 Thank you very much indeed Chairman, if I can start with something that's probably inappropriate at the beginning of a conference like this, it is to hope that it might happen again. I've already had more really educative conversations with delegates in this room in less than 24 hours since I've been here than I could have imagined, so I want to hope that this might happen again. Can I particularly thank the Secretary speaking last for giving such an extraordinarily integrated view of healthcare here in Hong Kong. My pitch this morning is to suggest it's much less integrated in London. And you saw those pictures which Ricky Baudette showed you earlier of cholera, the streets of London defined by the cholera outbreak in 1854. One of the hospitals which I'm sort of responsible is 100 years older than that and the other one is 700 years older than that. So there is an extraordinary history of healthcare in London, but it is deeply fractured in my view. And it's about the conundrum, the puzzle of this fracture that I want to spend my time this morning. As you know we have this national health service which is kind of the envy of the whole health world. It's been going a long time, 60, 70 years, and it appears to work well. We have in London one of the most prosperous cities in the globe and we have a media that is deeply, deeply interested in health, particularly what worked really well and what the disasters are. And we have world class hospitals and world class research. But I live and work on the east side of London. It's a community of about one million people, about one eighth of the total population of London itself. And the health equalities here are absolutely resilient. We've made very little impact vis-à-vis the rest of our health economy, I think, in the last 60 years. There are various ways of expressing this and I have only time for a couple of references to it. One, and Ricky will show you the chart later, as you move eastwards from the centre of government in Westminster, your life expectancy decreases by one year for each stop on the underground that you pass through. It's absolutely dramatic. Or if you take another example, TB is rampant in East London, it's growing. I thought before I got involved in the health world that it was eradicated in Britain. We are now in East London, the TB capital of Europe. So what is wrong, the area I'm talking about has had a long history of good intentions and good philanthropy, but somehow 150 years of lavishing these things on it has not made the difference. So I'm forced to conclude that what we're looking at is a failure of structure, or I suppose you could call it governance. The NHS is run from the centre, it's run from the very heart of government itself. It has had a whole range of efforts to devolve parts of itself over the last 60 or 70 years, but mostly power has been retained at the centre. This is because everybody in England is supposed to receive the same quality of care and the same density of care and is subject to being testified, monitored under the same kind of regime. But what I think has happened is the National Health Service has become a kind of end in itself. It calls itself the health economy. It is in effect, in my view, isolated from the rest of government in the United Kingdom. And it is very good at protecting itself when politicians want to change that. Local government in London is responsible for many of the other services that affect people's wellbeing, social care, education, housing and planning and so forth. The interface with health is almost non-existent, I think, and very difficult to achieve. I recently visited some old ladies in my area of East London and found myself in their homes rather downmarket council public sector property and watched as a successive group of public health employees came to treat them. One was a district nurse with the second one coming in to deal with the same person, a social care worker, and the third one was from the mental health trust. Now as it happened, this worked extremely well and I was able to say how amazing that the hospital, the GPs and these professional workers were all actually round the bed of these individuals. But I think this happens pretty rarely. We talk in general about the complication of running a great hotel like this or a big restaurant somewhere in the world where your last experience is the only one that you really remember. Same with health care, it is very, very difficult to coordinate and make effective around the patients. I don't think we do it very well in London. Another example would be I recently knocked on the door of a number of fast food restaurants in this part of London and told them that I thought they were probably killing their own customers. They, to be fair, were extremely responsive to this and some changes in the kind of food and their purchasing have already taken place. But the tragedy behind that is that the authority that gives them planning permission without any controls on what they serve to their customers is alongside but totally separate from health that stays with the local authority. I hope I've said enough to just give you the picture that I want to paint of dysfunction in the London Health Service. We have, however, made two interventions recently which looked to be full of promise. The first was that we created a mayor for all of London in the year 2000 thinking that this would give us the integration which health care needs. I don't think we really achieved that and we made sure, of course, that the new mayor of London wouldn't have much real authority over health and health care. And so it is a decade later that the London mayor and the health authorities, centralized health authorities, operate, it appears, on pretty diversion paths. The second intervention was to bid for to win the Olympic Games in East London. Huge activity and it is causing