So I'm going to tell you about the future, as it says on the door knob, because I get visions.
Visions get you get psychiatric referral. But the future is not like the Isle of Skye or Tasmania, a destination awaiting our arrival.
The future is much more like Sydney Opera House or the Great Western Railway, something we imagined design, plan and build.
And in the words of William Gibson, the so-called science fiction writer.
The future is here, just not evenly distributed. So everything I'm telling you I can see happening somewhere, it's just going to happen everywhere.
So let's think a little bit about the past, because as Santayana said, those who don't learn from the lessons of past are condemned to repeat it.
So we've had two revolutions in health care. This is the first revolution in the 19th century.
What is this icon? And if you recognise this somewhere in London.
Oxford Street? Yep. Broad Street. Just know that.
John. John Snow. John Snow. John Stones. The doctor who remove the pump.
The handle of the pump there said there's a pub there. You can go. You go to London.
She must go and see the John Snow pub and he remove the handle of the pump.
And all of these cases of cholera were drinking water from the pump.
He had nothing but bacteria. Bacteria weren't discovered for another 30 years.
So it was empirical but not scientific, like the first industrial revolution.
They didn't know the I mean, Stevenson didn't know the physics of steam.
He just knew what to do with something here. A steam engines would drive things.
And I often think of the first industrial revolution, like the first health care revolution in the 19th century in Europe.
And it worked for many years. The most important building in any city in Europe was what if you go to Milan or Paris or Cathedral?
That's where the power of God. God.
In the 19th century, the most important building was the railway station, the railway station, St Pancras Station and Waverley Station, Edinburgh.
They looked quite like cathedrals, you know, the windows were and that was a power.
But in the 20th century, the new cathedrals became the hospitals.
If you walk along Euston Road from St Pancras and Euclid, you use University College, London Hospital like a cathedral, quite shining.
Hope is there health? Is there hospitals?
That has been fantastic. The second revolution has been fantastic and it's 50 years since I went to medical school.
And these are things, you know, these are things that have happened. Quite astonishing what's happened.
It's been the same as this. But but at the end of 50 years of progress, every society on Earth faces three big problems.
So we've had 50 years of money and technology and 20 years of evidence based medicine, quality improvement.
But every society now faces three big problems. And the first of these is unwarranted variation.
This is first described by Jack Van Berg in 1999 as variation that cannot be explained by variation in need or explicit preferences.
And we published like Jack Bamberger, following him Atlas is a variation on many of these maps we publish.
We don't know what good is, you know, sometimes you know,
what good is the percentage of people admitted to a stroke unit part of the better percentage of hips and he replaced in five years.
The lower the better, the worse the right level of anti-depressant prescribing or MRI or knee replacement, I don't know.
So we publish these maps mainly to to disturb the medical profession, to upset them,
and because they all thought they were doing evidence based medicine and guideline based medicine.
But then here's some of the map nurses. So these are the percentage of people dying in hospital from 45% to 75%.
That's probably £1,000,000, £1,000,000,000 spent and people dying in hospital above the average.
But is the average rate what's right for you population?
I don't know. What you think amounts up is people that never thought so.
If you see this map here, ultrasound activity, everything looked at three fold difference, five fold difference,
15 fold difference in thyroid testing, all the people who thought they were doing the right thing.
Now, the importance of unwarranted variation is that it shows two other problems.
And the first of these is that under use of effective high value intervention.
So one example of this was. Treatment of atrial fibrillation, which when we did the work a couple of years back,
we estimated about 5000 fewer strokes and 10% less vascular dementia.
If they manage atrial fibrillation as well as they did in Bradford. No more money, no more technology.
Just bad for the got a grip of it. And underuse is often complicated by inequity.
So this is a study from Oxford showing that hip replacement and knee replacement in the most deprived populations was about 30%.
This is in the NHS, it's not private practice or anything.
So there's a huge difference that is revealed by amount of variation.
