None of this would have made much sense to Montefiore’s founding fathers. On 4 February 1884, a group of prosperous German and Sephardic Jews met at Congregation Shearith Israel to discuss charitable works. Something needed to be done for the thousands of East European Jews crowding into tenements on the Lower East Side. And a cause was required to mark the 100th birthday of Sir Moses Montefiore, the most famous Jewish leader of the time. Some argued for a school, others for housing; the rabbis wanted to establish a reformatory for young Jewish criminals. In the politics of just deserts, health care prevailed over education, housing and rehabilitation, a precursor of things to come, and the Montefiore Home for Chronic Invalids was born.
Montefiore’s first half century charts the evolution of western health care from superstition to science. The original Home for Chronic Invalids offered little more than housing and palliative care. In the last hours of the 19th century, it pursued a brief passion for hydrotherapy as a cure-all for, among other things, typhoid, pneumonia and gout. But by the start of the 20th century, nurses were attending classes on sterilisation and wound dressing, the hospital had a laboratory for blood tests and doctors were carrying out structured trials. In the 1950s, Jewish donors supported the creation of a new medical school, the Albert Einstein College of Medicine, which offered places to Jewish trainees excluded from other schools and quickly became a leader in the study of diabetes, liver disease and heart disease (Levenson 1984).
Over the same period, the population of the Bronx conducted its own revolution. The original Irish, Italian and Jewish settlers started to leave from the 1930s, escaping prohibition gangs for calmer suburbs. Hispanic and African Americans filled the vacuum from the 1930s to the 1960s, the Bronx’s cheap housing preferable to grinding poverty in Puerto Rico or discrimination in the South. The remaining middle-class families fled in the 1970s when drug gangs and heroin took possession of the borough. On 12 October 1977, the cameras covering the world series at the Yankee stadium cut to helicopter shots of a huge blaze. As commentator Howard Cosell supposedly said, ‘Ladies and gentlemen, the Bronx is burning’ (Mahler 2005). From the 1970s, arsonist landlords torched their properties for the insurance. This was the period when city authorities warned tourists not to leave Manhattan.
As society changed, so did the diseases of poverty. By the 1960s, diabetes, hypertension, respiratory disease and heart disease had supplanted syphilis and tuberculosis. When opioid addiction took hold in the 1970s, prevalence of hepatitis C, HIV and AIDS skyrocketed. Researchers in the 1980s described a ‘synergism of plagues’: destruction of housing, homelessness, drug abuse, violence, economic decline and disease (Wallace 1998). That legacy is visible in the Bronx today: 13 per cent of Medicaid recipients in the Bronx have asthma, in comparison with around 8 per cent of American adults as a whole; 15 per cent of adults in Fordham and Bronx Park have diabetes, in comparison with around 9 per cent of American adults as a whole; 8 to 9 per cent of residents in the South Bronx report severe psychological distress, in comparison with around 3 to 4 per cent of American adults as a whole (New York State Comptroller 2014; New York City Department of Health and Mental Hygiene 2013; Centers for Disease Control and Prevention 2016; New York City Health Provider Partnership 2014). According to the County Health rankings the Bronx is the least healthy community of 62 counties in New York State and has been since the rankings began (County Health Rankings 2018).
A social mission
Founded on Jewish philanthropy, Montefiore adopted from the beginning a mission to support this disadvantaged population. Doctors and other staff didn’t join Montefiore primarily for the prestige or the money – there were larger offices and better fees to be had in Manhattan – but from a sense of social responsibility and the opportunity to tackle pressing social challenges. From the 1960s onwards, Montefiore started experimenting with new models of community care for deprived areas, developing an early version of the patient-centred medical home. In the 1970s, it was one of the first hospitals in the United States to develop a residency programme in social medicine, training a new cadre of primary and community doctors to serve in tough urban communities, their purpose, explicitly, to use medicine as an instrument for social justice (Paccione 2013).
A hospital without walls
But even if the heart was willing, the infrastructure at Montefiore’s disposal was disintegrating. When large numbers of middle-class families abandoned central Bronx neighbourhoods in the 1970s, so too did their primary care doctors. By the late 1980s, there were 34 primary care doctors for every 100,000 people in the Mott Haven / Hunts Point district of the Bronx, in comparison with 1,450 for every 100,000 in the Upper East Side of Manhattan (Jonsen and Stryker 1993) and 84 per 100,000 in the US as a whole (Health Affairs 2002). Poor people without commercial insurance would queue at a grilled kiosk, a ‘pill mill’, and pay $5 to talk to a doctor for a few seconds, before receiving a prescription for antibiotics or painkillers. Only a small proportion of the Bronx population had a dedicated general practitioner. Vaccination was sporadic. In the poorest neighbourhoods, preventive medicine was non-existent.
