit about those other devolved administrations. 

But fundamentally, what I'm trying to show here is that it's a very complex system. So the idea that the NHS is just one entity is misconstrued. It's a complex set of organizations. 

And if I highlight a little bit of it to you-- then essentially, funded out of taxation. So here's the government, either through tax or borrowing, distributes the money through NHS England. We're in there somewhere. And we then distribute it to a whole load of local commissioning groups, which are essentially the local payers. And they pay hospitals and providers, including primary care, general practitioners. 

Remember, GPs are actually small businesses. They are private small businesses. They've never been integrated fully into the NHS as employers-- as employees to deliver services. 

And then there's a whole lot of other organizations, such as Public Health England. Here's NHS England here, Public Health England that manage the public health of the nation, Health Education England, that manage training and education. It's a really complex system. 

And often when I'm asked, what's the toughest thing about my job, sometimes I say it's dealing with all the handoffs and interactions between different parts of the system. I'm sure that's a familiar theme here as well, in terms of how you navigate your way through. 

So to explain it a little bit better, let me just play you a few minutes, just so that you know how it is that the NHS is organized. The King's Fund, which is a independent think tank in Britain, has-- get this right-- has-- whoops-- accept cookies-- has put a cartoon together which, hopefully, if we do it, tells you a little bit about how the NHS is organized. 

[VIDEO PLAYBACK] 

- How does the NHS in England work? What organizations make it up? And how is it changing over time? 

Since the NHS is largely funded by our taxes, let's start with the government. They decide how much money the NHS receives and do top-level priority setting. 

The Secretary of State for Health is in charge of the Department of Health, which has actually quite slimmed down compared to what it used to be. And it passes most of its money onto a range of other organizations. 

The lion's share goes to an organization called NHS England. It was created in 2013 as part of sweeping reforms aimed at improving services by increasing competition, cutting red tape, and keeping the government out of the day to day running of the NHS. But this is all actually quite far from what's really happening, as we'll see. 

NHS England is responsible for overseeing the commissioning, the planning, and buying of NHS services. In practice, it also sets quite a lot of NHS strategy and behaves like an NHS headquarters. 

NHS England commissions some services itself, but passes most of its money onto 200 or so clinical commissioning groups across England, also known as CCGs, which identify local health needs, and then plan and buy care for people in their area, people like you and me. 

CCGs buy services from organizations of different shapes and sizes, from NHS trusts that run hospitals and community services, to GPs and others that provide NHS care, including organizations run by charities in the private sector. 

Jostling for position alongside NHS England is NHS Improvement. It oversees NHS trusts, and right now its focus is very much on managing the money. So for example, it tries to ensure that trusts keep a lid on costs, operate efficiently, and improve. 

Also in the mix is the Care Quality Commission, which inspects the quality of care provided. There are also a whole load of other bodies with their own remits and acronyms. 

This is quite a crowded landscape. And the upshot is that these different organiza-- 

[END PLAYBACK] 

I think we'll stop there because I think you've got the gist that it's quite a crowded landscape. But fundamentally, that describes how the NHS works. So it is through a system of payers and providers, but through an internal market where the ultimate payer is the government. 

So how would I summarize the NHS in 2019 or at its 70th anniversary in 2018? So we clearly operate under a huge amount of pressure. Some of those pressures are the pressures that you see. 

I've been in the situation room here today and yesterday, and the conversations you've been having are very similar to the conversations that hospitals across England will be having around capacity and flows through the emergency department, ITUs that are bursting at the seams-- very familiar conversations. The number of people that we see is increasing every year. They are sicker and they are older. 

But we'll continue to improve. The big story of the last 15 years in the NHS is a real focus on bringing down waiting times, which had become the NHS's Achilles heel. People were waiting too long to see clinicians, too long for procedures. And now we are much, much better at that. 

Our outcomes are improving, but as I'll talk about in a minute, there's further work to be done. And actually, we're more efficient than the rest of the economy. 

In the last few years, our productivity in health care has actually increased at a higher rate than the rest of the economy in terms of other industries. So the outcomes that we get, and again, I'll show you some data in a minute, is pretty good for the inputs that we put in. 

But how do we compare internationally? Well, here's the analysis by the Commonwealth Fund, a New York-based think tank, ranking 11 or so health systems in developed countries. And the Commonwealth fund ranks-- it has an overall ranking, and then splits its ranking into various components. 

And the good news for us is that the Commonwealth Fund ranks the NHS as the number one health care system in the world. The bad news, I'm afraid for you, is it ranks the United States health care system as number 11. 

