Correspondence
NHS manifesto:
the missing piece of
the puzzle
The NHS Manifesto published in The
Lancet by Nigel Crisp and colleagues
(Dec 10, 2016, e24) 1 is a broadly
compelling one, and yet it mirrors
an error made by National Health
Service (NHS) England’s Five Year
Forward View2 in calling for a major
transformation of the UK’s largest
public service without acknowledging
the importance of public engagement
in those plans. To be sure, Crisp
and colleagues1 call for services to
be made patient-centred, and for
patients and carers to be engaged “in
decision making and care”. But the
overwhelming role outlined for the
wider public and communities is as a
provider of the informal care required
to shrink NHS services.
The absence of an empowered public
role in this manifesto is problematic
because the continued “great national
coming together”1 of the NHS depends
upon public support. This support
should be nurtured through careful,
genuine public engagement to build
collective ownership of the future shape
of the NHS. Instead, Crisp and colleagues
present a ready-made blueprint for a
future NHS, with transformation to be
accelerated and improvement to be
driven forward by central government
“plan[ning] at scale”, rather than a plan
developed in partnership with the very
public the NHS serves.
Even those who see public engage­
ment as a luxury, or pandering to
wrong-headed populism, should face
the political realities of large-scale
health-system change in the UK.
When the public is dictated to and
not meaningfully involved in decision
making, there will be noisy, time-
consuming, and expensive conflicts,
and perhaps judicial review of NHS
decisions. If a case for change exists,
make it. But seek to progress health
system transformation with, and not
despite, the wider public.
www.thelancet.com Vol 390 July 22, 2017
We declare no competing interests. ES receives The second point, encompassed
research funding from the Chief Scientist Office, in our third aim, is that every
Scotland and the Health Foundation. IY receives
part of society needs to accept its
research funding from the Chief Scientist Office,
Scotland. SC-B receives research funding from the responsibility to develop a healthy
Wellcome Trust, the Economic and Social Research and health-creating society. Stewart
Council, the National Institute for Health Research, and
the Medical Research Council. None of these funding
and colleagues seem to suggest that
bodies had any involvement in this Correspondence. this aim is about taking the strain
off the NHS. Our point is much more
*Ellen Stewart, Ingrid Young,
profound—health-care organisations
Sarah Cunningham-Burley
share responsibility for health and
e.stewart@ed.ac.uk
wellbeing, and would have these
Usher Institute, University of Edinburgh, Edinburgh,
EH8 9AG, UK
responsibilities even if the NHS did not
exist. These organisations are not just
1 Crisp N, Stuckler D, Horton R, et al. Manifesto
for a healthy and health-creating society. about making the NHS more effective,
Lancet 2016; 388: e24–28. but about acting on their own behalf.
2 NHS England. Five Year Forward View. 2014.
https://www.england.nhs.uk/wp-content/
The St Paul’s Way Transformation
uploads/2014/10/5yfv-web.pdf (accessed Project 2 in east London, which we
Sept 1, 2016. refer to, is a model of successful
community partnership. Its phil­
Authors’ reply osophy is bringing together “partner­
We welcome the interest our Lancet ships between public, business and
NHS Manifesto1 has generated. In it community organisations with a
we call, among other things, for the UK view to addressing the problems
government to take a leadership role faced by local communities”. 2 This
in helping to accelerate transformation model is one of social entrepreneurs
of the National Health Service (NHS) to supporting changes from below,
a people-centred system. In so doing, rather than through top-down plan­
we fully agree with Ellen Stewart and ning. At the centre is the role of the
colleagues about the importance of community in identifying local needs
iStock
encouraging health system trans­ and challenges and appropriate
formation in partnership with the inter­v entions to ameliorate these.
wider public. Similarly, the City Mental Health For more on the City Mental
There are two points here. First, Alliance is an example of companies Health Alliance see
http://citymha.org.uk/
we agree that our second aim of accepting their responsibilities for
transformation from a hospital‑­ the health and well­b eing of their
centred and illness-based service to employees. We call this approach
a person‑centred and health-based health creation, because it is about
system does need to engage the providing the conditions and
public fully as partners in shaping incentives that enable people and
local change. This engagement has communities to be healthy and that
not generally been done well in the promote human flourishing.
past. Good examples can be found DS is funded by a Wellcome Trust Investigator
of sustainability and transformation Award, and is funded by ERC HRES 313590. NS For more on sustainability and
plans that are now attempting to declares no competing interests. transformation plans see
https:// www.england.nhs.uk/stps
do this. However, we also believe *David Stuckler, Nigel Crisp
that the overall direction of travel
david.stuckler@unibocconi.it
for the whole system needs to
be firmly established in NHS and Department of Policy Analysis and Public
Management, Universita Bocconi, Milan 20136,
government policy. The way that Italy (DS); and House of Lords, London, UK (NC)
this is implemented locally should 1 Crisp N, Stuckler D, Horton R, et al. Manifesto
be subject to local decision making for a healthy and health-creating society.
Lancet 2016; 388: e24–28.
involving all parties. Report after
2 St Paul’s Way Transformation Project.
report has recommended this, and it http://www.stpaulsway.com (accessed
is time to deliver. April 10, 2017).
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