1 00:00:00,060 --> 00:00:04,530 We've invited Nick to come and talk to say for a number of reasons, really. 2 00:00:04,530 --> 00:00:11,430 And one of the things that we've been talking about this week is what students and health organisations and policy module, 3 00:00:11,430 --> 00:00:18,150 what to do next and what they want to do in the world. And one of the things that they've talked about wanting to do is making a difference, 4 00:00:18,150 --> 00:00:21,660 making it change, improving health services, improving health systems. 5 00:00:21,660 --> 00:00:30,060 Even Nick's actually spent a lot of thought in a lot of different epic tackle change and innovation in health care. 6 00:00:30,060 --> 00:00:38,670 And to tackle some of those transition challenges. So next to the serious career action and you say, what do I say about next? 7 00:00:38,670 --> 00:00:46,050 She says. And Nick has worked with internationally instance health policy, 8 00:00:46,050 --> 00:00:52,020 including a fairly long spell at the European Commission, including being head of the Health Information Unit, 9 00:00:52,020 --> 00:01:05,160 that he's also talked quite like doing a degree and studying, and he's also been an expert on innovation and implementation of policy. 10 00:01:05,160 --> 00:01:10,230 And we met when I was a Dr. Burke, and he's also worked here. 11 00:01:10,230 --> 00:01:21,840 Senior Research Fellow in. Nick was actually the founder of the Health Organisations and Policy Module, which is hosting a session tonight. 12 00:01:21,840 --> 00:01:28,620 It was his brainchild. And we had a happy time teaching together on the hot modules last year, 13 00:01:28,620 --> 00:01:36,000 and Nick then got some sick new job and left me to take over the reins and take it forward in 14 00:01:36,000 --> 00:01:42,630 a slightly different direction to find much building on his brilliant ideas and what he did. 15 00:01:42,630 --> 00:01:47,760 We've invited Nick to come back and talk to US politics. It's really, really nice to see him. 16 00:01:47,760 --> 00:01:54,990 And we're going to have afterwards. But also because it's now got this new job as research groups are active around Europe, 17 00:01:54,990 --> 00:01:58,440 and you're going to say a bit about what it does when you talk. 18 00:01:58,440 --> 00:02:04,830 And it's a really interesting opportunity to hear from him a bit more about the role of research in translational health 19 00:02:04,830 --> 00:02:11,730 sciences and hear about what you can do and work in different settings to make a difference to innovate and change. 20 00:02:11,730 --> 00:02:17,190 So the next positive, empty net? Thank you very much indeed. 21 00:02:17,190 --> 00:02:24,310 All nice things to take with a pinch of salt and many thanks to you for the invitation to come here. 22 00:02:24,310 --> 00:02:35,160 So let me introduce myself just to confirm because course I need to pay credit to a few different organisations from speaking with on behalf of which, 23 00:02:35,160 --> 00:02:37,440 thanks to this evening, I put it that way. 24 00:02:37,440 --> 00:02:45,780 So as James Overby said in CBDs up here, by the way, in case anyone is boring, we will put a version of this up on campus afterwards. 25 00:02:45,780 --> 00:02:55,250 So don't worry about notes and stuff like that. I'll tell you a bit more about what that job for around Europe means, but just to describe up front, 26 00:02:55,250 --> 00:03:04,520 Rand is an independent, non-profit research institutes doing independent research for policy and decision making. 27 00:03:04,520 --> 00:03:08,240 So what we do a lot of history behind that. We're talking about a bit more. 28 00:03:08,240 --> 00:03:16,550 I still have links to the University of Oxford, as you can see up there and to the European Secretary on health systems and policies and colleagues. 29 00:03:16,550 --> 00:03:27,140 You are a little bit of a test group. I don't know if you're if you happy with this, but together with some colleagues at the European Observatory, 30 00:03:27,140 --> 00:03:36,110 we're writing a book on innovation and implementation. And so I am road testing some of the material from that this evening, 31 00:03:36,110 --> 00:03:43,940 which means your comments and feedback and questions will be especially welcome because you'll help to improve the book. 32 00:03:43,940 --> 00:03:50,630 And particularly good questions and insights will get a mention in the acknowledgements section. 33 00:03:50,630 --> 00:03:57,740 And that draws also on Europe's work on health innovation and on my previous role here, 34 00:03:57,740 --> 00:04:03,260 working in particular with Tricia on the theme that she leads on. 35 00:04:03,260 --> 00:04:14,480 If you like the social science part of itself, a really interesting partnership for innovation in health between the university and the hospital. 36 00:04:14,480 --> 00:04:19,640 So credits and background, what am I going to talk about today? 37 00:04:19,640 --> 00:04:26,270 But to talk about this topic of knowledge, too bright ideas, how research can support innovative health systems, 38 00:04:26,270 --> 00:04:30,980 and I'm going to break this down into a bit of an initial introduction. 39 00:04:30,980 --> 00:04:37,430 So I, you know, this is Oxford. I do have to do a little bit of academic theory and background and all the rest of that kind of stuff. 40 00:04:37,430 --> 00:04:49,370 Apologies. But then, because of the space that I now working for, I'm also really interested in is how does this relate to policy questions? 41 00:04:49,370 --> 00:04:57,740 And the three policy questions that I want to talk about this evening are how do we get the innovations that we want? 42 00:04:57,740 --> 00:05:04,580 Because one thing is innovation. We sort of think that innovation is always a good thing, but innovation is not always a good thing. 