While many other US hospitals facing similar challenges sat on their hands, Montefiore’s response was to build an entire primary care system from the bottom up. From the 1980s to the 1990s, it trained or recruited its own primary care doctors and established its own primary care clinics. By the end of the 1980s, it had established three health centres in its most underserved neighbourhoods. By the 2000s it had established one of the largest primary care systems in the country: more than 300 doctors employed at 21 primary care clinics providing close to 800,000 appointments per year (Foreman 2004).
This was the start of a tradition of reaching beyond the hospital’s walls, and beyond the confines of hospital medicine, to support a struggling population. As Dr Spencer Foreman (Montefiore’s chief executive from 1986 to 2007) argued, an academic medical centre is often the only organisation in a deprived US neighbourhood with the professional expertise, the managerial strength, the physical resources and the financial clout to improve the health of its community (Foreman 2004).
Over three decades, Montefiore used these managerial, clinical and financial resources to fill gaps in the out-of-hospital system, irrespective of its formal responsibilities or whom else might be to blame. It established behavioural health services to work with primary care and created its own methadone programme for drug users. It also developed its own domiciliary care and residential care services.
As Montefiore’s doctors and nurses explained, if you wish to support the most deprived people in your population, you must go out and find them. There is little point in sending letters to people with profound physical health, behavioural health and social challenges inviting them to appointments in three months’ time, even if you do happen to know who they are and where they live. Montefiore established mobile paediatric clinics in poor neighbourhoods, health services in homeless shelters and behavioural health services in primary care practices so that it connected with vulnerable people wherever they can be found. When Cambodian refugees were deposited in the Bronx in the 1980s, Montefiore hired Cambodian staff and developed new services for a community scarred by genocide and internment camps. By the early 2000s, Montefiore had established the United States’ largest school health programme: school-based clinics providing primary care, counselling, optometry and dentistry to 40,000 children who might otherwise go without. Health care improved and so did attendance at school, participation in class, and educational outcomes.
This was also the start of a tradition of civic leadership extending beyond health care to address the social crisis poisoning the Bronx. The Albert Einstein College of Medicine and the Montefiore Medical Centre were among the first to explore the social and environmental factors fuelling the epidemic in chronic diseases. From the 1970s, Dr John Rosen pioneered research on the link between lead poisoning and children’s neuro-behavioural development, arthritis and other conditions. For poor children with an average IQ, Dr Rosen argued, lead paint was what stood between a lifetime flipping burgers and a meaningful career (New York Times 2012). Since the early 1990s, Dr Philip Ozuah, Montefiore’s Executive Vice President and Chief Operating Officer, has researched the link between environmental factors and asthma. Montefiore’s recent research highlights the impact of poor housing, rodents and pests on chronic illness. As Sir Michael Marmot would put it, what was the point in handing out inhalers, only to return children to the damp, rat-infested housing causing their conditions (Marmot 2015)?
Montefiore's answer was to establish a not-for-profit subsidiary, the Mosholu Preservation Corporation, to act as a buyer of last resort for those ruined blocks that had been gutted for the insurance. By the end of the 1980s, the corporation had ensured that nearly every apartment building in the Norwood neighbourhood surrounding the medical centre had been renovated (Foreman 2004). Montefiore successfully negotiated stricter environmental standards on lead poisoning, campaigned for active programmes to remove lead from residential buildings, and set up a lead-free safe house for families to live while lead paint was being stripped from their homes. These efforts to reshape the Bronx are continuing: Montefiore is working with local shops to improve the availability of fruit and vegetables, hosting a network of farmers’ markets in hospital car parks, and supporting a business improvement district.
When doing so, Montefiore rarely acts as a sole crusader. As its leaders pointed out, the difficulty in improving the health of a deprived population lies in the range of contributing factors and the interconnections between them.There are limits to what can be achieved by focusing on just one or two of these factors at a time, say increasing vaccination rates or improving bus timetables, valuable as those isolated actions might be. To move the dial on population health, let alone make progress towards the higher objectives of greater wellbeing and prosperity, requires action across the panoply of factors that determine whether a society is sick or healthy: support for young children, diet, education, job opportunities, transport, housing, public spaces, care for elders, access to health care among many others. No single organisation has the wingspan to touch more than a handful of these issues on its own. Working in consort within a broad coalition – collective action to achieve collective impact – is both an obligation and an immense challenge (Kania and Kramer 2011).