a major, major change. In the wake of it, a whole range of other big interventions in transport and in health care. My own hospital trust is in the process of opening the largest new hospital health care service in Western Europe as a matter of interest. I believe that we are still in time, so far as the Olympics are concerned, to turn it into a major, major campaign for changing the public health and the view of young people in London. There are signs now that we're beginning to do it, so I would hope when I come to a conference like this next year to be able to say we have made huge changes. My conclusion from this quick survey of London is we need to concentrate on three things. One is the real integration of primary, secondary and tertiary health care in London. They're all divided. Secondly, to make our commissioning happen really locally, so that we're commissioning locally for local people and local services. And, certainly, and perhaps most importantly of all, we need to devise services where the patient is at the heart of health care. And we are a long way from that in London and I'm looking forward greatly to learn, as I've just been learning in Hong Kong, how much better it's done in other parts of the world. Thank you very much. Why don't you stay up for a couple of direct questions? There's a very informative review of the situation in London. Are there any questions? First, can I take you up directly on your last comment? And that is you have a very centralized national health service and then you mentioned you want to decentralize that with respect to care and interaction of the various components of health care. How is that to be reconciled? It needs to have the central powers pushed down to local level. They're retained very, very fiercely by central government. So, for instance, the staff who work in my part of the health care system in East London don't really see their authority and responsibility coming back to me as chairman of their local health trust. They see it running back to the Department of Health, which ultimately will control their careers much more effectively than I will. It has to be devolved. I'm still very much puzzled why you have this declining life expectancy moving east. You told us the phenomenon but I cannot understand the reasoning behind it. They all put on the same regime and the same rules and how come life expectancy declines towards the east? The east side of London has been the centre of the poorest communities for 150 years at least, and longer I suspect. Successive local governments and the health service have failed really to create an integrated system where better housing, better education, better health actually all work together. They are disaggregated and that's the heart of what I think the problem is. Otherwise, you'd assume in a place which is bounded on both sides by huge wealth we have on one side the city of London on the other canary wharf with its huge participation in the world's financial sector. You would have thought we could have cracked it, but we haven't and I think it's the disaggregation of the public sector. Odea. East London has traditionally had intense poverty to some extent reinforced by industrialisation and deindustrialisation in the east. Laterally some of the phenomena you described have been reinforced by the complexities of mass immigration as well. So east London fulfills first an industrial then a deindustrialised position and now as for so many years a place of rapid turnover of people moving in and then escalating out. So there's an escalator problem in that part of the city that is as people get better off they move out. Is that true? It is true. It has been true historically and it's something that I'm very hopeful that the new attention provided by the Olympic Games improved transport infrastructure and various other big projects might solve in my lifetime perhaps, but I rather doubted in yours Tony, I think it might. The Olympic Games is being supported by the beginnings of much much better mixed housing for example in the eastern side of London. What's happened is as people did better in our society because the housing and the overcrowding were such in the east they wanted to move out. We're beginning to correct that and build communities that are much more evenly balanced in terms of the kind of people who will want to stay there. So it's not hopeless but it's taken big and sort of outside the main political sphere kind of activities to change it I think. Take a final question there please. Thank you very much for a great presentation. A little question is it possible that today one of the transformations maybe that starts 30 years ago is structural discontinuities within cities. So even if you have a very good system and even if you have sort of a local point in healthcare delivery that this question of structural discontinuities breakage points is truly an obstacle. To the best you know intentions and to what extent from your perspective can this be overcome. So the example of the eastern neighbourhoods surrounded by wealth. It doesn't matter that it's so close by to plenty if those structural breakages exist. I think plenty of structural breakages within the health service alone, let alone beyond that. And for example the doctors in my hospital many of them well class in their reputations expect the community to beat a path to their door. They don't expect it's their job to understand what the needs of the local community really are. So you get this disjunction which is right at the heart of the system. And I suspect it's probably because it was invented and was so greatly applauded 60 years ago that it's proved very difficult to reform and change and politicians at their peril really tamper with our NHS system at the moment. And that's why it's so hard to move I think. Let's go on to the next talk. Thank you very much again.