43 00:05:04,580 --> 00:05:08,470 And also, there are good innovations that we don't yet have. 44 00:05:08,470 --> 00:05:16,160 Yeah. And I think during COVID, we've all seen that the scale of the gaps that exist between what we would like to have and what we actually have. 45 00:05:16,160 --> 00:05:24,390 So how do we get the innovations that we want? How do we make the best use of the innovations that we do have? 46 00:05:24,390 --> 00:05:32,810 And and this is the one that really bothers the national health ministries and the other people in terms of health systems, how do we pay for. 47 00:05:32,810 --> 00:05:39,470 Because colleagues has everybody heard about the challenge of demographic ageing for health systems? 48 00:05:39,470 --> 00:05:44,210 This is the key challenge in terms of long term costs for our health systems, right? 49 00:05:44,210 --> 00:05:54,710 Lots of nodding. I hate to break it to you, but you're wrong. The key challenge, the key challenge facing the future sustainability of health systems. 50 00:05:54,710 --> 00:05:59,630 The reason why they have expanded in cost for the last 50 years. 51 00:05:59,630 --> 00:06:06,800 And the key challenge as to whether or not we will be able to afford them for the next 50 years is not ageing. 52 00:06:06,800 --> 00:06:12,080 Ageing is relatively minor. Lots of evidence on that, which I won't go into tonight. 53 00:06:12,080 --> 00:06:17,180 It's an innovation. It's this. It's new products, new techniques. 54 00:06:17,180 --> 00:06:26,930 Basically, the good part of this story is we have lots of new ways of treating and intervening and improving health. 55 00:06:26,930 --> 00:06:35,450 The backhaul is actually become more and more capable. We have a bigger and bigger size of opportunity that we have to pay for. 56 00:06:35,450 --> 00:06:41,030 That's the key challenge which underpins that third question how do we pay for it? 57 00:06:41,030 --> 00:06:47,280 So. Let's get into. 58 00:06:47,280 --> 00:06:53,310 Start with a bit of background for some of these, this will be extremely familiar territory. 59 00:06:53,310 --> 00:06:59,920 So tell me general funding to skip over this constant. 60 00:06:59,920 --> 00:07:03,450 I think we did go through this in quite that way. 61 00:07:03,450 --> 00:07:08,800 No, no, no. Worth a quick with a quick read diffusion of innovations, 62 00:07:08,800 --> 00:07:12,630 but it's pretty much a quick recap because not everyone in the room has been in the course of a week. 63 00:07:12,630 --> 00:07:18,810 So OK, so let's start with what is an innovation. 64 00:07:18,810 --> 00:07:27,390 And the classic definition of average is book diffusion of innovations, an idea or a practise, or a technology that is perceived as new. 65 00:07:27,390 --> 00:07:36,350 So there's two things to note in that definition. One, it's very broad, quite an idea. 66 00:07:36,350 --> 00:07:47,740 Or a practise or a technology. There's all sorts of things which can be innovations, masks, wearing masks to prevent transmission of COVID. 67 00:07:47,740 --> 00:07:51,220 Arguably an innovation mosques on me must have been around for ages, 68 00:07:51,220 --> 00:07:58,540 but this way of using them in a different way, perhaps more so for some countries than others. 69 00:07:58,540 --> 00:08:07,270 Which brings us to the other point, which is perceived as new. If it's new here, it's an innovation over there. 70 00:08:07,270 --> 00:08:13,120 It might be old hat boring and I do it all the time, but if it's new here, here it's an innovation. 71 00:08:13,120 --> 00:08:20,010 And so isn't some kind of objective thing that has never existed before. 72 00:08:20,010 --> 00:08:27,570 That is two distinguished terms, the very first time that something is conceived of. 73 00:08:27,570 --> 00:08:30,150 We would better call an invention. 74 00:08:30,150 --> 00:08:39,870 The very, you know, that first insight, that first discovery of something like penicillin in a dish or something like that, that is an invention. 75 00:08:39,870 --> 00:08:46,230 But when you can actually take it into something where you or someone else might make use of it, that's when it becomes an innovation. 76 00:08:46,230 --> 00:08:52,460 And that doesn't have to be new ones. It can be new where you are. 77 00:08:52,460 --> 00:09:00,630 Stages of innovation, I'm going to come back to this and we'll talk a bit more about these different stages as we go through. 78 00:09:00,630 --> 00:09:04,680 But I just wanted to sort of talk about that's not terribly clear. 79 00:09:04,680 --> 00:09:11,700 See if we can make it becomes clearer on my screen, which isn't any help to you. 80 00:09:11,700 --> 00:09:20,030 It's just to say that when we talk about innovation and innovation doesn't just sort of arise and then suddenly it is magically everywhere. 81 00:09:20,030 --> 00:09:25,520 You've got stages that we need to be thinking about, stages that this process goes through, and from the point of view of, of course, 82 00:09:25,520 --> 00:09:34,340 like all health organisations and policy, different parts of the system play different roles in these stages as we go through them. 83 00:09:34,340 --> 00:09:40,620 And I'm just going to describe a few of them just as a sort of a framework to have in mind as we're going through the rest of the programme. 84 00:09:40,620 --> 00:09:47,800 Invention is what I talked about is, you know, that very first discovery, where might that take place? 85 00:09:47,800 --> 00:10:02,300 Like most plausible. This is partly a test to see if everyone's awake. 86 00:10:02,300 --> 00:10:09,680 And the answer is no, they're not. What's going on, what he done to them? The universities, for example, yes, I you know, 87 00:10:09,680 --> 00:10:14,120 I would have been very distressed if we'd been sacked in the University of Oxford and if 88 00:10:14,120 --> 00:10:20,120 at least one person hadn't said one place where inventions take place in a university. 89 00:10:20,120 --> 00:10:30,060 Other universities are available here, and obviously this is our city and for a little bit to, 90 00:10:30,060 --> 00:10:37,130 you know, one side of it, where else in health care, in particular thinking about health, where else? 91 00:10:37,130 --> 00:10:42,020 What might there be inventions that brilliant first in pharmaceutical? 92 00:10:42,020 --> 00:10:46,640 Yes, in industry and pharmaceutical companies, in other types of industries. 93 00:10:46,640 --> 00:10:56,090 The number of people? Yeah. I think in time of crisis, we usually come up with solutions, and sometimes that could be an invention. 