1
00:00:00,390 --> 00:00:05,670
So I'm going to tell you about the future, as it says on the door knob, because I get visions.

2
00:00:05,670 --> 00:00:14,340
Visions get you get psychiatric referral. But the future is not like the Isle of Skye or Tasmania, a destination awaiting our arrival.

3
00:00:15,210 --> 00:00:22,350
The future is much more like Sydney Opera House or the Great Western Railway, something we imagined design, plan and build.

4
00:00:23,460 --> 00:00:27,540
And in the words of William Gibson, the so-called science fiction writer.

5
00:00:28,080 --> 00:00:34,590
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.

6
00:00:35,490 --> 00:00:44,190
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.

7
00:00:44,850 --> 00:00:50,520
So we've had two revolutions in health care. This is the first revolution in the 19th century.

8
00:00:50,850 --> 00:00:55,889
What is this icon? And if you recognise this somewhere in London.

9
00:00:55,890 --> 00:01:01,110
Oxford Street? Yep. Broad Street. Just know that.

10
00:01:01,110 --> 00:01:05,490
John. John Snow. John Snow. John Stones. The doctor who remove the pump.

11
00:01:05,910 --> 00:01:09,510
The handle of the pump there said there's a pub there. You can go. You go to London.

12
00:01:09,520 --> 00:01:13,620
She must go and see the John Snow pub and he remove the handle of the pump.

13
00:01:13,830 --> 00:01:17,130
And all of these cases of cholera were drinking water from the pump.

14
00:01:18,300 --> 00:01:21,990
He had nothing but bacteria. Bacteria weren't discovered for another 30 years.

15
00:01:22,890 --> 00:01:27,810
So it was empirical but not scientific, like the first industrial revolution.

16
00:01:28,050 --> 00:01:31,170
They didn't know the I mean, Stevenson didn't know the physics of steam.

17
00:01:31,170 --> 00:01:35,430
He just knew what to do with something here. A steam engines would drive things.

18
00:01:36,300 --> 00:01:42,000
And I often think of the first industrial revolution, like the first health care revolution in the 19th century in Europe.

19
00:01:42,870 --> 00:01:56,070
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?

20
00:01:56,790 --> 00:01:59,070
That's where the power of God. God.

21
00:02:00,420 --> 00:02:15,140
In the 19th century, the most important building was the railway station, the railway station, St Pancras Station and Waverley Station, Edinburgh.

22
00:02:15,150 --> 00:02:18,809
They looked quite like cathedrals, you know, the windows were and that was a power.

23
00:02:18,810 --> 00:02:23,250
But in the 20th century, the new cathedrals became the hospitals.

24
00:02:24,690 --> 00:02:33,000
If you walk along Euston Road from St Pancras and Euclid, you use University College, London Hospital like a cathedral, quite shining.

25
00:02:33,810 --> 00:02:37,230
Hope is there health? Is there hospitals?

26
00:02:37,230 --> 00:02:43,950
That has been fantastic. The second revolution has been fantastic and it's 50 years since I went to medical school.

27
00:02:44,460 --> 00:02:49,650
And these are things, you know, these are things that have happened. Quite astonishing what's happened.

28
00:02:49,650 --> 00:03:00,210
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.

29
00:03:00,510 --> 00:03:07,320
So we've had 50 years of money and technology and 20 years of evidence based medicine, quality improvement.

30
00:03:07,920 --> 00:03:13,410
But every society now faces three big problems. And the first of these is unwarranted variation.

31
00:03:13,830 --> 00:03:23,220
This is first described by Jack Van Berg in 1999 as variation that cannot be explained by variation in need or explicit preferences.

32
00:03:24,090 --> 00:03:33,200
And we published like Jack Bamberger, following him Atlas is a variation on many of these maps we publish.

33
00:03:33,390 --> 00:03:36,680
We don't know what good is, you know, sometimes you know,

34
00:03:36,690 --> 00:03:45,419
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.

35
00:03:45,420 --> 00:03:54,060
The lower the better, the worse the right level of anti-depressant prescribing or MRI or knee replacement, I don't know.

36
00:03:55,350 --> 00:04:01,590
So we publish these maps mainly to to disturb the medical profession, to upset them,

37
00:04:02,490 --> 00:04:06,330
and because they all thought they were doing evidence based medicine and guideline based medicine.

38
00:04:07,260 --> 00:04:15,780
But then here's some of the map nurses. So these are the percentage of people dying in hospital from 45% to 75%.

39
00:04:17,580 --> 00:04:23,040
That's probably £1,000,000, £1,000,000,000 spent and people dying in hospital above the average.

40
00:04:23,040 --> 00:04:26,610
But is the average rate what's right for you population?

41
00:04:26,940 --> 00:04:32,610
I don't know. What you think amounts up is people that never thought so.

42
00:04:32,610 --> 00:04:40,320
If you see this map here, ultrasound activity, everything looked at three fold difference, five fold difference,

43
00:04:41,070 --> 00:04:45,910
15 fold difference in thyroid testing, all the people who thought they were doing the right thing.

44
00:04:45,930 --> 00:04:51,600
Now, the importance of unwarranted variation is that it shows two other problems.

45
00:04:52,830 --> 00:04:57,030
And the first of these is that under use of effective high value intervention.

46
00:04:57,030 --> 00:05:05,170
So one example of this was. Treatment of atrial fibrillation, which when we did the work a couple of years back,

47
00:05:05,770 --> 00:05:11,560
we estimated about 5000 fewer strokes and 10% less vascular dementia.

48
00:05:12,070 --> 00:05:17,649
If they manage atrial fibrillation as well as they did in Bradford. No more money, no more technology.

49
00:05:17,650 --> 00:05:24,790
Just bad for the got a grip of it. And underuse is often complicated by inequity.

50
00:05:24,850 --> 00:05:34,090
So this is a study from Oxford showing that hip replacement and knee replacement in the most deprived populations was about 30%.

51
00:05:35,980 --> 00:05:39,070
This is in the NHS, it's not private practice or anything.

52
00:05:40,150 --> 00:05:44,200
So there's a huge difference that is revealed by amount of variation.

