Geoff Mulgan Speech King's Fund Conference

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King's Fund conference - November 2008 Key note speech by Geoff Mulgan - given to the King's Fund conference on Tuesday 25 November Bounce and the future of healthcare Some of you may have seen a short PIXAR film thats shown before the main film is screened in cinemas. It shows an array of computer generated small animals and anglepoise lamps joyously bouncing up and down. That's what I want to talk about this morning - or rather about its equivalent in healthcare - and its implications for the role of public policy, as well as for practitioners. Everyone in this room has experience of people bouncing back - often against the odds, and of others failing to do so. We have hunches why this happens - often described with very unscientific words like willpower. But the question of why bouncing back happens, and why some individuals and communities are resilient, is simultaneously becoming more scientific, more urgent and more central to how health will be organised. The perspective I bring is not that of a clinician or a health policy maker but some one with experience of working within governments, primarily in the UK but also now in Australia, and running at the Young Foundation an organisation with a long tradition of creating new ventures and enterprises to meet social needs, with a specialised team bringing together clinicians, public policy experts, social entrepreneurs and finance experts to develop ideas and make them real. Our work on the likely evolution of healthcare confirms that although there are no certainties in health there are some strong probabilities. It is hard to envisage any scenario over the next two to three decades where we do not see a steady stream of clinical discovery, of understanding of genetic dispositions, and of new treatments... It's hard to imagine a future where need and demand for care do not rise faster than the likely capacity of professions, taxpayers - primarily as a result of ageing and the rising incidence of long-term conditions. And it's hard to imagine a future in which we do not see a continuing culture shift to an even more knowledge saturated society meaning that there will be many more sources of guidance and in all likelihood fewer clear boundaries between experts and non-experts. These triple trends - new knowledge, new demands, new openness - are not absolute certainties but they are high probabilities. They imply - as many have argued for decades - the unavoidable need for a parallel increase in the quality of healthcare provision and in the responsibility taken by citizens themselves, their friends and family. GOOD HEALTH These three trends will have many effects - but one is already very present in how most people now think about health. In the world of NHS targets, good health means not being sick. But in daily life being well is not just the absence of illness. Instead health exists on a continuum from being very sick to the very well. This is a very old idea - certainly found amongst ancient Greece and Rome, or for that matter China. Most writers about health were concerned with the habits that would make people thrive. Dietetics was concerned with how to shape ourselves through exercise and habits so as to achieve the greatest possible wellness of both mind and body. It was assumed that inner health - confidence, optimism, a positive outlook - would protect the physical body from illness and help it recover fast. These ways of thinking baout health have a very long lineage but were rather marginalised as modern health systems took shape to cure illness, or prevent it, and of course dietetics wasnt much help if you were suffering from TB or a malignant tumour. Yet perhaps as consequence of success in dealing with so many other aspects of disease, these issues are returning. Science is exploring what it means to be very healthy as well as what it is that helps people bounce back from disease, shock and trauma. In some hands this is a purely physical question - see for example Ray Kurzweil's influential writings on how to greatly extend longevity, while in others the mental and physical are seen as closely intertwined. A mounting body of evidence is showing the importance of optimism for recovery in the work of researchers such as Giltay, Kubzansky, Leedham, and Scheier, and there is strong evidence, for example that negative emotions such as anger, anxiety and depression significantly increase the risk for cardiac events, and that exercise is often more effective and cheaper than drugs for conditions as varied as diabetes and depression. We can expect more data, and more insights, not least because the psychologist Martin Seligman with support from US Foundations is coordinating a fascinating project to accmulate more understanding, looking in a fresh way at some of the long time series data sets on health to understand the dynamics of positive health. This work is likely to point in similar directions to the vast range of evidence on the importance of social networks for longevity and recovery, and the very suggestive evidence on the importance of status and self-worth explored so imaginatively in Michael Marmot's WHO Commission. This research confirms that health and illness and related but different just as mental health is not just the absence of mental illness.The correlation between "happiness" and depression is not minus 1.0-rather it is closer to minus 0.35. Mental illnesses damage but do not exclude positive engagement, relationships and meanings. For anyone concerned with the design and delivery of healthcare these are fascinating but also challenging findings. They force us to pay attention to resilience - to the dispositions and contexts that help patients - and to modes of diagnosis that attend to these. They will imply prescriptions that seek to mobilise not just the individuals' own optimism but also all the resources that surround a patient - friends, family, support networks. They will not be easy to measure, to apply tariffs to, in part because they're about relationships not markets and so out of kilter with the consumerist thrust of the last 15 years.