94 00:10:56,090 --> 00:11:03,330 I love that. So when I was talking about a place in terms of which I was thinking geographical place and you've completely reframed the question into, 95 00:11:03,330 --> 00:11:13,970 as you know, into a situation or a context. But yes, of course, in time of crisis, such as we have just had one where we have a lot of those. 96 00:11:13,970 --> 00:11:20,120 This is a new way of doing it, but we're just going to do it solutions. Where has that taken place in healthcare? 97 00:11:20,120 --> 00:11:23,120 Elsewhere hospital. Yes. 98 00:11:23,120 --> 00:11:32,240 So not in your research setting, not in the people who are making the money from it, but in the people who actually have to fix the problems. 99 00:11:32,240 --> 00:11:41,990 And I think that's really important. We'll come back to. And then you've got your bright idea, can you make it work? 100 00:11:41,990 --> 00:11:48,620 And so actually, you're right. Pharmaceutical intervention doesn't contact tracing pharmaceutical companies, 101 00:11:48,620 --> 00:11:55,580 but actually the real strength of pharmaceutical companies tends to be later on because what tends to happen in this 102 00:11:55,580 --> 00:12:01,310 process of innovation is that let's imagine that you've got a brilliant academic or brilliant clinical researcher, 103 00:12:01,310 --> 00:12:07,610 and they come up with this insight into how it might be possible to understand the disease differently, 104 00:12:07,610 --> 00:12:17,870 or how they created a new light programme that diagnoses things in a way that no one's done before, especially if it's a disease inside. 105 00:12:17,870 --> 00:12:22,010 It's almost certainly not immediately a pill you could give to someone, right? 106 00:12:22,010 --> 00:12:27,740 You've got a lot of work to do to get from your disease mechanism inside to something you could 107 00:12:27,740 --> 00:12:32,660 actually give it to something that tends to be increasingly where the industry steps in. 108 00:12:32,660 --> 00:12:37,250 Because if you're an academic, why would you know how to do that? 109 00:12:37,250 --> 00:12:48,710 You probably don't. Even if you've come up with a device that in principle works, your device typically uses gaffer tape and bits of plastic. 110 00:12:48,710 --> 00:12:55,810 You can't sell it to someone, but you need engineering and manufacturing skills that you don't have because you're not that person. 111 00:12:55,810 --> 00:13:02,630 Why would you? So the next stages are when you turn this into, well, can, is this something that can work? 112 00:13:02,630 --> 00:13:12,320 Typically, this is a a boundary between, say, academia or research into various forms of industry, especially for pharmaceuticals. 113 00:13:12,320 --> 00:13:16,880 That development stage quite often involves lots of evidence generation. 114 00:13:16,880 --> 00:13:19,440 So even once you've got your product, you think it's safe. 115 00:13:19,440 --> 00:13:26,440 You have to generate a lot of evidence to be able to demonstrate the licencing authorities that it is. 116 00:13:26,440 --> 00:13:29,290 Then you get something which you can actually sell. 117 00:13:29,290 --> 00:13:40,420 I've used a very, very good which is realisation, which is an awful word because it means nothing, but that's what I to you because all the different, 118 00:13:40,420 --> 00:13:46,270 because depending on what kind of innovation you're talking about, 119 00:13:46,270 --> 00:13:54,460 what step you have to go through to get from the thing that you think is good to the thing that can be generally used looks very different. 120 00:13:54,460 --> 00:14:00,940 The drugs, it's licencing for medical devices, it's well, that depends what jurisdiction you are in, 121 00:14:00,940 --> 00:14:04,630 but it's quite often a form of certification or standards bodies. 122 00:14:04,630 --> 00:14:13,260 It's not licencing by the national regulator. If it's a surgical technique, you might not need anything or it might be your professional body, 123 00:14:13,260 --> 00:14:23,190 so that that's what's hiding underneath that blue box is lots of different ways of getting to market and then adoption nice and simple. 124 00:14:23,190 --> 00:14:28,320 I've even put it as green because that's the easy bit, isn't it? 125 00:14:28,320 --> 00:14:40,390 We'll come back to that. So does anyone have any questions on those stages before I go any? 126 00:14:40,390 --> 00:14:45,850 You guys talk about the at about how you might bridge those divisions between the two. 127 00:14:45,850 --> 00:14:52,690 Is that something? Yes. However, I have already spent waiting on a single person, 128 00:14:52,690 --> 00:14:57,460 so one of the first bits of feedback to myself is this is far too much material for short talk. 129 00:14:57,460 --> 00:15:02,360 So this is a book thing. So we have confidence and diffusion of innovation. 130 00:15:02,360 --> 00:15:06,520 So I think it's really helpful to say we presented a slightly different way. 131 00:15:06,520 --> 00:15:09,850 And you know, it's good to set that safe and well. 132 00:15:09,850 --> 00:15:15,640 And I am one of the other things I should say before I move on too far is I have presented that in a linear way. 133 00:15:15,640 --> 00:15:20,700 So I presented that as though you start at one end and you go through it and you go to the other. 134 00:15:20,700 --> 00:15:25,650 OK. Sometimes it's like part of the whole message that I'm wanting to try and give to 135 00:15:25,650 --> 00:15:30,780 you is that it is not actually like all of these stages loop backwards and forwards. 136 00:15:30,780 --> 00:15:35,190 You get this far. Oh crap, this doesn't work. Go all the way back. 137 00:15:35,190 --> 00:15:43,950 Sometimes the licencing state, he saw this during COVID. The licencing authorities were quite involved in these early stages. 138 00:15:43,950 --> 00:15:47,490 And so I'm presenting it as a nice, simple set of discrete steps. 139 00:15:47,490 --> 00:15:51,390 It's not like that, and there's a whole ecosystem and outward system is something of a contract. 