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The future is not a destination like Tasmania or the North Pole.

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The future of something like the Great Western Railway or the Sydney Harbour Bridge that we imagine plan and build.

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If we don't do it, other people will do it. So it's your job to make the future.

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And I'm going to tell you about the future. My views of the future and share these views with you.

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And I can tell you about the future with confidence, not because of vision.

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Vision. Get your get your either psychiatric referral or sainthood, but in the wonderful words of William Gibson.

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The future is here. It's just not evenly distributed. The president of Toyota said Toyota has a knowledge industry either as a car business.

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He said Knowledge business. So if Toyota's a knowledge business and should a health care and knowledge business were in the knowledge business,

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I find it helps to think of a revolution. And this is a revolution we're in the middle of a revolution is the third revolution in health care.

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The first revolution was a revolution based on epidemiology.

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This is the. I'm sure you recognise the cholera map from Soho.

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Have you been to the pub in London? There's a pub called the John Snow somewhere about about here.

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And he didn't know what caused cholera, but he knew something in the water and not some in the air.

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Ricciardo didn't know. Ricciardo looked out the window in Gower Street, which is beside UCL,

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and he thought that it wondered does the internal combustion engine cause lung cancer?

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He says Go back to 19 1950s.

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But he didn't know what caused lung cancer in tobacco smoke when he died.

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Then the second revolution, the last 50 years I've been 40 years graduated.

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We've seen the most amazing changes take place in health care.

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And these are the same you know, this was done by scientists.

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By who? Who are the engineers here? Yeah, this was done.

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This is engineering, you know, physics, chemistry. This is voted the the operation of the century.

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So this is heavy, heavy metal science here, bench science working with doctors.

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But I remember we also invented these things in the last 50 years.

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So the second health care revolution has been fantastic. But.

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After 50 years of progress, every health service in the world still has these five problems.

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At the top of the slide there problems of quality of safety, waste of resources, health inequalities, and failure to prevent the preventable.

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Furthermore, in the 21st century, we have these challenges coming.

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Rising need and expectations. Climate change.

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Climate change will affect some countries very quickly, very directly.

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And it will affect every country, health care and every country affected by climate change.

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So we need to think about these challenges. And it may well be that the carbon constraints are more important than the financial constraints.

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I speak a lot to clinicians and if you are all the the rheumatologists in England or in Europe,

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I'd be saying to you, ladies and gentlemen, there is no more money.

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In fact, there's probably going to be less money. That's going to be a lot less carbon.

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The carbon footprint of health care has to fall by 80% from 1997 levels, and that means 90% from here.

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So you guys, I run a campaign for better health care, and I'd love you to come up to our campaign.

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We need to think of the transformation of clinical practice. I just mentioned the carbon.

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I didn't know we're going to have engineers in the audience, and even if we switched to renewable energy completely,

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we would still not achieve our target because most of the carbon is spent in travel, drugs and equipment to have to change clinical practice.

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And that requires technology and new pathways.

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So these people are no role or remembered of the campaign for being in health care.

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It's just two miles up the road, so be good to meet you. Manuel Castells is Spanish.

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He wrote a big three volume book called The Network Society.

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And the network society says this.

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We're in the middle of a third industrial revolution, and the third industrial revolution is driven by these three forces.

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It's out of control of politicians and managers.

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Now the third revolution is affected, mostly banks and building societies and travel agents.

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It's just that we are too slow in the health service to make use of this and this.

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And we we don't recognise the power of these people here.

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And even then, even of course, in England, we're not citizens.

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We are subjects. You know that, don't you? You're only citizens in a republic.

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But so citizens information and knowledge.

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And I'll speak a little bit about some of these issues and then we'll have some discussions. They just didn't find the language I'm going to use.

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Knowledge is the sum of all that is known. And the Oxford English Dictionary.

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And I find it helpful to think of two types of knowledge. General knowledge.

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Which is generalisable wherever you are in Spain and England and Africa.

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And particular knowledge. And three types of generalisable knowledge.

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Knowledge from research we call evidence. Knowledge from the analysis of routinely collected data, recall stats and knowledge from experience.

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The knowledge that actually is least well organised now is knowledge from experience.