And they involve a more obvious role for other parts of the public sector - not just care, and public health, but schooling, planning, housing, and welfare too, and the whole paraphernalia of LAAs and CAAs that will increasingly encompass health. In our work at the Young Foundation these insights are forcing new types of approach New ways of mobilising volunteers as with our work with the isolated elderly in Tyneside and Manchester. New ways of engaging schools - as with a large scale initiative with 4000 11 year olds learning resilience in schools, with a big evaluation to see impact on depression. New ways of promoting learning about health, and seeing health, like well-being, as a set of learned skills, alongside knowledge about food, exercise or first aid. INNOVATION This takes me to my second point. The Darzi review confirmed that there is a surprisingly wide consensus on the overall direction of change needed in health care. But there is much less agreement about the precise forms that will be needed in a health service in which individuals and families are able to take much greater responsibility, and where the supports they get help to enhance health as well as protect it. Blueprints and plans devised by clever institutions like this one, or the department, are one way. But in conditions of uncertainty we also need to discover the future through intelligent experiment and learning. Over the last century support for innovation in health has generally meant university based knowledge, under the control of senior clinicians. That route to innovation has certainly delivered many advances, and will continue to do so, with an ever greater linear flow from research into practice with various intermediaries, generously funded from the public purse. But this is only part of the story. Any examination of living health systems confirms that many different types of innovation are contributing to health gain: policy innovation, service innovation, innovation in behaviour change, innovations that start from practice, as well as innovations in pharmaceuticals or medical instruments. This should be obvious, yet there is a surprising paucity of evidence on the relative effectiveness of these different kinds of innovation in delivering health gain. Which channels get the most private investment is strongly shaped by the particular conditions of markets - which drugs meet the needs of rich people, with highly repetitive uses, and with strong IP control. And which channels get the most public money is more easily explained in terms of power, tradition and access rather than science or evalution. The growing body of evidence from NICE and QALYs is highly suggestive of where innovation is delivering the most (and very challenging for past policy, and for the big emphasis on pharma) but I'm not aware that anyone has systematically cross-correlated it with investment in different kinds of innovation. That other kinds of innovation are cost effective should not be a surprise. The greatest success of health in the last half century - the elimination of smallpox - was described by the WHO's Dr Mahler as a triumph of management not medicine. The greatest single step forward of the last decade - the bans on smoking - were helped by clinical evidence but were a political innovation not a clinical one. It follows that we need a more pluralistic approach to innovation that deliberately works on many fronts simultaneously, while building up a more solid base on which deliver the most bang for the buck. These will include science driven, university based R&D; professional practice and professionally led continuous improvement, they will include formal pilots and RCTs, and the many methods used by the NHS Institute They will also include experimental service innovation; social entrepreneurship; the use of open innovation methods of the kind increasingly common in other fields; as well as innovation in which patients and the public play a leading role. And they will require the right mix of supports for these very different types of innovation, with the full mix of funding from pure grants for speculative research, through convertible grants and loans to equity. These sets of tasks are likely to become increasingly important for SHAs as they widen their role in innovation. They are certainly already a large part of our work at the Young Foundation where we now have experience of direct investment in commercial enterprises, embedding innovation within the NHS, as well as creating new social enterprises and charities. Our current portfolio ranges from creating a health incentives company with the PCT in Birmingham East and north which we hope will blaze the trail for more systematic ways of rewarding people for making healthier choices, through to projects like Neuroresponse in London working with MS sufferers, Maslaha working with muslim communities on diabetes, and many others in development on men's health, settings of care and new care pathways. All of these are promising - and show on a small scale some of the outlines of the future NHS. But we would be the first to admit that this is a fairly young field. Although there are established protocols for formal R&D, clinical trials and the like, other kinds of innovation lack the same support structures or widely understood methods. That's why alongside our practical work we have been working with international partners, and NESTA here in the UK, to survey and analyse the many methods being used to innovate in fields like health, from forms of public finance to philanthropy, looking at the methods used for testing, piloting, pathfinders, incubators, prizes, collaborations, user led design through to RCTs. This work is ongoing - and is still multiplying - and there are many striking features of the methods we are analysing. But one which I would particularly emphasise is that of well over 300 we have identified only a small fraction have been used in health and an even smaller fraction are familiar to many in the field. So in short - innovation matters; it needs to be organised more systematically, and with a wider range of methods; and innovation on a small scale needs to be seen as the complement to the efficient implementation of already proven methods (the British vice has been to experiment on whole populations at once). INFORMATION The third topic I want to mention concerns just one field of innovation, but one that I'm increasingly convinced will be a crucial battleground and crucial condition for a more resilience, alongside innovation in such things as health coaches and telehealth. This is the field of medical data. For the last decade the big arguments have been about information within the system - the nature of EPRs, how centralised or federated, and what the role of GPs and managers should be. There are undoubtedly benefits from having a much better informed health service. But even as the push to EPRs continues it's also already clear that we need a very different kind of information infrastructure as well - one that is in the hands of the individual and their family, that can help them track, manage and improve their health. Perhaps we might call it a home health hub or log, a myhealth equivalent to myspace. Some of its potential features are easy to describe. It would include some personal records, drawn from the records within the system. It would include some monitoring of conditions particularly for people with a long-term condition, using equipment based in the home. It would include a record of such things as vaccinations. It could be a place to set goals and targets. It might connect to other sites to provide a rough first diagnosis based on monitoring data - for example for a diabetic with a worrying reading. It might provide quick guidance on the everyday challenges families face - like how to move a bedridden spouse to the toilet, with simple video messages and diagrams, potentially tailored to different cognitive and cultural styles. It might offer a range of levels of access - to carers, relatives as well as GPs and others provide a quality assurance oversight.