Why does it rank the UK at the top? Well, it ranks it predominantly because of its processes, its access, its efficiency, and of course, its equity. It's a universal-- its a health care system based on universal access. So it should be pretty good at equity. I'd be disappointed if it wasn't. 

But where we do very badly, unfortunately, like the United States, is on health care outcomes, where we are 10th, and you are 11th. So when you look at those international comparisons, it's pretty clear where the NHS needs to improve. We need to make our improvements in health care outcomes. 

Now, here's some of the data that the Commonwealth Fund published along with that high-level analysis. So you can see that in terms of spending, we spend relatively less as a proportion of GDP than our neighbors. Of course, you're at the top there, I'm afraid, in terms of expenditure for GDP. 

Health care system performance compared to spending, we do pretty well. Unfortunately, I'm afraid you're an outlier. And when you dig down into those health care outcomes that we're not doing well at, let's look at a report from an equivalent to the Commonwealth Fund in the UK. I've told you about the King's Fund, so these are the think tanks in the UK-- the King's Fund, the Health Foundation, the Nuffield Trust. 

And to coincide with the 70th anniversary of the NHS, they published the report, "How Good is the NHS Internationally?" And they found very similar results to the Commonwealth Fund. But here you can see they have done bigger-- dug down to a greater level of detail in terms of those health outcomes, where we are performing less well internationally. 

And to summarize-- it's cancer, it's cardiovascular disease, it's lung disease, and it is neonatal mortality. Those are the areas where we are lagging behind. Now, it's not that we are not doing better than we've ever done in those areas. More people are surviving cancer than they ever have. But our survival rates are about 7% or 8% behind our comparable health care systems. 

And here's the summary. You don't need to read it all directly from that report. You can look at it later if you want. But you will see its main weakness of the NHS is health care outcomes. The UK appears to perform less well than similar countries on the overall rate at which people die when successful medical care could have saved their lives. So a lot of strengths, but that is the main weakness. 

So 70th anniversary of the NHS last summer, the government made a recommitment to the NHS. And in a speech in June of last year, actually at my old hospital, the Royal Free Hospital, the prime minister announced a funding settlement, a budget for the NHS for the next five years. 

And that was rather unusual because the government doesn't usually make a commitment for that length of time. And of course a five-year budgetary settlement means we can plan for five years. And it was also an increase of 2.4% per year in real terms growth, which is back towards the average level of real terms growth of NHS funding, coming out of the period of austerity, where funding had been much less. 

Now, the prime minister didn't ask for much in return. But what she did ask for was a long-term plan. She asked the NHS, and NHS England specifically, to develop a long-term plan, a strategic plan for the next 10 years. 

And I want to spend a few minutes just telling you about how that long-term plan was developed and what's in it. Because it does set the framework for what we are going to do in the NHS, and how we are going to improve the health of our population over the next decade. 

These are the key themes. And I'll talk, not about all of them, but about a few of them. Now, firstly, you will see in there, number three, improve care-- they're not in any particular priority-- improve care quality and outcomes for major conditions. The reason for that is what I have just shown you-- improve the health care outcomes in those areas where internationally we know that we are lagging. 

So it will not surprise you that in the long-term plan, there are specific plans and interventions for cardiovascular disease, cancer, respiratory disease, and children, because those are the areas where we're lagging behind. 

We also need to do things differently. So I've talked about the NHS internal market. And it turns out that when you set organizations to compete against each other, actually, it doesn't always work very well from the patient's perspective. 

You end up with a fragmented service where the patient goes to one organization for one piece of treatment and another for another. And of course, in a more elderly population with multimorbidity, that just ends up in fragmented care. 

So what we have realized is that we need to move much more towards a strategy of integrated health care, with a much more holistic approach which focuses on joined-up pathways of care for patients-- between primary care and secondary care, between mental health and physical health, between local governments and social care, between the NHS and health care. And I'll describe a little bit of how we're doing that. 

We talked about workforce. So we need more. So we need a strategy for numbers. I won't talk about specifically, but also, better support. 

Because like you here, I hear about burnout a lot. So there's no doubt that our doctors, our clinicians, for all sorts of reasons are under increasing levels of stress. And we need to address that as employers. 

We absolutely do need to make better use of data and digital technology. I'll say a little bit about that. And I'll say something about prevention and health inequalities. 