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And we're not seeing enough sharing of knowledge. So for the 21st century, what do we need to do?

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Very simple. Health care is very simple. We need to do the right things.

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And every year do them better, safer, greener and cheaper.

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Okay, that's what we have to do. And I'm just launching a new project in the Department of Health,

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and I've been given I'm the washroom lead for doing the right things, doing the right things, not doing things right.

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We have to do it, doing things better, but doing the right things.

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And most of what you're doing, the course here is about the right things to do, either as a clinician or manager up here.

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So I'm going to just speak about four bits of work that we're doing here that are relevant to knowledge.

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Number one, professionals and patients need clean, clear knowledge, just as any crinkly water.

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And the 19th century health was transformed by clean, clear water.

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In the 21st century, health will be transformed by clean, clear knowledge.

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What? I mean look clear. But be polluted and poisonous. This.

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This is the type of knowledge that most people have. You see, I'm using the metaphor now.

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I'm not going to say I'm talking about knowledge, but this is what most people in England still get their water like their knowledge like this.

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So what are we trying to do? Firstly, we can teach people critical appraisal skills.

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This is a little filter you can buy to filter out your diocese JDA But really it's much better to give people clean, clear water.

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And the way we give people clean, clear water as we start off by collecting in reservoirs and this is the reservoir for my home city of Glasgow.

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Why do we have reservoirs? What's the function of a reservoir?

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Engineers. Why do we have reservoirs? Stillwater to Stillwater and.

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Yes. How does it treated in a reservoir? So that said, the rubbish sinks to the bottom.

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So if a sheep dies here, it rolls in.

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And that's why people do not need the latest evidence.

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John, I already showed a third of all randomised trials that invalidated that right poll within a year of 14 out of 47 or something,

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randomised trials or were weakened or proved wrong within a year because of publication bias.

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I'm sure you're studying publication bias.

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So we gather the evidence and then we the next stage is to filter it filtering like Cochrane reviews systematically as a form of filtering.

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You take the rubbish out and you can examine the rubbish, but it's there and then we, we send this is, this is what I think the internet looks like.

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It's big pipes up in the sky somewhere. I mean, that must be how it works.

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You and the knowledge flows through these pipes and gets into smaller pipes.

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So but the big issue is the water.

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The knowledge can get to the door or the hospital or the health centre.

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But how does how does knowledge appear?

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How does water appear in the fourth floor of a hospital? Well, this is not for engineers.

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They know all about this, not engineers. How does water come out of a tap in the fourth floor of a hospital?

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One word is coming to your mind over this. Pressure.

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So we've we've introduced something called a chief knowledge officer in every health care organisation.

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We've said there should be someone at the board level who's responsible for knowledge.

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And I'm the chief knowledge also for the NHS. I was given the job with no resources apart from authority.

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So you need someone on the board of every health care organisation who's responsible.

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Ian Chalmers once said, who's responsible for pressing the what's new button in the Cochrane Library?

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And saying to the chief exec, Here's three things we should start and two things should stop.

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The answer is nobody. Everywhere you look, it's just so everyone acknowledges everybody's on the Internet.

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It's in the library. You need to manage knowledge like you manage money and water.

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So we now have all but 60% of all our health care organisations have someone who says, I'm the chief knowledge officer.

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The first thing you do, of course, a chief knowledge officer, is you say, Well, I need support, I need a librarian.

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And they say, Oh, we don't you know, we don't have any money for librarians who will close the library at 3:00.

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Your libraries and libraries. Not more than half a day, anyway.

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Yeah. I need the librarian here planning the guidelines or on the water in the boardroom.

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So the Chief Knowledge Officer is a role as it's a responsibility, not a job.

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Again. This is a phrase I use often. Ignorance is like cholera.

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They kind be controlled with the individual alone. It requires the organised efforts of society.

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And this, this of course is the definition of public health services, the organised efforts of society.

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Okay. So that's the. The first point.

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Now, here's the second way of of getting knowledge and into operation.

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Why is it I ask my colleagues who are in senior positions?

