Good evening, ladies and gentlemen. It's wonderful to see such a large audience for the first in this year's Gizzi lecture series.
So I'm Denise Livesey.
The principle of Green Templeton College and a warm welcome to you all, but particularly those of you who are new to green Templeton College.
So each year we we have a series of lectures that are around a theme that have been selected has been
selected as being of relevance to a broader part of the community of Green Templeton College as possible.
And this year, the series title is on delivering health, clinical management and policy challenges.
So absolutely wonderful subject as well as being really important these days.
It's also, as I say, have great relevance to all of our different communities.
I have a medical community, a management community are applied.
Social science, community and policy community.
Delivering health and health care is an immensely complex and expensive activity and needs cooperation and collaboration between patients,
clinical expertise, management and policy makers.
If we are to achieve future improvements and new ways of power sharing between those and interested parties,
and this decision making needs to be explored.
So this theme is a full 40 evenings, and this evening our topic is why is it so difficult to implement evidence based health care?
I'll tell you at the end of the evening, the next, the next few themes.
So the format is going to be that we've got two speakers, we've got Professor Sue Dobson from the side business school and then we've got an I
think we're going in that order away and then we're going the opposite way around,
right? So first of all, we've got Richard Gleave, the deputy chief executive for Public Health England, and then we've got Sue Dobson.
And then one of the students will be getting a vote of thanks.
So that's fantastic. And we will open up for broader discussion and we aim to finish at about 7:20.
So that's the timetable for this evening.
So let me start off by introducing Richard, who's going to talk about who is accountable for what and to whom and delivering health.
Richard joined the NHS as a national management trainee in the West Midlands and
spent 18 years working in hospital and community services in central London,
the North East and the South West,
including appointments as a board director in Sunderland and Bristol and as chief executive of the Royal United Hospital Bath.
He's held academic appointments and health services management at Newcastle University.
He's now the deputy chief executive for Public Health England.
His background is I won't go through all of the rest of his career,
but his background is that he has a first degree in geography from Oxford University
and an MSI in health economics and management from Sheffield University.
So you couldn't, in fact, choose a better person to make this linkage for us at Green Templeton College.
And we're really pleased to have you here, Richard. Thank you. We look forward to hearing you.
Thank you very much for those kind words, and good evening.
Then.
So I'm going to look at the this question around why is it so difficult to implement evidence, evidence based medicine, evidence based health care?
And Sue and I are approaching the same question, but from contrasting but complementary perspectives.
Oh my, oh my.
The definition of the question, because you're always allowed to do that, aren't you near the beginning is to is to adjust.
The question is really is really to focus around this issue of accountability.
So is accountability an important reason why it's difficult to implement the evidence base?
And I'm going to focus that around the area in which I work.
I'm not a public health professional, but around the task of improving and protecting the public's health.
So I'm speaking to you today as someone who stands with only two legs, but actually with feet in three different camps.
So that can be quite uncomfortable. But the discomfort can actually often be very stimulating and make you think about things in a different way.
So I have one leg in the implementation world. I'm a practitioner, I'm a I'm a manager for most of my career.
I have another like standing in the academic world, as you mentioned,
and I also have a leg that stands in the policy world because I'm a civil servant actually in my job now.
And so I do quite a lot of work with ministers providing policy advice as well as then implementing the consequences.
And so it's from those three different perspectives that I'm going to try and pull together
my reflections and hopefully stimulate some questions and some thoughts for you to take away.
So since the beginning of January, I've been to probably four or five meetings,
all of which have been at the paper that was published in The BMJ in January about the diabetes prevention programme has come up.
I don't know some people in here who who work in the medical field will have will have seen this paper, which is essentially a discussion.
No, it's it's it's an analysis of some data actually about whether the diabetes
prevention programme is an effective intervention at NHS England and my employer,
Public Health England and Diabetes UK.
The charity have together come together to run a diabetes prevention programme in this country, and it's quite a high profile programme.
It was signed off specifically by the Treasury,
and the review concludes that the evidence based upon which this is based in the model that this programme is using is not yet there.
It draws a contrast between two different approaches to how you might adopt prevention, what they call a screen and treat approach,
and then a whole population approach and the screen and treat programme approach,
which is the one that's the main focus of the diabetes prevention programme as they are looking at.
It concludes that by itself, that isn't sufficient.
And in these meetings with secondary care doctors, hospital doctors, primary care doctors,
managers, policymakers, medical statisticians, local government politicians,
in all of these different meetings,
people have been mulling over what should we be doing in response to this sort at this sort of a problem, and it's not an unusual problem.