Wherever these broader social issues are being discussed, representatives of Montefiore are present at the table. Since the early 1980s, Montefiore has nurtured partnerships with the city government and its health, education and housing departments. When Mayor Bloomberg announced his ban on supersized soft drinks in 2012, he did so at the Medical Centre alongside Dr Steven Safyer, Montefiore’s chief executive since 2008, and his medical staff. When the city authorities convened a taskforce to develop the Kingsbridge Armory, a large, vacant armory complex in the centre of the borough, Dr Safyer joined the board.
Montefiore is a founder or member of dozens of coalitions to improve the local community, whether focusing on health, education, housing, homelessness, justice, the environment or economic development. When Montefiore sees an opportunity to further its partners’ agendas, whether it’s keeping children in school or supporting the homeless, it does so. When a safety net hospital in the Bronx falls over, the city’s health department looks to Montefiore to turn it around. In turn, when Steven Safyer or Montefiore’s other leaders focus on a new challenge, whether it’s improving children’s health or getting the homeless out of hospital, there is a willing coalition to support them.
British readers might wonder what riches Montefiore has at its disposal to play such a role in its community. The truth is that by the early 1990s it was close to bankruptcy. Most hospitals in the United States rely on patients with commercial insurance, whose income helps to subsidise a smaller proportion of patients who have the government’s lower paying, Medicare or Medicaid insurance or who lack insurance entirely. More than 80 per cent of Montefiore’s insured patients had, and continue to have, Medicare and Medicaid insurance and a large proportion of the remainder have other public sector or union insurance with relatively low reimbursement rates. Before Obamacare, a quarter of the adult population of the Bronx had no insurance at all.
Under these circumstances, Montefiore’s leaders recognised that they were unlikely to achieve financial sustainability, let alone deliver the type of care they wanted for the community, by chasing revenues for individual hospital procedures. In many cases, the reimbursement would fail to cover the costs of services. Instead, they needed to take overall responsibility for the available health care funding for their population and achieve quality improvement, savings and financial stability through managing resources more efficiently across the continuum of care.
Montefiore’s preference was to start offering integrated packages of both insurance and health services, like Kaiser Permanente and other health maintenance organisations on the west coast, but it lacked the capital to assume full liability for patients’ insurance. Instead, it decided to pursue risk-based contracts with insurers, taking a proportion of the financial risk of managing groups of patients in exchange for a proportion of the savings if it managed to improve the quality of care while bringing costs down. What is now a defined path was at that time a leap in the dark. As Dr Safyer explained: ‘They were throwing things at us. They thought we were completely insane.’
Montefiore took on its first risk-based contract with US Health Care (now Aetna) in 1996, initially for a few tens of thousands of commercially insured patients. In 2011, it was selected as one of 32 Pioneer accountable care organisations and took on a shared-savings contract for around 23,000 Medicare beneficiaries. By 2017, it held risk-based contracts with the government and commercial insurers for around 400,000 patients, around 11 per cent of its current service population in the Bronx and neighbouring counties. These include 55,000 Medicare beneficiaries in the government’s accountable care organisation programme that succeeded the Pioneer programme.
Around 55 per cent of these 400,000 patients are on capitation: Montefiore receives a proportion of each person’s annual membership fees (or ‘premiums’) to their insurer, benefits if it delivers the agreed services and meets agreed quality standards for less than the total budget and assumes all the losses if costs are higher. The remaining 45 per cent are on shared-savings arrangements where Montefiore and its network continue to receive a fee for service payments but receive a share of the savings if they meet agreed targets for quality and avoid unnecessary treatment such as avoidable hospital admissions.
In the United States, if not necessarily in the UK, any health care organisation that wishes to take on risk-based contracts needs to do so at significant scale, capturing enough of the patients holding particular insurance packages, of which there are many, to manage the risk that some will present unexpectedly higher costs than others. It also needs to capture a sufficient number of patients within particular localities to achieve economies of scale in service delivery, for example to be able to put in place the necessary infrastructure to manage the health of a population.