And of course, in all of this we have to remain efficient and productive. Because we can't forever keep on increasing the percentage of GDP we spend on health care. Otherwise, the government may not have anything for anything else, such as teachers, the police force, and the Armed Services. So we do have to use our taxpayer pound efficiently. 

Now, let me spend a few minutes going through the high-level plans that we have for those areas in terms of health outcomes. And I'll start with cancer. 

So the problem we have with cancer in the UK is that we diagnose cancer too late. We are diagnosing too little cancer or too few cancers at stage one and stage two. So currently, about 52% of cancers are diagnosed at stage one and stage two. 

And you all know that if you diagnose cancer late, the outlook is less good, and the treatment is often more complex and expensive. So our number one goal over the next 10 years is to diagnose cancer at an early stage. And we want to increase the rate from 52% to 75%. 

And we need to do that through a whole host of different interventions, from our screening services and how we screen for cancer, through to how we encourage individuals to come forward with symptoms, through to how we deal with people with non-specific symptoms, where it's not clear that we can pin down a cancer in the first place. 

Won't go into details, but for instance, these are the portable CT scanners, and the mobile CT scanners, that we have started to put in supermarket's car parks, particularly in areas of the country where the smoking rates have been high, to grab people as they come out from their shopping and invite them for a CT scan after they've gone through a questionnaire process, to see if we can diagnose lung cancer early. 

And it's working. We are picking up lung cancers. We are taking health care to the population, to high-risk members of the population, rather than asking them to come to us. 

Of course, we pick up a lot of other chronic lung disease as well, which is a good thing. Because when I talk about respiratory disease, I'll tell you our problem is that we're not diagnosing chronic lung disease early enough. 

We are about to start rethinking how we deliver screening services. A report was published only two days ago, actually, while I was here on Wednesday, on screening services in England, thinking about breast screening, colon screening. And there were really exciting developments in those areas, both in terms of genetics and testing. 

And of course, we need to-- all the other things that we need to do with cancer, so we absolutely need to get the great new technologies into patients as quickly as possible. So CAR-T-- I know you have patients here who are going through CAR-T. 

So we very rapidly, as soon as CAR-T was licensed, got that on the NHS. And of course the cost of that is borne by the NHS for individual patients. And so we are taking people through CAR-T at the moment. So we can bring these technologies on very quickly. 

Cardiovascular disease-- so the issue with cardiovascular disease is not that we don't know what we need to do to prevent cardiovascular disease and to reduce the number of people who die. We need to control blood pressure. We need to focus on cholesterol. We need to focus on obesity. And for stroke, we need to make sure that everybody with atrial fibrillation who should be anticoagulated is anticoagulated. 

We know all that. We've known it for years. I knew it in medical school. What we've not been great at doing is making sure that we address, and we have the interventions. 

I remember running a conference on uremia a few years ago, where we got international experts for two days talking about factors that might drive chronic kidney disease. And we talked about superoxides and all sorts of metabolites. 

And at the end of it, one of my co-organizers who's in epidemiology stood up and said, the truth is, everything that we've spoken about today, although it's academically exciting, probably accounts for 1% to 2% of chronic kidney disease. And if we just spent the two days controlling blood pressure in our patients, we would probably have made a greater difference than all this academic discussion. 

So what we're really focusing on is how we bridge the gap of those people in the UK with high blood pressure that we don't know about. And I'll say a little bit about that later. But it's primarily through a very, very enhanced multiprofessional primary care service. Because this needs to happen in primary care, and also through the use of community pharmacies. 

We can also do an awful lot in cardiac disease over and above prevention. So one of my passions is out-of-hospital cardiac arrest. And there are cities around the world that have incredibly good rates of survival when there's cardiac arrest out of hospital. Because they have a population who knows how to respond, and they have defibrillators available, and they have quick ambulance response time. 

In fact, I have an app on my phone called GoodSAM. I don't know if you've ever come across GoodSAM. GoodSAM's a simple app that links trained responders-- doctors, people who've gone through training courses-- to the location of defibrillators. And if somebody has a cardiac arrest in London and I'm close by, I will get an alert on that app. 

I will be able to talk to the ambulance service directly with a video link. In fact, in the next generation of the app, I believe I'll be able to potentially take physical measurements as well. And I'll be able to alert other responders nearby to come and assist. And that sort of technology, I think, will be able to drive a big improvement in out of hospital cardiac arrests. 

Stroke, I've talked about. Prevention of stroke is the same risk factors as prevention for cardiovascular disease. But in addition, atrial fibrillation, arrhythmias, or dysrhythmias are important. And we need to do much better, particularly amongst groups of population who don't traditionally access health care as well as others. 