53
00:05:45,160 --> 00:05:52,030
And no, the other high. The other problem review all the unwarranted variation is overuse.

54
00:05:53,050 --> 00:05:57,490
Now, this is the most important picture in health care. I want you all to take a picture of this.

55
00:05:57,860 --> 00:06:02,020
Take your phones out. This is a yes, so you must take it.

56
00:06:02,390 --> 00:06:07,570
This is is compulsory. It's compulsory. You must take it. I don't know how many of you have seen this before.

57
00:06:09,070 --> 00:06:15,130
This is the most important picture in health care. First drawn by very strong, obedient in 1966.

58
00:06:16,390 --> 00:06:22,360
And you see in health care, as you put it, more money to health care.

59
00:06:22,360 --> 00:06:32,220
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.

60
00:06:32,260 --> 00:06:36,430
Worry there'll be more coming up. So as the benefits go up and then they flatten off.

61
00:06:37,150 --> 00:06:41,950
So once in a lifetime, cervical smear, ten year interval, five year interval, three interval,

62
00:06:41,950 --> 00:06:48,070
one year interval, one intensive care bed per million, population ten, 20, 30.

63
00:06:49,000 --> 00:06:56,440
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.

64
00:06:58,090 --> 00:07:01,600
The quality improvements, very important, but quality improvement.

65
00:07:01,780 --> 00:07:09,800
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.

66
00:07:09,820 --> 00:07:14,350
Abedian subtracted the harm from the benefit, and he called this a part of optimality.

67
00:07:14,470 --> 00:07:21,610
Now I'd like to turn to your neighbour and discuss where you think in your own society.

68
00:07:22,240 --> 00:07:26,590
Health care has gone beyond the point of optimality. For example, antibiotic prescribing.

69
00:07:27,040 --> 00:07:32,499
Okay, so touch your neighbour. Now introduce yourself if you haven't met before and work out where you've

70
00:07:32,500 --> 00:07:38,170
been going beyond the point of optimality where you've ever seen what you say.

71
00:07:38,260 --> 00:07:45,820
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?

72
00:07:46,510 --> 00:07:58,300
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.

73
00:07:58,360 --> 00:08:01,990
And then you say this is not about the money. You know, it's not about the money.

74
00:08:02,800 --> 00:08:08,140
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?

75
00:08:09,430 --> 00:08:15,100
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?

76
00:08:15,730 --> 00:08:20,320
My estimate is that we spend about £1,000,000,000 a year doing more harm than good in the last year of life.

77
00:08:23,740 --> 00:08:28,060
And that's all to do with anxieties and drift and surgery.

78
00:08:28,180 --> 00:08:34,720
This comes up here. The hip, hip replacement was the operation of the century and yep, shoulder decompression.

79
00:08:35,410 --> 00:08:39,180
So this is a debate we have to have now and this is the most important.

80
00:08:39,200 --> 00:08:44,170
Now, let's just look ahead, know which way we start to think, what the world is going to be like.

81
00:08:44,770 --> 00:08:52,690
So this is a very strong debate. In 1980 and 1966, he invented structure, process and outcome quality assurance.

82
00:08:54,070 --> 00:09:01,870
But then in 1980, his big book, in 1980, he did this diagram which was hardly, hardly been recognised.

83
00:09:02,050 --> 00:09:08,980
But it's this is the key issue in every country now and then sometimes you get what we call triple whammy health care.

84
00:09:09,610 --> 00:09:17,350
So the knee office of Surgery, this is a professor of orthopaedics in Oxford, Andy Carr,

85
00:09:17,920 --> 00:09:26,740
overuse ineffective and potentially harmful 54 variation in knee and knee arthroscopy and poor people not getting knee replacement.

86
00:09:27,880 --> 00:09:31,000
So there's an example of all three of those factors happening.

87
00:09:31,130 --> 00:09:36,640
The one time it's called triple whammy health care. That's a new scientific definition of healthcare.

88
00:09:37,480 --> 00:09:42,860
Now, here's a question that I've been asking for many years.

89
00:09:42,860 --> 00:09:49,120
So when I first came to to Oxford, I asked a question, is care for people with asthma in Oxfordshire better than Cambridgeshire?

90
00:09:50,530 --> 00:09:53,530
And I said, We don't know. 45 years ago we didn't know.

91
00:09:54,760 --> 00:09:58,330
Now I can tell you 45 years later we still don't bloody well know.

92
00:09:59,690 --> 00:10:05,930
£2 billion a year in asthma. We don't know if care is better in Oxford or Cambridge or Hungary or Wales or Denmark.

93
00:10:06,950 --> 00:10:15,320
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.

94
00:10:16,100 --> 00:10:24,350
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.

95
00:10:24,360 --> 00:10:28,219
So I think what we're going to be doing in future well, let's look back.

96
00:10:28,220 --> 00:10:32,660
For the last 20 years, we've done four things that are all very, very important.

97
00:10:32,660 --> 00:10:36,320
Prevention, evidence based decision making.

98
00:10:36,470 --> 00:10:39,550
Very, very important. I'm glad you covered the course. Who's all in the course here?

99
00:10:39,560 --> 00:10:44,000
Hands up. So, evidence based decision making.

100
00:10:44,000 --> 00:10:48,920
Very, very important quality improvement. Very, very important and cost reduction.

101
00:10:50,270 --> 00:10:57,410
But you see why we've been doing these four things. The unwanted variation has either developed, persisted or increased.

102
00:10:58,760 --> 00:11:03,440
So these are necessary, but not sufficient. So we now need to focus on value.

103
00:11:03,860 --> 00:11:09,140
Value. Now, value value is a tricky word.

104
00:11:09,500 --> 00:11:14,690
English is a very difficult language and it's been exacerbated in England.

105
00:11:14,810 --> 00:11:18,670
It commercialised megastar by death and England.

106
00:11:18,710 --> 00:11:27,440
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.

107
00:11:28,610 --> 00:11:34,790
And just over the road, there's Oxford University Press, which is where the Oxford English Dictionary comes from.

108
00:11:35,870 --> 00:11:50,590
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.

