The future is not a destination like Tasmania or the North Pole.
The future of something like the Great Western Railway or the Sydney Harbour Bridge that we imagine plan and build.
If we don't do it, other people will do it. So it's your job to make the future.
And I'm going to tell you about the future. My views of the future and share these views with you.
And I can tell you about the future with confidence, not because of vision.
Vision. Get your get your either psychiatric referral or sainthood, but in the wonderful words of William Gibson.
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.
He said Knowledge business. So if Toyota's a knowledge business and should a health care and knowledge business were in the knowledge business,
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.
The first revolution was a revolution based on epidemiology.
This is the. I'm sure you recognise the cholera map from Soho.
Have you been to the pub in London? There's a pub called the John Snow somewhere about about here.
And he didn't know what caused cholera, but he knew something in the water and not some in the air.
Ricciardo didn't know. Ricciardo looked out the window in Gower Street, which is beside UCL,
and he thought that it wondered does the internal combustion engine cause lung cancer?
He says Go back to 19 1950s.
But he didn't know what caused lung cancer in tobacco smoke when he died.
Then the second revolution, the last 50 years I've been 40 years graduated.
We've seen the most amazing changes take place in health care.
And these are the same you know, this was done by scientists.
By who? Who are the engineers here? Yeah, this was done.
This is engineering, you know, physics, chemistry. This is voted the the operation of the century.
So this is heavy, heavy metal science here, bench science working with doctors.
But I remember we also invented these things in the last 50 years.
So the second health care revolution has been fantastic. But.
After 50 years of progress, every health service in the world still has these five problems.
At the top of the slide there problems of quality of safety, waste of resources, health inequalities, and failure to prevent the preventable.
Furthermore, in the 21st century, we have these challenges coming.
Rising need and expectations. Climate change.
Climate change will affect some countries very quickly, very directly.
And it will affect every country, health care and every country affected by climate change.
So we need to think about these challenges. And it may well be that the carbon constraints are more important than the financial constraints.
I speak a lot to clinicians and if you are all the the rheumatologists in England or in Europe,
I'd be saying to you, ladies and gentlemen, there is no more money.
In fact, there's probably going to be less money. That's going to be a lot less carbon.
The carbon footprint of health care has to fall by 80% from 1997 levels, and that means 90% from here.
So you guys, I run a campaign for better health care, and I'd love you to come up to our campaign.
We need to think of the transformation of clinical practice. I just mentioned the carbon.
I didn't know we're going to have engineers in the audience, and even if we switched to renewable energy completely,
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.
And that requires technology and new pathways.
So these people are no role or remembered of the campaign for being in health care.
It's just two miles up the road, so be good to meet you. Manuel Castells is Spanish.
He wrote a big three volume book called The Network Society.
And the network society says this.
We're in the middle of a third industrial revolution, and the third industrial revolution is driven by these three forces.
It's out of control of politicians and managers.
Now the third revolution is affected, mostly banks and building societies and travel agents.
It's just that we are too slow in the health service to make use of this and this.
And we we don't recognise the power of these people here.
And even then, even of course, in England, we're not citizens.
We are subjects. You know that, don't you? You're only citizens in a republic.
But so citizens information and knowledge.
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.
Knowledge is the sum of all that is known. And the Oxford English Dictionary.
And I find it helpful to think of two types of knowledge. General knowledge.
Which is generalisable wherever you are in Spain and England and Africa.
And particular knowledge. And three types of generalisable knowledge.
Knowledge from research we call evidence. Knowledge from the analysis of routinely collected data, recall stats and knowledge from experience.
The knowledge that actually is least well organised now is knowledge from experience.
And we're not seeing enough sharing of knowledge. So for the 21st century, what do we need to do?
Very simple. Health care is very simple. We need to do the right things.
And every year do them better, safer, greener and cheaper.
Okay, that's what we have to do. And I'm just launching a new project in the Department of Health,
and I've been given I'm the washroom lead for doing the right things, doing the right things, not doing things right.
We have to do it, doing things better, but doing the right things.
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.
So I'm going to just speak about four bits of work that we're doing here that are relevant to knowledge.
Number one, professionals and patients need clean, clear knowledge, just as any crinkly water.