From the mid-1990s, then, Montefiore pursued expansion. In 1995, it established an ‘independent provider association,’ bringing together all its employed doctors and other independent primary and community doctors to hold these new risk-based contracts. Over the next 20 years, it encouraged increasing numbers of independent primary care practices to join the network. Progress was neither quick nor easy. Independent primary care doctors were deeply suspicious of ‘takeover’ by a large hospital group. But, by 2017, Montefiore had succeeded in bringing together more than 3,500 employed doctors and more than 1,300 independent doctors in the Bronx, the neighbouring county of Westchester and the Hudson Valley.
Montefiore also pursued expansion of its hospital network. By the 2000s, the Montefiore system included the Albert Einstein College of Medicine (initially affiliated to, and only later owned by Montefiore), the flagship Moses campus, which provides many of Montefiore’s tertiary services, and two other major hospitals in the Bronx. In 2001, Montefiore established a specialist children’s hospital to complement its network of community-based paediatric clinics. By 2018, it had purchased or partnered with eight additional hospitals in the Bronx, Westchester and the Hudson Valley. Over the same period, it built centres of excellence on a small number of sites to deliver cancer care, heart and vascular care, transplantations and neurosurgery. The system today also includes 16 mental health and substance abuse clinics, 73 specialty care clinics for paediatrics, women’s health and other services, and a separate rehabilitation hospital.
Other case studies will need to be written about the strengths of Montefiore’s specialist services. For NHS leaders grappling with integrating care, the jewel in Montefiore’s crown is its Care Management Organisation, a management company that brings together 1000 staff to help Montefiore manage its risk-based contracts. Established in 1996, the Care Management Organisation manages relationships with insurers and handles the billing, reporting and compliance that comes with risk-sharing. It crunches the numbers to identify opportunities to improve quality and bring down costs. It also takes charge of patients with particularly complex needs to improve their care, and brings disparate primary care, hospital, social care and voluntary services together to work as a coherent team.
Every month, the analytics staff in the Care Management Organisation search their claims and clinical databases to identify those patients whose medical history and use of health services suggest the need for more active and co-ordinated care. An ‘initial assessment team’ runs 90-minute telephone interviews to understand these patient’s challenges and life goals. A team of 200 nurse case managers and social workers works with enrolled patients to surface the underlying problems that are contributing to their ill health, identify the changes that will make a difference, and pull together the medical, social and voluntary services needed to turn their lives around. Geriatricians, psychiatrists, pharmacists and other specialists give advice where needed. The nurse case managers draw in specialist teams to help with specific problems such as access to food or housing.
Nobody is simply going through the motions – ticking boxes to count the numbers of patients who got a call or received a care plan. Staff will search for a patient when they arrive in accident and emergency or are admitted into a hospital ward if that’s what’s needed to enrol them into care management. When the case managers identify housing as a critical issue, they don’t simply ‘signpost’ patients to housing services or hand over a telephone number. They prepare the housing application, hound the housing department to do something, or sit with people in their interviews with housing associations if required.
One senior nurse described a 65-year-old patient with diabetes, heart disease, learning disabilities, anxiety and depression. Over the previous 18 months she had crashed in and out of hospitals and nursing homes 20 times, inadequate health care costing $500,000 per year. Montefiore’s staff tracked her down in the hospital to bring her into the programme. The nurse case manager was working with her to improve her diet and ensure that she took her most important medications. They were looking for a chaperone to ensure she attended the visits they had set up with her primary care doctor and a psychiatrist. They were working with housing services to remove the dead rats, bugs and spiders that had stopped domiciliary care workers from visiting. They were asking social services to investigate the possibility that she was suffering abuse in her home, another possible contributor to her regular emergency department visits. Nothing was off limits. Whatever the problem, they were searching for a solution.
Underpinning these efforts is a hard-nosed focus on continuous improvement and achieving measurable results. Montefiore’s improvement staff work with new primary care practices in the network to benchmark performance, redesign workflows, and put in place preventive services. Primary care and hospital doctors meet quarterly in learning collaboratives to compare performance and share the results of improvement projects. Using 3M’s population health analytics, Montefiore can pinpoint with ever-increasing accuracy the combinations of physical health, behavioural health and social challenges that signal a high-risk patient, the patients and diseases that present greatest opportunities for improvements in care, and whether interventions to improve quality and reduce costs had the desired impact.
