NHS: Reorganisation
Lord Mawson Excerpts(13 years, 5 months ago)
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Lord Mawson
My Lords, I thank the noble Lord, Lord Touhig, for securing this debate. We are entering one of the biggest reorganisations of the health service since 1948 by passing budgets and power locally to GPs. I welcome this move. However, difficult questions must be asked, not just about how we can more efficiently manage, organise and run the health service but about whether the story that we tell as a nation about our health is true, life-giving and sustainable.
In the health debate in October, I asked how we could provide quality healthcare that meets the real needs of patients in today’s world. Is the popular biomedical model of health in which we invest good for our health and sustainable? Will it help those most in need, or does its internal logic present us with a costly and limited view of what a healthy human being is?
The GPs with whom I work tell me that in deprived communities such as Tower Hamlets 50 per cent of the patients whom they see do not need a doctor. One GP at an NHS walk-in centre told me that, out of the 80 patients he saw in one day, only 20 really needed to see him. A nurse told me of one patient who came into her surgery last week to ask her for hand cream on the NHS rather than buying it at the chemist. Let us tell a story about the personal responsibility of patients. Often, “patients” do not need a doctor; they need something else. What presents itself as a health issue may be more to do with a patient’s isolation or the need for a better job or lifestyle. People have bought into a culture of illness because it costs them nothing, but in reality the cost to our society is running into millions of pounds. A Times article this week stated that 7 million patients failed to show up for hospital appointments in the past year, costing the NHS millions of pounds. If those 80 patients at the clinic had had to pay £5 each to see the doctor, they would first have asked themselves, “Is this visit really necessary?”.
A sensible balance and perspective need to be found. There is a cultural belief that there is a pill for every ailment, and that if there is not there should be. We are in danger of medicalising people out of existence and creating levels of anxiety that have unintended consequences. Only last week, “experts” advised those of us over 50—I declare an interest here—to take an aspirin every day, but the sting in the tale was that, for some of us, it might mean bleeding to death internally. I am in danger of becoming a nervous wreck.
We must return to the question that the innovative Dr George Scott Williamson from the Pioneer Health Centre in Peckham asked all those years ago before the founding of the NHS: “What is health?”. Although we love them dearly, the BMA and their powerful allies in the medical profession have many financial and other interests in keeping the health narrative unchanged and unchallenged. Our health is matter not just for our doctors.
Most of us engage with the health service through primary care and not, fortunately, through the acute sector. It is in preventive medicine in primary care that limited funds can have the most impact. Some fantastic innovative attempts in preventive health care have been made, and some successes achieved, by using the power of modern media to change behaviour. Jamie Oliver, a well known social entrepreneur—not a doctor—challenged our preconceptions about unhealthy eating. The Government have published an excellent white paper on public health, Healthy Lives, Healthy People. It underscores the importance of preventive actions taken at the initiative of the community and local businesses.
My colleagues and I have radical plans for a social business to regenerate communities in east London through good food—I declare an interest here, too. We want to teach non-cooks how to cook in their communities and young mums how to create healthy meals for their children. We have partnered with Jamie Oliver’s team and the most well-known academics in the field. We also have support from the local NHS. However, obtaining start-up grants to support this work has not been easy. We suspect that this is because we are unashamedly a social business and not a charity. Why are innovative projects such as this, with all their potential for cost saving, still so hard to get going? Why are more innovative partnerships such as this not being brought together by local GPs and social entrepreneurs? It is because they live in different worlds, and because government and charitable funding silos discourage cross-fertilisation and make it so hard to do. New thinking comes not out of theoretical clouds but out of novel and unexpected practical partnerships. Yet the present professional structures discourage this. Why?
What might a new health narrative sound like? First, the NHS needs to tell a story about a changing demography and the financial realities that lie behind it. We have an ageing population and a health system that is unsustainable. Let us tell people the truth. We all need to take more individual responsibility for our health. The NHS should be a supportive shoulder on which to lean, if and when required, instead of encouraging a dependency culture and maintaining its present stranglehold.
Secondly, Governments must tell a new story about the importance of preventive medicine and illustrate it by telling the stories of GPs who are now forming relationships outside the box. Governments must be more honest with us all and stop feeding on papers, statistics and structures that can magically be manipulated to tell them exactly what they want to hear. They go home happy; the patients do not.