And no, the other high. The other problem review all the unwarranted variation is overuse.
Now, this is the most important picture in health care. I want you all to take a picture of this.
Take your phones out. This is a yes, so you must take it.
This is is compulsory. It's compulsory. You must take it. I don't know how many of you have seen this before.
This is the most important picture in health care. First drawn by very strong, obedient in 1966.
And you see in health care, as you put it, more money to health care.
The benefits go up and then they flatten off. I can give you an action photo to give you a bit more of this stuff.
Worry there'll be more coming up. So as the benefits go up and then they flatten off.
So once in a lifetime, cervical smear, ten year interval, five year interval, three interval,
one year interval, one intensive care bed per million, population ten, 20, 30.
The trouble with health care is that all health care does harm and the harm goes up in direct proportion to the amount of health care we do.
The quality improvements, very important, but quality improvement.
It moves that line down little bit and it moves that line up a little bit, but it doesn't change the relationship and then don't.
Abedian subtracted the harm from the benefit, and he called this a part of optimality.
Now I'd like to turn to your neighbour and discuss where you think in your own society.
Health care has gone beyond the point of optimality. For example, antibiotic prescribing.
Okay, so touch your neighbour. Now introduce yourself if you haven't met before and work out where you've
been going beyond the point of optimality where you've ever seen what you say.
I could. You can always pick on someone in the audience. You see, when you're doing stand up, you pick a tone for Do you guys make of overuse?
Just one example. What else might come up? Well, they simply want to hear a tone is raised about the eighth or ninth round of chemotherapy and this.
And then you say this is not about the money. You know, it's not about the money.
It's about and I'm not saying that, Ed. No. Should have the eighth or ninth round of chemotherapy, but did they really know what the option was?
And same as care in the last year of life. And remember that map I showed you of the percent of people dying in hospital?
My estimate is that we spend about £1,000,000,000 a year doing more harm than good in the last year of life.
And that's all to do with anxieties and drift and surgery.
This comes up here. The hip, hip replacement was the operation of the century and yep, shoulder decompression.
So this is a debate we have to have now and this is the most important.
Now, let's just look ahead, know which way we start to think, what the world is going to be like.
So this is a very strong debate. In 1980 and 1966, he invented structure, process and outcome quality assurance.
But then in 1980, his big book, in 1980, he did this diagram which was hardly, hardly been recognised.
But it's this is the key issue in every country now and then sometimes you get what we call triple whammy health care.
So the knee office of Surgery, this is a professor of orthopaedics in Oxford, Andy Carr,
overuse ineffective and potentially harmful 54 variation in knee and knee arthroscopy and poor people not getting knee replacement.
So there's an example of all three of those factors happening.
The one time it's called triple whammy health care. That's a new scientific definition of healthcare.
Now, here's a question that I've been asking for many years.
So when I first came to to Oxford, I asked a question, is care for people with asthma in Oxfordshire better than Cambridgeshire?
And I said, We don't know. 45 years ago we didn't know.
Now I can tell you 45 years later we still don't bloody well know.
£2 billion a year in asthma. We don't know if care is better in Oxford or Cambridge or Hungary or Wales or Denmark.
We're not looking at health care in a population basis, but you have to look at it in a population basis because that's where the value comes in.
So starting to think about asking questions, not about the quality of care that will come on to what we mean by that in just a minute.
So I think what we're going to be doing in future well, let's look back.
For the last 20 years, we've done four things that are all very, very important.
Prevention, evidence based decision making.
Very, very important. I'm glad you covered the course. Who's all in the course here?
Hands up. So, evidence based decision making.
Very, very important quality improvement. Very, very important and cost reduction.
But you see why we've been doing these four things. The unwanted variation has either developed, persisted or increased.
So these are necessary, but not sufficient. So we now need to focus on value.
Value. Now, value value is a tricky word.
English is a very difficult language and it's been exacerbated in England.