It's quite a common problem. The people sitting around the table, I'm not haven't come together.
We know to design a rubbish programme that has no evidence that isn't going to benefit patients, and he's going to waste taxpayer money.
So how do you deal with this dilemma between establishing an intervention that that's trying
to be effective and then what is often some quite difficult and contrasting evidence?
So that's why I'm interested in focussing at the overlapping point of these four circles, evidence based medicine and evidence based health care.
I'm not going to dwell on the difference between those two things we might want to touch on it later.
Evidence based practise, she's much more around the implementation and an evidence based policy,
with my focus being around this challenge in the in the box to the side using the evidence to design a population level intervention.
So not interventions about individual patients, but about at the population level that can be implemented.
So they need to be practical and they lead to at a population health level.
Some clear benefit. So Trish Greenhill, who's at the university here, has done a really interesting article,
it's a few years old now that talks about the the difference between evidence based policy and evidence based medicine and health care,
arguing that they're fundamentally different in the paradigms that they start from with
evidence based medicine essentially be based within the positive based imperatives paradigm.
Evidence based policy comes from a different school, much more interpretive stick,
addressing specific issues about implementation and understanding the context within which things happen and understanding the value ladened of policy
and what that actually means in practise and how we deal with people's different people's perceptions and values about what we're trying to do.
But for many people, the thing that sums up the little populist bit,
you won't be surprised when I say Who's who I'm going to quote now that managed to capture this was Tony Blair going back in time, and his face was.
What matters is what works. And that created a whole set of interest in an evidence based policy,
but it created also that interface between evidence based medicine and evidence based policy.
Of course, what doesn't work is just as important as what does work.
But I'm going to I'm going to explore this sort of an overlap.
I'm going to start by thinking a little bit about the evidence, and we could go into enormous detail here about the nature of the of the evidence.
I'm going to just give you a few little vignettes that will try and capture that.
And this report from the Academy of Medical Sciences, which came out in the autumn last year,
I think we will we will judge that this has been a really helpful and important report in trying to stimulate
the debate about what research we should be doing about the public's health for the next decade or so.
It's quite a it's quite a weighty document,
and it talks about this new research paradigm that we suggests we need to adopt about the health of the public.
And there's a specific recommendations in the report that relates to to my employer and to some of the partner organisations that we work with,
which is which is up there. And we've decided that report is going to fit.
That recommendation will appear prominently in our business plan for next year.
This is a recommendation we want to pick up and run with and really try and pull it apart a bit just to test what sits behind.
What's quite a simple statement that it would be difficult to disagree with this.
That's a different issue from putting it into practise and actually saying,
How are we going to commit resources, time, energy and effort and energy to make this real?
So when we come to think about the evidence that's going to inform that sort of a research paradigm for all
the work that in the organisation that I'm part of do about improving and protecting the public's health,
and that the paradigm is going to require us to think quite broadly about the evidence that we're going to use.
Often when you see these sorts of tables, you think the two rows, the two sides, the two columns are actually in contrast.
But here, in order to deliver on this paradigm,
we need to consider the evidence that comes from both of these two columns to focus
exclusively on what is only going to lead to a partial understanding about the issue.
And I'm going to just focus on the ones that I've highlighted there in yellow
about the nature of the causes of the problem that we're trying to address.
We may touch upon the nature of the wicked, messy problem to use the jargon about about public health problems.
And we've got a couple of people in the audience who are real experts in this area around it.
But there is not a simple, single linear cause for most of the issues about the public's health.
But that doesn't mean we shouldn't be looking at things where possible in order to establish that.
But it isn't sufficient and that we have this model in evidence based medicine that's very strong around cost effectiveness now on.
And as you know, as Denise mentioned, I have an interest in health economics and you know this as a substantive body of material about how we
do cost effectiveness analysis and how that's different from some of the other health economic analysis,
cost benefit analysis. Cost utility analysis. Cost efficiency analysis. But.
In the practical part of my job, most people just want to talk about the return on investment.
So what's the relationship between cost effectiveness and the return on investment?
And then the timescale around the evidence, how often we're looking at things that we have collected data on usually and ideally purposefully,
we've set up a study, you know, to do this and looked at it and then we have the results of that.
But in many of the areas that that I deal with in my day to day life of my colleagues deal with,
we were actually talking about things that take such a long time.
In order to be clear about what the consequences are, we need to establish a different way of collecting that evidence and using that evidence.
And that can be really quite fraught with problems as I'm going to show around tobacco control.
So just picking those three, the multi causal approach, I'm reading a fantastic the best thriller I've read for a long time.