109
00:11:50,670 --> 00:11:54,470
He may still be a teacher. He may have moved on to be something or other, arguably,

110
00:11:54,890 --> 00:12:06,680
but each were so values in the plural and in means principle like this hospital's values are compassion and excellence,

111
00:12:08,180 --> 00:12:11,659
but value in a singular has got a different meaning.

112
00:12:11,660 --> 00:12:16,970
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.

113
00:12:17,510 --> 00:12:21,700
But I do find it quite consistent in different countries.

114
00:12:21,710 --> 00:12:26,370
So now why did you turn to your neighbour again and discuss the meaning of the word value?

115
00:12:26,390 --> 00:12:31,070
When I say the word value in the singular is the key word for 20 years.

116
00:12:31,520 --> 00:12:36,380
What is the word value in health care mean to you? Okay, couple of minutes to discuss with your neighbour.

117
00:12:38,770 --> 00:12:43,120
There's three. Firstly, there's personal value to you as an individual.

118
00:12:43,540 --> 00:12:49,600
What is a value to you? And this is very close to the work you're doing on the evidence based health care record.

119
00:12:50,380 --> 00:12:55,870
And then there's population value. You can have all these these points and anyone who wants them.

120
00:12:56,020 --> 00:12:59,829
Yeah. Thank you. So and then secondly, there's population value.

121
00:12:59,830 --> 00:13:06,580
And there's two aspects that one is advocate of how do you allocate resources?

122
00:13:07,030 --> 00:13:10,930
And the second is, how do you use them once they've been allocated? We'll go through both of these.

123
00:13:10,960 --> 00:13:15,400
So this is another another interesting.

124
00:13:15,400 --> 00:13:24,670
What waste. Waste. And I mentioned the Hungarian for waste to I think someone said Hungarians get 17 known endings.

125
00:13:24,670 --> 00:13:27,850
So we would ask you to get through them all but.

126
00:13:28,330 --> 00:13:33,580
So waste. This is very Toyota and we use this and it is not add value.

127
00:13:34,930 --> 00:13:38,950
Have you had of Kaizen continuous quality improvement.

128
00:13:39,250 --> 00:13:43,240
Toyota. Toyota and muda is waste.

129
00:13:43,660 --> 00:13:49,660
They hated waste and and Toyota and waste as anything is not add value.

130
00:13:49,710 --> 00:13:53,890
So if a patient comes to the clinic and the notes are missing, it's a waste.

131
00:13:54,670 --> 00:13:58,370
We hate it as another very nice Japanese word called mouth.

132
00:13:58,390 --> 00:14:01,629
And I. I think my pronunciation is quite good.

133
00:14:01,630 --> 00:14:04,030
But problem is, no one can correct me in the room.

134
00:14:04,570 --> 00:14:11,830
But a Japanese student taught me this mouth and I is a feeling of remorse for having wasted resources or shouldn't have.

135
00:14:11,840 --> 00:14:15,850
Or that MRI. Oh, no, no, no. Why did I order it?

136
00:14:16,720 --> 00:14:23,950
I don't see much of that. The manager said England are a mountain high and they the Academy Medical Colleges

137
00:14:23,950 --> 00:14:26,860
wrote a very good report where they talked about the culture of stewardship.

138
00:14:28,060 --> 00:14:37,990
Now, stewardship is quite a difficult word, the English word, and I haven't found a German equivalent for it, Italians sort of curation.

139
00:14:39,040 --> 00:14:48,850
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.

140
00:14:49,990 --> 00:14:54,790
They don't own the land, but they look after it and they leave it in better condition.

141
00:14:55,720 --> 00:14:59,560
And of course, the word stewardship has come back into use with environmental issues.

142
00:15:00,520 --> 00:15:05,590
We are the stewards of the planet. We hold it in trust for future generations.

143
00:15:06,730 --> 00:15:14,920
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.

144
00:15:14,920 --> 00:15:21,249
They're there. They have to keep the thing going. Just ordering 12% more images every year.

145
00:15:21,250 --> 00:15:26,649
It doesn't seem to me to be very sensible if we are stewards of something and the fact that

146
00:15:26,650 --> 00:15:32,500
you're not being charged for it or has not come out of your budget is is it's a culture.

147
00:15:32,620 --> 00:15:38,230
I'll come back to the issue of culture. Okay. Let's take so so this is this is the jargon.

148
00:15:39,280 --> 00:15:43,630
Productivity is output over inputs.

149
00:15:45,040 --> 00:15:48,730
Number of operations done per theatre session.

150
00:15:49,390 --> 00:15:53,930
Nothing to do with outcome doesn't matter. Just the percentage of drugs are present.

151
00:15:53,950 --> 00:15:57,910
Of drugs that are genetic is a measure of productivity.

152
00:15:58,630 --> 00:16:02,620
Efficiency is outcomes over cost.

153
00:16:03,250 --> 00:16:11,260
Outcomes over costs and value is more than this because if you are running a

154
00:16:11,260 --> 00:16:16,510
health service somewhere in the direction or somewhere in Hungary in a hospital,

155
00:16:18,130 --> 00:16:21,940
I don't want you just to get efficiency for the patients who get to the hospital.

156
00:16:21,940 --> 00:16:26,470
I want you to be thinking about what region is the richest in in Hungary.

157
00:16:27,310 --> 00:16:30,520
Is it in a month? Does it look after account? Is it depression?

158
00:16:30,520 --> 00:16:35,390
Is it what? What region is it in? Carpathian, Carpathia.

159
00:16:35,650 --> 00:16:42,340
So how are we seeing the people with asthma? I wonder if there's people out there who are not getting a knee replacement.

160
00:16:43,000 --> 00:16:46,540
Who would benefit more are the ones we're seeing because of GP's having to offer them.

161
00:16:47,680 --> 00:16:50,980
You see the difference here between value and efficiency.

162
00:16:54,970 --> 00:17:03,400
Now here's the new agenda, which will go through. So the four things that have been done have to continue.

163
00:17:03,580 --> 00:17:08,559
Prevention, evidence based decision making, quality improvement and co-production.

164
00:17:08,560 --> 00:17:14,080
All absolutely essential and must continue. But why were we doing it?

165
00:17:14,380 --> 00:17:20,950
Unwanted variation, overuse and under use have developed. So here are the new the three new things that we need to do.