140 00:15:51,390 --> 00:16:02,370 But for now, I'm going to move on. For health, I think I've already alluded to there being different types of health innovation, 141 00:16:02,370 --> 00:16:09,440 and I'm going to distinguish for the purposes of this three different types. 142 00:16:09,440 --> 00:16:13,370 And I want to distinguish the not because it's theoretically useful and interesting, 143 00:16:13,370 --> 00:16:18,530 but I want to distinguish them because I think it begins to illustrate some of the issues that we have 144 00:16:18,530 --> 00:16:23,630 when we think about the role the research plays and how these different sectors interact with each other. 145 00:16:23,630 --> 00:16:30,770 And I can see from looking at you all that I shouldn't have put all of that up at once. It's everyone is really not a lot of you. 146 00:16:30,770 --> 00:16:35,540 So let's start with biomedical and pharmaceuticals. 147 00:16:35,540 --> 00:16:41,500 This is what we most think of when we think about health innovation, right? 148 00:16:41,500 --> 00:16:49,170 Big multinationals. Mostly not the people doing the initial research, as I said, 149 00:16:49,170 --> 00:16:57,500 but they're the people who step in once you've got your initial idea, but you need millions to take it through clinical trials. 150 00:16:57,500 --> 00:17:03,040 That's their particular role. And as we've also seen recently, 151 00:17:03,040 --> 00:17:06,910 they are also the organisations that they have the distribution networks and the 152 00:17:06,910 --> 00:17:11,170 processing networks to be able to ensure that things become accessible around the world. 153 00:17:11,170 --> 00:17:19,820 In principle, huge product life cycles, huge, very strong intellectual property protection. 154 00:17:19,820 --> 00:17:23,120 There is a whole bit in the book, by the way, 155 00:17:23,120 --> 00:17:31,160 about different types of intellectual property and the difference between patents and copyrights and trademarks. 156 00:17:31,160 --> 00:17:39,340 And I'm not going to do that now. I'm just going to say strong and moderate and weak, but it's really interesting. 157 00:17:39,340 --> 00:17:47,590 OK, it's really interesting to me that we have constructed really different ways of protecting different types of intellectual property, 158 00:17:47,590 --> 00:17:51,580 and it makes a massive difference to the types of innovations we get. 159 00:17:51,580 --> 00:17:57,880 That's why I'm putting it up there because you can invest for 20 years in pharmaceuticals, 160 00:17:57,880 --> 00:18:02,530 because you have intellectual property protection that lasts for decades. 161 00:18:02,530 --> 00:18:10,090 Medical devices is a completely different sector, 95 percent of medical devices, companies are any. 162 00:18:10,090 --> 00:18:14,780 All small. Producing products that last one or two years, 163 00:18:14,780 --> 00:18:21,710 and part of the reason for that is that they don't have anything like the same intellectual property protection. 164 00:18:21,710 --> 00:18:28,730 You can basically imagine I've come up with a pulse oximeter. And I come up with a great pulse oximeters, goes on the end of your fingers, 165 00:18:28,730 --> 00:18:33,180 marvellous if someone else can come it with a slightly differently functioning pulse oximeter. 166 00:18:33,180 --> 00:18:40,120 They can sell it as long as it's made in a slightly different way. So how do you keep your profits going? 167 00:18:40,120 --> 00:18:46,480 You have to make a slightly better pulse oximeter when you have to eat, so you have to keep updating in ways that the pharmaceutical companies don't. 168 00:18:46,480 --> 00:18:53,990 It's a completely different marketplace, and a lot of that comes down to intellectual property and organisational innovations. 169 00:18:53,990 --> 00:19:01,250 So this is typically not all one way of thinking about it, it's mostly not in the private sector at all. 170 00:19:01,250 --> 00:19:04,700 So one group of people who innovate a lot organisation new ministries, 171 00:19:04,700 --> 00:19:10,790 think about things like payment mechanisms and you think about things like organisational structures, 172 00:19:10,790 --> 00:19:17,090 like initiatives like trying to create integrated care systems. It's an organisational innovation. 173 00:19:17,090 --> 00:19:21,620 Well, clinical innovations like how do we get this group of clinicians to work together differently? 174 00:19:21,620 --> 00:19:26,000 How do we redesign this patient pathway? There might not be a different pill. 175 00:19:26,000 --> 00:19:28,870 There might not be a different medical device. 176 00:19:28,870 --> 00:19:35,170 But you're still working differently in a way that creates different health outcomes, and that's an organisational innovation. 177 00:19:35,170 --> 00:19:42,600 How much intellectual property protection? Almost none. So how do you make money out of it? 178 00:19:42,600 --> 00:19:55,440 You don't you don't know which, of course, means if you're investing in innovation in the sector, where does the money come? 179 00:19:55,440 --> 00:20:07,590 Of course, because that's where you get your power. Now I'm not going to spend very long on this. 180 00:20:07,590 --> 00:20:12,210 I've been talking about an innovation as a sort of a thing that just happens. 181 00:20:12,210 --> 00:20:18,570 But of course, governments, funders, all sorts of people don't just want health innovation to just happen. 182 00:20:18,570 --> 00:20:25,990 They really want to be encouraging. Make it happen. And so how do you do that? 183 00:20:25,990 --> 00:20:28,360 Is it as simple as just throwing out lots of money? 184 00:20:28,360 --> 00:20:34,750 Well, to be honest, when you read a lot of national health innovation strategies, the answer is yes, pretty much. 185 00:20:34,750 --> 00:20:37,720 But there is some classical theoretical models. 186 00:20:37,720 --> 00:20:48,800 One of them is the triple helix model, which is that you have that innovation takes place in this intersection between academia and industry. 187 00:20:48,800 --> 00:20:58,360 And it's about how do you create these different spaces between these three different parties and you have what they refer to as hybrid institutions? 188 00:20:58,360 --> 00:21:03,490 How do you create institutions that bring these different ideas together? 