So we know that we have far more untreated AF in certain ethnic groups and in certain socioeconomic groups. So in stroke, a real focus on blood pressure control, cholesterol control, to an extent. But also, in identifying untreated AF. 

Respiratory disease-- so our problem with respiratory disease is we are not detecting it early enough. Too many of our patients are being diagnosed with chronic lung disease when they first attend the emergency departments with an exacerbation. 

So we need better primary care, better spirometry, better interpretation of spirometry, and better management of respiratory disease. We also need to do something about air quality, because air quality is a big factor in respiratory disease. 

So if I told you that 5% of the travel in England on any weekday is generated by health care-- 5% of the travel, either our vehicles, or patients coming in to see us in health care settings. So we have an ambition in the long-term plan to reduce the number of outpatient visits by a third. 

That was 35 billion outpatients we want to reduce. Because we believe using technology, using different ways of managing patients-- and you do that here through telemedicine-- will avoid people having to make the journey. 

And not only will that be better for patients, but it will actually be better for the air quality. And we can make our contribution to reducing pollution and the effects of air quality, which will benefit our respiratory patients. 

Maternity-- we really want to focus on maternal safety. So we have an ambition to halve the rates of stillbirths. And we want much more personalized care in pregnancy. 

We also have a real focus on smoking in pregnancy. So smoking has been a success story. Since legislation was introduced to prevent smoking in public places, we've seen a decrease in smoking. 

But we still see too many women smoking in pregnancy. And that is a major cause of maternal and neonatal mortality of-- morbidity and mortality, so a real focus on smoking in pregnancy. 

Children and young people-- there's a list of things that we are focused on. Integrated care, I've talked about. The three long-term conditions in children that we need to spend most time on are asthma, epilepsy, and diabetes. But of course, like you, we have a huge problem with obesity. And we are seeing more and more childhood obesity. 

We can't do a huge amount in the NHS because we haven't got the evidence-based interventions yet. We want those to be generated. It doesn't really matter where they're generated. If they were generated in this country, it would be just as good for us. 

But we can influence government policy on this. And so we are constantly talking to government about sugar levies, reducing sugar in food, about what we can do at a population level in terms of policy to reduce the obesity epidemic that we're seeing. 

Aging well-- so back to that population that are living longer with multimorbid conditions. And for the next 10 years, we need to change the paradigm really from the frail elderly, who we see at time of crisis, into an older person living with frailty, where there is much more community-based anticipatory care. 

So the sort of systems that are being developed where local health care systems understand who the frailest in their population are, and work proactively to ensure that they don't fall ill, that they don't have to come to the emergency department, they've got everything that they need in place, is the way that we need to move forward. Because we are still seeing too many elderly people with frailty and multiple conditions presenting in acute crisis in the emergency department. 

So a little bit about the way we will do that. So we need to really focus on urgent community responses, so setting standards. So if there is a crisis, we get a community team out to you quickly to avoid the crisis becoming a hospital admission. 

Finally, just a few slides on mental health. We have underinvested in mental health. So for too many years, mental health has been a bit of a Cinderella. And we need to change that. 

So over the last few years, and in the next few years, we will be investing a higher proportion of the health budget in our mental health services. And we are particularly worried about children. 

So one of the things that I've been doing is speaking out a lot about social media and the effect it has on children, around celebrities who peddle diets and pills, cosmetic procedures that will make young people look better and feel better. About a quarter-- I can't remember the exact statistic-- of young people, if you ask them, have thoughts about body image. 

And I'm really pleased that as a result of some of that, and the pressure by other celebrities, Instagram recently announced they were going to change their policy on how they filter and how they promote these sorts of things. So there's an awful lot we can do in mental health. 

How are we going to organize all this? I've mentioned a little bit about that. And I've said that we want to get to a more integrated system. So in primary care, we are asking our primary care physicians to work in large groups, to serve populations of about 30,000 to 50,000 people, and to work much more closely together. 

So the days of the single-handed practitioner are gone. We now have multiprofessional primary care teams, usually led by doctors, but care delivered by pharmacists, physiotherapists, social prescribers, and paramedics. 

Above the primary care network, which will focus on the 30,000 to 50,000 population, again, we are focused on health systems, which are much more integrated. I've spoken about this already. 

This is moving our organizations away from competition into a much more collaborative system, where their success is going to be measured on the joined-upness of care of patients, and also on a good understanding of population health and anticipatory care to prevent illness. And there's a few examples there if you want to have a look later. 

