Time present and time pastare both present in time future

JohnCooper

Utopia-DystopiaBinary choicesMapoftheEnglishCivilWar

loyalties

Brexitspread

Utopia-DystopiaBinary choices

Immeasurable changeTheFirstIndustrialRevolutionusedwaterandsteampowertomechanizeproduction.TheSecondusedelectricpowertocreatemassproduction.TheThirdusedelectronicsandinformationtechnologytoautomateproduction.NowaFourthIndustrialRevolution:characterizedbyafusionoftechnologiesthatisblurringthelinesbetweenthephysical,digital,andbiologicalspheres.TheFourthischaracterisedby:• Velocity• Scope• Systemsimpact

Thespeedofcurrentbreakthroughshasnohistoricalprecedent.Whencomparedwithpreviousindustrialrevolutions,theFourthisevolvingatanexponentialratherthanalinearpace.

Utopia-Dystopia

Probable fixes or near fixesMigratorypatterns

Urbanity

Travel

Patternsofsettlement

Humaninstitutions

Humanhealth

Humanneeds

Certainties for the healthcare future• AIwillhaveaprofoundlydisruptiveeffectonalllevelsoftheworkforce

• AIwillperformmanydiagnostictasks

• AIwillenablehugereductionsinimagingcosts

• Smartphonesenablerealtimepointofcarediagnostics

• Smartphonesenableremoteexamination

• Smartphonesenableremotemonitoring

• Networks:doctorswithdoctors,doctorswithpatientsandpatientswithpatients

Certainties for the healthcare future• Medicinewillbecomeincreasinglypredictiveandthereforepreventative

• Robotics

• Nanotechology

Remote possibility: end of scarcity

nanotechnology

My thoughts on the matter 1852

2013

The strange links

Self careMonitoringAutomated treatmentInformation and adviceNHS direct

Social carePrimary careOutreach careInformation and advice

Basic diagnostic servicesDay interventionsMinor injuriesNurse led inpatient careIntensive rehabilitationChronic care management

Planned interventionsEmergency careComplex diagnostic treatment & inpatient care

Home

Healthandsocialcare

centresupto10kcloseto

home

Communitycarecentres

100kheartofthecommunity

Specialistcarecentres250k,

500k,1000koncentralcity

sites

A lost decade: institutional torpor

2000 2005 2010 2015 2020

1950s

1970s

A lost decade: institutional torpor

Reasons: Procurement: commissioningbuildingsthroughtheconstructionindustry

Simpleeconomics:PFI

EvenasitsfutureremainsuncertainintheUK,PFIhasbecomeoneofBritain’s

mostsuccessfulexportswithcountriesfromCanadatoIndiaandAustraliainthe

processofrollingoutbillionsofpoundsworthofPFIschools,hospitals,roadsand

infrastructure.

“TheUKhascreatedamarketforBritishcompanieswithPFIexpertise,”says

RichardHowson,chiefexecutiveofCarillion,whichisamongthemoresignificant

companiesinthePFIsector,earningabout8percentofunderlyingoperating

profitsfrompublic/privatesectorpartnerships(PPPs)worldwide.

WithprojectsintheUKslowingtoatrickleasaresultofthegovernment’syear-

longreviewintothePFI’sfuture,contractorsincludingCarillionhavebeenbeefing

uptheiroverseasteams,particularlyinCanada,wheremorethan$7bnofhealth,

education,leisureandtransportprojectsweresignedofflastyear.

Do the Maths

PFIBidCost: £4-5million

Averageprofitforatoptwentycontractor: say3%(actuallynearer1.5%)

Costofrecoupingbidcost: £130-150millioncontract

Ifyoumakea£45millionloss £1.5billioncontractrepaysthisloss

(60%ofthe8th largestcontractor’sturnover)

Do the diligence : commissioningdesignthroughthe

constructionindustry

Procurement: Business Cases

Thecost

£1.5- £3.0million

Procurement: Business Cases

£40millionspent– nothingtoshowforthis

£100millionspent(probably)acrossLondon

Example1

SmalltoMediumSizeTrust

• Turnover£272million

Commercialopportunity

• Aplotofsurpluslandcanbesoldfor£15million

Finances10days’Trustactivity

Financesa2500-3500squaremetrehealthcaredevelopment

Disposal based funding: do the Maths

Example2

LargeSizeTrust

• Turnover£650million

Commercialopportunity

• Aplotofsurpluslandcanbesoldfor£50million

Finances28days’Trustactivity

Financesa10-12000squaremetrehealthcaredevelopment

Disposals: Do the Maths

Briefing and planningwestartinthewrongplace

90%ofwhatspecialists

doisthesameyetwe

identifytheirspacesby

the10%difference

Meanwhile: tech change accelerates

Moore’s Law

2001- 2018 Information technologyTheextraordinaryandacceleratingadvancesthataretakingplace

