@Exponhs Sessed About, Which I'm Really Thrilled About

Professor Sir Malcolm Grant CBE keynote

Future NHS Stage

Thursday 6 September 2018

14.30-15.30

Chair: Richard Vize – Journalist – Expo main stage host

Speaker: Professor Sir Malcolm Grant CBE - Chairman, NHS England

Richard: Good afternoon. I'm delighted to welcome you to the keynote address by Professor Malcolm Grant. Of course he's here in his capacity as Chair of NHS England, but the theme of his talk today is one of the great passions of his professional career which is research and innovation. So I would just like to go through actually the edited highlights of Malcolm's role and extraordinary CV. He was pro-vice-chancellor of Cambridge University, he led UCL for a decade, which as you well know a renowned international player in medical research. Among many developments there Malcolm established UCL Partners and helped establish the renowned Francis Crick Institute. He's currently Chancellor of York university. He holds academic posts in Russia and France. He's a director genomics England and he's also a UK business ambassador. So I can't think of a better person to talk to us today about the wonderful opportunities and challenges of research and innovation. Malcolm, you are most welcome.

Malcolm: Thank you so much for that introduction. Some of you will be aware that I'm now in the last seven weeks of my seven years as chair of the NHS England, and of course its 70th anniversary. A nice round coincidence of numbers. But much more than that, to reflect on how this institution has continued to change and evolve over the seven years that I have had the huge privilege of chairing it. What I wanted to do was to reflect on research and innovation in the NHS and try to capture in the round a great deal of what we have been talking about in the various lecture theatres and seminars and the stalls here at expo, with 5,000 people coming through the door every day and a huge buzz, what is it about research and innovation in the NHS that is different from anywhere else. So what the session is about is to try to understand first of all what is the economic case for research and innovation in the NHS. What is unique about this country and the way in which we work with universities and industry. What are the opportunities to build research and innovation into the long- term plan, what are the foundations on which we will build, and what are the areas for future development? I'm going to deal with one or two things that I really get ob-

First of all, a data point and this is all based upon research which is in very small writing at the bottom of the screen so as to be completely impossible to read. I wanted to demonstrate the academic trait is still with me, there has to be there even if you can't read it. Hospitals with a research arm have a lower mortality rate than those who have not. There are a huge number of variables that might explain why that is the case. It might just be that hospitals that are research active attract and retain high-quality clinicians and that leads to better quality outcomes. 3% of people believe that health research is very important. 48% believe they receive better care in hospitals that are undertaking research. One could understand that intuitively sounds right, if you go to one of our leading tertiary hospitals for specialist care, then you ought to believe you are getting better care as a result of research. Let me return to two fascinating data points. In the UK for every pound on research the combined health and economic return is between 24-27p per annum in perpetuity, a four-year payback and then pay back as a consequence of the investment.

Then an international point about research. A £1 increase in Government spending on medical research is associated to between 83p and 1.73p increase in private research funding. That fore goes to the critical question of what is the role of Govern- ment in stimulating private research and getting the double benefit both for patients in the NHS and the economy more generally and an immensely pertinent question at the time when we are contemplating a reorganisation of the way we have our relationship with the rest of Europe and the focus on the life sciences industry in this country.

Its formulation was led by Sir John Bell of the University of Oxford and it's created a number of initial stages we may go through in creating a new set of relationships that can reinforce industry in the Life Sciences in this country. Now, it's immensely com- plicated. But if I could describe John's thinking at its very essence, it is that the NHS is at the heart of this. No other country in the world has this volume of data, of longi- tudinal medical records data in a single repository capable of being interrogate and being used on a suitably anonymised and deidentified basis to help us understand human biology in a way which is of value to investment from the Life Sciences industry, as well as two our patients. Our job, by the way, is to try to join together some of those pieces, to make that work, and I will deal with that a little more in my remarks in the course of this address.

We, the board of NHS England, earlier this year, adopted an NHS 12-action program around research and innovation. I think it's been quite, how shall I say, buried in the intestines of the organisations historically and on the board we wanted to bring to it the forefront to understand what we, as an organisation, nationally should be doing to drive research and innovation in the NHS. Simplifying some of those processes. Articulating our own research priorities. Enhancing our data infrastructure, supporting advanced research into leading edge technologies, I'll come back to two or three of those in my address. And improving and simplifying adoption ecosystems. So, please, be assured that, at the national leadership level of the NHS, there is a com- mitment for research and innovation to drive patient improvement and care that we can offer, as also as a major contribution to the economy as a nation. That then leads us to, how do we do this? The long-term plan has been on everybody's lips over the last two days and long-term plans are a magnificent way of trying to envi- sion what the future might look like. Knowing that the long-term by the way will be completely different to how we imagine it today. Lots of things we'll do, we'll not actually fluctuate in the way we see it.

