This letter pulls together the findings from 9 "Deliberative Groups"1 held earlier this year to consider the future of the NHS and produce a "report" for your important Conference. It is written in the spirit of partnership. Our vision of a healthier future, and indeed the journey there, is an exciting one entailing a great deal more participation of us all as fellow citizens - not just as "patients", "carers", "professionals", and "managers", and so on. Health and the health of future generations is a matter for all fellow citizens. This is about the kind of society we want for our future.

Many of us came to our Groups with this view - we were willing volunteers. And, through a process which enabled us to share our experiences, thoughts and feelings as equally valued participants, we produced a strong consensus. We created dissent too. It is important that dissenting voices are heard.

Above all, we believe that if we all find ways to co-operate, deliberate and work together, the next fifty years offer a better second chance to continue to improve our nation's health and health care.

By working co-operatively we have tried to create a view that is not constrained by current structures and vested interests. We learned to speak for ourselves and that has its own validity.

There are four fundamentals to our vision of the future:

1. The core values of the NHS will remain central: a free public service, largely funded from taxation, achieving equality of access and equity of treatment.

2. The context of the NHS will be very different:

• Care in our communities will be integral to health promotion, treatment and care. It will be seen as part of a preventive strategy, especially for elders. In this the role and work of informal carers will be highly valued.

• The workforce will be more highly valued, with health professionals working on a mutually respectful basis with patients and carers. Informed dialogue will be the essence of a more mature relationship between people and services.

• Also, a new, more balanced relationship will have been established with all commercial vested interests, entailing a major shift in emphasis from profitability towards social responsibility.

• Locally accessible networks of care and communications will enable users, carers and citizens to be much more fully engaged in the planning and monitoring of services - as well as in delivery. Joint development and use of new technologies will make this all the more possible. "Self Health" will have a much bigger part of play, as will the use of alternative therapies.

3. We shall all share a much more "whole life" perspective on health and well-being which will influence all aspects of policy-making and organisational assumptions.

4. Finally, health will be subject to a much more democratic system of accountability with public participation at all levels and in all processes… including research.

We are reassured that on the best of our experiences the future is here in the present, if we are all prepared to listen and to learn on the journey to this vision. We want to share this responsibility and we recognise that the pace of change will be different for different groups. Remember, we already share responsibility for care to a massive, largely unrecognised extent.

This "journey" will be full of risks which we want to share with you through your Conference. Our meetings provoked important questions:

• How can we develop health and healthcare systems that are not dominated by particular interests and fragmented by organisational structures and hierarchies?

• Can we achieve a rigorous review of the "contract" with doctors and other professions, and the impact of commercial interests on the health sector? We are divided on this, seeing a big tension between the underlying principles and necessary pragmatism, especially in relation to private healthcare and the profitability of the drug companies.

• Can we learn to work together to build consensus on priorities, plans and performance standards that is genuinely grounded in reliable information and a people's perspective? We particularly want a role in the Research agenda.

• How do we work together to address the long-term challenge and overcome short-term political interference and private vested interest? In particular, we need to achieve better use of existing resources and wiser investment of new resources.

• As fellow citizens, how can we all share in the ethical debates that arise as our knowledge of what is possible grows?

We have also identified significant risks to our working well together:

• Fundamental social and economic inequalities are not being addressed.

• We worry that the NHS remains very discriminatory - especially if you are from an ethnic minority, or if you are getting old, if you have a communication disability, or if you are seen as disabled and not able, or even if you are a woman.

• From the bottom-up we see the system from the perspective of the whole person; from the top-down our lives and services get divided and fragmented.

• There is not much listening going on! It is a matter of training, education and attitude… on all sides. Openness, transparency and reliable information help too!

• We recognise that we want both a fast, reliable emergency system and a responsive long-term health system. Is this achievable?

• Finally, our colleagues in Scotland and Wales see enormous potential in their new democracies. Will Regionalisation in England help too?

We are confident that these challenges can be addressed and that together we can move forward. All the best for your deliberations.

With good wishes,
Your Fellow Citizens

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