And then on prevention-- finally, on prevention. Of course, it's always better to prevent ill health rather than treat ill health. We know what the priorities are in prevention-- tobacco, dietary risks, obesity, glucose, blood pressure, et cetera. Air pollution there as well. And I've talked a little bit about what we're doing in air pollution, what we're doing in secondary prevention around high blood pressure. 

But there's also a whole lot of other things that we can do. And one of the things I'd highlight, because you talked about it at your situation room yesterday, is around antimicrobial resistance. So the government has set an ambition for us to reduce the use of antimicrobials in humans by 15% in the next five years, which is an incredibly tough challenge. 

And it's incredibly tough for me, because I'm the responsible person to deliver that. But if we're going to have a future where we don't need to worry about running out of antibiotics, we need to do it. 

Digital is really important. I haven't got much time to talk about it. But over the next 10 years, I think there are two revolutions that will revolutionize health care. 

The digital revolution, I think we're in the foothills of. I've heard this week about work that you are doing on use scoring and using technology to monitor people, patients who are triggering on use scoring. 

So they're all free. Before I went into NHS England we did work on triggering AKI, Acute Kidney Injury alerts. And this is an app that was developed with DeepMind health, which is owned by Google. It's Google DeepMind, one of the world's premier artificial intelligence companies based just down the road from the Royal Free in London. 

And this is an app that takes AKI alerts from the moment the creatinine comes up our lab. It compares it with previous creatinines, and sends an alert directly to a nephrologist if the patient is at risk of AKI. 

So in that hospital, nephrologists are turning up on wards to see patients at risk of AKI before the treating team actually knows it's a problem, because it's occurring in seconds-- an example of how you cut out variation and you drive good outcomes. And they published their outcomes in the summer, showing reduced length of stay and reduced costs and quicker treatment. 

And then I've only put one renal slide in, which is to remind me that the other big revolution over the next 10 years will be genetics. This is what we did a few years ago on the genetics membranous nephropathy, showing the risk factors, the genetic risk factors in the HLA complex, and also the PLA2R, gene locus for membranous. 

We published this in the New England Journal of Medicine, and within four weeks of that, a patient of mine with membranous nephropathy came to see me and said their son, who had deposited his DNA at 23andMe or one of those companies, had phoned him up to say they just emailed him to say he was at risk of membranous nephropathy. What should he do? 

And of course, that's the world that we're going to live in, where the genetic information that increasingly people will have will not only allow us to think about disease prevention, but will also pose all sorts of questions about how we manage them over long periods of time. 

And then finally, we need to reduce health inequalities. Health inequalities still exist in the UK. We do very well on equity, as I said. But we have too big a gap in health outcomes between the richest and the poorest. And we still have problems of access. 

OK. So back to the 70th anniversary of the NHS. So I had a busy day on the 5th of July last year. I did the news studio. So here I am in the BBC newsroom having just done an interview there. There's the weather forecast for the day. I didn't have to read the weather, but I could have done it. 

And here I am at Westminster Abbey, where we had a service of celebration, where politicians, public, patients, clinicians came together to celebrate 70 years of the NHS. And I put these up deliberately because we have a number of religions in the UK. So of course, the Church of England is the state religion. The BBC is a little bit of a religion as well. But the NHS is probably the biggest religion of all. 

And a former chancellor, and one of senior government ministers famously quoted, the NHS is the nearest thing that the British people have to a true religion, because they believe in it and they are so passionate about it. 

And why is that? Well, it really goes back to the creation of the NHS in 1948. And in the days before the 5th of July, these were the leaflets that were distributed through the doors and in the streets to the citizens of the UK-- four-page leaflet describing what the National Health Service was going to be. 

And the first paragraph on the first page probably describes everything that I've said more succinctly and more eloquently than I could ever do. 

The NHS-- what is it? How do you get it? It will provide you with all medical, dental, and nursing care, everyone-- rich or poor, man, woman, or child-- could use it or any parts of it. There are no charges except for a few special items. There are no insurance qualifications. 

But it's not a charity. You're all paying for it mainly as taxpayers, and it will relieve your money worries in time of illness. That's what it did in 1948. That's what it does now. And when you ask the public in the UK, they consistently rank the NHS as their highest-rated organization, their most trusted and most loved institution. 

So yes, we are passionate about it. And sometimes when I give talks, I talk about kindness and our requirements as clinicians to be kind to our patients and kind to each other. And that's one of the fundamental things about being a health care professional and a health care leader. 