It stands up there with the The Girl with the Dragon Tattoo, so and it's called Saving Gotham.
It's not about Batman. It is the story of Mayor Bloomberg and Tom Frieden, who was his public health, who led the Public Health Service in New York,
and how they designed a population health level in a set of interventions across the city of New York.
How they ban smoking in bars. If you go to New York, you know some of these things because they're part of the life that we now live,
how they took on the retail industry around trans fats, how they had food labelling, a whole series of population health interventions.
And it's it's a riveting read because the ups and the downs,
the arguments with politicians remember the public with sectors of industry, the disappointment when rulings go against them.
It's absolutely fascinating and very entertaining book.
It's written by the person who was Tom's deputy. Tom is now the director of the Centre for Disease Control of the CDC in Atlanta.
I. Moving on, just to think a little bit about the cost effectiveness and the return on investment.
So this is becoming better understood and the link between the two is becoming more explicit.
If we look at the work that the National Institute for Health and Clinical Excellence nice have done,
they now put out a stamp on their public health studies both that cost effectiveness, our analysis and their return on investment analysis.
And so just to pick a couple of numbers to just help illustrate at their work on cost effectiveness analysis shows that running a briefing today,
a brief intervention around helping to stop people stopped smoking.
And if you add some self-help to that, you have a highly effective cost effectiveness ratio intervention.
It's better than if you do the brief intervention by itself that the numbers are sort of mind bogglingly small.
When you think that we normally talk about some of these drugs having a 20 or 30 thousand pound cost per quality.
Here we're talking about three hundred and seventy pounds cost per quality.
But at the same time, they've done a return on investment model based around the borough in Manchester about bevvy.
And that gives you then the length of the return that you have for every pound that you invest.
Recognising that in Bury, the director of public health and the local authority, you're going to be sitting there thinking, you know, reducing budget.
We need to know what is the point at which the additional pounds we choose to spend on this area is going to lead to a financial payback?
It's about three to three and a half years is the it's the level, as you can tell from the numbers that are there.
But that understanding that sophistication of having both cost effectiveness and the vigour that's gone into
that and converting that into return on investment is a big struggle and is relatively rare across the system.
And then and then finally, this issue about prospective evidence and what better example we got than the debate over e-cigarettes,
where first to be absolutely clear about the public health benefit, the population health benefit that comes from e-cigarettes,
we need to look into the future through our crystal ball,
but through mixed methods through a variety of different analytical tools
through collecting evidence that it's not just it's partly about surveillance,
it's partly about toxicology, but is also about expert opinion.
Then you can start to think, well, what might be the the the the effectiveness of it of e-cigarettes.
As a as part of an integrated tobacco control plan in an idea,
and you probably know that the report that Public Health England published concluded that any form of smoking is is not what we should be promoting.
But if you are going to smoke, then e-cigarettes are 95 percent safer than smoking conventional cigarettes.
And then we have just before Christmas, a report from the surgeon general in the states.
It gives a very different perspective on the evidence about the dangers of e-cigarettes
as essentially a gateway for young people moving into other forms of addiction.
Around it, and we have two bits of evidence hanging there and there, the contrast,
and we see these in quite a number of areas that probably some people in the room who are looking at the childhood flu vaccine, where again,
it's another example of where the UK and the US have got very different evidence bases and we're
dealing with that contradiction is the explanation for this in the nature of the context,
is it the way in which the interventions have been designed and implemented?
Is it because as a methodological flaw in the studies? We say all of those things.
So that leads to think what's good enough evidence, and we need to be really clear about what our evidence is there for.
What does in Tony Barr's face working, what does that really mean?
It's very easy to say we want to have evidence about what works, but we have to define what working means, as well as what the evidence is.
And so there are all sorts of quite tricky questions that we need to peel back in order to be clear about how
we reach the point that we have an evidence based policy that is also aligned with evidence based health care.
I'm going to just reflect on that a little bit further by by another, and we have and so I was four for six months last year acting into another vote,
which meant I got very involved in the debate around what became the childhood obesity plan.
I think all of us, whether we're clinicians or social scientists,
will recognise the issue about what a complex issue obesity is and how there are so many different aspects
of our life that play into the in addressing the what we call the obesity challenge the obesity epidemic.
And Tom was just reflecting really on the on the journey of the of the evidence into practise over the last few years,
starting with a growing number of academic studies. I, you know, if I'd have had the time,
I'd have gone back and just looked at the the number of papers that have been published over that and how that's a clear,
I guess, exponential growth would be my guess. How increasingly that became more and more surveillance data when the government decided to
invest somewhat controversially in invest in a programme to actually measure childhood weight,
some sort of synthesis of all of that evidence coming together.