It commercialised megastar by death and England.
English is very difficult. And you're here in Oxford you're they say know they see Cambridge good at science for Oxford good at language.
And just over the road, there's Oxford University Press, which is where the Oxford English Dictionary comes from.
I met a friend of mine who works there the other day and I met him here, so I won't be doing this morning, he said each and then worked on each.
He may still be a teacher. He may have moved on to be something or other, arguably,
but each were so values in the plural and in means principle like this hospital's values are compassion and excellence,
but value in a singular has got a different meaning.
It's a bit more economic. And I do find it, I don't know, Hungarian for value, but I'd like you to write it down for me.
But I do find it quite consistent in different countries.
So now why did you turn to your neighbour again and discuss the meaning of the word value?
When I say the word value in the singular is the key word for 20 years.
What is the word value in health care mean to you? Okay, couple of minutes to discuss with your neighbour.
There's three. Firstly, there's personal value to you as an individual.
What is a value to you? And this is very close to the work you're doing on the evidence based health care record.
And then there's population value. You can have all these these points and anyone who wants them.
Yeah. Thank you. So and then secondly, there's population value.
And there's two aspects that one is advocate of how do you allocate resources?
And the second is, how do you use them once they've been allocated? We'll go through both of these.
So this is another another interesting.
What waste. Waste. And I mentioned the Hungarian for waste to I think someone said Hungarians get 17 known endings.
So we would ask you to get through them all but.
So waste. This is very Toyota and we use this and it is not add value.
Have you had of Kaizen continuous quality improvement.
Toyota. Toyota and muda is waste.
They hated waste and and Toyota and waste as anything is not add value.
So if a patient comes to the clinic and the notes are missing, it's a waste.
We hate it as another very nice Japanese word called mouth.
And I. I think my pronunciation is quite good.
But problem is, no one can correct me in the room.
But a Japanese student taught me this mouth and I is a feeling of remorse for having wasted resources or shouldn't have.
Or that MRI. Oh, no, no, no. Why did I order it?
I don't see much of that. The manager said England are a mountain high and they the Academy Medical Colleges
wrote a very good report where they talked about the culture of stewardship.
Now, stewardship is quite a difficult word, the English word, and I haven't found a German equivalent for it, Italians sort of curation.
But there's a biblical word and there's similar story in the Koran to the good steward leaves the land in better condition than they find it.
They don't own the land, but they look after it and they leave it in better condition.
And of course, the word stewardship has come back into use with environmental issues.
We are the stewards of the planet. We hold it in trust for future generations.
So this is trying to get their clinicians to think that they are the stewards of the health service and not just spending the money.
They're there. They have to keep the thing going. Just ordering 12% more images every year.
It doesn't seem to me to be very sensible if we are stewards of something and the fact that
you're not being charged for it or has not come out of your budget is is it's a culture.
I'll come back to the issue of culture. Okay. Let's take so so this is this is the jargon.
Productivity is output over inputs.
Number of operations done per theatre session.
Nothing to do with outcome doesn't matter. Just the percentage of drugs are present.
Of drugs that are genetic is a measure of productivity.
Efficiency is outcomes over cost.
Outcomes over costs and value is more than this because if you are running a
health service somewhere in the direction or somewhere in Hungary in a hospital,
I don't want you just to get efficiency for the patients who get to the hospital.
I want you to be thinking about what region is the richest in in Hungary.
Is it in a month? Does it look after account? Is it depression?
Is it what? What region is it in? Carpathian, Carpathia.
So how are we seeing the people with asthma? I wonder if there's people out there who are not getting a knee replacement.
Who would benefit more are the ones we're seeing because of GP's having to offer them.
You see the difference here between value and efficiency.
Now here's the new agenda, which will go through. So the four things that have been done have to continue.
Prevention, evidence based decision making, quality improvement and co-production.
All absolutely essential and must continue. But why were we doing it?