189 00:21:03,490 --> 00:21:08,440 And if you looked at what, for example, the Oxford, Stanley, Clorox A, B or C was doing, 190 00:21:08,440 --> 00:21:12,940 some of what it was doing was about trying to create these kinds of spaces. 191 00:21:12,940 --> 00:21:17,930 The thing about those spaces, by the way, is that they're quite uncomfortable. Quite. 192 00:21:17,930 --> 00:21:21,410 Because we were like, Okay, where are we now we're in the universe. 193 00:21:21,410 --> 00:21:29,330 Good thing if we were sort of in the university and sort of in industry brackets, a little bit less. 194 00:21:29,330 --> 00:21:35,870 So it's very interesting the whole field of research around this, which I don't have time to talk about. 195 00:21:35,870 --> 00:21:40,040 But I also think that model is a bit limited as far as health is concerned. 196 00:21:40,040 --> 00:21:44,060 And this is exactly where the answers that some of you gave about where do these innovations come from? 197 00:21:44,060 --> 00:21:51,350 For me is really important because one of the things I want to argue in this book is that actually, 198 00:21:51,350 --> 00:21:56,070 we don't in health, we don't need a three helix model. We need a five helix model. 199 00:21:56,070 --> 00:22:00,330 Which I suppose I should call the quintuple helix model, but that really doesn't sound like a good idea. 200 00:22:00,330 --> 00:22:03,540 So what we're going for? Because yes, 201 00:22:03,540 --> 00:22:10,260 of course you have government setting the rules in the framework of industry doing what industry does and you have research is generating inventions, 202 00:22:10,260 --> 00:22:18,730 but you also have the people within the health system who we discussed. And also, Teresa will be particularly underlining this in her. 203 00:22:18,730 --> 00:22:27,940 We have patients and citizens, so much of the driver of what comes out of our innovation systems comes not from patients and citizens want. 204 00:22:27,940 --> 00:22:36,790 And so for us, I think in health innovation, we need to conceive of where these spaces of interaction are a little bit differently 205 00:22:36,790 --> 00:22:42,580 to the way that we do more typically within innovation systems of the health system. 206 00:22:42,580 --> 00:22:48,570 And that is a little bit more about systems. 207 00:22:48,570 --> 00:22:56,430 Yes. Oh, absolutely. And find the person responsible for a kidney. 208 00:22:56,430 --> 00:23:00,150 There are people beyond everything health system. 209 00:23:00,150 --> 00:23:08,940 Do you mean Minister of health or the like? Do you mean? No, I mean, I mean, people working in providing health care and paying for health care. 210 00:23:08,940 --> 00:23:15,790 So I mean, people within the actual provision of health within the system as a whole. 211 00:23:15,790 --> 00:23:31,490 Definitely, people, very few of them are not people, although knowing some of the surgeons anyway, that's a whole is a whole separate discussion. 212 00:23:31,490 --> 00:23:36,080 Then I'm going to do this really, really quickly, because I think again, 213 00:23:36,080 --> 00:23:43,190 you have almost certainly covered this in the talk in the call so far, which is about that. 214 00:23:43,190 --> 00:23:47,260 Remember I said that last stage of adoption. That's the easy part. 215 00:23:47,260 --> 00:23:54,970 All right, you've got you're right. That is actually possibly the hardest bit of all right. 216 00:23:54,970 --> 00:24:01,570 OK, lots of nodding. I don't need to spend time on this. So I'm just going to say you have all these different models. 217 00:24:01,570 --> 00:24:05,440 I'm sure you've talked about the diffusion of innovation. Fish will kill me. 218 00:24:05,440 --> 00:24:14,930 But the one that I put up here is damn Schroder's consolidated framework for implementation research, which is this one. 219 00:24:14,930 --> 00:24:21,490 Well, we also obviously as the lead author on the Nass framework, which is another way and more up to date way, perhaps of looking at this. 220 00:24:21,490 --> 00:24:28,390 The key point about all of these is just to emphasise that we tend to when we talk about adoption of innovations, 221 00:24:28,390 --> 00:24:32,560 we very naturally, I mean, what's the noun we're talking about? We're talking about the innovation. 222 00:24:32,560 --> 00:24:36,090 If there's one message to take out of all of this work, I would say, 223 00:24:36,090 --> 00:24:43,930 is that the innovation is only one component of a much more complicated context and setting, 224 00:24:43,930 --> 00:24:49,570 and you cannot expect to achieve anything in terms of implementation without looking at them. 225 00:24:49,570 --> 00:24:53,470 We do a lot of work in round, by the way, around exactly this, you know, 226 00:24:53,470 --> 00:24:59,170 understanding why particular innovations did or did not work in particular settings. 227 00:24:59,170 --> 00:25:00,940 And it is always about the sector. 228 00:25:00,940 --> 00:25:10,040 It's almost never about the innovation without going into more detail, which I just put up there was the importance of context. 229 00:25:10,040 --> 00:25:14,690 Jim mentioned the importance of talking about research on what role research plays in all of this, 230 00:25:14,690 --> 00:25:21,620 and I'm not going to have time to talk about this as much as I would want people and leave time for questions. 231 00:25:21,620 --> 00:25:24,250 But I'm just going to say. 232 00:25:24,250 --> 00:25:35,840 When you look back over all of these stages that I described, hopefully you can see that research is important across all of these different stages. 233 00:25:35,840 --> 00:25:41,720 And all of these different types of innovation, right? 234 00:25:41,720 --> 00:25:51,350 The key thing I would say about it is the actual research that he's done is very unevenly distributed across all of that. 235 00:25:51,350 --> 00:25:59,150 So the overwhelming priority of research in terms of the types of innovation, as you said, 236 00:25:59,150 --> 00:26:06,080 is a heavily concentrated on biomedical, somewhat technological, almost not one organisational. 