And, you know, Cochrane published 2011 still essentially in an academic context, but then starting to move into the policy sphere.
And we have the purple document at the top form, the government's advisory committee about that chaired by a professor from Oxford.
But essentially being still. That's right at the threshold between evidence and and into policy.
Moving into our report about sugar reduction, which is much more policy orientated,
includes specific recommendations to government about a multi strand policy in terms of addressing obesity.
The document that I can't show you because but it's been on the television widely because Channel four Dispatches programme on a whole programme
contrasting the original document that was written and we're sitting with David
Cameron before the referendum and the document that came out afterwards,
which is the document and the far left hand side, which was the childhood obesity plan.
So it moved from childhood obesity strategy to childhood obesity plan,
but also spinning off into the decision that the chancellor took about the sugary drink levy, which we learnt about on the morning of the budget.
And lots of people have been able to speculate quite widely about how the sugar levy managed to capture all the headlines around the budget,
which meant that the amount of coverage about some of the other things in the budget was much less.
So that long and winding road that really built up over many years is is a great little example of the journey that we go on with evidence and policy.
Because what a huge day that might be quite might seem long and winding as you're in the middle of it.
But that's a hugely simplistic portrayal of what what happens.
Toby post-hoc rationalisation because in the middle of it, you just weren't aware of it.
I was a good deal of muddling through,
which is a phrase in the in the policy literature going right back to the 1950s from Lyn Bloom about how policy goals aren't clear.
And there are all sorts of little loops that were happening and the real politic that goes on.
So that nice, neat sort of logical line that I described before my view is it is helpful to us to keep this.
The pure and inadequate but important way of thinking about it is the way in which we start the discussion.
But we need to deal with some of the political reality.
I've often wondered would any of this happened if Jamie Oliver hadn't decided to take the role that he took on and won a very strong campaign?
He has a significant foundation behind him that enables him to achieve all sorts
of things that are not just related to the power of his media personality,
but related to a good deal that sits behind that. And then the practicalities, not just of getting the policy, the evidence into policy,
but the practical issues about implementation and what does this mean?
You know, with a set of policy interventions, some of which are about national policy,
but most of which are about what happens that we make our own decisions about, that we make decisions for our families about that.
We deal with our friends and our communities that all local authorities and local health
service providers deal with that of employers in terms of what they offer us at lunch time.
The practical realities of implementation. It's going to reflect on it on another example.
As Denise said, I'm originally a geographer from Oxford.
We have a prime minister who's a geographer from Oxford. So she will have had she was considering a few years before me, I hasten to add,
but I can be absolutely sure she will have had a very good grounding in health inequalities from her undergraduate training at this this institution.
And so therefore, on the steps of Downing Street in her four and a half minute talk,
she decided that the majority of that was going to talk about inequalities in our in our country.
Although the way in which she became prime minister was a unique set of events.
She won't have made that speech lightly and there will have been some very clear thought about what was behind it.
I. What does that mean for policy?
So we're in that middle stage now with a statement of political ambition and intent,
but a lack of clarity about what that actually means by a neat irony.
We a lot of the statistics that we produce in Public Health England,
all the statistics that with the Office of National Statistics that sit behind that
and this is one of Dennis especially stab you saw recognising the expertise in the.
But when we really start inequality figures, we actually have the whole from a professor of geography on our advisory committee.
And he is quoted prominently, you know, in our press release,
and we're now starting to think through, how can we say, what are the evidence based interventions?
Well, that's not coming from nowhere because there was a major report commissioned by
the Labour government published just a few months before the 2010 election,
and its commission was about the evidence about addressing health inequalities.
But the issue for us? I just wanted to open up was this issue about are we interested in the evidence base?
But are we interested in best practise?
Because at the same time, the team that had done a lot of the work working with Sir Michael Marmot produced its best practise guide.
And these are a material difference between best practise and best evidence.
I'm going to now just pick up the accountability issue.
And obviously there the word accountability is part of our everyday speech and we use it in a number of different ways.
But it also has some very precise meanings. It has a meaning in the in the management world.
I've drawn on it from the project literature here about the the individual who is ultimately answerable.
But it also has a big meaning in the public policy sphere.
And there it tends to be much more in a wider context about who holds whom to account and for what sort of a relationship.
And so in the new public health system that was designed in two thousand and thirteen,
what we had is a number of different lines of accountability within the system.