None of our interviewees claimed that Montefiore was a perfect health system. This is now an extremely large system serving a population of more than 3 million. There is ongoing work to bring different parts of it together, such as incorporating the new hospitals into the group and linking some hospital specialists more closely with primary and community services. Although it now has 400,000 patients under risk-based contracts, Montefiore still serves many patients under fee-for-service arrangements. If more people were under capitation, Montefiore might go even further to reduce the need for hospital treatment and move care into the community. In 2015, Montefiore suffered a significant shortfall in one of its risk-based contracts, the result of higher than expected costs for a small number of patients. This lead to redoubled efforts to manage these patients’ care more efficiently.
Our interviewees were, however, proud of Montefiore’s results. Montefiore became the poster-child for the Pioneer accountable care organisations programme when it announced the best performance scores of the 32 pioneers in their first two years. In the fifth year of the programme, Montefiore achieved a 96 per cent performance score on 30 metrics covering preventive health, treatment for high-risk groups, care co-ordination, patient safety and patient satisfaction. While improving quality of care, it also reduced the costs of care for its enrolled Medicare patients by a total of approximately $74 million over the five years of the programme. Montefiore’s quality scores on most measures of population health management, including cancer screening, diabetes care and paediatric preventive care, are equal to or better than national rates calculated by the National Commission on Quality Assurance. Staff described an improvement programme for a group of patients with end-stage renal disease projected to deliver $10 million in savings within a year.
Reflections for local health systems
If cut-and-paste approaches to health system design worked, we would all be enjoying excellent health care. We cannot simply dismantle a century-old health system, like London Bridge or a Greek temple, and reassemble it on foreign soil. The wiring and the plumbing are all different. Our plugs don’t fit in their sockets. Local NHS health systems face similar challenges to Montefiore and, in many cases, are pursuing similar solutions. But the jury is out on, say, whether the details of US accountable care contracts, replete with risk transfer and incentives and penalties, can bear the trip across the Atlantic. (The jury is also out on whether ACOs can thrive in the US and on how much they can save.)
If there isn’t a manual, Montefiore does offer us some guiding principles. It highlights the benefits of health care organisations adopting a broad perspective on their social purpose: being willing to apply their skills to the most pressing health care or broader problems facing their communities, even when that leads them far outside their own institutional walls. Indeed, it offers a particularly ambitious objective for consideration: the objective of using the skills and resources of health care to address inequality and achieve social justice. This is what appears to have allowed Montefiore to see past the hospital boundaries, escape the straitjacket of conventional health care and focus on what mattered to its population.
It also reminds us of the importance of consistent leadership and consistency of purpose. Dr Foreman led Montefiore with vision and courage for two decades. Dr Safyer studied at the Albert Einstein College of Medicine, completed his residency at Montefiore, became its medical director in 1993 and has now been chief executive for 10 years. Stephen Rosenthal, the Senior Vice President for Population Health, established the Care Management Organisation in the mid-1990s and leads it today. Montefiore has now pursued its vision of integrated services and population health, not for the five years of a forward view, but for at least three decades. It has made strides in short periods without waiting for changes to payments or contracting to deliver progress, but it has taken decades to build an integrated system and touch the social and environmental problems causing ill health in a poor community.
Montefiore makes the case for large academic medical centres and hospitals, the health care organisations with the greatest resources in most countries, to take responsibility for building the missing primary, community and social infrastructure needed for an effective health system. It was through Montefiore’s active intervention, and effective partnering, that a poor community has access to a system of primary and community services. Some hospitals in the English NHS are working to support the local primary care system. Montefiore throws down the gauntlet by demonstrating the scale and pace of change that a large hospital group might engineer.
Montefiore shows what health care organisations with sufficient ambition can do to support their most deprived populations. The number 5 tram from Manchester to Oldham tells a similar story to the 4 train from Manhattan to the Bronx. If we really want to help deprived people, Montefiore’s experience (like areas of England such as Wigan or Coventry) says that we need to go out and find them, connect with them wherever they are, understand the reality of their lives, and offer the services they want, on their terms, where they want them. If that means that expensive doctors should travel to poor people, that behavioural health should park next to primary care, that we offer taxis and bus tickets, we should do so.
Montefiore also shows what health care organisations can achieve through sustained strategic partnerships with the other public and voluntary organisations that touch local communities. Health care organisations cannot have a profound impact on wellbeing on their own. They need to work in broad coalitions if the ambition is to tackle intractable social problems. Montefiore does not see its work with partners outside health as a secondary activity, something to turn to when the waiting lists are eradicated. Partnership is integral to its mission and critical for its effectiveness.