Unwanted variation, overuse and under use have developed. So here are the new the three new things that we need to do.
Number one, ensure that every individual receives information that will help them make the right decision.
And this is the this is the model we we developed and the picture we developed for evidence based medicine.
This is the 1996 editorial evidence based medicine, what it is and what it isn't.
But they can say and said that every idea is a picture.
And we were very much criticised for promoting what they called a cookbook medicine with evidence based medicine.
And I think if we could put a picture in the BMJ editorial, it would be much better.
But editorial editorials don't take pictures.
But here's the picture. So does the evidence derived from the study of groups of patients.
And there's that clearly relation of this patient, this patient who's often very different from the people in the randomised controlled trial.
And it's the other diagnosis, risk factor, genomic information.
And then there's the values this patient does, what value to the place and risk taking.
You know, one in a thousand cataract operation goes wrong.
So what values you place in that, not just a one in a thousand, but the fact some people place a value on,
you know, I wouldn't like to take a decision that might go wrong. I could live with it.
Other people say, oh, Sara, Sara doesn't bother me.
So this is evidence based medicine. And we're now in the third health care revolution.
And the third health care revolution is driven by three forces, citizens knowledge.
And where's my jacket? That's not the search.
No, no, no, no, no, no.
What am I looking for? My phone. My phone.
No, no. Just stay. I better find it in case. Say for me.
Okay. Not good. So the third boat in the third revolution.
And this is if you were all genomic people. This is more important than the human genome.
This will change things more than the human genome. Even even the professor of medicine agrees with that.
No, I think he does think John Bell agrees with it. Thank you, Erica.
The the human genome in me, it's a quiz, you know, producing information.
But it's not that different from biochemical information. But this this changes the power balance.
And it's just we are in the health service in this country, 20 years of the piece and using this.
I still get letters from the hospital on paper and First-Class stamps.
Some hospitals have tried to increase productivity by moving to second class stamps.
But you know what happens when they do that? The letter telling you your appointment is being cancelled arrives after the appointment.
So you people turn up. So where do you come from?
Spain. Spain. And how much is the phone use?
Much. Which which province are you in? In Spain? Which region? I know because some of some of your Valencia things get very good systems.
And so some countries are making more progress.
Hungary, the people there's the hospital send letters to people, email will reload.
And so including how much?
How much I think if you'd find out from a family, how much, sure.
I haven't been able to find out in Oxford how much we spend on stamps every year she's spent around the trust.
Over £1,000,000. If only it was emailed around one minute before Christmas.
They did the 12 days of Christmas, the other money, and one of them was converting from first to second class stamps.
Yeah. Yeah. £700,000. Yes. Across a year to convert for the first time, we spend millions.
Oh, yeah. But for Christians having an email. Oh, my God.
They're not. Couldn't do that. I mean, their confidentiality is what someone said to me.
Fine. Well, you have you had a House of Malta occupation. A letter arrives.
So we're in the third revolution, and it's driven by citizens knowledge.
And this, the 20th century was a century of the doctor.
The 21st century is the century of the person we call a patient, the citizen.
The power has changed, not just in health care, but in this.
Is this a man called Manuel Castells Spanish, who writes about the Industrial Revolution?
He doesn't write about health care, but is his work is very relevant to health care.
So here we're in the third revolution, citizens knowledge and the smartphone.
So let's look at the thank you the second.
So that's the first thing we got to do is make sure that individuals really, really understand what the options are.
The second thing is they shift resources from budgets where there's lower value to higher value.
So here's the way we spend money in the health service in England, diabetes, 90 million, gastrointestinal 100 million, respiratory under 30 million.
There's a lot more specialised cancer money, but how much you think we spend on mental health turning off a quarter,
a quarter, twice as much and yep, billion U.S. million pounds per million population, million pounds, 4 million population.
And people are really surprised when you tell them actually spend a minute, maybe it's not enough.