If we tried to define what is the public, the activity that happens for the public's health and it it manifests itself through
a number of different lines of accountability reporting up to the government.
And I'm just looking at it from a top down perspective here.
We have a specific sum of money that sits with NHS England for national public health interventions that need to happen.
Similar in the same way across the country. Screening and immunisation being the best examples.
We have a lot of what happens from the clinical commissioning groups as being the local commissioners of NHS services,
but much of that is not explicit. It's difficult to know exactly what they do.
That is clear. Public health and that boundary between clinical care and public health becomes very, very much of an issue for them.
We have what most people think of as the bulk of the public health spending in this country now sits with the upper tier local authorities.
The $3.4 billion, that was money that was in the NHS.
It's money that's voted to the Department of Health, but is allocated through Public Health England to local authorities.
And then there's a well, I can quite safely say it's a tiny sum of money relative to the others that comes to to my organisation to do what we do,
which a lot of which is about advice about the evidence,
but also running a number of things that run through the whole system around information, data and responding to emergencies.
There's very little research about this system. David Hunter and Linda Marks up in Durham have got a grunt, and I had it.
I was part of a detailed presentation that they gave just before Christmas.
It's essentially a description about some of the dynamics that's happening in that.
In that system, we've had a number of select committees that have done hearings into that.
I'm told through evidence and had a number of contributions to it.
I think by and large, they've been saying that whether you agree with the policy or not, the system has that.
You can you can track some things in this system that it was impossible to track in the previous system.
We had no idea how much money was spent on public health before 2013. Now there is a clear set of sums of money and clear accountabilities for those.
But the Hunter and Mark's work is clearly showing that there are some real problems
about aligning the different components of that to give a cohesive picture.
So when we think about the evidence and the public health system where we're left with this with with a at a simple level,
it's a high level this contrast between speaking with independents.
And speaking to gain influence,
how some people may not agree that these are contrasting issues that need to be balanced and there may be some inherent tension between them.
But the practical reality sometimes that I've experienced is that you need to be able to manage both of these, those these two things simultaneously.
And the government has obviously invested and wanted independent advice.
I'm not talking about the NHS here, I'm talking just about public health.
We've got four sources of independent advice, all created very explicitly and publicly by government.
We have Public Health England, and I'll touch on this again in a minute.
We have the Chief Medical Officer of O by Stat. We have joint committees and we have the National Institute of Health and Clinical Excellence.
The issue of of accountability is a one that's very topical, it was a big issue when we created the debate in the House of Lords.
The issue for us is. We feel we have and we're clear that we have the independence to speak to the evidence,
the bit that we've agreed to do in the trade is when is that published?
So it's the the timing, not the content, and that's the way of for us of ensuring that we do sit at the table.
Being at the table is sometimes important. It would be very easy to be absent from table.
So how do we strike that balance? I'm going to very quickly rattle through just the last three slides.
The implementation issue is one that faces local government. How do local government put evidence into practise?
They don't come from an evidence based medicine paradigm. And so far for it is much more of an issue for them.
And this has been an issue for many directors of public health who've moved from the health service into local government.
Perhaps the most likely route of this is around the peer challenge and sector led improvement approach to it,
which retains the flexibility and the lightness of touch that you sometimes need in order to put the evidence the most topical evidence into practise.
What we have from the NHS perspective is essentially a contrasting approach between the top down implementation,
which says the evidence says you will assess this and you will go off and do it where the National Accountability Fund,
likewise the local but potentially in the sustainability and transformation plans that the NHS is, has asked 44 footprints around the country.
A whole debate about that accountability is saying You come up with what you think,
the evidence base says, where potentially the local accountability far outweighs the national.
And so I end up where I started really about this issue,
about what is the evidence and what does it lead us to think about because in many areas that I work with, the evidence is not clear.
The evidence is either partial because it taste comes through a particular lens or it doesn't yet exist.
And very often I hear people say we want to innovate, and the evidence base doesn't allow us to innovate.
So sometimes tying ourselves to evidence based medicine and evidence based healthcare acts as a restriction upon our innovation.
But for me, I was the midwife for the academic health science networks, and we thought very hard about how we address that problem.
And we did it through three mechanisms.
Firstly, we made sure that the NHS and had an accountability that was the primary accountability was to each other.
It was about peer challenge, peer support.
Secondly, where we needed to have national accountability, we made that very tight around doing specific things,
which was a contract for implementing particular pieces of evidence. But thirdly, that isn't sufficient.
We needed to allocate resources which enabled organisations to grow and nurture and to have flexibility and freedom to do their own work.
