time present and time past are both present in time future · chronic care management planned...
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Time present and time pastare both present in time future
JohnCooper
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Utopia-DystopiaBinary choicesMapoftheEnglishCivilWar
loyalties
Brexitspread
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Utopia-DystopiaBinary choices
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Immeasurable changeTheFirstIndustrialRevolutionusedwaterandsteampowertomechanizeproduction.TheSecondusedelectricpowertocreatemassproduction.TheThirdusedelectronicsandinformationtechnologytoautomateproduction.NowaFourthIndustrialRevolution:characterizedbyafusionoftechnologiesthatisblurringthelinesbetweenthephysical,digital,andbiologicalspheres.TheFourthischaracterisedby:• Velocity• Scope• Systemsimpact
Thespeedofcurrentbreakthroughshasnohistoricalprecedent.Whencomparedwithpreviousindustrialrevolutions,theFourthisevolvingatanexponentialratherthanalinearpace.
Utopia-Dystopia
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Probable fixes or near fixesMigratorypatterns
Urbanity
Travel
Patternsofsettlement
Humaninstitutions
Humanhealth
Humanneeds
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Certainties for the healthcare future• AIwillhaveaprofoundlydisruptiveeffectonalllevelsoftheworkforce
• AIwillperformmanydiagnostictasks
• AIwillenablehugereductionsinimagingcosts
• Smartphonesenablerealtimepointofcarediagnostics
• Smartphonesenableremoteexamination
• Smartphonesenableremotemonitoring
• Networks:doctorswithdoctors,doctorswithpatientsandpatientswithpatients
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Certainties for the healthcare future• Medicinewillbecomeincreasinglypredictiveandthereforepreventative
• Robotics
• Nanotechology
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Remote possibility: end of scarcity
nanotechnology
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My thoughts on the matter 1852
2013
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The strange links
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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
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2000 2005 2010 2015 2020
1950s
1970s
A lost decade: institutional torpor
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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.
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Do the Maths
PFIBidCost: £4-5million
Averageprofitforatoptwentycontractor: say3%(actuallynearer1.5%)
Costofrecoupingbidcost: £130-150millioncontract
Ifyoumakea£45millionloss £1.5billioncontractrepaysthisloss
(60%ofthe8th largestcontractor’sturnover)
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Do the diligence : commissioningdesignthroughthe
constructionindustry
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Procurement: Business Cases
Thecost
£1.5- £3.0million
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Procurement: Business Cases
£40millionspent– nothingtoshowforthis
£100millionspent(probably)acrossLondon
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Example1
SmalltoMediumSizeTrust
• Turnover£272million
Commercialopportunity
• Aplotofsurpluslandcanbesoldfor£15million
Finances10days’Trustactivity
Financesa2500-3500squaremetrehealthcaredevelopment
Disposal based funding: do the Maths
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Example2
LargeSizeTrust
• Turnover£650million
Commercialopportunity
• Aplotofsurpluslandcanbesoldfor£50million
Finances28days’Trustactivity
Financesa10-12000squaremetrehealthcaredevelopment
Disposals: Do the Maths
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Briefing and planningwestartinthewrongplace
90%ofwhatspecialists
doisthesameyetwe
identifytheirspacesby
the10%difference
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Meanwhile: tech change accelerates
Moore’s Law
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2001- 2018 Information technologyTheextraordinaryandacceleratingadvancesthataretakingplace
Healthcaretalksaboutyesterday’stechnologyastoday’sandtoday’sastomorrow’s:
• smartphonetechnology
• algorithmictriageanddiagnosis
• telemedicine
• miniaturisation– realtimeremotediagnosis
• miniaturisation- imaging
• nano-sensors
• robotics
• pharmaceuticals/genomics
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Smart phones• pharmaceuticals/genomics Monitoring
Examination
Networking
Communication
Telehealth
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Remote monitoring
respiratoryrate
heartrate
bloodoxygenlevels
bloodglucoselevels
systolicbloodpressure
temperature
urineoutput
sleepandmovement
Realtimeagainstthepatient’srecordandthepatient’spersonalassessment
COPD
Asthma
Cardiacconditions
Diabetes
Mentalhealth
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Monitoring
respiratoryrate
heartrate
bloodoxygenlevels
bloodglucoselevels
systolicbloodpressure
temperature
urineoutput
sleepandmovement
Realtimeagainstthepatient’srecordandthepatient’spersonalassessment
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Wedevelopclinicallyvalidatedsoftwareapplicationspoweredbyartificialintelligenceincludingprescribeddigital
therapeuticsandhospitalsystemsforclinicalcare.Ourproductsconnectpatients,cliniciansandresearchers,generating
largedatabasesofphenotypicdata,enablingdiscoveryresearchandimprovingpatientoutcomes.