Healthcaretalksaboutyesterday’stechnologyastoday’sandtoday’sastomorrow’s:

• smartphonetechnology

• algorithmictriageanddiagnosis

• telemedicine

• miniaturisation– realtimeremotediagnosis

• miniaturisation- imaging

• nano-sensors

• robotics

• pharmaceuticals/genomics

Smart phones• pharmaceuticals/genomics Monitoring

Examination

Networking

Communication

Telehealth

Remote monitoring

respiratoryrate

heartrate

bloodoxygenlevels

bloodglucoselevels

systolicbloodpressure

temperature

urineoutput

sleepandmovement

Realtimeagainstthepatient’srecordandthepatient’spersonalassessment

COPD

Asthma

Cardiacconditions

Diabetes

Mentalhealth

Monitoring

respiratoryrate

heartrate

bloodoxygenlevels

bloodglucoselevels

systolicbloodpressure

temperature

urineoutput

sleepandmovement

Realtimeagainstthepatient’srecordandthepatient’spersonalassessment

Wedevelopclinicallyvalidatedsoftwareapplicationspoweredbyartificialintelligenceincludingprescribeddigital

therapeuticsandhospitalsystemsforclinicalcare.Ourproductsconnectpatients,cliniciansandresearchers,generating

largedatabasesofphenotypicdata,enablingdiscoveryresearchandimprovingpatientoutcomes.

Networks: linkingpatients,cliniciansandresearchers

28% reductioninvisitstoseeaGP

17% reductioninhospitaladmissions

40% reductioninhospitalvisits

toseepracticenurses

EDGEisaprescribeddigitaltherapeuticformonitoringchronicobstructivepulmonarydisease(COPD)athomethatwas

developedbyOxfordUniversity(theInstituteofBiomedicalEngineeringandtheDepartmentofPrimaryHealthcareSciences),with

supportfromtheDepartmentofHealthandtheWellcomeTrustthroughtheHealthInnovationChallengeFund.

The dot com bubble risk

CambridgeUniversityColormetrix

Real time point of care diagnostics:

Theapp,developedbyresearchersattheUniversityofCambridge,accuratelymeasurescolour-based,orcolorimetric,testsforuseinhome,clinicalorremotesettings,andenablesthetransmissionofmedicaldatafrompatientsdirectlytohealthprofessionals.

Decentralisationofhealthcarethroughlow-costandhighlyportablepoint-of-carediagnosticshasthepotentialtorevolutionisecurrentlimitationsinpatientscreening.

TricorderPrize

Hand held technology

RequiredCoreHealthConditions(10):

Anaemia,AtrialFibrillation(AFib),ChronicObstructivePulmonaryDisease(COPD),Diabetes,Leukocytosis,Pneumonia,OtitisMedia,SleepApnea,UrinaryTractInfection,Absenceofcondition.

ElectiveHealthConditions(Choiceof3):

CholesterolScreen,Food-borneIllness,HIVScreen,Hypertension,Hypothyroidism/Hyperthyroidism,Melanoma,Mononucleosis,Pertussis(WhoopingCough),Shingles,StrepThroat.

RequiredHealthVitalSigns(5):

BloodPressure,HeartRate,OxygenSaturation,RespiratoryRate,Temperature

Hand held technology:TricorderPrize

Patient responsibility Thewinnerisactuallyasmallcollectionofspecializedandsmartmedicaldevicesthatinteractwiththeuser'stablet.

Thisincludesacompactspirometerthatcanmeasurethestrengthofapatient'slungs,aMonotestkit,medical-gradeheartrateandrespirationmonitors,anddevicesliketheDxtEROrb,whichdoublesasathermometerandstethoscope.

Thesedevicescan'tscanpatientsatamicroscopiclevellike StarTrek's device,butBasilLeaftechnologyco-founderGeorgeHarrissaysitimprovesontheshow'stricorderinonekeyarea:It'sdesignedforpatientstousethemselves.