And so we created a licence for the NHS ends, which was in effect a licence for them to operate, to do the things that they thought were right.
And so therefore, in order to strike this balance, my personal view is that we should be looking at ever increasing ways of creating this
horizontal accountability between peers as the best way of implementing evidence into practise.
Thank you very much. Thank you enormously, Richard,
that was the first a fabulous first lecture you set up so many of the issues that we're going to be addressing over the next few weeks.
I'm going to pass straight across to Sue Dobson and then we'll open up for discussion.
So Professor Dobson's research centres on leadership and transformational change in the public and health care sectors.
And as I mentioned earlier, she is from the side business school.
She is also I'm very pleased and proud to say, a governing body fellow here at Green Templeton College.
Her work is informed and influence many government bodies, such as the Department of Health, Nice, the National Institute for Health,
etc. and its influence their thinking in areas such as the dissemination of clinical evidence and to practise medical leadership.
This is an area that she's particularly known for and the role of the support worker in the NHS so soon.
You're very welcome. Thank you. I'm just trying.
All right, Richard. OK. No, not you again.
I am the one below you to see. OK, so thank you very much for that warm introduction.
I'm indeed from the side business school and I spent gosh,
I started with intermittent college some 28 years ago, was only 12 when I started my own long time.
And I've always been very curious about health care and leadership in health care.
And I guess over my career, I've been studying in somewhere on the, you know, lots of change in the health service and kind of have given up the 2010.
But, you know, I've been a kind of in this space for four plus one was incredibly interesting is, you know,
the kind of repetitive nature of the structures and the and frankly, the failure of the system to really learn from anything ever.
I've really written or colleagues have written about why change is difficult, but anyway.
But that's very that's very sad, very true.
So I am interested in leadership,
and I am particularly interested in how difficult leadership is in complex systems such as health care, not the only complex system.
My favourite definition of leadership is actually disappointing people as a right they can cope with.
But because I think it's such a hard, a such a hard gig.
So in some ways, what I want to do in this, this very brief talk is talk a little bit about a couple of the projects that I've been involved in.
One was indeed evidence based medicine, but I came out.
It was really trying to understand what really motivated clinicians to either practise
evidence based medicine and what really was going on in terms of their decision process.
I've also lots more recently evidence based management, such as saying, right, and I'll say a little bit about about that.
And there's some reoccurring themes that are about the nature of what evidence is and the
complexity and the way in which it becomes something that grabbed hold of and shaped.
So I have a real problem with the word translation in the sense that it becomes very rational.
I think it's much messier than that, and I'll try and talk a little bit about why that is.
But I wanted to present very brief vignettes or case study.
Looking at a network, you mentioned networks and you and your tool,
and we know that networks are very much seen as the vehicle for translation good ideas into practise.
And I want to just showcase a little vignettes of one that me and my team studied for over five years,
looking at the role of genetics, trying to get great science into practise in that space.
And then I'll just make some final conclusions or observations about why, frankly,
we need different models of change and why we need different models of leadership if we're going to make any progress at all.
So that's roughly what I'm going to do in the next 15 or so minutes.
So let me just say a little bit first, though, about this, the study that we did do where we did look at evidence based medicine and what it meant.
So lots of my work and my team's work are just spending lots of time talking to people,
doing quite in-depth interviews and asking people what really influenced their practise.
So talking to clinicians about what influenced your practise?
And of course, what we found, though for them, there was no such thing as evidence, necessarily.
It was more complicated that it wasn't just the guidelines, but evidence to them was also one doctor when,
when, when they had to have the first death and then they looked at it.
It was experiential and they talked about experiences. So when we're talking about evidence, it's not just about Cochrane and the guidelines,
it's also this blended approach about how people make sense of their own experience.
So one theme of that work, and I'm really summarising quite a lot of work, is where there's no such thing as evidence in a very concrete way.
It can mean all sorts of things. It's a malleable concept.
And of course, we know in professional work there are hierarchies of evidence, and we need to understand that.
Part of the reason is I'll show in a minute. What different professions find it hard to talk to one another.
It's because they have different views about what is real data. And sometimes we just can't talk about it.
And in that work also came the importance of opinion. It is you do get in systems, people who really are brave and mavericks,
and they can cross boundaries and they can translate Evans and their model good practise by supporting those opinions.
You can get good evidence into practise if they are supported.
And I guess the final thing that I wanted to talk about that came up very strongly
is that a theme in my work is the importance of leaders understanding context.
Whatever you're doing, whether you're trying to get good ideas into practise or evidence into practise or innovation to practise.
We do not spend enough time as leaders thinking about context and want to come back to that.