Why not start asking how government can help to bring together doctors and social entrepreneurs, innovators, artists and creative people in shared health buildings so that we develop innovative approaches to basic health care and prescriptions that meet people's real health and social needs? This is not about new money but about asking how money that already exists in local communities can be brought together in a more integrated and efficient way. Let us bring together practitioners from different disciplines into the same building and move beyond the collocation of services to integration. We have in east London.
Thirdly, let us tell a story that admits that ploughing vast amounts of money into the health service does not inevitably improve people's health; it can have unintended consequences. People in poorer areas still die seven years earlier than in richer areas, and health inequalities between rich and poor are getting progressively worse, even after all the investment in recent years. More money is not necessarily the answer. We need to think more imaginatively than this.
I leave a couple of questions for the Minister. How in practice is government going to use the restructuring of the health service to create a new narrative relevant to modern health? Secondly, what is government going to do to ensure that doctors engage with innovators and entrepreneurs?
Healthcare
Lord Mawson Excerpts(13 years, 6 months ago)
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Lord Mawson
My Lords, I want to make a few points about health and social care. How do we provide quality healthcare that meets the real needs of patients in today's world? Will the popular biomedical model of health meet all those patient needs, or does its internal logic present us with a limited view of what a human being is and provide us with an expensive approach to healthcare? Is what we say that we believe about health believable?
The GPs I work with in east London tell me that in poor communities such as Tower Hamlets, 50 per cent of the patients they see do not actually need a doctor; they need something else. What presents itself as illness may actually be more to do with a patient's isolation, the need for a friend or a job, better housing or a more creative lifestyle. In such cases, attempts to find a magic pill or potion are inappropriate and a waste of resources; GPs and patients need our help.
In this new financial environment, there is an opportunity to begin to open up a more integrated and cost-effective approach to healthcare at a national level which builds partnerships between health and social care professionals and with the voluntary and social enterprise sectors, but it will require encouragement and leadership from within government if this more integrated and cost-effective approach is to work.
GP practices are anchors in local communities that could play an important role in the development of the big society. Four years ago, I was asked to intervene by the then CEO of the local authority in St Paul's Way in Tower Hamlets, which is a single street in one of our most challenged housing estates. I am now leading the St Paul's Way transformational project, so I declare an interest in this project, but I am pleased to say that it is fast becoming a pathfinder used to illustrate the benefits of joined-up working. We are now exploring the possibility of creating a community interest company, which in time may manage the facilities along the whole street. When I first arrived on the street, I was shocked to discover that there was the possibility of developing a new £40-million school under the BSF programme, a new health centre across the road and 500 new homes. So what was wrong? None of the key players in health, housing or education were talking to each other.
The new focus on patient-led healthcare could result in new relationships between doctors and health professionals and local members of the voluntary and social sectors. This more integrated approach is important because, at present, strategy is running on departmental lines. Education is introducing free schools, health is devolving budgets to GPs and social services are extending personalisation budgets. Society does not operate along departmental budgets. Go to any town or city district and ask the police for the top 100 families that they routinely deal with for anti-social behaviour. Ask the GPs who are their most demanding patients; ask the housing office and the courts. The same names will keep appearing. Despite decades of rhetoric, the same tragic newspaper headlines will keep appearing—baby Peter being one horrifying example.
Unlike the initiatives of the previous Government where the state was encouraged to be joined up, my colleagues and I would suggest that the state will never be joined up and that the answer is to let communities and local organisations, such as GP practices, join up on local streets to deliver joined-up services. I am encouraged that this is the direction that the Government seem to be taking us. We must take the opportunities that this presents. I suggest that in this financially strapped environment there is a new opportunity to turn this old health logic on its head. But the Minister will ask how we are going to do this and how we will create the physical environments on the ground within which this can take place.
One answer is already there; namely, LIFT, the Local Improvement Finance Trust. We could do a great deal with this, but there is not time to go into the detail. I leave the Minister with one question: will he tell the House how he proposes to encourage GPs to take up the opportunities presented by the transfer of funding to GP practices? What is the Government’s plan for general practice to play in the creation of the big society?
Health: Primary and Community Care
Lord Mawson Excerpts(13 years, 10 months ago)
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Lord Mawson
To call attention to practical lessons from changes in primary and community care during the last 10 years; and to move for Papers.