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Why is it we know to the nearest pound? How much we spend on the health centre in Beaumont Street or the Oxford Hospital,

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and not to the near 100 million how much we spend on heart failure or depression or rheumatoid arthritis.

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What business are we in with the business running buildings?

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Are we in the business of dealing with headache and rheumatoid arthritis and bronchitis?

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And the answer, of course, is core business are health problems like presentations and conditions.

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No country I know has any idea. I believe some business of that program budgeting.

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We now have program budgeting. But for example, I know we spend £4 billion on respiratory disease.

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Plus or -300 million. But when you actually see, well, how much is spent on asthma and how much was spent in chronic bronchitis.

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Then we've still got a budget saying £2 billion other.

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We have no idea how much has been a slip up. Neo and no other country.

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No, no in history. But the next stage is to create program budgets and then create systems.

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Now these are three words which are the words of the 21st century.

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The 20th century was the century of the doctor and the hospital.

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The 21st century is a century of the patient. The system and the system is a set of activities with a common set of objectives.

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And you people, of course in engineering will be very familiar with systems and a network is a set of organisation individuals

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who deliver the system and a pathway the route that most patients follow through the network systems,

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networks, pathways, knowledge systems, networks, pathways.

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That's what we were. I mean, I know you do lots of numbers and evidence based medicine, but it's really language, it's words that change things.

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So here's an example of a system. This was developed by Alice in St Louis, and she got involved in a problem with what's called blood spot screening.

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It's about a blood taken on the heel of a newborn and there's a mix up.

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And she said, Look, this is chaos. Most of health care is Brownian motion.

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The random movement of patients, clinicians and samples.

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And it took her maybe five years to do this. Sickle cell disease, very complicated.

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Lots of different ethnic groups, different carrier states, very complex.

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But there. Objectives. Criteria standard.

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So we now know what we're trying to do and we can now measure progress or the lack of it and compare it with standard.

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Here is a pathway, and this is software called the map of medicine.

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And this is very simple. This is a breast cancer assessment.

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And we give this to women. So that women can find out their path.

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You know, if you're a breast cancer specialist, you don't need this.

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If you drive from Oxford to Banbury every day, you read the map of Oxford at Banbury.

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But if you're driving to Exeter for the first time or you haven't driven to excel for some time,

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or if it may, maybe roadworks or something, you as happened, you need a map.

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This is called the map of medicines, a software. It was developed and I was involved in it, say,

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from its earliest days and funding it because it just seemed to me this is something very powerful and you

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start to put in here and this links in here to Cochrane reviews you can start to put in things here like,

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like telephone numbers of clinics and a whole variety of, of local stuff.

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But it's technology. It's very simple sort of.

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Now I mentioned networking. And you see, the 20th century was a centre of the bureaucracy and the hierarchy.

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The 21st century is essentially a network. And is it a nice.

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This is a very important book, actually, Clayton Christiansen's book.

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And he's written most of it, Engineering and The Innovator's Dilemma, as you may know.

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And the subtitle of The Innovator's Dilemma is When New Technologies Cause Great Companies to Fail.

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For example, he said, Oh, personal computers are a sort of passing fad, doesn't exist anymore.

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When hydraulic pumps come in, a number of our digging companies said, well, hydraulics, what's that?

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You know, we'll use them to drive the the wires a bit faster.

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Don't exist anymore. He's written this vanishing book with two doctors called Individuals Prescription and Networks.

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It's people working together who trust one another. And of course, with the Internet that has really created made it much easier to work in networks.

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But networks exist long before the Internet, and we need to think of ways in which we use networking.

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You see, it's often an alternative to either markets or hierarchies.

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Transactions, transactions are quoted and controlled on a mutually agreed basis.

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This is a very good definition. This is one of the classic books in an organisation.

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We can give you all these references and things. So in the 20th century, we did this.

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And the 21st century, we've moved to this. It's not hub and spoke.

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We're not letting the teaching hospital say, well, we the centre centre, I think.

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No, actually I am. I've said this to Paul that if I were creating, I was in the position I was in many years ago with the evidence based medicine.

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I would not have called it the Centre for Evidence based Medicine that I call it the evidence based medicine programme at Oxford.