237 00:26:06,080 --> 00:26:13,220 And in terms of the stages, the research is the funding is overwhelmingly up here. 238 00:26:13,220 --> 00:26:16,760 And basically, as you go along this process, 239 00:26:16,760 --> 00:26:22,910 you get less and less actual research engagement with these different stages and with the processes that are taking place. 240 00:26:22,910 --> 00:26:34,840 So yes, research can help with all of these strategies, but in practise, the money will sit in a few parts of this process. 241 00:26:34,840 --> 00:26:45,340 So far, so straightforward. This is the context. This is the background I know half an hour and we're still on background. 242 00:26:45,340 --> 00:26:57,070 I'm really sorry. We're going to get onto the policy questions. So first question, as you know, our vote will do questions as we go through. 243 00:26:57,070 --> 00:27:03,390 First of all, how do we get the innovations that we want? 244 00:27:03,390 --> 00:27:11,460 One way would be to understand what we want. That sounds obvious. 245 00:27:11,460 --> 00:27:21,430 It's actually not so actual research looking at what the needs are that we have. 246 00:27:21,430 --> 00:27:28,990 Is not readily available. There are some obvious ones we have a mapping of burden of disease. 247 00:27:28,990 --> 00:27:34,990 Lots of leading work for years, which was published. 248 00:27:34,990 --> 00:27:40,150 Lots of work out of this. The entire centre about mapping the global burden of disease. 249 00:27:40,150 --> 00:27:50,890 But a burden of disease isn't the same thing as a health need because some of those areas have acceptable treatments and have acceptable diagnostics, 250 00:27:50,890 --> 00:27:55,970 but which aren't implemented. Some of them have no treatment whatsoever. 251 00:27:55,970 --> 00:28:03,530 I hope we don't have this kidnapping about how those different things fit together and what at what stage the research need is is the research need. 252 00:28:03,530 --> 00:28:09,350 We have nothing is research. We have something, but it doesn't work for these people. 253 00:28:09,350 --> 00:28:14,910 Is the research need. We have exactly what we need, but most people can't force people. 254 00:28:14,910 --> 00:28:19,210 Those are completely different research needs in terms of what we need to address. 255 00:28:19,210 --> 00:28:26,740 There are some very obvious areas which always get highlighted mental health as well, consistently under research. 256 00:28:26,740 --> 00:28:30,430 There's the obvious area. If you look at a global level of neglected diseases, 257 00:28:30,430 --> 00:28:35,890 there's the triumvirate which we been talking about rather depressingly for nearly as long as I've been in this business, 258 00:28:35,890 --> 00:28:40,120 which is now too long of HIV, TB and malaria. 259 00:28:40,120 --> 00:28:48,550 I don't need to pick on those three and those areas which have become which have always been Cinderella areas of health and of health and care policy, 260 00:28:48,550 --> 00:28:58,830 and which I think has been really highlighted during the pandemic, which is social, which is non-clinical, which we under-researched currently. 261 00:28:58,830 --> 00:29:06,840 And then, as I said, different stages are really underresourced, different types of areas already onto results, 262 00:29:06,840 --> 00:29:13,410 and we don't I mean, we have these marvellous work that is done here and has been done, for example, 263 00:29:13,410 --> 00:29:21,990 through the Oxford the sea on involving patients in the public and trying to set and define research priorities because fundamentally, 264 00:29:21,990 --> 00:29:28,400 if you're going to put a lot of public money into different areas of research. 265 00:29:28,400 --> 00:29:34,250 To ensure that that actually meets not just the needs that the experts think that the needs of the community thinks are relevant, 266 00:29:34,250 --> 00:29:37,250 you have to have some means of engaging with the community. 267 00:29:37,250 --> 00:29:47,260 But that's that again is itself a topic of research in the one, which is huge as research as it might be. 268 00:29:47,260 --> 00:29:55,310 So first of all, let's understand what we need, then we need to think about how we actually align the system. 269 00:29:55,310 --> 00:30:01,820 One of the things that will have struck you, hopefully, about the innovation structures which I'm talking about is that it is essentially 270 00:30:01,820 --> 00:30:05,630 a mix of actors from different sectors come back to that triple helix model, 271 00:30:05,630 --> 00:30:09,320 its industry as well as government as well as universities. 272 00:30:09,320 --> 00:30:16,620 You have lots of different actors in this, and we think of it as a market and we've tried different solutions. 273 00:30:16,620 --> 00:30:20,000 I should have explained eyepieces, advanced purchase commitment. 274 00:30:20,000 --> 00:30:26,420 This is a topic that's been a tactic that's been used for some particular conditions, such as the neglected diseases. 275 00:30:26,420 --> 00:30:31,190 There are others, such as additional intellectual property protections for things like rare diseases, 276 00:30:31,190 --> 00:30:36,080 which both the EU and the US which have had effect. 277 00:30:36,080 --> 00:30:42,530 But creating a market at the end of a 20 year development cycle doesn't necessarily influence the 278 00:30:42,530 --> 00:30:48,680 behaviour of the academic who is currently researching things or even the early stage development. 279 00:30:48,680 --> 00:30:54,990 Anyone who's ever had any contact with pharmaceutical companies will have heard the Expression Quarterly report. 280 00:30:54,990 --> 00:31:02,670 A market which is 20 years away doesn't do a lot to influence the perspectives, necessarily of the people looking at their quarterly outcomes. 281 00:31:02,670 --> 00:31:10,290 So just creating markets doesn't create solutions. You need to build stronger links between stages. 282 00:31:10,290 --> 00:31:19,260 One other topic slightly skipping for point of time talking about these different actors within the innovation system. 283 00:31:19,260 --> 00:31:25,140 I want to highlight the role of failure. We don't often talk about failure. 