Lord Mawson
My Lords, it is a privilege to be able to lead this debate on the future of primary and community care at this early stage in the new coalition Government. The vision that the Government have set out for primary care, where resources are deployed in the hands of practitioners close to the ground, has significant risks but is full of opportunity. As a social entrepreneur, I welcome this bold step.
As noble Lords will know, over the past 13 years in an area of great deprivation and health need, where the health authority had left a gaping hole in primary care provision, we, with the local community of Bromley by Bow, have set up a health centre which is integrated with housing, education, businesses and the arts. I declare an interest as the founder and, now, president of the centre, and that, in my professional life, I am increasingly working across the country advising on this area of health development.
The Bromley by Bow Centre is about health, not sickness, which is reflected throughout the building. You enter through a beautiful cloistered garden, recently full of purple wisteria. There are no gruesome pictures of human bodies on the walls greeting our patients, the kind of images that used to haunt me as an imaginative eight year-old at our local doctor’s surgery in Bradford. Instead, you walk into an art gallery and open-plan reception made of natural timbers and bathed in natural light. A high-quality environment, a focus on human relationships, open communication and customer focus are the keys to the Bromley by Bow approach. Doctors come out into the reception to chat and greet their patients in person. In the consulting rooms, patients and doctors sit side by side around curved wooden tables, looking at the computer screen together. At Bromley by Bow, doctors, nurses and patients work in partnership together.
Patients are not merely prescribed pills, referred and sent on their way. The drug we give to a patient with depression is only part of what our GPs prescribe as a fully comprehensive care programme. At the centre, we can offer on-site career advice; support to overcome debt; vocational training qualifications, and even a university degree programme; business support, including the opportunity to set up your own business; and practical housing and legal assistance.
Over the past 13 years the Bromley by Bow Centre has become an exemplar of an integrated approach to health and social care. It inspired the £300-million healthy living centre programme, run by the then New Opportunities Fund, and the £2-billion NHS LIFT initiative, which is of course the public/private partnership programme for building primary health and social care centres in the most disadvantaged areas across the UK.
Others have developed integrated approaches to health in other parts of the country. Dr Angela Lennox built a police station in her health centre in Leicester and reduced crime in the housing estate where it is based. The Westbank Community Care Centre in Exeter promotes healthy living across Devon. The Gracefield Gardens health centre in Streatham works in partnership with Lambeth PCT and Lambeth Council to deliver better healthcare. We ourselves now run three health centres for over 18,000 patients and are the largest primary care provider in the London Borough of Tower Hamlets.
I apologise for not being able to speak last week in the debate on the big society, but are these not all examples of where, in the micro, a big idea like the big society might take root? If integrated models of health and community care were encouraged in every community up and down the land, and the necessary local relationships and partnerships brought together, this important idea—the big society—might not become subject to yet further cynicism and be seen as more meaningless government spin with little substance underneath. It might actually become the fertile ground within which a wholly new definition of what it means to be a healthy society—a thriving community—took root. Of course, such an approach would need to be given time and consistent leadership.
There is a wealth of untapped social entrepreneurial talent in our country. Many of these entrepreneurs have it in them to generate creative and innovative approaches to primary and community care. There are hundreds of latent and undernourished third-sector organisations in this country with the capability to become like Bromley by Bow and take on the task of transforming how public services are delivered in communities up and down the UK. Our task is to find these people and organisations and put the wind in their sails. Over the past 10 years I have travelled up and down the country and discovered social entrepreneurs who are massively frustrated at how hard it is to be trusted and resourced to take on public contracts, including in the areas of health and social care. Despite the positive rhetoric from successive government Ministers, it has been intensely difficult for dedicated and talented social entrepreneurs to develop creative solutions.
My noble friend Lady Finlay and I offer the Minister a visit to some of these centres and the opportunity for him to see in detail what a successful integrated approach to health and community care actually looks like in practice, and what conditions need to prevail if it is to grow exponentially and to take root. The sad fact remains that these examples of an integrated health model are still few and far between. Despite all the rhetoric and promises, there has been little practical encouragement for these integrated approaches to health. It was ironic that our approach, which everyone now thinks is a great idea, was physically blocked by a boulder across our road to delivery back in the mid-1990s. The boulder was not local people but the local health authority at that time.