And the 19th century health was transformed by clean, clear water.
In the 21st century, health will be transformed by clean, clear knowledge.
What? I mean look clear. But be polluted and poisonous. This.
This is the type of knowledge that most people have. You see, I'm using the metaphor now.
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.
So what are we trying to do? Firstly, we can teach people critical appraisal skills.
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.
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.
Why do we have reservoirs? What's the function of a reservoir?
Engineers. Why do we have reservoirs? Stillwater to Stillwater and.
Yes. How does it treated in a reservoir? So that said, the rubbish sinks to the bottom.
So if a sheep dies here, it rolls in.
And that's why people do not need the latest evidence.
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,
randomised trials or were weakened or proved wrong within a year because of publication bias.
I'm sure you're studying publication bias.
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.
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.
It's big pipes up in the sky somewhere. I mean, that must be how it works.
You and the knowledge flows through these pipes and gets into smaller pipes.
So but the big issue is the water.
The knowledge can get to the door or the hospital or the health centre.
But how does how does knowledge appear?
How does water appear in the fourth floor of a hospital? Well, this is not for engineers.
They know all about this, not engineers. How does water come out of a tap in the fourth floor of a hospital?
One word is coming to your mind over this. Pressure.
So we've we've introduced something called a chief knowledge officer in every health care organisation.
We've said there should be someone at the board level who's responsible for knowledge.
And I'm the chief knowledge also for the NHS. I was given the job with no resources apart from authority.
So you need someone on the board of every health care organisation who's responsible.
Ian Chalmers once said, who's responsible for pressing the what's new button in the Cochrane Library?
And saying to the chief exec, Here's three things we should start and two things should stop.
The answer is nobody. Everywhere you look, it's just so everyone acknowledges everybody's on the Internet.
It's in the library. You need to manage knowledge like you manage money and water.
So we now have all but 60% of all our health care organisations have someone who says, I'm the chief knowledge officer.
The first thing you do, of course, a chief knowledge officer, is you say, Well, I need support, I need a librarian.
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.
Your libraries and libraries. Not more than half a day, anyway.
Yeah. I need the librarian here planning the guidelines or on the water in the boardroom.
So the Chief Knowledge Officer is a role as it's a responsibility, not a job.
Again. This is a phrase I use often. Ignorance is like cholera.
They kind be controlled with the individual alone. It requires the organised efforts of society.
And this, this of course is the definition of public health services, the organised efforts of society.
Okay. So that's the. The first point.
Now, here's the second way of of getting knowledge and into operation.
Why is it I ask my colleagues who are in senior positions?
Why is it we know to the nearest pound? How much we spend on the health centre in Beaumont Street or the Oxford Hospital,
and not to the near 100 million how much we spend on heart failure or depression or rheumatoid arthritis.
What business are we in with the business running buildings?
Are we in the business of dealing with headache and rheumatoid arthritis and bronchitis?
And the answer, of course, is core business are health problems like presentations and conditions.
No country I know has any idea. I believe some business of that program budgeting.
We now have program budgeting. But for example, I know we spend £4 billion on respiratory disease.
Plus or -300 million. But when you actually see, well, how much is spent on asthma and how much was spent in chronic bronchitis.
Then we've still got a budget saying £2 billion other.
We have no idea how much has been a slip up. Neo and no other country.
No, no in history. But the next stage is to create program budgets and then create systems.
Now these are three words which are the words of the 21st century.
The 20th century was the century of the doctor and the hospital.
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.
And you people, of course in engineering will be very familiar with systems and a network is a set of organisation individuals
who deliver the system and a pathway the route that most patients follow through the network systems,
networks, pathways, knowledge systems, networks, pathways.
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.
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.
It's about a blood taken on the heel of a newborn and there's a mix up.
And she said, Look, this is chaos. Most of health care is Brownian motion.
The random movement of patients, clinicians and samples.
And it took her maybe five years to do this. Sickle cell disease, very complicated.
Lots of different ethnic groups, different carrier states, very complex.
But there. Objectives. Criteria standard.
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.
Here is a pathway, and this is software called the map of medicine.
And this is very simple. This is a breast cancer assessment.