284 00:31:25,140 --> 00:31:30,000 We like to gloss over failure as quickly as possible and move on and talk about success. 285 00:31:30,000 --> 00:31:36,420 It's a much nicer thing to be talking about, but failure is inherent to innovation. 286 00:31:36,420 --> 00:31:39,450 Our point about innovation is it's something new and something different. 287 00:31:39,450 --> 00:31:44,370 If you're not willing to fail, trust me, you're not going to be very innovative. 288 00:31:44,370 --> 00:31:53,890 How willing is the public sector to fail? When it's public money on the line, how well is failure tolerated? 289 00:31:53,890 --> 00:32:02,820 Less than five months, I. I was just going to say I, especially from some people who I know have worked in the public sector. 290 00:32:02,820 --> 00:32:07,680 I'm seeing some no room for failure. So. 291 00:32:07,680 --> 00:32:13,890 One reaction that we quite often have as people who come to the health sector with strong values, to universality, to solidarity, 292 00:32:13,890 --> 00:32:22,650 to access for all is we look at the private sector and be a bit like why those people who are they just making all of this money? 293 00:32:22,650 --> 00:32:28,690 But one of the reasons why the private sector is here because failure is much better tolerated in the private sector. 294 00:32:28,690 --> 00:32:33,670 But that's because failure also comes alongside the potential for awards. 295 00:32:33,670 --> 00:32:37,610 And then the question is, how do we balance them? 296 00:32:37,610 --> 00:32:44,090 How do we ensure that the rewards which are being given are the ones that we want and are fair in comparison to the degree of failure? 297 00:32:44,090 --> 00:32:51,410 One other point I'm going to make here is about the globe what this all looks like from a global perspective, 298 00:32:51,410 --> 00:33:00,080 it's very easy for us here just to focus on the UK to focus on Europe, but again, saw very clearly during COVID. 299 00:33:00,080 --> 00:33:05,540 Innovation is something global. Right? If you think about all the different stages about you, think about the supply chain. 300 00:33:05,540 --> 00:33:13,940 Where does it come from? But even more fundamentally, when you are developing your product, 301 00:33:13,940 --> 00:33:19,700 one of the things that you need to think about is, well, where am I going to sell this? Who am I clients? 302 00:33:19,700 --> 00:33:27,170 And the US market? Is as large as the rest of the world put together in terms of health care. 303 00:33:27,170 --> 00:33:34,320 So who do we design our health innovation system? Overwhelmingly, United States. 304 00:33:34,320 --> 00:33:41,340 So if you invent something here in this marvellous University of Oxford and you go to the Oxford University innovation, 305 00:33:41,340 --> 00:33:43,470 which is the technology transfer office, 306 00:33:43,470 --> 00:33:49,710 and they're advising you on where you're going to take your brilliant, life saving invention and how you're going to develop it into something. 307 00:33:49,710 --> 00:33:52,270 Do you know where they're going to advise you to look? 308 00:33:52,270 --> 00:33:58,420 Are they going to advise you to look at the NHS, all they [INAUDIBLE], the NHS insists on really good value for money and wants lots of evidence. 309 00:33:58,420 --> 00:34:03,720 No, they're not going to you. You're not going to tell you to go to. So what are we getting? 310 00:34:03,720 --> 00:34:13,150 It's a global level. We're getting innovation adapted to the US market because that's where the money's. 311 00:34:13,150 --> 00:34:19,580 Nobody designed it. And there are quite a lot of American politicians who would rather it didn't work that way. 312 00:34:19,580 --> 00:34:29,270 But that's what we are. I'm going to skip really quickly through these next two. 313 00:34:29,270 --> 00:34:35,210 That's mainly to Utah in case you're looking at time. 314 00:34:35,210 --> 00:34:42,470 This slightly recap some of the stuff I was talking about before, so I think have you talked about how technology assessment on this module, 315 00:34:42,470 --> 00:34:48,740 but on the student in your neck, would you want to get some comfort from that? 316 00:34:48,740 --> 00:34:53,580 Well, in that case, you can tell me so. 317 00:34:53,580 --> 00:35:02,100 It's very interesting. So obviously, one of the key ways in which we can ensure that we are making best use of the 318 00:35:02,100 --> 00:35:06,300 innovations that we have is to understand the value that those innovations bring. 319 00:35:06,300 --> 00:35:11,670 But one of the key things about health tech or one of the weaknesses about health technology assessment, 320 00:35:11,670 --> 00:35:22,920 said trying to find the relevant bit of the presentation is if you think about that whole chain, that whole process is all for Pete's sake. 321 00:35:22,920 --> 00:35:31,660 I haven't done this in a while, you can't tell. HDR sits about here. 322 00:35:31,660 --> 00:35:37,900 Just normally just off the licencing, you decide something is safe, you give it a licence and then you decide if you want to pay for it. 323 00:35:37,900 --> 00:35:44,470 And that's where I started. How much of the innovation process has happened by that point? 324 00:35:44,470 --> 00:35:50,660 Not much. Well, hit in 1992. 325 00:35:50,660 --> 00:35:55,550 Exactly. You've pretty much defined everything that you're doing by this point. 326 00:35:55,550 --> 00:35:59,720 There's not there's not much left to do. There's not that smart. That's exactly my point. 327 00:35:59,720 --> 00:36:02,900 There's very little room at this point. 328 00:36:02,900 --> 00:36:09,440 So we're standing at the end of this process with our chequebook deciding whether or not we want to pay for it. 329 00:36:09,440 --> 00:36:15,020 But the eight has already been shaped. 330 00:36:15,020 --> 00:36:27,300 So one of the key issues is not just making our understandings of value, making that assessment here, it's building that assessment, in fact here. 331 00:36:27,300 --> 00:36:30,210 And finding ways of doing that, which at the moment, we're not very good at. 332 00:36:30,210 --> 00:36:34,890 So health technology assessment, to be fair to the agencies, they do try and do that. 333 00:36:34,890 --> 00:36:38,850 But there are all sorts of barriers in the way that implementation we've talked about. 