I am not convinced that things have moved on much. Yes, money has been spent on building new buildings and, yes, there has been investment in services, but the principle of broadening the base of primary and social care delivery and engaging social enterprises has barely been understood. I am aware that the language of social enterprise is spoken inside Whitehall, but I am profoundly doubtful as to whether it is understood. Indeed, the evidence is that it is not. Our public services need to be known for doing and achieving, not just endless talking, restructuring or writing yet another new stack of policy documents. In a modern enterprise economy, we are nowadays returning to the sensible practice of “learning by doing”. The idea that we learn much through the writing of endless documents that are out of date within weeks can seem rather outdated. There is nothing better than getting your hands dirty in the practicalities to really understand what is going on. When I spoke to the recently departed chair of NHS London, he told me that his mission was to build stand-alone “medical model” health centres without what he called “the distraction of social and community care”. Evidently, the complications inherent in the lives of disadvantaged Londoners were outside the brief of the chair of NHS London.
Similarly, the vision of the noble Lord, Lord Darzi, of a network of polyclinics, announced in your Lordships’ House, was in practice another missed opportunity. When you get into the practical detail with those of us who are practitioners, you see that it was not at all a vision of polyclinics, but of monoclinics—that is, health centres that are almost solely about the clinical model of healthcare. It is a sophisticated clinical model and, invariably, these clinics are full of state-of-the-art equipment and procedures. However, I am vexed to say that they pay scant lip service to the lessons many of us have learnt about integration and the bringing of different disciplines together in the way I have described—that the route into addressing the pressing and underlying health needs in some of our most challenging communities in this country lies in getting GPs to work with their non-health colleagues. It is as simple and as complicated as that.
We need our health service to be open to working in partnership with the third sector and social enterprises in integrated schemes which address the real, practical day-to-day issues that face patients. These include poor social housing, underachievement in education, credit card debt and fear of bailiffs, concern over street violence and anti-social behaviour, and the lack of opportunities to take control of their lives. We are not asking the NHS to solve all these problems. We are simply asking that the health profession be willing to work more collaboratively with others who have the tools to change our communities for the better, including by addressing their physical and mental health needs.
What those of us who have had real experience of running successful integrated health centres found was that the definition of a polyclinic changed on a six-monthly basis, and each new definition was communicated by NHS London with such clarity and certainty that real players and practitioners in the field were left totally paralysed. This meant that important health centres still remain not built, with enormous potential abortive costs. I know of one health centre that has had to go through so many NHS London-inspired redesigns that it has incurred over £1.5 million of design fees and still sits in NHS London’s in-tray. I truly wish I could say that this is the only example I am aware of in London but it is not. I am afraid that the last Government were rather fond of initiatives that never in practice happened, and of trusting the reports of young consultants at McKinsey rather than those who do the job.
I welcome a world envisioned by the coalition Government where resources are put in the hands of practitioners on the ground with a real understanding of their neighbourhoods and local needs. However, this vision is far from straightforward. Not all GPs will deliver the integrated model of healthcare that I described earlier. Many GPs who support an integrated approach tell me that their colleagues who do not support it fear loss of status and title, without realising that real status in communities is based on the strength of their relationships with patients. Often in deprived areas there is a stark lack of GPs with the capacity to rise to the challenges that they now face. This new approach has important implications for the ways in which doctors are now trained.
The Government need to ensure that GPs are encouraged not to resist change, nor protect an expensive biomedical model of health. We need to show our doctors that an integrated approach to healthcare will address the profound problems that people in disadvantaged areas face, with considerable savings to the public purse. At Bromley by Bow, we run our health centre like any successful customer-focused business. For example, 20 per cent of consultations are conducted on the phone, which saves not only the patient’s time but the GP’s as well. What we all have to realise is that the NHS has access to people across the country which any business would die for. Eighty per cent of consultations in the NHS take place in general practice, and 90 per cent of the population is seen in any one year. If we encourage entrepreneurship in the world of health, then the more capable practitioners will step into these gaps in the market and ensure successful delivery of care.
As the new Government begin to formulate their health policy, I have three questions for the coalition and the Minister, who I wish to thank for a very helpful discussion earlier this week on this subject. First, what is the Government’s vision for the future make-up of primary and community care? Will they simply leave it to the marketplace? Will they promote the standard medical model or the integrated approach of the type I have described? A clear approach is essential for the dedicated medical staff, who have had to suffer countless changes in direction over the last decade and now feel disillusioned, confused and frustrated. Secondly, once the Government have clarified what their future model of primary care and community care will be, how will they deliver and develop this approach effectively? This has simply not been happening. Finally, who in the coalition Government will lead with consistency and longevity, and pursue this course? Under the previous Government, we saw a succession of initiatives and restructuring led by “here today, gone tomorrow” Ministers, which has left the health service, frankly, in ill health. Who will be the leader? That is my key question.