But people often say, oh, 25 million per million population, it's a lot of money and it's quite hard to see what we get for it.
So for start to think about how we shift resources and I'll come back to the point you raised.
Of course many people have more than one health problem and we call this complexity.
And the complexity is an 85 year old woman with five diagnosis and 12 prescriptions looked after by a 50 year old doctor with an alcoholic husband,
standard general practice and a GP's in the room.
GP's are very good at complexity, but when one of the problems goes wrong, they refer to a specialist.
This is not really official language, complexity and complicated, but it's quite useful language I think in terms of of speaking to people.
Now this is the first and it varies from country to country.
Where do you come from? From Brazil. Brazil. And how is how does the money go from the government?
Does it go to regions? Does it or not? Necessarily. It goes from the government to anywhere else.
But the health care is not a priority there right now.
Nobody ever main priority. But I suppose in the US certain some of the government, the Minister of health get money.
Does it go to the regions first or it goes through the region. Yeah. So, so here is what the regions have to do something like this.
And in Spain it's big difference in insurance based countries like Germany and the Netherlands.
So where insurance is in is a little bit different, but it's this.
So this is what you have to do when you're a peer. You've got a population and you're going to think, how do you allocate the resources?
And this is a very difficult thing to do because there is no formula, there's no evidence that will allow you to do it.
And Canada, who died last year, a Nobel Prize winner in economics, he developed something called the Impossibility Theorem.
It's impossible to tell, but I can give you all the data you want and you put into a computer doesn't do the sums.
And what's fascinating what's emerging is that that what the public expect is not magic.
They know it's impossible, but they.
They want what Norman Daniels calls accountability for reasonableness,
namely that the government of the state of Sao Paolo had all the different patient groups.
They didn't have any corruption. And they use the evidence in the same way for all the different groups.
Accountability for reasonableness. That's all people are looking for.
And because these are we call these in a conference, we run hellish decisions.
These are impossible decisions of prioritisation and rationing.
Now, interestingly, the second level of allocation is this level.
So once we've given the money to the people of Madrid for respiratory disease, then there's a second level of allocation.
And really, the peers, the ministries of health, they don't have the technical knowledge.
And also what you find is that the variation between these three is so markedly different from one place to another.
So if you go to county, one county, and they've got a very good COPD service,
and then you go three miles down the road and they're very good asthma service.
Why is that? Because in one place they had one clinician who is very good at getting money from the government.
And then 30 miles down the road there, another clinician injured in something else.
So there's often very marked imbalance. And so we are saying this is the clinicians.
You see, if you take this, this is respiratory disease.
Well, there is a new big article. I don't have it with me in The Sunday Times.
A new drug for cystic fibrosis. Looks pretty good to me.
So where's the money going to come from for the new drug for cystic fibrosis?
We don't have any growth money, so it'll have to come from, you know,
maybe in one place it be from the asthma expenditure down the road in another county, it might be from the COPD or sleep it.
So starting at the clinicians to think this way, the clinicians to think this way.
Okay. So just to think of the three new things, firstly, the, the individual patient has to understand.
Secondly, to allocate resources optimally,
the aim should be that the resources are distributed in such a way you could
not get more value by shifting a pound or a dollar from one budget to another.
No one's ever done it, of course, but so-called optimal allocation.
Now, the third level of value is population value.
And we've called this population health care.
So this is health care that doesn't focus on hospitals or primary care or teaching hospitals, but on populations in need.
People with headache, people with asthma.
People in the last year of life. Population, health care. You see in every country I know people.
There's bureaucracies, regions or hospitals or universities or health centres.
And you have to have bureaucracies very important, but only for the linear, simple tasks like the fair and open employment of staff.
Bureaucracies are not good at dealing with complexity. Health care is complex.
Bureaucracies are linear organisations.
Health care is nonlinear. And then we've got these things that you can see self care and formal care, primary, save or tertiary.
