Professor Keith McNeil

CCIO Health & Care

Confessions of a special forces

sniper…

…who’s in the crosshairs?

Parker-Hale 7.62

The path to…

…here & now

4

“This is not just about improving

technology;

this is all about improving clinical

care”

Current State of Affairs

• Worldwide

– Societies struggling with the sustainability and

affordability of modern healthcare

• resource vs demand & expectation

• What is driving all this…

– and what is the problem we need to address?

Healthcare in the 21st century

And… within this context

• The challenge is to deliver the “triple aim” of

modern healthcare:

– better clinical outcomes

– with a better patient experience

– with better affordability

• To respond to this new disease paradigm we need to change our thinking…

– Shift of focus from traditional acute episodic disease models

– How we engage patients in their health care

– How we embrace disease prevention

So…to the challenge

• We need to “disrupt” the way we think about

how best to provide care to an ageing

population with an increasingly complex,

chronic, co-morbid disease paradigm…

…implying:

• evidence based decision making

• thus a critical need for data, information & knowledge

Outline

• Disruption

• the stimulus for transformation

• Complex systems, chaos and entanglement

• the environment for innovation

• Information & the digital agenda

Disruption

• Provokes adaptation and change

• System level

• Need a disruption to provoke rapid change

• Rapid change = transformation (rapid evolution)

Disruption

• Unwelcome - Enforced• Yucatán peninsula meteorite

• GEC / HIV / Alzheimer's dementia

• Welcome - Serendipitous• penicillin / streptomycin

• X-rays

• Targeted = innovation• coronary stenting

But…

• Little if any evidence of effectiveness

• Thus… a clear need for data to

– evaluate changes made

– Inform an agile response to that evaluation

• stop an reconsider; or

• rapid spread and adoption of success

Established business paradigm

• Good-Fast-Cheap

– good care fast, but it won’t be cheap

– or, good care cheap, but it won’t be fast

– or, cheap care fast, but it won’t be good!

• The triple aim however is to provide:

– good care (better outcomes)

– fast (better experience)

– and cheap ! (affordable)

…in a world of competing logics

Global and local

economic crisisPolitical expectations

Corporate expectations

Public expectationPatient / consumer

expectations

Clinician expectations

Triple

Aim

Which brings us to this seeming paradoxWhich brings us to this seeming paradox……

Demand

(bespoke needs of

each individual)

Resource

(the whole system

perspective)

Vs

We need to “disrupt” the way we think

through this paradox

• Traditional thinking

– Based on linear system dynamics

• hierarchical decision making

• command and control dominant

• management vs leadership paradigms

• Is there another paradigm; and how do

data & information play into this?

The universe has its own versionThe universe has its own version……

Quantum physics

(fundamental particle

level)

Conventional physics

(the whole system perspective)Vs

Or put another wayOr put another way……

Nature’s solutions

• Whole system

– complex adaptive/chaotic systems

• Fundamental particle level

– entanglement

…these solutions are critically dependent on the flow & exchange of information

Complex Adaptive Systems

• Interdependent

– critical dependence on the flow of information

• Respond to feedback loops

• Obey the “law” of unintended consequences

• Based on “rules”

– in steady state 20-30% works in an hierarchical fashion

Health is a Complex Adaptive System

Political

expectations

Public

expectations

Clinical Services

Economic factors

Corporate

expectations

Patient

expectations

Clinician

expectations

How did we let it end up like thisHow did we let it end up like this!!

Information & Chaos

• Information brings order to chaos…

…data enables the reduction of uncertainty

• Our understanding of “chaos” is dependent on the quality of the information we have available

• Chaos is not random– It appears unpredictable because we aren’t

sophisticated enough to measure & interpret all the variables and variation in the data • ventricular fibrillation

Entanglement

• Quantum theory

– Complex systems are based on their most fundamental elements

• subatomic particles

– The system as a whole is ‘designed’ to ensure effective interactions between fundamental particles

• these interactions are information dependent

• interference of these interactions compromises the integrity of the system

Entanglement and Healthcare

• Like any complex system, healthcare follows the same principles

• The fundamental ‘elements’ of healthcare are the clinician : patient.

– their interactions (c1m every 36 hours across the NHS)

define the outcomes of the triple aim

• Quality, safety and clinical outcomes

• Patient experience

• Cost (affordability)

We need then to…

• Recognise healthcare as a complex, chaotic

system, and…

• design and set the system up to ensure the

fundamental (clinician : patient) interactions

are effective each and every time they occur

…so what does our system look like now?