334 00:36:38,850 --> 00:36:46,500 One final thing I'm going to say about policy when you switch to the ministry, I have sat in the ministry. 335 00:36:46,500 --> 00:36:49,980 You like to think that you're in charge? 336 00:36:49,980 --> 00:36:58,740 It's a wonderful delusion that you sort of have to have, otherwise he gets very uncomfortable and you think, Well, what am I doing? 337 00:36:58,740 --> 00:37:06,780 And we all participate in this delusion, by the way, because we all hold health ministers accountable for what happens in the health system. 338 00:37:06,780 --> 00:37:10,890 Well, to be honest, if we were completely fair with ourselves and with them, 339 00:37:10,890 --> 00:37:15,090 we would admit that most of what happens in health systems got very little to do with the health minister. 340 00:37:15,090 --> 00:37:21,850 And so what can the health minister realistically control about their health system? 341 00:37:21,850 --> 00:37:26,740 Farm money, that's the big one, how much money if you go. 342 00:37:26,740 --> 00:37:31,870 Can they control what happens in a particular hospital? No, not really. 343 00:37:31,870 --> 00:37:36,950 I mean, they can certainly make it more or less easy and they can influence things. 344 00:37:36,950 --> 00:37:45,830 But actually, policy has much less control over how these processes happen in policy, like think. 345 00:37:45,830 --> 00:37:55,190 So the reality of this is that what does policy do policy should be trying to support processes of local adaptation, local innovation. 346 00:37:55,190 --> 00:37:59,510 And but when you do that, you have to accept that you're not actually in charge and it's the people in each 347 00:37:59,510 --> 00:38:04,370 of these local situations who are in charge and who are making things change. 348 00:38:04,370 --> 00:38:10,730 Now that's very constructive. It reflects complex systems theory and of respect, our understanding of how health systems work. 349 00:38:10,730 --> 00:38:18,170 But if you're a policy maker, it makes you sound almost irrelevant. 350 00:38:18,170 --> 00:38:28,610 And I don't know very many people in ministries who like feeling sorry and then how do we pay? 351 00:38:28,610 --> 00:38:33,410 Well, the easiest way to work out how we can pay for innovation is to get these two things right. 352 00:38:33,410 --> 00:38:38,080 Get the right innovations and make best use of the innovations that we've got. 353 00:38:38,080 --> 00:38:42,460 One thing we could do is we could much better account for the contribution of health 354 00:38:42,460 --> 00:38:48,580 to the wider economy because at the moment we see all the cost of what we spend them, 355 00:38:48,580 --> 00:38:52,810 but we don't build into that budget everything that we gain from health. 356 00:38:52,810 --> 00:38:59,020 And again, have we not seen in the last two years everything that we gain when people are healthy and everything that we lose and people are, 357 00:38:59,020 --> 00:39:08,350 we don't account for that. We could do better. That whole field was kicked off or crystallised by the sacks report on the Global 358 00:39:08,350 --> 00:39:15,010 Commission on my current macroeconomics and Health more than must be 20 years ago. 359 00:39:15,010 --> 00:39:22,180 But the big agenda is creating better links between all of these stages of the health system. 360 00:39:22,180 --> 00:39:27,000 And I'm going to I won't go into the example of other than to say. 361 00:39:27,000 --> 00:39:33,990 If we think about this innovation system and I've described it as a system, I've spent this whole evening describing it as a system. 362 00:39:33,990 --> 00:39:36,550 But if we were to go into it. 363 00:39:36,550 --> 00:39:45,520 No one talks about this entire sets of activities as a system, we don't think of it as a system, we have different policies for different bits of it. 364 00:39:45,520 --> 00:39:53,440 But my fundamental point, the reason why we want to write a bloody book is because I think we should think of it as a system, 365 00:39:53,440 --> 00:40:04,030 because when you start to see that whole process as one in one interlocking set of activities that should be giving us what we 366 00:40:04,030 --> 00:40:13,240 need in a way that enables us to implement it in practise and make use of it in practise and do so in a way that we can afford. 367 00:40:13,240 --> 00:40:17,860 Then you start to see that our current structure of everything from intellectual property to research 368 00:40:17,860 --> 00:40:25,450 funding to orientations and incentives within markets isn't well aligned to achieve those objectives. 369 00:40:25,450 --> 00:40:31,250 And we're doing short of time. We'll come back to questions and say I'm. 370 00:40:31,250 --> 00:40:37,430 And you might if you want a pandemic, example what I would run out of time so I won't go into detail, but I will just illustrate. 371 00:40:37,430 --> 00:40:45,350 We've we've had a very if you like, a very hot pandemic in the last few years, a very urgent and visible one. 372 00:40:45,350 --> 00:40:51,110 What is often described is the slow motion pandemic is anti-microbial resistance. 373 00:40:51,110 --> 00:40:57,140 And when you look at it, you see a system, you see public practise, private actors, 374 00:40:57,140 --> 00:41:01,610 everything from bats to farmers to individual doctors to members of the public. 375 00:41:01,610 --> 00:41:05,420 You see a research base that has to be generating new antibiotics, 376 00:41:05,420 --> 00:41:12,980 but also generating things like point of care diagnostics so that we use the right antibiotic for the particular conditions that people have. 377 00:41:12,980 --> 00:41:19,440 We see a global issue where what happens in one country very much affects what happens in other countries. 378 00:41:19,440 --> 00:41:28,080 And we are only going to overcome that challenge by seeing the overall innovation system as a system. 379 00:41:28,080 --> 00:41:42,414 And at the moment. We kind of don't. And so the reason for writing the book is to try and get us to see that overall system as an innovation system.