166
00:17:22,870 --> 00:17:31,690
Number one, ensure that every individual receives information that will help them make the right decision.

167
00:17:33,130 --> 00:17:40,750
And this is the this is the model we we developed and the picture we developed for evidence based medicine.

168
00:17:41,140 --> 00:17:46,490
This is the 1996 editorial evidence based medicine, what it is and what it isn't.

169
00:17:47,200 --> 00:17:50,980
But they can say and said that every idea is a picture.

170
00:17:52,270 --> 00:17:58,720
And we were very much criticised for promoting what they called a cookbook medicine with evidence based medicine.

171
00:17:59,620 --> 00:18:03,440
And I think if we could put a picture in the BMJ editorial, it would be much better.

172
00:18:03,520 --> 00:18:07,540
But editorial editorials don't take pictures.

173
00:18:08,240 --> 00:18:12,970
But here's the picture. So does the evidence derived from the study of groups of patients.

174
00:18:14,440 --> 00:18:22,340
And there's that clearly relation of this patient, this patient who's often very different from the people in the randomised controlled trial.

175
00:18:23,320 --> 00:18:27,370
And it's the other diagnosis, risk factor, genomic information.

176
00:18:27,940 --> 00:18:34,210
And then there's the values this patient does, what value to the place and risk taking.

177
00:18:34,510 --> 00:18:37,960
You know, one in a thousand cataract operation goes wrong.

178
00:18:37,970 --> 00:18:43,830
So what values you place in that, not just a one in a thousand, but the fact some people place a value on,

179
00:18:44,390 --> 00:18:48,850
you know, I wouldn't like to take a decision that might go wrong. I could live with it.

180
00:18:49,790 --> 00:18:53,830
Other people say, oh, Sara, Sara doesn't bother me.

181
00:18:54,820 --> 00:19:03,430
So this is evidence based medicine. And we're now in the third health care revolution.

182
00:19:04,180 --> 00:19:11,200
And the third health care revolution is driven by three forces, citizens knowledge.

183
00:19:11,200 --> 00:19:15,140
And where's my jacket? That's not the search.

184
00:19:15,440 --> 00:19:20,950
No, no, no, no, no, no.

185
00:19:25,010 --> 00:19:28,370
What am I looking for? My phone. My phone.

186
00:19:30,410 --> 00:19:34,430
No, no. Just stay. I better find it in case. Say for me.

187
00:19:35,060 --> 00:19:38,990
Okay. Not good. So the third boat in the third revolution.

188
00:19:38,990 --> 00:19:45,800
And this is if you were all genomic people. This is more important than the human genome.

189
00:19:46,430 --> 00:19:51,499
This will change things more than the human genome. Even even the professor of medicine agrees with that.

190
00:19:51,500 --> 00:19:55,470
No, I think he does think John Bell agrees with it. Thank you, Erica.

191
00:19:55,940 --> 00:20:01,760
The the human genome in me, it's a quiz, you know, producing information.

192
00:20:02,720 --> 00:20:07,160
But it's not that different from biochemical information. But this this changes the power balance.

193
00:20:08,390 --> 00:20:13,760
And it's just we are in the health service in this country, 20 years of the piece and using this.

194
00:20:14,870 --> 00:20:19,850
I still get letters from the hospital on paper and First-Class stamps.

195
00:20:21,080 --> 00:20:25,820
Some hospitals have tried to increase productivity by moving to second class stamps.

196
00:20:26,930 --> 00:20:33,290
But you know what happens when they do that? The letter telling you your appointment is being cancelled arrives after the appointment.

197
00:20:35,180 --> 00:20:38,780
So you people turn up. So where do you come from?

198
00:20:39,170 --> 00:20:42,680
Spain. Spain. And how much is the phone use?

199
00:20:42,680 --> 00:20:52,209
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.

200
00:20:52,210 --> 00:20:55,550
And so some countries are making more progress.

201
00:20:55,570 --> 00:21:02,530
Hungary, the people there's the hospital send letters to people, email will reload.

202
00:21:02,860 --> 00:21:06,190
And so including how much?

203
00:21:06,910 --> 00:21:10,720
How much I think if you'd find out from a family, how much, sure.

204
00:21:10,750 --> 00:21:16,100
I haven't been able to find out in Oxford how much we spend on stamps every year she's spent around the trust.

205
00:21:16,480 --> 00:21:21,040
Over £1,000,000. If only it was emailed around one minute before Christmas.

206
00:21:21,040 --> 00:21:26,950
They did the 12 days of Christmas, the other money, and one of them was converting from first to second class stamps.

207
00:21:27,610 --> 00:21:33,430
Yeah. Yeah. £700,000. Yes. Across a year to convert for the first time, we spend millions.

208
00:21:33,640 --> 00:21:37,940
Oh, yeah. But for Christians having an email. Oh, my God.

209
00:21:37,940 --> 00:21:42,490
They're not. Couldn't do that. I mean, their confidentiality is what someone said to me.

210
00:21:42,920 --> 00:21:46,660
Fine. Well, you have you had a House of Malta occupation. A letter arrives.

211
00:21:47,710 --> 00:21:51,640
So we're in the third revolution, and it's driven by citizens knowledge.

212
00:21:52,330 --> 00:21:55,540
And this, the 20th century was a century of the doctor.

213
00:21:56,260 --> 00:22:01,089
The 21st century is the century of the person we call a patient, the citizen.

214
00:22:01,090 --> 00:22:05,799
The power has changed, not just in health care, but in this.

215
00:22:05,800 --> 00:22:11,280
Is this a man called Manuel Castells Spanish, who writes about the Industrial Revolution?

216
00:22:11,290 --> 00:22:15,040
He doesn't write about health care, but is his work is very relevant to health care.

217
00:22:15,700 --> 00:22:20,170
So here we're in the third revolution, citizens knowledge and the smartphone.

218
00:22:21,340 --> 00:22:28,630
So let's look at the thank you the second.

219
00:22:29,530 --> 00:22:35,470
So that's the first thing we got to do is make sure that individuals really, really understand what the options are.

220
00:22:36,550 --> 00:22:41,440
The second thing is they shift resources from budgets where there's lower value to higher value.