And actually, I also think of this as a sort of collective act of kindness. It's the point at which the population of the UK decided that everybody, rich or poor, young or old, had the right to health care, irrespective of their circumstances or their financial situation. 

It's a collective act of kindness. And it doesn't have to be that way. It could be organized differently. But continuously, we reaffirm in the UK that this is the way we want to do things. 

It has its strengths. It absolutely has its weaknesses. It delivers great care. It can also deliver poor care as well. But fundamentally, those principles have remained unchanged. 

And of course, Bevan, who could see the future very well when he set it up said this. We'll never have enough. We never shall have all we need. Expectation will always exceed capacity. The service must always be changing, growing, and improving. It must always appear inadequate, because we always have to strive to do better. 

So I hope I've told you a little bit about how the health service in England and the UK developed. I hope I've told you what its strengths are, where it needs to improve. 

And I hope I've given you some insight into over the next 10 years how at a national level, we intend to improve it. Whether we will or not, we'll see. Maybe in 10 years time I can come back and tell you how we did. But very happy to take questions. Thank you. 

[APPLAUSE] 

We have time for a few questions if you'll just wait for a microphone to [INAUDIBLE]. 

Thank you for that fantastic review. We appreciate your coming. One of our intractable public health problems is one of ambulatory mental health. And you read almost every week of some horrible disaster occurring that is linked to inefficient and inadequate mental health services. 

So I'd be interested in your view of how the British Health System, National Health System, has been able to deal with that. 

So as I said, we have almost certainly underinvested in mental health. So there is catching up to do. I don't think it is quite as bad as you've described. But I think we have a journey to go on improving mental health. 

So we have invested quite a lot in talking services, and in digital office as well. So part of that around some mental health conditions, particularly the price of illnesses, et cetera, is getting speed of response an awful lot better than it's been in the past. 

We have over the last 20, 30 years increasingly moved mental health out to long-stay facilities into the community. And all the problems that occur when you do that in terms of providing out of hospital care, which is the ambulatory care, have been lessons that we've learned. But I think we have bit by bit done better at that. 

We have not got a set of national standards for mental health in terms of responsiveness that we do for physical health. So one of the things I'm also doing at the request of the prime minister is reviewing our highest level reportable public standards of health. 

And one of the things I've proposed, which have been widely welcomed, is that we bring in a set of standards for access to mental health, including crisis response within hours, and include quick access to a mental health professional. That will take time because we have a shortage of workforce in mental health. 

And then a final thing I'd say that we are also focusing on, which is not necessarily mental health but there's an overlap, is learning disabilities and autism. So we have too many individuals in long-term institutions who would be much better managed in the community if we put in place the right support. 

So we have a very, very active program for those individuals who are in institutions with learning disabilities, to get them out into community with appropriate support. And we're also reviewing the deaths-- every death of somebody with learning disabilities. 

Because we believe that we are not yet at a standard of care which is equivalent to everybody else in terms of people with learning disabilities. And that's been quite a revealing process and quite a shocking process actually, in what we've learned in professionals' attitudes to learning disabilities. 

Thanks. Thank you. It was a wonderful talk, and we're really happy to have you here. It's a perfect time for you to be here, too. 

Do you feel like-- we've had conversations in this country about a lot of what happens in what we call the big white house-- the hospital, the acute care hospital, and even maybe what happens in our clinics moving out into the home. So the hospital at home notion, the comeback of house calls and a lot of technology in homes that can-- do you see that happening in the UK? 

Yes. So one of the interesting things, of course, of reading books like The Five Giants and health care history is that the problems that we grapple with have been grappled with over 70 years. So every single report that's ever been written on the NHS has in it that we need to move more towards prevention rather than treatment. And we need to move to out of hospital settings, rather than hospital settings. 

But I do think there are lots of opportunities with technology. So I described the program to completely revolutionize outpatients. I don't know what you think, but I think our outpatient model of care has probably existed for the last 100 years relatively unchanged. And I think this is the time. 

So the Royal College of Physicians, the Royal College of Physicians over there, issued a report last year which essentially said, if you ask patients, they think outpatients is broken. And if you ask staff, they think it's broken, too. And so there's a collective will to do something different. 

So that's partly about technology. It's partly about doing a thing once rather than twice. It's partly about using primary care better and doing things in primary and secondary care. 

But I do think there's opportunity, such as remote monitoring, teleconferencing, and just simple things like text messaging. I mean, some of this is not difficult technology.