And we give this to women. So that women can find out their path.
You know, if you're a breast cancer specialist, you don't need this.
If you drive from Oxford to Banbury every day, you read the map of Oxford at Banbury.
But if you're driving to Exeter for the first time or you haven't driven to excel for some time,
or if it may, maybe roadworks or something, you as happened, you need a map.
This is called the map of medicines, a software. It was developed and I was involved in it, say,
from its earliest days and funding it because it just seemed to me this is something very powerful and you
start to put in here and this links in here to Cochrane reviews you can start to put in things here like,
like telephone numbers of clinics and a whole variety of, of local stuff.
But it's technology. It's very simple sort of.
Now I mentioned networking. And you see, the 20th century was a centre of the bureaucracy and the hierarchy.
The 21st century is essentially a network. And is it a nice.
This is a very important book, actually, Clayton Christiansen's book.
And he's written most of it, Engineering and The Innovator's Dilemma, as you may know.
And the subtitle of The Innovator's Dilemma is When New Technologies Cause Great Companies to Fail.
For example, he said, Oh, personal computers are a sort of passing fad, doesn't exist anymore.
When hydraulic pumps come in, a number of our digging companies said, well, hydraulics, what's that?
You know, we'll use them to drive the the wires a bit faster.
Don't exist anymore. He's written this vanishing book with two doctors called Individuals Prescription and Networks.
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.
But networks exist long before the Internet, and we need to think of ways in which we use networking.
You see, it's often an alternative to either markets or hierarchies.
Transactions, transactions are quoted and controlled on a mutually agreed basis.
This is a very good definition. This is one of the classic books in an organisation.
We can give you all these references and things. So in the 20th century, we did this.
And the 21st century, we've moved to this. It's not hub and spoke.
We're not letting the teaching hospital say, well, we the centre centre, I think.
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.
I would not have called it the Centre for Evidence based Medicine that I call it the evidence based medicine programme at Oxford.
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.
Very important. Neither is it. A market, nor is it one blob taking over the others.
You see, the the you see you have to have hierarchies, bureaucracies to manage money and employ people.
But hierarchies cannot solve complex problems. Only this can solve complex problems.
Supposing I was discussing today the epilepsy in London, and my guess is spent about to £50 million in epilepsy in London.
No one's got an idea what's happening. So how would you how would you make epilepsy care better?
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.
Too complicated, too complex. These are what's called complex adaptive systems.
So what you want to do is get all the people with epilepsy and parents and people like teachers of learning disabled
children together because half of learning is disabled children have epilepsy and you get neurologists and GP's and you say,
okay, let's spend a day just talking about epilepsy and you know, what are the problems and what we can do about it.
And solutions will emerge not from command and control but through networks.
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.
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.
And in Welwyn Garden City or a GP in Camden or a patient in Islington.
So if a patient doesn't take the medicine, the patient is at least as important as the professor.
She's a different type of important. This is this is revolutionary stuff, of course.
Networks are revolutionaries different from that.
And just this issue of creativity is a very, very good book called The Knowledge Creating Company that I think the engineers,
if you're going into innovation and this how the Japanese industry creates new things.
It creates networks cutting across organisations.
It's got a very firm bureaucracy, but it's creates these networks.
That's how the bread making machine was developed over the other.
So the Lexis, you know, these are you can encourage creativity by bringing together these networks.
You make them what they call hypertext organisations. Okay, now the third thing, the patient, the citizen.
Now imagine I've got familial hypercholesterolaemia. This is the way it will be.
I get reminders by my phone. Why is it someone said that my hairdresser can send me reminders but not the NHS?
Very good question. And then the lab result comes to me.
I might just slip this into our recent review. And so the lab result comes to me in something like this.
And here's an example of what the lab results will look like.
And it says, Cholesterol unchanged.
It says, look, this last test was only done 12 months ago.
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.
Try to walk an extra 30 minutes a day to find a big dog.
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.
That's in Abingdon. That's six miles from here. Very simple, isn't it?
Does it happen? Not at all. You see, 150 million lab reports are sent out, usually on paper or electronically to GP's.
So then I've got to drive to the health centre or take a morning off work or phone up or something.
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.