221
00:22:42,880 --> 00:22:53,290
So here's the way we spend money in the health service in England, diabetes, 90 million, gastrointestinal 100 million, respiratory under 30 million.

222
00:22:54,600 --> 00:23:03,780
There's a lot more specialised cancer money, but how much you think we spend on mental health turning off a quarter,

223
00:23:04,210 --> 00:23:17,020
a quarter, twice as much and yep, billion U.S. million pounds per million population, million pounds, 4 million population.

224
00:23:18,160 --> 00:23:21,610
And people are really surprised when you tell them actually spend a minute, maybe it's not enough.

225
00:23:22,690 --> 00:23:30,160
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.

226
00:23:30,460 --> 00:23:36,040
So for start to think about how we shift resources and I'll come back to the point you raised.

227
00:23:36,460 --> 00:23:41,860
Of course many people have more than one health problem and we call this complexity.

228
00:23:43,570 --> 00:23:52,660
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,

229
00:23:53,770 --> 00:23:56,290
standard general practice and a GP's in the room.

230
00:23:57,250 --> 00:24:02,650
GP's are very good at complexity, but when one of the problems goes wrong, they refer to a specialist.

231
00:24:03,670 --> 00:24:11,590
This is not really official language, complexity and complicated, but it's quite useful language I think in terms of of speaking to people.

232
00:24:12,850 --> 00:24:19,059
Now this is the first and it varies from country to country.

233
00:24:19,060 --> 00:24:23,650
Where do you come from? From Brazil. Brazil. And how is how does the money go from the government?

234
00:24:23,950 --> 00:24:28,599
Does it go to regions? Does it or not? Necessarily. It goes from the government to anywhere else.

235
00:24:28,600 --> 00:24:33,070
But the health care is not a priority there right now.

236
00:24:33,100 --> 00:24:38,200
Nobody ever main priority. But I suppose in the US certain some of the government, the Minister of health get money.

237
00:24:38,440 --> 00:24:44,470
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.

238
00:24:45,160 --> 00:24:52,600
And in Spain it's big difference in insurance based countries like Germany and the Netherlands.

239
00:24:52,600 --> 00:24:56,410
So where insurance is in is a little bit different, but it's this.

240
00:24:56,890 --> 00:25:03,430
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?

241
00:25:04,840 --> 00:25:14,230
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.

242
00:25:17,770 --> 00:25:25,090
And Canada, who died last year, a Nobel Prize winner in economics, he developed something called the Impossibility Theorem.

243
00:25:26,530 --> 00:25:34,060
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.

244
00:25:35,020 --> 00:25:42,610
And what's fascinating what's emerging is that that what the public expect is not magic.

245
00:25:43,630 --> 00:25:46,960
They know it's impossible, but they.

246
00:25:47,610 --> 00:25:51,900
They want what Norman Daniels calls accountability for reasonableness,

247
00:25:53,220 --> 00:25:58,170
namely that the government of the state of Sao Paolo had all the different patient groups.

248
00:25:58,350 --> 00:26:03,330
They didn't have any corruption. And they use the evidence in the same way for all the different groups.

249
00:26:03,780 --> 00:26:06,930
Accountability for reasonableness. That's all people are looking for.

250
00:26:07,680 --> 00:26:11,640
And because these are we call these in a conference, we run hellish decisions.

251
00:26:12,390 --> 00:26:16,110
These are impossible decisions of prioritisation and rationing.

252
00:26:16,710 --> 00:26:22,080
Now, interestingly, the second level of allocation is this level.

253
00:26:23,670 --> 00:26:33,420
So once we've given the money to the people of Madrid for respiratory disease, then there's a second level of allocation.

254
00:26:34,290 --> 00:26:39,240
And really, the peers, the ministries of health, they don't have the technical knowledge.

255
00:26:39,660 --> 00:26:50,400
And also what you find is that the variation between these three is so markedly different from one place to another.

256
00:26:51,480 --> 00:26:59,910
So if you go to county, one county, and they've got a very good COPD service,

257
00:27:00,840 --> 00:27:04,590
and then you go three miles down the road and they're very good asthma service.

258
00:27:06,150 --> 00:27:13,890
Why is that? Because in one place they had one clinician who is very good at getting money from the government.

259
00:27:14,100 --> 00:27:17,220
And then 30 miles down the road there, another clinician injured in something else.

260
00:27:18,420 --> 00:27:23,450
So there's often very marked imbalance. And so we are saying this is the clinicians.

261
00:27:23,460 --> 00:27:26,520
You see, if you take this, this is respiratory disease.

262
00:27:27,390 --> 00:27:31,590
Well, there is a new big article. I don't have it with me in The Sunday Times.

263
00:27:31,590 --> 00:27:36,210
A new drug for cystic fibrosis. Looks pretty good to me.

264
00:27:37,110 --> 00:27:40,200
So where's the money going to come from for the new drug for cystic fibrosis?

265
00:27:41,490 --> 00:27:46,350
We don't have any growth money, so it'll have to come from, you know,

266
00:27:46,900 --> 00:27:54,850
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.

267
00:27:55,890 --> 00:28:00,360
So starting at the clinicians to think this way, the clinicians to think this way.

268
00:28:02,160 --> 00:28:12,660
Okay. So just to think of the three new things, firstly, the, the individual patient has to understand.

269
00:28:13,020 --> 00:28:17,730
Secondly, to allocate resources optimally,

270
00:28:18,720 --> 00:28:22,440
the aim should be that the resources are distributed in such a way you could

271
00:28:22,440 --> 00:28:26,280
not get more value by shifting a pound or a dollar from one budget to another.

272
00:28:26,400 --> 00:28:29,790
No one's ever done it, of course, but so-called optimal allocation.

273
00:28:30,030 --> 00:28:34,830
Now, the third level of value is population value.

274
00:28:35,670 --> 00:28:38,490
And we've called this population health care.

275
00:28:39,450 --> 00:28:48,480
So this is health care that doesn't focus on hospitals or primary care or teaching hospitals, but on populations in need.

276
00:28:49,620 --> 00:28:53,220
People with headache, people with asthma.