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Just just at Oxford. So it could be at Barcelona or it could be, you know, for Spain or it could be, you know, the just to say the language.

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Very important. Neither is it. A market, nor is it one blob taking over the others.

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You see, the the you see you have to have hierarchies, bureaucracies to manage money and employ people.

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But hierarchies cannot solve complex problems. Only this can solve complex problems.

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Supposing I was discussing today the epilepsy in London, and my guess is spent about to £50 million in epilepsy in London.

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No one's got an idea what's happening. So how would you how would you make epilepsy care better?

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One way is to say, well, well, you know, we'll get the chief executives and they'll tell the people under them and they'll tell them it doesn't work.

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Too complicated, too complex. These are what's called complex adaptive systems.

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So what you want to do is get all the people with epilepsy and parents and people like teachers of learning disabled

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children together because half of learning is disabled children have epilepsy and you get neurologists and GP's and you say,

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okay, let's spend a day just talking about epilepsy and you know, what are the problems and what we can do about it.

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And solutions will emerge not from command and control but through networks.

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And you see these people. Someone said to me, what you need to create a network of for rheumatoid arthritis in London, in the north of London.

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I said, you need you need to have a professor of neurology who believes that he or she is no more important than a pharmacist.

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And in Welwyn Garden City or a GP in Camden or a patient in Islington.

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So if a patient doesn't take the medicine, the patient is at least as important as the professor.

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She's a different type of important. This is this is revolutionary stuff, of course.

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Networks are revolutionaries different from that.

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And just this issue of creativity is a very, very good book called The Knowledge Creating Company that I think the engineers,

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if you're going into innovation and this how the Japanese industry creates new things.

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It creates networks cutting across organisations.

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It's got a very firm bureaucracy, but it's creates these networks.

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That's how the bread making machine was developed over the other.

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So the Lexis, you know, these are you can encourage creativity by bringing together these networks.

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You make them what they call hypertext organisations. Okay, now the third thing, the patient, the citizen.

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Now imagine I've got familial hypercholesterolaemia. This is the way it will be.

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I get reminders by my phone. Why is it someone said that my hairdresser can send me reminders but not the NHS?

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Very good question. And then the lab result comes to me.

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I might just slip this into our recent review. And so the lab result comes to me in something like this.

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And here's an example of what the lab results will look like.

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And it says, Cholesterol unchanged.

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It says, look, this last test was only done 12 months ago.

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If you, your doctor send other tests, we're going to check it out. And it says, here, you see, the first test is increase the amount you walk.

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Try to walk an extra 30 minutes a day to find a big dog.

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Click here and. You see the lab is my post code the labs at Google and this is this is like this is in Abingdon.

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That's in Abingdon. That's six miles from here. Very simple, isn't it?

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Does it happen? Not at all. You see, 150 million lab reports are sent out, usually on paper or electronically to GP's.

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So then I've got to drive to the health centre or take a morning off work or phone up or something.

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Of course this issue with doctors. Many doctors will immediately say, well, I can think of a patient who doesn't want it that way.

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Okay. Well, I can think of 30 million who do. So they start with 30 million.

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You do another 20 million a year and you'll have to for them, operate them or do something.

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But yeah, that would probably save, you know, 30 million visits to the doctor every year.

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600 million prescriptions, the same thing. Now, here's patients.

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This is something I helped a young doctor start, which is proved very interesting, very controversial.

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I want great care and it's very simple.

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It's providing ratings on feedback, on on services.

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And we start off with giving ratings and doctors, which the BMA didn't like.

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But everything's rated these days. You know, there's a there's an article in the Atlantic Monthly if it moves rated,

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you know, and in America, kids are rating a schoolteacher in the USA.

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So you maybe maybe rating me at the moment I you on your right. But increasingly, we're turning this into what's called co-production.

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That if patients are having their time wasted, should it professions are wasting their time.

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My wife went to pick up some from hospital, took her about 4 hours to take them home and get a prescription.

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Well, it wasn't like her time was being wasted.

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You know, it's just the most the clinician say I was always like this, you know, no, no, we can't do it that way.

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She said, Well, can you why can't you write a prescription or it's not possible, you know.