Okay. Well, I can think of 30 million who do. So they start with 30 million.
You do another 20 million a year and you'll have to for them, operate them or do something.
But yeah, that would probably save, you know, 30 million visits to the doctor every year.
600 million prescriptions, the same thing. Now, here's patients.
This is something I helped a young doctor start, which is proved very interesting, very controversial.
I want great care and it's very simple.
It's providing ratings on feedback, on on services.
And we start off with giving ratings and doctors, which the BMA didn't like.
But everything's rated these days. You know, there's a there's an article in the Atlantic Monthly if it moves rated,
you know, and in America, kids are rating a schoolteacher in the USA.
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.
That if patients are having their time wasted, should it professions are wasting their time.
My wife went to pick up some from hospital, took her about 4 hours to take them home and get a prescription.
Well, it wasn't like her time was being wasted.
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.
She said, Well, can you why can't you write a prescription or it's not possible, you know.
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.
Is crowdsourcing is the jargon, one of the very clever young people who I worked with on this.
He said to me, Oh, crowd sourcing. That's a very 2009 concept.
It was that thing. InnoCentive is the innovation website, the innovation competitions, and these are things people produce,
have problems up on the web for other people to solve, either with rewards or without rewards.
And a lot of brainpower out there doing these things that, of course, Amanda's think, well, idea is very similar.
The last thing effectiveness and cost effectiveness are 20th century concepts, which are equally valid.
But in the 21st century, we need to think of values.
And this is my very simple model, which stands me stood quite well over ten years when speaking to clinicians.
For example, there's the evidence, the clinical condition of this patient and the values of this patient and.
And this is what what Peter Rothman calls personalised medicine here,
how you relate that and decision support, of course, tries to do this not very well,
but increasingly we'll see a decision support system of trying to relate the evidence to my particular clinical situation.
So that's a computerised decision support system. And then when we think of populations, there's a similar model.
So the evidence about breast cancer screening is the same in Hong Kong as in England.
But because breast cancer is much less common in Hong Kong, they decided not to implement breast cancer screening.
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.
Values Trump Evidence. In a democracy.
A U.S. officials, as you will be, name a people paid to give advice.
You've got to live with that and you have to know what your point of resignation is.
But the minister, when I dealt with scrutiny of the minister, wanted to introduce prostate cancer screening against my will.
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.
And they meet lots of men who have had a PSA test and I'm still alive.
Therefore it must work and I haven't persuaded them. Then it's values trump evidence.
You just have to decide whether you can live with it or not. Values Trump evidence.
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.
And finally say, this is the the charity I run called the Campaign for Health Care.
And I'm hoping that many of you will come in and work with me.
Certainly, I'd love to see the engineers and talk about the sort of problems we're facing.
But these problems are going to be we've finished with a just to say a word about sustainability,
because climate change is the major challenge that health faces in the 21st century.
And sustainable health care equals sustainable estates and facilities.
Plus sustainable clinical practice in clinical practice in the 21st century will have four features.
Every clinician will be involved in prevention because prevention is the best
thing to do for preventing the reducing the carbon footprint of health care.
Secondly, patient centred care put the patient at the centre of everything.
Not for moral reasons, but for practical reasons. Thirdly, leading pathways.
There are millions of follow up visits for which there is no evidence.
So let's rip those out and reduce the pathway.
And fourthly, a balancing one of low carbon treatment options, online psychotherapy as opposed to drugs.
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.
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
designing and the indirect carbon costs or the indirect carbon savings of the number of visits reduced.
My friends at Public Health and am in North Yorkshire, which are very big parts of England and the NHS staff,
never mind the patients drove 16 million miles last year. And one out of 152 primary care trusts has a lot of copper.
So we have to find solutions to that. So that's the future.
The and these are the four principles about knowledge.
There's lots of other things to think about. For example, how do you develop payment systems that encourage good behaviour?
Because the payment system we've got at the moment encourages bad behaviour, namely more hostile admissions.
And these are for ideas, for managing knowledge.
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.
I'd like you to reflect on what I've been saying and come up with other ideas
about how the 21st century health care will be different from 20th century.
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.
Okay, starting now. Keep the lights up, please.