277
00:28:54,210 --> 00:29:01,780
People in the last year of life. Population, health care. You see in every country I know people.

278
00:29:01,810 --> 00:29:08,880
There's bureaucracies, regions or hospitals or universities or health centres.

279
00:29:09,720 --> 00:29:18,300
And you have to have bureaucracies very important, but only for the linear, simple tasks like the fair and open employment of staff.

280
00:29:19,470 --> 00:29:23,640
Bureaucracies are not good at dealing with complexity. Health care is complex.

281
00:29:24,390 --> 00:29:27,700
Bureaucracies are linear organisations.

282
00:29:27,750 --> 00:29:34,830
Health care is nonlinear. And then we've got these things that you can see self care and formal care, primary, save or tertiary.

283
00:29:35,340 --> 00:29:38,730
So what we've been doing is introducing what we call three D health care.

284
00:29:40,290 --> 00:29:50,579
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

285
00:29:50,580 --> 00:29:56,700
with epilepsy or inflammatory bowel disease or people with multiple conditions.

286
00:29:58,020 --> 00:30:03,870
These are and now another typical Oxford line.

287
00:30:04,560 --> 00:30:07,820
So sure, this is someone who is an academic. He said, oh, yes.

288
00:30:08,910 --> 00:30:14,410
It's quite, quite, quite a good diagram. You are. But you're trying to represent algebra geometrically.

289
00:30:17,370 --> 00:30:20,579
And so there we are. So it is much more complex.

290
00:30:20,580 --> 00:30:25,260
And this is the part they're making, but it's certainly much more complex than this.

291
00:30:26,220 --> 00:30:30,000
This is linear thinking. This is a template.

292
00:30:30,120 --> 00:30:38,550
So you see the sort of problems we see are a bit broken legs on a problem.

293
00:30:39,990 --> 00:30:47,370
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.

294
00:30:47,470 --> 00:30:51,370
The right place. Same as being same as having cancer.

295
00:30:52,270 --> 00:30:59,120
Eventually you get to the cancer hospital. But most of health care is more complex than that, you know, headache and mass, man.

296
00:30:59,830 --> 00:31:06,580
So what you see is that the people receiving the specialist service are not the people who benefit most.

297
00:31:09,590 --> 00:31:13,270
And what we should do is to move and to change the way people think.

298
00:31:14,650 --> 00:31:21,190
So the specialists see people, but they're also thinking about the people they don't see.

299
00:31:22,510 --> 00:31:27,730
I was discussing type two diabetes with a colleague in Ulster University Hospital today,

300
00:31:28,570 --> 00:31:32,500
and I said, How many people have got type two diabetes in Oxfordshire?

301
00:31:33,790 --> 00:31:37,150
And he said, over 24,000 people. I said, What do you mean, 24,000?

302
00:31:37,180 --> 00:31:42,190
He said, Well, that's the ones on our hospital books as well, or ones who are not in the hospital books.

303
00:31:42,310 --> 00:31:46,870
Oh, I hadn't thought about them. And then I said, How many pharmacies are there in Oxfordshire?

304
00:31:48,490 --> 00:31:53,799
Because the pharmacies are seeing people and they don't know much about type two diabetes because it's ten years

305
00:31:53,800 --> 00:31:58,120
since they left university and the people in the hospital know a [INAUDIBLE] of a lot about type two diabetes,

306
00:31:58,120 --> 00:32:06,610
but they're not connecting with the pharmacies. So you're starting to think about the specialist service being a knowledge service.

307
00:32:08,620 --> 00:32:12,820
And the president of Toyota said Toyota is a knowledge business.

308
00:32:14,030 --> 00:32:18,180
They care about that, isn't it? And we're just plastic and steel.

309
00:32:18,190 --> 00:32:24,460
It was, you know, our the people who buy our cars what they like, the people who buy our competitors cars.

310
00:32:24,700 --> 00:32:28,090
They're like, what's the future going to be like for cars?

311
00:32:29,530 --> 00:32:35,349
Has knowledge Toyota the knowledge business and I say to hospital chief exec,

312
00:32:35,350 --> 00:32:39,370
so you're in the real estate business of the knowledge business some I look

313
00:32:39,370 --> 00:32:43,059
a bit funny at me when I ask them because you've got this huge real estate,

314
00:32:43,060 --> 00:32:49,510
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.

315
00:32:50,410 --> 00:32:54,220
But you employ all these clever people, but they don't. Naturally the knowledge isn't being used.

316
00:32:56,560 --> 00:33:03,310
So these systems we all seem to think of, if you had the budget all together and you want to innovate.

317
00:33:04,180 --> 00:33:13,770
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.

318
00:33:13,790 --> 00:33:23,809
For example, we so the threat level of allocation here is we did a view of of COPD and made a decision

319
00:33:23,810 --> 00:33:27,950
to move money from triple drug therapy to smoking cessation and rehabilitation.

320
00:33:30,260 --> 00:33:38,060
You might move money the other way from anti drug therapy, but but the clinicians and the patients together had to make that decision.

321
00:33:39,740 --> 00:33:42,590
The clinicians in the patients together make these sorts of decisions.

322
00:33:42,660 --> 00:33:48,350
So I think the patients should take this decision to this level of the government.

323
00:33:50,390 --> 00:33:58,550
Well, this this this is could be taken locally because they set the service balance might be quite different from one city to another.

324
00:33:59,240 --> 00:34:06,990
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.

325
00:34:07,010 --> 00:34:11,120
Don't campaign for more money for COPD tomorrow.

326
00:34:11,120 --> 00:34:17,870
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?

327
00:34:17,870 --> 00:34:20,150
Yeah, yeah. We can see things that could be done differently.

328
00:34:21,020 --> 00:34:25,700
Tomorrow we'll campaign for more money for COPD, but we know it's got to come from somewhere else.

329
00:34:26,270 --> 00:34:30,530
But we can see. So we get patients involved and they're very reasonable, in my experience.

330
00:34:33,710 --> 00:34:48,450
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.

331
00:34:48,480 --> 00:34:57,120
Population value and personal value. So remember here and Dave, I think I need you out here.

332
00:34:57,220 --> 00:35:02,310
Actually, I'd like you to reproduce the donor body and curve here, Dave.