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And so the idea I've now started to think a lot more about citizens, a good a good experience for patients is, is not only an end, it's a means.

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Is crowdsourcing is the jargon, one of the very clever young people who I worked with on this.

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He said to me, Oh, crowd sourcing. That's a very 2009 concept.

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It was that thing. InnoCentive is the innovation website, the innovation competitions, and these are things people produce,

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have problems up on the web for other people to solve, either with rewards or without rewards.

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And a lot of brainpower out there doing these things that, of course, Amanda's think, well, idea is very similar.

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The last thing effectiveness and cost effectiveness are 20th century concepts, which are equally valid.

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But in the 21st century, we need to think of values.

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And this is my very simple model, which stands me stood quite well over ten years when speaking to clinicians.

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For example, there's the evidence, the clinical condition of this patient and the values of this patient and.

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And this is what what Peter Rothman calls personalised medicine here,

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how you relate that and decision support, of course, tries to do this not very well,

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but increasingly we'll see a decision support system of trying to relate the evidence to my particular clinical situation.

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So that's a computerised decision support system. And then when we think of populations, there's a similar model.

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So the evidence about breast cancer screening is the same in Hong Kong as in England.

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But because breast cancer is much less common in Hong Kong, they decided not to implement breast cancer screening.

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I think they have no because of a value decision. And it's very important to remember that politicians can make any decision they want.

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Values Trump Evidence. In a democracy.

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A U.S. officials, as you will be, name a people paid to give advice.

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You've got to live with that and you have to know what your point of resignation is.

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But the minister, when I dealt with scrutiny of the minister, wanted to introduce prostate cancer screening against my will.

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My advice was, don't do it. But the politicians, if they felt well, men are very concerned about this and they feel it makes it less anxious.

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And they meet lots of men who have had a PSA test and I'm still alive.

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Therefore it must work and I haven't persuaded them. Then it's values trump evidence.

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You just have to decide whether you can live with it or not. Values Trump evidence.

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They are very good writing. But this is a book by Marc Mauer called Creating Public Value, not about health care, about how we do these things.

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And finally say, this is the the charity I run called the Campaign for Health Care.

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And I'm hoping that many of you will come in and work with me.

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Certainly, I'd love to see the engineers and talk about the sort of problems we're facing.

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But these problems are going to be we've finished with a just to say a word about sustainability,

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because climate change is the major challenge that health faces in the 21st century.

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And sustainable health care equals sustainable estates and facilities.

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Plus sustainable clinical practice in clinical practice in the 21st century will have four features.

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Every clinician will be involved in prevention because prevention is the best

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thing to do for preventing the reducing the carbon footprint of health care.

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Secondly, patient centred care put the patient at the centre of everything.

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Not for moral reasons, but for practical reasons. Thirdly, leading pathways.

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There are millions of follow up visits for which there is no evidence.

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So let's rip those out and reduce the pathway.

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And fourthly, a balancing one of low carbon treatment options, online psychotherapy as opposed to drugs.

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And so we'll see how technology in future we'll have to assess the carbon footprint of technology as well as the financial cost.

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And I mean, to discuss that with you guys as you're starting to think about both the direct carbon costs of what you're

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designing and the indirect carbon costs or the indirect carbon savings of the number of visits reduced.

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My friends at Public Health and am in North Yorkshire, which are very big parts of England and the NHS staff,

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never mind the patients drove 16 million miles last year. And one out of 152 primary care trusts has a lot of copper.

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So we have to find solutions to that. So that's the future.

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The and these are the four principles about knowledge.

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There's lots of other things to think about. For example, how do you develop payment systems that encourage good behaviour?

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Because the payment system we've got at the moment encourages bad behaviour, namely more hostile admissions.

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And these are for ideas, for managing knowledge.

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I'd like you to turn to your neighbour. Remember, I've only spoken about a part of the future, primarily concerned with knowledge and sustainability.

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I'd like you to reflect on what I've been saying and come up with other ideas

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about how the 21st century health care will be different from 20th century.

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I will take some feedback. Okay, so 2 minutes to discuss this with someone else and then we'll have 10 minutes to take feedback.

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Okay, starting now. Keep the lights up, please.