Networks: linkingpatients,cliniciansandresearchers
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28% reductioninvisitstoseeaGP
17% reductioninhospitaladmissions
40% reductioninhospitalvisits
toseepracticenurses
EDGEisaprescribeddigitaltherapeuticformonitoringchronicobstructivepulmonarydisease(COPD)athomethatwas
developedbyOxfordUniversity(theInstituteofBiomedicalEngineeringandtheDepartmentofPrimaryHealthcareSciences),with
supportfromtheDepartmentofHealthandtheWellcomeTrustthroughtheHealthInnovationChallengeFund.
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The dot com bubble risk
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CambridgeUniversityColormetrix
Real time point of care diagnostics:
Theapp,developedbyresearchersattheUniversityofCambridge,accuratelymeasurescolour-based,orcolorimetric,testsforuseinhome,clinicalorremotesettings,andenablesthetransmissionofmedicaldatafrompatientsdirectlytohealthprofessionals.
Decentralisationofhealthcarethroughlow-costandhighlyportablepoint-of-carediagnosticshasthepotentialtorevolutionisecurrentlimitationsinpatientscreening.
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TricorderPrize
Hand held technology
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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
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Patient responsibility Thewinnerisactuallyasmallcollectionofspecializedandsmartmedicaldevicesthatinteractwiththeuser'stablet.
Thisincludesacompactspirometerthatcanmeasurethestrengthofapatient'slungs,aMonotestkit,medical-gradeheartrateandrespirationmonitors,anddevicesliketheDxtEROrb,whichdoublesasathermometerandstethoscope.
Thesedevicescan'tscanpatientsatamicroscopiclevellike StarTrek's device,butBasilLeaftechnologyco-founderGeorgeHarrissaysitimprovesontheshow'stricorderinonekeyarea:It'sdesignedforpatientstousethemselves.
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Technology is getting smallerMRI Technology
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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).
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Catalytic changeMtech co-existencewithsystemfailureandapolarisingsociety– firstandthirdworldhealthprovisionwithinthesameservice
Theirabilitytoextendmedicine’sreachtotheexcludedorunderserved
Thechangeswhichtheywillcatalyseinthehealthprofessionsandthebuildingstypes
Thelikelihoodoftheirnarrowingorwideningthehealthgapbetweenrichandpoor
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What has this got to do with hospitals?
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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
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Current position:number of acute beds in England
142000acutebeds
114000inuse
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Over65yearolds 50%ofthesebedscouldbe
treated
elsewhere
Current position:number of acute beds in England
142000acutebeds
114000inuse
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Change: 50%ofthesebedscouldbetreatedelsewhere
Virtualwards
Preventativemedicine
Extracarehousing
Rehab/stepup/stepdownbeds
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TheRoyalHospitalforIncurablesinPutneyLondon
Let us think back
Aren’t wetalkingaboutchronicdiseasemanagement
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The need for new models for acute care
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John Cooper / Director JCA
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Brand
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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
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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
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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
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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
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How do we make sustainable buildings
Goodbuildingsgetre-usedPoorbuildingsaredemolished
Badbuildingsgetdemolished
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Design: Lariboisiere
Space
Ventilation
Light
Patientgroupings
Management
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Lariboisiere Hospital
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Design:
Space
Ventilation
Light
Patientgroupings
Management
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Lariboisiere Hospital
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Thomaswas34whenStThomas’opened– thefirstPavilionhospitalinBritain
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Hospital in the city
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Hospital in the City
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New Necker Hospital
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No hierarchy within
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The re-usable hospital: maximsLocation
Chassis
Space
Ventilation
Light
Patientgroupings
Chassis
Residentialaccommodation
Theatres
Widthoffloorplate
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The re-usable hospital: maxims
ICUoutpatientsinpatients
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Nursing
home
nursinghome
extra-careflats
GPpractice
communityhub
The flexible building block
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The flexible chassis
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Eliminating hospital-landsuccess
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Eliminating hospital-landfailure
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Palestine’s Cancer Centre
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Palestine’s Cancer Centre
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Palestine’s Cancer Centre
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Palestine’s Cancer Centre
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Eliminating hospital-land
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Eliminating hospitals like this
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Eliminating hospital land
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Re-using hospitals Servicedoffice/medicaloffices/
startupsspaces
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Mixed use hospitals: de la Tour Geneva
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Mixed use hospitals: de la Tour Geneva
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Thank you
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Challenge: howtouseoldbuildingsandhospitalestates
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Model developments
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Example One: West LondonAnew350bedhospital
Acommunityhealthcarehub
90stepdownbedfacility
650-780apartments
24townhouses
50courtyardhouses
60shelteredapartments
Retailopportunities
Healthplex gym
A new community for 2500
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Workhouse conversionThesebuildingshavearchitecturalqualities
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Workhouse conversionCoherentarchitecturalform
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Carparking levelbeneath(exploitinghospital’sexistingbasement)
Conversion of Victorian core
30x80metregarden
30x80metregarden