So what we've been doing is introducing what we call three D health care.
So to total the budget round in a different way. So we're really thinking about people with headache or people with back pain or people
with epilepsy or inflammatory bowel disease or people with multiple conditions.
These are and now another typical Oxford line.
So sure, this is someone who is an academic. He said, oh, yes.
It's quite, quite, quite a good diagram. You are. But you're trying to represent algebra geometrically.
And so there we are. So it is much more complex.
And this is the part they're making, but it's certainly much more complex than this.
This is linear thinking. This is a template.
So you see the sort of problems we see are a bit broken legs on a problem.
So if you get run down in the street there and you get your leg broken here, if you know where the hospital is, you'll get.
The right place. Same as being same as having cancer.
Eventually you get to the cancer hospital. But most of health care is more complex than that, you know, headache and mass, man.
So what you see is that the people receiving the specialist service are not the people who benefit most.
And what we should do is to move and to change the way people think.
So the specialists see people, but they're also thinking about the people they don't see.
I was discussing type two diabetes with a colleague in Ulster University Hospital today,
and I said, How many people have got type two diabetes in Oxfordshire?
And he said, over 24,000 people. I said, What do you mean, 24,000?
He said, Well, that's the ones on our hospital books as well, or ones who are not in the hospital books.
Oh, I hadn't thought about them. And then I said, How many pharmacies are there in Oxfordshire?
Because the pharmacies are seeing people and they don't know much about type two diabetes because it's ten years
since they left university and the people in the hospital know a [INAUDIBLE] of a lot about type two diabetes,
but they're not connecting with the pharmacies. So you're starting to think about the specialist service being a knowledge service.
And the president of Toyota said Toyota is a knowledge business.
They care about that, isn't it? And we're just plastic and steel.
It was, you know, our the people who buy our cars what they like, the people who buy our competitors cars.
They're like, what's the future going to be like for cars?
Has knowledge Toyota the knowledge business and I say to hospital chief exec,
so you're in the real estate business of the knowledge business some I look
a bit funny at me when I ask them because you've got this huge real estate,
this huge hospital. I've got to run the hospital. I've got to keep it. I need money to keep it lit well heated and lighted.
But you employ all these clever people, but they don't. Naturally the knowledge isn't being used.
So these systems we all seem to think of, if you had the budget all together and you want to innovate.
The money's got to come from the existing budget. Because that's all the money there is, and that might come in different ways.
For example, we so the threat level of allocation here is we did a view of of COPD and made a decision
to move money from triple drug therapy to smoking cessation and rehabilitation.
You might move money the other way from anti drug therapy, but but the clinicians and the patients together had to make that decision.
The clinicians in the patients together make these sorts of decisions.
So I think the patients should take this decision to this level of the government.
Well, this this this is could be taken locally because they set the service balance might be quite different from one city to another.
But we just ask patient organisations to come in and we say to the patients, I'm pointing at the patient here and look for the next hour and a half.
Don't campaign for more money for COPD tomorrow.
You can do that. But we're here to discuss are we getting optimal value for the money we've got and the patient organiza?
Yeah, yeah. We can see things that could be done differently.
Tomorrow we'll campaign for more money for COPD, but we know it's got to come from somewhere else.
But we can see. So we get patients involved and they're very reasonable, in my experience.
So. The point I want to finish out here is that population, health care and personal health care value are two sides of the one coin.
Population value and personal value. So remember here and Dave, I think I need you out here.
Actually, I'd like you to reproduce the donor body and curve here, Dave.
Is that the the curve here that benefits the benefit and the harm goes in a straight line.
Okay. This is a straight please, Dave. So as you put more resources in from a population point of view, you reach a point of optimality.
But also as you put more resources in, you start to treat people who are less severely affected.
So, yes, I thank you very much. Big round of applause for.
So when you start, say, cataract operations, you only treat people who really, really go to benefit.