333
00:35:03,570 --> 00:35:08,640
Is that the the curve here that benefits the benefit and the harm goes in a straight line.

334
00:35:09,030 --> 00:35:20,070
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.

335
00:35:21,000 --> 00:35:24,960
But also as you put more resources in, you start to treat people who are less severely affected.

336
00:35:26,640 --> 00:35:29,440
So, yes, I thank you very much. Big round of applause for.

337
00:35:32,280 --> 00:35:36,930
So when you start, say, cataract operations, you only treat people who really, really go to benefit.

338
00:35:38,040 --> 00:35:43,260
The operation is necessary, then people are less severely affected, but it's still appropriate.

339
00:35:44,880 --> 00:35:50,940
Then it may become inappropriate. And then this is the world which is now entering the medical literature.

340
00:35:50,940 --> 00:35:57,960
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.

341
00:35:58,740 --> 00:36:03,240
Sometimes sometimes a a major operation and, you know, a frail elderly person.

342
00:36:03,300 --> 00:36:06,600
And there's this, of course, you are alluding to, to adhere to.

343
00:36:06,600 --> 00:36:12,720
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.

344
00:36:13,920 --> 00:36:17,210
And so population and personal.

345
00:36:17,220 --> 00:36:22,620
But it's not just people like me think of populations of there's people that you think of individual patients.

346
00:36:23,430 --> 00:36:27,370
These two things hang together. So how are we going to get there?

347
00:36:27,390 --> 00:36:31,280
Let's just finish.

348
00:36:32,490 --> 00:36:40,740
So this is my model of a health service, and I've had 22 reorganisations, most of which have made no difference at all.

349
00:36:42,510 --> 00:36:50,670
And Gandhi said There is no structure that will make bad people good, but the wrong structure can make good people behave badly.

350
00:36:50,680 --> 00:36:56,010
So you have to think about silly things that people do because of the payment system.

351
00:36:57,270 --> 00:37:03,150
But the key thing are systems and culture. So this is what health care looks like in most countries.

352
00:37:04,530 --> 00:37:07,980
You can see it's an archipelago, patients swimming from one to another.

353
00:37:09,090 --> 00:37:15,000
And this is the way we spend the money is five different flows of cash and the health service in England.

354
00:37:15,750 --> 00:37:17,129
Do they speak to one another? No.

355
00:37:17,130 --> 00:37:22,410
If they did speak to another, well, it wouldn't be much difference really, because here they're all defending their own budgets.

356
00:37:23,520 --> 00:37:34,350
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.

357
00:37:35,160 --> 00:37:44,400
Sometimes you need super specialist care and, you know, cancer or radiotherapy or post surgery for inflammatory bowel disease.

358
00:37:44,520 --> 00:37:50,250
So it's five box, a bit like a Russian doll. It's not the archipelago, it's integrated said.

359
00:37:51,480 --> 00:38:00,690
It's a system. The system looks like I said, knowledge just flows back all the time.

360
00:38:00,810 --> 00:38:04,860
And then it's an open system you're very much affected by.

361
00:38:05,670 --> 00:38:09,660
You know, for example, I don't know if you saw in the, the, uh,

362
00:38:09,990 --> 00:38:15,540
the news this morning about a company called Carillion employs 400 people in the Oxford Hospital.

363
00:38:16,230 --> 00:38:19,890
So something happens, you know? [INAUDIBLE] it, something's happened. Yeah.

364
00:38:20,520 --> 00:38:24,990
So it's an open system. It's where we can't. We're not in control of a closed system.

365
00:38:25,840 --> 00:38:31,260
And this is what a system looks like. Objectives, criteria and standards.

366
00:38:31,530 --> 00:38:36,780
So this is something I did about 15 years ago, a quite, quite difficult sickle cell.

367
00:38:37,740 --> 00:38:44,310
And one of the objectives and how we remeasure it and what are the standards?

368
00:38:45,510 --> 00:38:49,800
Objectives, criteria standards is we're a population.

369
00:38:50,460 --> 00:38:54,470
Don't worry about whether it's a hospital or health centre or primary care or secondary care.

370
00:38:55,020 --> 00:39:05,940
It's an obsession with sickle cell disease. So we move from this to this and the 20th century professor.

371
00:39:06,240 --> 00:39:10,559
Consultant. GP 21st century professor consultant.

372
00:39:10,560 --> 00:39:20,040
GP Pharmacist patient it's a network century, a network century, the 20th century of the century of the hierarchy.

373
00:39:20,640 --> 00:39:25,800
The 21st century is the centre of the network and finally culture.

374
00:39:26,880 --> 00:39:31,950
And usually the management theorists would envisage structures maybe 10%.

375
00:39:32,880 --> 00:39:36,660
That leaves 90%, then systems 40% and culture.

376
00:39:36,740 --> 00:39:45,889
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.

377
00:39:45,890 --> 00:39:51,590
And your job is is to get the culture, the culture of stewardship or the culture of collaboration.

378
00:39:52,280 --> 00:39:58,490
These are cultural changes, and sometimes images are good.

379
00:39:59,660 --> 00:40:07,100
And so if if you were all doctors and nurses and quarrelling with one another and say,

380
00:40:07,100 --> 00:40:11,210
this is the most this is the most effective, it's a complex, adaptive system.

381
00:40:12,170 --> 00:40:20,930
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.

382
00:40:21,260 --> 00:40:25,579
It's a complex adaptive system. They are the sort around.

383
00:40:25,580 --> 00:40:31,010
So I'm trying to get one over the workarounds. And and the queen doesn't tell them what to do.

384
00:40:31,040 --> 00:40:34,880
What does the queen undo? Lays eggs.

385
00:40:35,570 --> 00:40:40,970
It's not a bureaucracy in any way, communicating all the time a very clear sense of mission.

386
00:40:41,780 --> 00:40:50,209
And in that, there's a fantastic book in the Ants by whole novel and Wilson and £177.

387
00:40:50,210 --> 00:40:57,770
But I bought it once. Margaret Lichfield has a chapter on altruism, the ants give up the life for the good of the colony.

388
00:40:59,390 --> 00:41:02,780
I don't think we're asking you yet to give up your life for the good of the health service.