No doubt there are many ways in which the home health service could evolve. But the best ones will enhance learning, helping people to be more skilled about their own health. At the Young Foundation we're involved in two rather different variants, Planmycare providing a new infrastructure for patients to manage their own budgets, and Mydex a project which is not about health but provides the radical new way for citizens to control the data held on them by businesses and public bodies. Many others are engaged in other initiatives of this kind. But there are two crucial points I want to emphasise. The first is that this could be at the heart of our vision for the future of the NHS. As a nation we are much better placed to achieve a comprehensive, reliable home-based infrastructure to support greater responsibility than any other nation on earth - and although some will be sceptical, just as any home or family based services have been opposed in the past, this is an obvious area for innovation and experiment. The second is that it is already clear that control over this field of home information will become a great battleground over the next few years. Big business will undoubtedly want to capture it Google in particular has signalled its intent, and has the money and the brains. But it seems unlikely that in the long run any profit maximising business will be trusted, not just because we are probably entering another era of suspicion of monopolies, but also because the conflicts of interest, the temptations to advertise costly but inappropriate drugs or treatments, will simply be too visible. That's why public alternatives, and perhaps community owned alternatives, need to be developed, often with the private sector as a partner, but clearly accountable in the first instance to the patient and the citizen, and not either to big business or big government. DOWNTURN Let me end with a comment on the current downturn. Most of the acres of coverage have assumed that the recession is primarily a matter of economics, of material loss and money. But rather less has been written about the human aspects of the downturn. Many will suffer, but not many will go hungry, or sleep under bridges. The evidence we have - both from past downturns and from today - is that the far more damaging effects will be psychological - the trauma of losing a job or a home, and that this will especially when combined with debt (this is a key finding of the forthcoming interim report of our project on Britain's Unmet Needs). In this context bounce becomes even more important. Many risk being traumatised as the economy lurches downwards. But whether they can be helped to be resilient - helped to cope emotionally, with social supports will make all the different. Some GPs understand this very well. But I'm not sure how well the NHS as a whole does, or how much planning is being done now for the fairly predictable consequences this time next year, of what skills need to be nurtured. Let me conclude. Much of what I have been saying reflects the WHO's words in 1946 - that "health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity". Martin Luther King said that peace is not the absence of war: it is the presence of justice. Health is not just the absence of disease - it is the presence of vitality, thriving. Fortunately we now have more ways to make these more than mere words. We know more about the interaction of mental and physical health; more about how to be very well not just well; and we know more about wellbeing - including the evidence that happy nations seem to have higher life expectancy when other variables are stripped away (and even more intriguingly that blood pressure and wellbeing are inversely correlated). I've argued that we need to do more to make people resilient - more to innovate through all channels to find out how - more in the strategic fields such as health information - and all with an ethos that is about working with the public rather than just doing things to them. As the downturns deepens many will feel the very opposite of those small animals and anglepoise lamps in the Pixar film I mentioned at the beginning. But they will look more than ever to the health service to help them rediscover their bounce. Geoff Mulgan is director of the Young Foundation; a member of the Health Innovation Council. In 2007 he sat on the Academy of Medical Science committee on the environmental causes of disease and co-chaired the Department of Health's third sector sounding board. He is a visiting professor at LSE, UCL and Melbourne University and a part-time adviser to the Prime Minister of Australia.