For those with the most complex needs, Montefiore presents a model of care management applied on an industrial scale with precision and determination. It highlights the advantages of bringing doctors, nurses, social workers and others together in a large organisation capable of providing effective support for case managers and investing in rigorous care management processes. It reminds us of the need to bring health care and social support together. What is the point of lecturing a patient with diabetes on her diet if she is about to lose her house? It also highlights the need for the economists, programmers, researchers, data and analytics that can tell us if our interventions are working.
The danger when we dissect successful health services and label their component parts – the risk stratification algorithms, the motivational interviews, the holistic care plans and the population health solutions – is that we look past the magic of what makes them work. The mantra of Montefiore’s case managers is to take charge of people’s lives and do whatever it takes to allow them to regain health.
About this case study
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THIS is what I am wanting to bring to the U.K. I am an American, now living in the U.K., who all my life have seen the good, the bad and the ugly of the American Health Care system and although we are far from perfect, one thing I have noticed is the level of service. US hospitals and clinics feel like they go above and beyond to what they are required to do by proactively creating relationships with patients and not seeing them as another number (not saying that NHS nurses and GP's don't). One reason for this could be the way Americans pay for their own insurance, but if we look at this within the NHS, this can be achieved. Notice how one thing Montefiore did was produce their own GP's and Nurses. Why isn't this done more in the U.K.? We speak about integrating systems but we can't even supply the staff to run these services. Yes, we cannot pick up the Statue of Liberty and assemble it here, but we can definitely take bits and pieces and implement them within the NHS and see how it functions. One thing I have noticed thus far, is the lack of risk people are willing to take. I've read an article on the KF a few months back discussing how people in the NHS get nervous to take high-level risks that may produce high-level rewards and I completely agree. This is a well-written article that more people need to read and familiarise with. Somethings gotta give or I fear that the so beloved NHS is headed towards privatization.
''we cannot pick up the Statue of Liberty and assemble it here, but we can definitely take bits and pieces and implement them within the NHS and see how it functions. One thing I have noticed thus far, is the lack of risk people are willing to take.'' Yes guess why because we prefer to work on the basis of EVIDENCE and not take random 'lessons' from the country with the most dysfunctional and unequal healthcare system in the world. 28 million people with no insurance cover and several hundred thousand medical bankruptcies a year. I think the US need to learn from the NHS which covers everyone at about half the cost of the US system in terms of GDP. The notion of what the public may want seems absent from your comments and indeed the article. The UK population wants no part of this nonsense - they want a properly funded and fully public NHS and an end to cuts and privatisation.
Simon, thank you for your comment. In my opinion, working with evidence based approach has brought the NHS to where it is. The lack of risk has slowly deteriorated the rut spinning in the same hole. And it’s not all about taking, how you so easily put, a “random lesson” but rather taking on an approach that has the potential and explore it until you see the fruits. But I digress, I see you have spoken about how the USA has the “most dysfunctional and unequal healthcare system in the world.” Seems like more travel is needed but let me inform you that if you went to the A&E in America right now, you would be seen within 30 minutes, if you go to your local GP you know for a fact you’ll be able to have a meaningful dialogue with them rather than a 10 minute conversation and out the door you go. Yes, you are correct in stating that many Americans have no insurance, but do you know why? Insurance premiums are too high and with the already expensive cost of living many choose not to buy into something they don’t always use as much. And yes medical debt is one of the top reasons why Americans are in debt. But let that be a lesson and don’t lose to socialised healthcare that you are so blessed to have in this country. Healthcare cannot be seen as numbers and pound signs (£) but the sad reality is money makes the world go around. As you can see the NHS can barely hold on to GPs and Nurses. Your view on what the public might want could be a reason for this downfall. How can you ask the public to say what they want included in their healthcare when they themselves don’t even know what options and opportunities are available at their disposal. The biggest focal point I believe, should be how can the NHS produce, fund and keep Doctors, nurses and staff. With he U.K. currently having 2.8 doctors per 1,000 people, this isn’t a statistic that is worth praising. But to alleviate the pressure, you’re bringing foreign staff that don’t understand the people, culture or even the basics of this country and expect them to work at a five star rating paying them two stars. In all I believe there is no perfect model (yet), but still we can learn from different approaches and not be shy to try something new and radical.