The Government are rightly opening up a world of opportunity and I welcome that. However, the devil, as ever, will be in the detail and perhaps most importantly in consistent leadership not from civil servants but from practitioners—GPs and others who have done the job and understand the practical details on the ground. I encourage the Minister and his Government to lessen their reliance on academics and theorists, who have often never built anything, and to embrace the world of the practitioner and the social entrepreneur; to create a culture where we learn by doing, and not by talking and writing endless expensive documents and papers. We cannot afford this expensive, rather old fashioned way of doing things any more. Let us support—and learn from—people who do the job.
Lord Mawson
My Lords, I have found all the contributions to this debate particularly helpful. In many ways, the issues raised provide the raw material on which we all need to work as we move forward to the next stage of the development of primary and community care. I am only sad that there is not more time to debate some of those issues, but I want to make just a couple of points.
I agree with the noble Baroness, Lady Thornton, about the role of LIFT. In the early days, I tried to persuade GPs and others all over the country to get behind LIFT. It has created a very different kind of world. Indeed, my colleagues in east London won the first £35 million contract and began to demonstrate how it might work. My plea to the Government is that they should stay with LIFT, as I think they will. I suspect that, as a structure, it is achieving only 55 per cent of what could be achieved and that it could do a great deal more, as I pointed out earlier.
Some of the points that I made reflected conversations that I have had with colleagues who run the Big Life Company and with others with whom I am very much in touch. We are all aware that we have come a very long way but that we need to go further. That is the key point.
I thank the noble Earl, Lord Howe, for clarifying some of the issues that I raised. There is a great deal to do, and a lot of practical details that underlie this debate need to be addressed. However, I welcome what I have heard and am certainly willing to play my part in helping some of this thinking to take root.
Finally, if I have any further advice for the Minister, it is the following. First, as I know he is doing, he should decide what his vision for the future of primary and community care is and stick to it. At a time of limited financial resources, I encourage him to embrace the integrated approach to health that I have been describing. It is about more than just the medical profession. Not only does it make good health sense for patients and put flesh on the bones of the concept of the big society at a local level, but it may well enable the Government to get more for less from the limited resources that are now available to them.
Secondly, in deciding their vision, the Government should also take great effort to understand the practical details of how it will work in practice in different contexts within the United Kingdom—particularly in some of our more challenging areas. I very much agree with my noble friend Lady Finlay that we should be careful about unintended consequences. For example, the policy to create free schools, which I welcome, may have real benefits in some affluent areas of the country but may well create social havoc in multicultural areas of London, with which I am very familiar.
Thirdly, the Government should make sure that the people they ask to run these programmes are practical, businesslike people with in-depth experience.
As an entrepreneur, I say that we should back success and let 1,000 flowers bloom. I look forward, together with others, to seeing how the direction of travel develops in the months ahead. In the mean time, I beg leave to withdraw the Motion.
Queen's Speech
Lord Mawson Excerpts(13 years, 11 months ago)
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Lord Mawson
My Lords, I should like to add to the deluge of praise. I congratulate the new Government on their success and wish them well in the coming years as they try to develop a working partnership and deliver their programme. I also want to take this opportunity to wish the Minister, the noble Lord, Lord Hill, well in his new job and to thank new colleagues for four excellent maiden speeches. I also congratulate the noble Earl, Lord Howe, on his new appointment.
As a result of many years of bringing disparate groups of people together to deliver practical results, I know that the key to partnership is to focus on relationships and not just on new structures, processes and strategies. Focus on the relationships and everything will follow. Ignore them and you will face serious difficulties. My colleagues and I have spent more than a quarter of a century bringing together partnerships to modernise public services so that they are more responsive and fit for purpose in our modern enterprise culture.