The operation is necessary, then people are less severely affected, but it's still appropriate.
Then it may become inappropriate. And then this is the world which is now entering the medical literature.
I don't know if you've looked at any papers in futility where, you know, almost everyone thinks it's going to do more harm than good.
Sometimes sometimes a a major operation and, you know, a frail elderly person.
And there's this, of course, you are alluding to, to adhere to.
Well, come on. You know, this is says, yeah, I'll get them off the table, but they'll die ten years, ten days later in ITU.
And so population and personal.
But it's not just people like me think of populations of there's people that you think of individual patients.
These two things hang together. So how are we going to get there?
Let's just finish.
So this is my model of a health service, and I've had 22 reorganisations, most of which have made no difference at all.
And Gandhi said There is no structure that will make bad people good, but the wrong structure can make good people behave badly.
So you have to think about silly things that people do because of the payment system.
But the key thing are systems and culture. So this is what health care looks like in most countries.
You can see it's an archipelago, patients swimming from one to another.
And this is the way we spend the money is five different flows of cash and the health service in England.
Do they speak to one another? No.
If they did speak to another, well, it wouldn't be much difference really, because here they're all defending their own budgets.
So what we need to do is to do something like that, a system for people with asthma or people with psoriasis or people with breast cancer.
Sometimes you need super specialist care and, you know, cancer or radiotherapy or post surgery for inflammatory bowel disease.
So it's five box, a bit like a Russian doll. It's not the archipelago, it's integrated said.
It's a system. The system looks like I said, knowledge just flows back all the time.
And then it's an open system you're very much affected by.
You know, for example, I don't know if you saw in the, the, uh,
the news this morning about a company called Carillion employs 400 people in the Oxford Hospital.
So something happens, you know? [INAUDIBLE] it, something's happened. Yeah.
So it's an open system. It's where we can't. We're not in control of a closed system.
And this is what a system looks like. Objectives, criteria and standards.
So this is something I did about 15 years ago, a quite, quite difficult sickle cell.
And one of the objectives and how we remeasure it and what are the standards?
Objectives, criteria standards is we're a population.
Don't worry about whether it's a hospital or health centre or primary care or secondary care.
It's an obsession with sickle cell disease. So we move from this to this and the 20th century professor.
Consultant. GP 21st century professor consultant.
GP Pharmacist patient it's a network century, a network century, the 20th century of the century of the hierarchy.
The 21st century is the centre of the network and finally culture.
And usually the management theorists would envisage structures maybe 10%.
That leaves 90%, then systems 40% and culture.
50%. Culture is the key thing. The culture and its leadership, who shapes the culture and you are the leadership of the future of the health service.
And your job is is to get the culture, the culture of stewardship or the culture of collaboration.
These are cultural changes, and sometimes images are good.
And so if if you were all doctors and nurses and quarrelling with one another and say,
this is the most this is the most effective, it's a complex, adaptive system.
The and these guys will see us off, you know, the colony is the most much more flexible than the bees, but they're the cleverest.
It's a complex adaptive system. They are the sort around.
So I'm trying to get one over the workarounds. And and the queen doesn't tell them what to do.
What does the queen undo? Lays eggs.
It's not a bureaucracy in any way, communicating all the time a very clear sense of mission.
And in that, there's a fantastic book in the Ants by whole novel and Wilson and £177.
But I bought it once. Margaret Lichfield has a chapter on altruism, the ants give up the life for the good of the colony.
I don't think we're asking you yet to give up your life for the good of the health service.
But you never know. It might have to come, but you already have your SO to create a new language and new culture.
There is partly the behaviour of the leadership, how they relate to one another, but it's also a language.
So we we spend a lot of time as a doctor of course thinking about language.
And I so the new language value system network pathway program to the poor, the respiratory program has good systems for asthma,
for COPD, for sleep apnoea, for cystic fibrosis program system, network pathway.