Command and control heirarchies

Command and control

Challenger

NASANASA

NASANASA

NHSNHS

20th century NHS thinking…

• Grip

• Levers

Levers and Complexity

• A lever has a single fulcrum and moves/affects

one thing

• Complexity – law of

unintended/unanticipated consequences

Levers and Complexity

Cascade of unintended consequences…

…cascade of unintended consequences

Self organisation = organisational resilience

Risk paradigms

• Ultra safe – airlines

• Highly reliable – oil and gas rigs

• Unpredictable – healthcare

– need for organisational resilience

• relative risk

• ambiguity

Leadership in the Digital AgeCritical to dealing with complexity

• Allowing ecosystems to become self-organising

– fosters organisational resilience at every level

• Traditional hierarchy based governance will shrink as platform models (Google, Uber, Airbnb etc) become more prominent

– distributed decision making

• Less reliance on contracts and central enforcement

Leadership in the Digital Age

• Finding the best way of creating value and

improving customer (patient) experience by:

• defining who does what best

• determining who can contribute the most irrespective

of where they might sit

– engagement & empowerment

• Cost benefits flow as a result

Learn from the Best

• Uber, Air BnB, Amazon, Google, VISA etc

– Collecting, aggregating and analysing data, enables a

better understanding of demand, and reciprocally, a

better service can be provided in response

Leadership in the Digital Age

As in any age, leadership is critical to

encouraging and enabling innovation;

…and engaging and empowering those who

actually deliver healthcare

Paradigm Shift

E = mc2

Speed of light constant in a vacuum

“When people in leadership positions

begin to serve a vision infused with the

larger purpose, their work shifts

naturally from producing results to

encouraging the growth of people who encouraging the growth of people who encouraging the growth of people who encouraging the growth of people who

produce resultsproduce resultsproduce resultsproduce results”

Create the right environmentCreate the right environment

Innovation…“ the courage to fail”

“He who joyfully marches to music in rank and file has

already earned my contempt.

He has been given a large brain by mistake, since for him

the spinal cord would suffice.”

Albert Einstein

The digital Health Agenda:

what, why & how

The Digital Agenda

• …which leads us now to why the digital agenda is the

key to delivering the ‘triple aim’ and

transformational change in healthcare

– Why the effective flow of information is critical

– And why data & information underpin the delivery of

tomorrow’s medicine

Life is all about information

The Big Bang

DNA code

Patient outcomes

Observation, meticulous documentation and analysis of

data

Pasteur

Osler

Semmelweis

Flemming

William Farr

1852

William Farr

1852

Jon Snow

1853

1948

• NHS was born

• Year when the “bit” was conceived

– Claude Shannon at Bell labs

Data data everywhere and not a bit to think!

Data is the new crude

• Unrefined it cannot be used. It has to be changed into petrol, plastic, chemicals etc to create a valuable entity.

• So must data be broken down & analysed for it to have value

“Endow that data with relevance and purpose”

Data

• Last 2 years

– More data generated than in all human history

• Most people can handle up to 3 complex thought processes

– An intelligent person can process and deal with 5

– A genius can handle 7

• We are now dealing with hundreds of data inputs!

Why digital?

• Big data sets need “big data” analysis

– 100,000 genome = 21 petabytes

• 1 Pb music – 2000 years of continuous playing!

• Opportunity for use of AI & machine learning

– reliant on accurate longitudinal data sets

Artificial Intelligence

“The task is not so much to see what no one has yet

seen,

but to think what nobody has yet thought

but which everyone sees”Arthur Schopenhaur

What is needed

• Every 36 hours c1million patient interactions

occur across the NHS

– ‘all’ our data is derived from these interactions

• Capture the information from each & every

one of those interactions

There is a better way!