In the vignette. So. We have seen in that work that this kind of questioning the evidence is something that's very rational and tangible.
It's messier than that. The second problem or subject that I looked at quite recently is this idea of evidence based management.
And my goodness, if you work in a business, we're responsible for some of this stuff, right?
So there's lots and lots of facts and ideas about management evidence that's out there.
And the study that we looked at was again with with leaders in a range of health care settings.
What was it that made them curious about evidence? What was it that made them curious about evidence and what caused them to engage
with the stuff that I might write or the side business school might produce?
So kind of interesting there.
One thing we found by asking questions about what kind of evidence they draw on that you suddenly find that nobody reads any management stuff at all,
actually. And the journals and all the stuff that we get most often are not really very influential at all.
In fact, it is again personal experience.
And so the story here about why people grabbed a hold of some of these ideas was basically that they had a puzzle in a context.
They wanted to solve it. They were brave enough to solve it. And they again grabbed hold of evidence and grabbed hold of bits of context
and stitched together something that actually allowed them to implement it.
So we came up with this idea that that leaders and managers in this space don't translate evidence in a very rational way.
In fact, they transpose it. They mould it. They look at contacts.
They use contacts. They grab it, they mould it. It's a transposition for me is a better word for really representing this complex issue.
So can I then move on to looking at the case study where we begin to look at some of the more general challenges of getting great ideas
into practise and why it's so difficult to work across these boundaries that we see in health care between the university and the NHS,
between different professional groups. So we studied the genetics knowledge parks.
These were pre your academic health sciences centres and so forth.
But such May six genetics knowledge parts is set up in the UK.
Quite a large sum of money I can't remember, but an outstanding amount of money. And we studied one of those.
And what we always do when we when we look at our policy problem is we just where did the idea come from?
And this this this quotation here could be any any of the places that I studied adequately.
So the notion was the idea. So let me ask the idea of the genetics knowledge partners to get the university and the health care system
to work together in order to get great science into practise in the same trust and translational challenge.
So the idea for this appeared very late in the draught, even in part virtually just a sentence, just a throwaway sentence.
It took everyone by surprise, and when the health secretary was questioned, you tell me, and then we had to develop some things, right?
So we have here the basis of not very good, thoughtful change management, right?
And in a sense, there was no real specification of what these networks were there to do problem.
OK, so we studied one of these networks.
And again, you know, in my world, when you go in to look at change problems, you have to begin to understand in detail the context.
And I would argue that the more we can understand the complicated context in which we are seeking to intervene
and get evidence to practise the more likely we are to be able to at least get some traction and some success.
So this was the story here. So the Department of Health came in, they didn't know what they were doing.
They gave the money out, but no idea what was going on.
The Department of Trade Industry got involved because they thought genetics would have a commercial benefit.
And they frankly had money left in the pot and they didn't know what else to do with it.
So there we are. And then you get, you know, the crafting of the bit with the great,
the good on this and they're all there at the beginning, but then you find them disappearing.
OK? Over the first two years and you're left with a core of people.
So I want to tell you a bit about the story. So when we looked at this, there are all sorts of challenges.
But again, part of understanding the story has to be linked to this.
That if we really want to understand context, it's not just about who, what the groups are,
but it's also, you know, their unit that their affiliation organisation.
What does the organisation context allow them to do, how they incentivise, et cetera?
But also, how are they trained? How do they see the world?
We know that socialisation processes have huge impacts on how we think about evidence and how we use it.
So in this story, the Genetics Knowledge Caucus, we have these communities of practise.
Yeah. And each of whom have been trained in a different discipline, which shapes the way in which they think and feel and talk exceptional.
And it makes a difference how these groups get on, depending on where they're situated.
So even if you are trained in biomedicine, you if you're in a lab and nature's lab,
you request a very, very careful testing if you are a research lab.
You know, you in a sense, are looking for the papers to publish. So let me tell you a little bit about the story.
So in the end, this is five years, six years of work, right?
And genetic science scientists, we say nothing happens. So I'm like, You just all right.
So, you know, you have to do other things while this stuff's going on, otherwise you go mad.
But nonetheless, what you tend to find, what we found here is that, you know, these people were well-intentioned.
Everybody wanted to work together to get away genetic science into practise.
Everybody wants to try to there's no kind of nastiness. But we got conflicts all over the place, we got conflicts with the Department of Health,
who after three years decided that they ought to measure what was going on.
So we got lots of tick boxes for conflict. We got a conflict here in terms of the labs, I just to give you a bit of a quote on this.