I thought that it might be helpful if I shared with the new partnership Government a few lessons that my colleagues and I have learnt at the coalface. It might also help them to put some flesh on the bones of what the big society might look like in practice. Many people are wondering what this piece of marketing means. We all know that it is crucial for a new Government to lay solid foundation stones on which real change and development can grow. Real change is elusive and may not come to fruition until a Government have left office. Effective innovation can take a generation and requires committed individuals to champion it. It is rarely captured in a policy document, written by what my colleagues affectionately refer to as “the bright, young things”. Real change has to be grown and deeply rooted in communities, otherwise, as I suspect that new Labour is discovering, it will be blown away like the sand when the first gust of wind comes along.
What are the lessons? How do you create a big society and lift the game in education, health and welfare? First, I would suggest that this Government support organisations that already have a successful record of reforming public services. Do not reinvent the wheel, but build on what works. They should back success and learn from their many years of detailed practical work. Do not, as new Labour so often did, take their best ideas, pass them to the Civil Service machine and exclude these experienced innovators. Let them take the wheel. Support them and enable their efficiency. Do not think that it is now the Government’s job to take control. It is not. They should take the long-term view.
Secondly, we need to question what the overused term “fairness” means. The question to ask is: fairness for whom? If you are seeking to achieve fairness for Karen and her children on housing estates across the country and to improve their educational opportunities or access to health, you must back the best providers with a proven record. It is irrelevant whether they come from public, business, social enterprise or voluntary sectors. However, if you are seeking to be fair in dishing out grants and resources to the voluntary sector, you will do something quite different. Who are you trying to be fair to and why? Life is not fair, and where we began to challenge and question this thinking in east London and embrace not equality but diversity, a thousand flowers began to bloom. “Fair for whom?” is the exam question I leave with the Minister. It is not possible to be fair to everyone.
Thirdly, if fairness is about creating opportunities for employment and improved services, the future must be about enabling environments where business and social entrepreneurs can do business together. These are the new relationships that will reform public services and they are already showing significant success, but this means that some of our cherished ideology will need to be examined and probably dropped. For the last decade, bureaucrats have fed a bureaucracy monster and it is now very large indeed. Often, contracting out has transferred a large government bureaucracy to private sector companies with large contracts—prisons, for example. Then the civil servants have migrated from one large organisation to another. The contracting process seems designed to stifle innovation and risk taking. The role of the new Government needs to be to create a level playing field where new relationships and networks can grow, particularly between business and the social enterprise sector.
Fourthly, I would ask the Minister how he will practically encourage new environments where people “learn by doing”. Will he get his hands dirty by planting the seeds of enterprise in the fertile soil outside the comfortable but dry world of theory? If this new generation of politicians is to gain any understanding of how the real world works in practice, and not hide in the bubble of Westminster, I would humbly suggest that each Member of Parliament should become involved in one project in their constituency to play their part in building the “big society”. Do not pontificate about it: do it. Legislators might then begin to understand the relationship between legislation and practice because attempting to deliver a new school, health centre or service is a practical nightmare nowadays, given the number of contradictory hoops laden with half-baked ideology that practitioners like me have to jump through. The confusion that exists between delivery and democracy is a minefield. The micro is the clue to the macro. Learn from it and gain the public’s respect in the process.
If this Government are serious about empowering communities, Ministers will have to get involved in messy detail. For example, one of the difficulties we face in giving people more professional independence in health is the awkward fact that often doctors do not want to innovate. They have not been trained to think like entrepreneurs and so resist change because they have an entrenched view and an expensive biomedical model of health to protect. This is not just my view, but that of the doctors I have worked with. Can we leave commissioning with doctors? Will they be responsible? It depends on the mindset of the individual doctor.
Finally, the idea that devolving power to local authorities will deliver a plurality of outcomes is not always correct either. Local authorities are not neutral when commissioning services. They often have an aversion to selecting innovative approaches because they do not understand them. Many of their staff have only ever worked in the public sector. They do what they have always done, but change the wording on the forms to please the Government of the day. Look carefully and you will still see the same bodies under new clothes. Local authorities are often the least likely to choose an innovative approach to service delivery, so why are the Government looking to them alone? Could the Minister tell the House what criteria will be used to choose these authorities? How will he select the sheep from the goats? Or, like doctors, are they all as good as each other? Not in my experience.
I wish the Minister well in this time of opportunity. Partnership is a great thing and the present financial crisis is the time to embrace innovation. Never miss the opportunity presented by a good crisis. If you are to deliver, I would humbly suggest that you do not rely on structures or theories, but on people. Back the best people, be they in the business, public or social enterprise sectors, and, funnily enough, you will be fair to everyone.