Our Aim

• Create learning/knowledge based organisations; at all levels

– use information & knowledge to make more informed and therefore better decisions

“Individuals discipline their own performance through organised feedback from this data”

Peter Drucker

Clinician-Patient

aggregated data

sophisticated analysis

Information &

Knowledge

Research

Intelligence:

business

public health

Clinical intelligence

Towards a learning & knowledge

based system

“Virtuous Circle”

Clinician-Patient

aggregated data

sophisticated analysis

Information &

Knowledge

Research

Intelligence:

business

public health

Clinical intelligence

Audit

Education and

training

CPE

Personal outcomes

internet

apps

wearables

…and beyond, towards

precision medicine & sustainability

‘omics’

diagnostics

consent

Machine

learning/AI

analytics

System Sustainability

The Two Keys to Unlocking the Productivity Paradox

Improvements

in the

technology

Reimagining

the work

itself

Reference: Erik Brynjolfsson, MIT

…but this is not just about technology

This is about

patient outcomes

Delivered in a sustainable system

• Efficiency

– Intrinsically dependent on flow of information,

which allows:

• alignment of systems & processes

• avoidance of duplication & unintended variation

– Saves time

• one of our most precious resources

How we are doing this

• Ensure that information is captured as part of

the care giving process

– each & every one of those 1m interactions

– standardised and structured wherever possible

Building an integrated, ‘paper-free’ health and care system 10 domains with 33 programmes

The 2020 Strategy

• Simply, these programs

• Enable structured/standardised data collection from across the system

• Enable that data to be distributed across the system

• Encourage innovative ways of capturing data– wearable's, apps etc

• Facilitate analysis and application of data at multiple levels– local, population, cohort, metadata sets, ‘big’ datasets

Where we are we now…

Where we want to be…

• A learning & knowledge based organization at

all levels, at the cutting edge of digital

medicine, where:

– individuals use data to drive their own Q

» improving patient and organizational outcomes

– learning and benefits are shared across the system

– system sustainability and enhanced effectiveness is embedded

PORTFOLIO MAPPING

Better Health & Patient Outcome Better Care & Patient Experience Better Value & AffordabilityBetter Health & Patient Outcome Better Care & Patient Experience Better Value & Affordability

Empower the person

NHS.uk(2. NHS.uk)

Digital Tools Library

(3. Health Apps Assessment and

Uptake)

Developers’ Ecosystem(3. Health Apps Assessment and

Uptake)

WiFi & Home Page(31. WiFi)

Personal Health Record(4.Widen Digital participation 16.

Personal Health Record )

NIB Patient Reference Group

(6. Patient relationship management)

Support the clinician

Provider Digitisation & GDE Prog

(21. Provider Digitisation )

Digital Academy & Workforce Education

(24. Building a Digital Ready Workforce)

Digital transformation in general practice(9. General practice systems & services, 11. GP Transformation, 12. GP Data Implementation)

Wider uses of Summary Care Record(14. Interoperability & Architecture)

E-Prescribing

(17 Digitising community pharmacy and medicines , 18, Pharmacy supply chain, 19. Integrating

pharmacy across settings)

Decision Support

(5. Clinical Triage Support, 7. Access to Service Information)

Strategic Clinical Reference Group Clinical Requirements

Integrate services

Care of the Elderly

(13. Integration projects)

Care of the Elderly

(13. Integration projects)

Manage the System Effectively

Patient Identity (1. Citizen Identity, 33. National Opt Out)

Information Governance & Transparency (29. NHSMail2 , 32. Data and Cyber Security , 33. National Opt Out )

Interoperability & Enterprise Architecture (14. Interoperability and Architecture, 28. Spine 2 , 30. HSCN)

Personal Health Records & APIs for Apps (16. Personal Health Records, 3. Health Apps Assessment and Uptake)

API/Standards (7. Access to Services Implementation, 14. Interoperability and Architecture)

Individual

Sustainability & Transformation Plans

Analytic and Reporting Capabilities

WH

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HO

WIN

FR

AS

TR

UC

TU

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(£

65

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YS

TE

M

CO

NS

TR

UC

TS ALB / commissioning organisations Provider organisations

NHS First

(2. NHS.uk )

NHS First

(2. NHS.uk )

Social Care

(15. Social Care Programme )

Social Care

(15. Social Care Programme )

CDOCDO CCIOCCIOCD&ICD&ICIOCIO

Have we got it right ?… perspective

Children see nine dolphins –

they see the truth

We see what we want to see

This is a test to determine if you

have a corrupted mind.

If you don’t find the dolphins

within six seconds, your mind is

corrupted

This is all about patient safety and outcomes

…not technology!

A leap of faith?

There are 10 types of people in the world…

There are 10 types of people in the world…

…those that understand binary and those that

don’t

“… and so we come full circle,

to the place from which we set out,

and see it for the first time”

T.S. Elliot

So who is in the crosshairs?

• We all are:

– Leadership at all levels

– Embrace and embed digital technology in new

ways of working

– Maintain the focus on our patients and those who

deliver care

100,000 genomes