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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.