Technology is getting smallerMRI Technology

AI Algorithms:Embeddingdatainalgorithmsforcomputerapplicationtoproblemsolving

Examples:CancerandICU

Deep learning: recognising patterns in distinct layers

Theaccuracygapbetweenthehumananddigitaleyeisexpectedtowiden.Asdeep-

learningapproachesgaintraction,theywillcontinuetoadvancesuchdiagnosticfieldsas:

• radiology(CT,MRIandmammographyinterpretation)

• pathology(microscopicandcytologicaldiagnoses)

• dermatology(rashidentificationandpigmentedlesionevaluationforpotentialmelanoma)

• ophthalmology(retinalvesselexaminationtopredicttheriskfordiabeticretinopathyandcardiovasculardisease).

Catalytic changeMtech co-existencewithsystemfailureandapolarisingsociety– firstandthirdworldhealthprovisionwithinthesameservice

Theirabilitytoextendmedicine’sreachtotheexcludedorunderserved

Thechangeswhichtheywillcatalyseinthehealthprofessionsandthebuildingstypes

Thelikelihoodoftheirnarrowingorwideningthehealthgapbetweenrichandpoor

What has this got to do with hospitals?

Present :70% of the NHS budget is devoted to chronic disease management

40% of the NHS budget is devoted to people over 65

50% of medical beds are occupied by patients who could be cared for elsewhere

On average elderly patients spend 4 times longer in hospital than their consultants’ initial care plan

Current position:number of acute beds in England

142000acutebeds

114000inuse

Over65yearolds 50%ofthesebedscouldbe

treated

elsewhere

Current position:number of acute beds in England

142000acutebeds

114000inuse

Change: 50%ofthesebedscouldbetreatedelsewhere

Virtualwards

Preventativemedicine

Extracarehousing

Rehab/stepup/stepdownbeds

TheRoyalHospitalforIncurablesinPutneyLondon

Let us think back

Aren’t wetalkingaboutchronicdiseasemanagement

The need for new models for acute care

John Cooper / Director JCA

Brand

ED

0% 50% 100% 150%

Ou tp a t i e n t s e r v i c e s

Th e ra p i e s

Im a g i n g

T h e a t r e s

Components of change: now

ED

0% 50% 100% 150%

Ou tp a t i e n t s e r v i c e s

Th e ra p i e s

Im a g i n g

T h e a t r e s

Components of change: very soon

Pa t h o l o g y

0% 50% 100% 150%

I npa t i e n t s e r v i c e s

I CU

Te l e h e a l t h

Components of change: now

S y s t em d e v e l o pmen t

Pa t h o l o g y

0% 50% 100% 150%

I npa t i e n t s e r v i c e s

I CU

Te l e h e a l t h

Components of change: very soon

S y s t em d e v e l o pmen t

How do we make sustainable buildings

Goodbuildingsgetre-usedPoorbuildingsaredemolished

Badbuildingsgetdemolished

Design: Lariboisiere

Space

Ventilation

Light

Patientgroupings

Management

Lariboisiere Hospital

Design:

Space

Ventilation

Light

Patientgroupings

Management

Lariboisiere Hospital

Thomaswas34whenStThomas’opened– thefirstPavilionhospitalinBritain

Hospital in the city

Hospital in the City

New Necker Hospital

No hierarchy within

The re-usable hospital: maximsLocation

Chassis

Space

Ventilation

Light

Patientgroupings

Chassis

Residentialaccommodation

Theatres

Widthoffloorplate

The re-usable hospital: maxims

ICUoutpatientsinpatients

Nursing

home

nursinghome

extra-careflats

GPpractice

communityhub

The flexible building block

The flexible chassis

Eliminating hospital-landsuccess

Eliminating hospital-landfailure

Palestine’s Cancer Centre

Palestine’s Cancer Centre

Palestine’s Cancer Centre

Palestine’s Cancer Centre

Eliminating hospital-land

Eliminating hospitals like this

Eliminating hospital land

Re-using hospitals Servicedoffice/medicaloffices/

startupsspaces

Mixed use hospitals: de la Tour Geneva

Mixed use hospitals: de la Tour Geneva

Thank you

Challenge: howtouseoldbuildingsandhospitalestates

Model developments

Example One: West LondonAnew350bedhospital

Acommunityhealthcarehub

90stepdownbedfacility

650-780apartments

24townhouses

50courtyardhouses

60shelteredapartments

Retailopportunities

Healthplex gym

A new community for 2500

Workhouse conversionThesebuildingshavearchitecturalqualities

Workhouse conversionCoherentarchitecturalform

Carparking levelbeneath(exploitinghospital’sexistingbasement)

Conversion of Victorian core

30x80metregarden

30x80metregarden