389
00:41:02,780 --> 00:41:14,120
But you never know. It might have to come, but you already have your SO to create a new language and new culture.

390
00:41:14,870 --> 00:41:20,510
There is partly the behaviour of the leadership, how they relate to one another, but it's also a language.

391
00:41:21,440 --> 00:41:26,720
So we we spend a lot of time as a doctor of course thinking about language.

392
00:41:27,440 --> 00:41:39,739
And I so the new language value system network pathway program to the poor, the respiratory program has good systems for asthma,

393
00:41:39,740 --> 00:41:45,230
for COPD, for sleep apnoea, for cystic fibrosis program system, network pathway.

394
00:41:45,890 --> 00:41:49,730
And then sometimes you've got to try and ban all language.

395
00:41:50,000 --> 00:41:57,050
So I don't like primary and secondary and I don't like manager if I don't like the manager.

396
00:41:57,740 --> 00:42:02,570
Oh sorry. You're a lousy clinicians to hate the manager.

397
00:42:04,610 --> 00:42:09,980
So are you a clinician and your day job? Yeah. So, yeah, but not yet you see.

398
00:42:10,250 --> 00:42:16,540
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.

399
00:42:16,540 --> 00:42:24,920
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.

400
00:42:26,510 --> 00:42:31,520
The social world is created by language. This is a man called John Settle.

401
00:42:31,520 --> 00:42:36,260
If a lot of our language doesn't describe reality, language creates reality.

402
00:42:38,210 --> 00:42:40,430
So this day,

403
00:42:42,740 --> 00:42:51,649
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.

404
00:42:51,650 --> 00:42:57,890
So these are the new set of skills where we would like the leadership evidence and value based health care.

405
00:42:58,640 --> 00:43:04,490
So just let's finish touch your neighbour for 2 minutes and think about how, if any way,

406
00:43:05,270 --> 00:43:12,920
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.

407
00:43:13,280 --> 00:43:20,160
They spend a couple of minutes thinking and then we can go, Dave, can we offer a reception and yes.

408
00:43:20,330 --> 00:43:23,510
Discuss those on the programme. Yeah. Yeah.

409
00:43:23,930 --> 00:43:29,810
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.

410
00:43:29,900 --> 00:43:34,070
Okay. 10 minutes with your neighbour to reflect on what I've been saying and how it might

411
00:43:34,070 --> 00:43:39,470
change the way you when you would walk when you go back to the end of this week,

412
00:43:39,680 --> 00:43:46,819
okay, couple of minutes with your neighbour and of course there are very practical things like they when I came

413
00:43:46,820 --> 00:43:53,660
here there was one rheumatologist and there's over nine and there was one practice just near the hospital.

414
00:43:53,660 --> 00:44:02,719
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.

415
00:44:02,720 --> 00:44:10,550
Why not? Why not? Why do we have lunchtime meetings with GP's and they're parking, car parking.

416
00:44:11,720 --> 00:44:16,850
Yeah. That's a completely impossible. You can organise, it could be completely impossible to get but 4 hours to get there.

417
00:44:16,850 --> 00:44:21,980
And have you tried to talk to John Radcliffe ever. Don't, don't know about.

418
00:44:22,430 --> 00:44:30,160
Yes we now say to patients that they were notified a car parking space so we we are different

419
00:44:30,170 --> 00:44:34,310
but we have to think in a different way just if Dave and I are working in something.

420
00:44:36,720 --> 00:44:46,230
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?

421
00:44:46,240 --> 00:44:49,770
And so one brand is health is what you do for yourself, not.

422
00:44:50,220 --> 00:44:54,210
We deliver professional health services, but health care is what you do for yourself.

423
00:44:55,560 --> 00:45:00,480
Don't tell my wife. Why not say I'm from Glasgow? Health care is what you do for yourself.

424
00:45:03,810 --> 00:45:04,950
So we are. Thank you. We are.

425
00:45:04,950 --> 00:45:13,710
Well, we have launched an activity therapy service that everyone's long term condition will be given activity and prescriptions.

426
00:45:15,120 --> 00:45:22,649
So before you get metformin, you either get three months of exercise, the Mediterranean diet, most people will probably still need metformin.

427
00:45:22,650 --> 00:45:28,770
But the signal we send you by just giving you a pill or hypercholesterolaemia here's a pill,

428
00:45:29,070 --> 00:45:32,880
but you need the PSA to help you get a hold of the press are pressure.

429
00:45:33,010 --> 00:45:38,550
We're getting the press. I'm very much criticised by my public health colleagues for writing The Daily Mail.

430
00:45:39,720 --> 00:45:44,700
But I have to point out to them that writing The Guardian is not going to solve the problem of health inequalities.

431
00:45:45,600 --> 00:45:54,990
And no, it will raising the flashpoint term and it's broadening it out from health care that when we launched a walking app,

432
00:45:55,080 --> 00:46:05,790
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

433
00:46:05,790 --> 00:46:11,699
to walk briskly tells you how much brisk walk you're doing and we we said it's an environmental problem.

434
00:46:11,700 --> 00:46:20,100
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.

435
00:46:20,820 --> 00:46:24,870
And they're the papers that usually criticise us and that it's called nanny state.

436
00:46:25,500 --> 00:46:32,220
And the public reaction to what people like me say but they get is this life typically their commuting,

437
00:46:32,250 --> 00:46:36,000
commuting for an hour and sitting for 9 hours and then commuting for an hour at home.

438
00:46:36,330 --> 00:46:41,070
So Dave and I are saying it's not just medicine.

439
00:46:42,390 --> 00:46:44,340
It's it's what you do for yourself.

440
00:46:45,120 --> 00:46:51,960
Basically, I just had Dave, there's a trial of chemotherapy, most controlled trials of chemotherapy and St Thomas Hospital.

441
00:46:52,650 --> 00:47:01,440
And the people who got chemotherapy and exercise finished the course of chemotherapy and the ones who got chemotherapy without exercise,

442
00:47:02,520 --> 00:47:08,370
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.

443
00:47:08,700 --> 00:47:12,270
Okay. Nice to meet you all. Thank you for coming to Oxford. Those who come.