And then sometimes you've got to try and ban all language.
So I don't like primary and secondary and I don't like manager if I don't like the manager.
Oh sorry. You're a lousy clinicians to hate the manager.
So are you a clinician and your day job? Yeah. So, yeah, but not yet you see.
But most your colleagues. Will you manage resources? Oh no, no, I'm not a clinical director and I would say Gibraltar and actually a yes.
So if you're managing resources, people who manage, so you use language in that way to change the way the language creates the new reality.
The social world is created by language. This is a man called John Settle.
If a lot of our language doesn't describe reality, language creates reality.
So this day,
here's the new skills that we are now developing value modules and culture change modules to run as part of the evidence based health care set.
So these are the new set of skills where we would like the leadership evidence and value based health care.
So just let's finish touch your neighbour for 2 minutes and think about how, if any way,
this what I've been saying is relevant to the world which you live and work in, and Brazil or Spain or wherever you come from.
They spend a couple of minutes thinking and then we can go, Dave, can we offer a reception and yes.
Discuss those on the programme. Yeah. Yeah.
Okay. So a couple of minutes just to think and then we'll take just some feedback and then and go for a good walk.
Okay. 10 minutes with your neighbour to reflect on what I've been saying and how it might
change the way you when you would walk when you go back to the end of this week,
okay, couple of minutes with your neighbour and of course there are very practical things like they when I came
here there was one rheumatologist and there's over nine and there was one practice just near the hospital.
But for full time GP's there's no nine part time, 12 part time GP's and we don't even have lunchtime meetings in Oxford with GP's.
Why not? Why not? Why do we have lunchtime meetings with GP's and they're parking, car parking.
Yeah. That's a completely impossible. You can organise, it could be completely impossible to get but 4 hours to get there.
And have you tried to talk to John Radcliffe ever. Don't, don't know about.
Yes we now say to patients that they were notified a car parking space so we we are different
but we have to think in a different way just if Dave and I are working in something.
That is part of the change. So maybe we need to see if if I were and I'm still trying to do it, but how do we rebrand what we're doing?
And so one brand is health is what you do for yourself, not.
We deliver professional health services, but health care is what you do for yourself.
Don't tell my wife. Why not say I'm from Glasgow? Health care is what you do for yourself.
So we are. Thank you. We are.
Well, we have launched an activity therapy service that everyone's long term condition will be given activity and prescriptions.
So before you get metformin, you either get three months of exercise, the Mediterranean diet, most people will probably still need metformin.
But the signal we send you by just giving you a pill or hypercholesterolaemia here's a pill,
but you need the PSA to help you get a hold of the press are pressure.
We're getting the press. I'm very much criticised by my public health colleagues for writing The Daily Mail.
But I have to point out to them that writing The Guardian is not going to solve the problem of health inequalities.
And no, it will raising the flashpoint term and it's broadening it out from health care that when we launched a walking app,
we've got a walking app for brisk walking WW dot NHS dot UK slash one you and you buy very good app you got
to walk briskly tells you how much brisk walk you're doing and we we said it's an environmental problem.
It's not a lifestyle issue. You know, it's sitting 9 hours a day at a computer screen, which is what most people do, an environmental problem.
And they're the papers that usually criticise us and that it's called nanny state.
And the public reaction to what people like me say but they get is this life typically their commuting,
commuting for an hour and sitting for 9 hours and then commuting for an hour at home.
So Dave and I are saying it's not just medicine.
It's it's what you do for yourself.
Basically, I just had Dave, there's a trial of chemotherapy, most controlled trials of chemotherapy and St Thomas Hospital.
And the people who got chemotherapy and exercise finished the course of chemotherapy and the ones who got chemotherapy without exercise,
lots of them didn't finish the course because they didn't feel well. And so there's all sorts of interesting things to play for.
Okay. Nice to meet you all. Thank you for coming to Oxford. Those who come.