So there was a clash here between people who were trained in biomedicine, but they worked in the labs or they worked in the academic area.
And you see here a sense of flavour of the conflict, right?
The way we work in the research lab is to try and get everything as fast as possible because it's a compromise.
We need visible productivity to scrape over the surface for the big prise.
The clinical genetics lab is incredibly compulsive, obsessive. They do everything you duplicate and love.
Get it wrong. That's very reassuring. But the problem is that if you compulsive it, it takes too long.
Yeah, baby, I lecture.
Scientists feel that providing a service have been carefully weigh the risks until feckless people who wanted to let go of the thrill of the glory.
Right? So now so we also know in these networks again, and this has benefited my career quite a lot, that they like social science in them, right?
So that's great, OK? But you try working in this.
So we've got this clash again between science and social science.
Now, the economist interested me was able to get on better with the conditions because,
well, it's nice because you've got the gates, you've got the science school.
But this is not me, but it could be a sociology.
Work is weird, I don't know, but this will always very black and white something when a sociologist talks to me about theories.
It doesn't mean much to me story of my life, these weird sort of sociology people.
We're just providing material for them to write interesting papers.
And so it goes on. So at the point that I want to make here, I think, is just go back.
This is the kind of work. That we need to do to understand the context.
Before we start to use them as a kind of tried and tested change, management is critical.
It is complicated work and I haven't seen it very well done.
I mean, you can learn a lot from studying the history of the organisation historical analysis, but you really need to begin to do that.
And there are no magic contacts. People talk about that famous there's no magic bullets and say this image contest, and now we inherit contacts.
But also, I would argue that we can shake them. Leaders are a bit like farmers.
Farmers don't grow crops. They create the conditions for crops to grow.
And great leadership here could have nudged this system of thought about this,
and it might have led to better translation of what was fantastic science.
So I think one of my concerns really is to make sure that when we're thinking about change management and this is my kind of area of stuff, yeah,
I'm not going to it's not an MBA lecturer, but you know,
when we begin to think about change management where policymakers often think about it, I think this is changing.
But certainly when I've been doing that research, it's about rational management. This is all good stuff, right?
This is all good stuff and you need to do it. But we really need new models of change and I want you to come on to that.
But just just thinking about your point that about wicked problems in leadership work, not enough time is spent by leaders analysing the problem.
What problem is it that you want to solve? And Chief Bratton was a dear colleague of yours that we went somewhere else that he bought anyway.
He did and talked about three kinds of problems that leaders face,
and each kind of problem requires a different kind of approach to leadership and decision making.
So there are times as a leader when you have to just tell him what to do and that's what you need to do.
There are times when you're faced with team challenges where you have to go out and get, find best practises, try and bring them back.
You still need to nudge it and messages that bring it back.
But this kind of work about translating great ideas of good science and innovation to practise is, as you've said in that wiki space.
It's very much in that working space. So my concern is really that we think about trying to innovate with new models of major change.
And when you're dealing with wicked problems, you are in this space of asking questions, not telling people what to do.
And some of the some of the lessons from our work around evidence based management
and what what really seems to to work is the importance of being curious.
What are the puzzles in the organisation?
One of the puzzles in the organiser, she really beginning to stand back on high fits talks about the leadership guru.
Good chat, though, and he says it's about standing on the balcony and beginning to really think in this kind of way about the complexity.
What are the patterns here? What do you notice? What do you notice?
And here the clashes were partly because they couldn't talk to one another. But it was also how they were incentivised.
Publications or not? And what was interesting is that the university it was hard to move people around since the age
old system in the university in the NHS is so different you couldn't move somebody around.
It's not the i t didn't speak to another.
So if you get on the balcony, you begin to ask questions of this star you begin to see, Oh my goodness, no wonder they can't work together.
And that's the kind of work that we need to do. So we need to identify the contacts.
We need to think very carefully about the challenge. And in our work,
there's been lots of evidence which suggests that leaders who provide safe spaces for conversations to
happen that wouldn't normally have fun are more likely to get translational work evidence into practise.
They're more likely to do that. So part of it? How do you provide a holding space, a safe space for conversations that wouldn't normally happen?
And that's how you begin to solve wicked problems. So I can give you a lecture on adaptive leadership.
But but then I think the point is we need to have time for questions is really to make the point that we do
need very different kinds of models of leadership and change an appreciation of the complexity of contacts.
And people are part of that group, some part of that and how we know.
And if we can nudge the context a little bit more, we may be more likely to get fantastic evidence.
Takes practise. People to go through all sides, but I think that's probably enough to get a discussion going.
Thank you.