I'm reminded by the comment made by the Dean of Yale medical school in 1930. He was speaking to the graduation class and he said, "gentlemen, I've got two apologies to make to you, I've been discussing with the faculty where we have gone wrong and we have got to admit that, about a half of what we've taught you is wrong. The second apology is, we don't know what half" they were all men here. A Dean would have to make exactly the same admission. Indeed the pace of change is so dramatically faster than it was even in 1930. But research and innovation in the long-term plan creates for me an intellectual dilemma. The first is that, you can see in the bottom left hand corner, research and innovation is in a box. It's not in a box, that's just a way in which we symbolise it on a slide, we know it's part of a vibrant ecosystem running through the whole thing. But there are two elements to it.

One is that, research and innovation has to drive all of those clinical priorities, the lenses, we know, and I'll come on to it again, that when we talk about genome sequencing, that is going to have significant implications for cancer, as well as for rare diseases, which have been the two major areas of the whole genome sequencing to date. We have to understand that research and innovation permeates everything in the long-term plan, but we have to have it, not only as part of a clinical priority, but also as an enabling factor, an enabling thing that runs right through the whole of the system. So we will, in the coming few weeks, be focusing strongly on how we ensure that we capture these enabling technologies within a long-term plan that doesn't over-state what we are going to be able to do, but actually establishing, with reason- able precision, a forecast of where we can take care within the NHS. We have been listening. What is it that people feel inhibit the running of innovation in the NHS and, there are many, many explanations of this, many people will tell you that the average time from the discovery of something which could be a benefit to patients until it's actually incorporated into the practices of, let's say 50% of the providers in the country's 17 and a half years. If that were true, and if people are denied treatment which is life-saving, or reducing morbidity, that is a scandal.

We know it's not as simple as that and that there are many complexities involved in the innovation pipeline. But when we have listened to what people have been asking us to do, we have heard these messages, first of all, what we need is an integrated service for innovators. It's at the moment, a fragmented, ecosystem, as I say. People want something better joined up and better supported from within the NHS. Second- ly, expanded real world testing. I'm going to come back to real world testing because now real world data starts to provide us with a different environment and support mechanism for taking through innovation within the NHS. A single signal of readi- ness for commissioning, we, by the way are trade name is NHS England, our formal name is the National Economising Board, and commissioning is what we do, and we do it really well. However, commissioning for new therapies and new drugs within the NHS remains complex and difficult to achieve and, to have a single reckoning for commissioning is really important too. I'll come back to that when we look at the therapies. Building awareness and demand at point of care. There has to be a pull, as well as a push.

And when we talk about whole genome sequencing or new condition sear drugs, what often works is the pull that comes from patients and the NGOs that represent patient interest and campaign for the drug to be brought into every day practice, building awareness and demand at the point of care is not just patients, but it's also clinicians and trying to ensure that innovation gets through to the bedside. Under- standing up take and providing incentives, we have developed a tariff to promote innovation in the NHS and I'll demonstrate shortly the weaknesses and the successes of that. Building capacity and capability and adoption and spread, all of this is absolutely right and proper, the complexity lies in the detail, the high-level messages say it all of where we should be. By the way, it's not just an NHS phenomenon. What we are talking about here, is a global phenomenon, but the context in which the NHS operates is slightly different. If I were the Chief Medical Officer of the Mayo Clinic, what would drive me to adopt innovation would be two things - first of all, have the Cleveland Clinic done it? And if they have, then we'll do it and we'll do it better. And the second is, what is the profitability of doing this? Will this attract more patients to come to the Mayo than to the Cleveland and, how do I drive that into the clinic in order to get more patient flow which means more profit. And by the way I should emphasise that, the Mayo in particular doesn't pay its doctors by it automatic of service but by salaries, so the profit motive doesn't go into that point, but it does go into the way in which they run the whole high technology and high cost business of those two leading clinics. We don't have that. We have competition. That is embedded in the way the NHS works.

But it's a different sort of competition, it's the competition that I want my team, my clinical team to be better than the one in the other hospital in the other city and I want to do the very best for my patients. But it doesn't drive competitiveness in the commercial sense to which most other health care systems are well attuned. So, where are the potential areas for improvement across the NHS? I would suggest that here are just a small handful of things that we are concentrating on and should be

Raw transcript taken from live talks at Health and Care Innovation Expo 2018. Not for publication without consent from the NHS England Expo team. Needs checking and signing off prior to any subsequent publication, to ensure content is correct and accurate. Please contact [email protected] www.england.nhs.uk/expo @ExpoNHS concentrating on, number one, partnerships with industry that are aligned to the needs of the NHS. Two, providing parity of evaluation and commissioning between new types of innovation. We have an historic model. Is it fit for the 21st century? Thirdly, developing a culture where the adoption of proven innovation is everybody's responsibility. I'll come and say some more words about that in the subsequent slides and then investing in mechanisms that will spread innovation. So new para- digms with industry. I've called this a pitch, new partnerships with industry and the obvious example in this city is the Salford Lung Study. This is globally recognised now as a paradigm changer, as a result of a different set of relationships driven by GSK, but in conjunction with data providers and with general practitioners, 4,200 consenting patients, 80 GPs and 180 pharmacies, so what is the difference? Not double-blind randomised trials in the historical traditional sense. They want to establish whether their drug for COPD has had superiority over the normal treatments that were being provided in Salford. Actually, this was a huge risk, imagine if they'd spent £80 million and found rival drugs were better. A sufficient self-confidence allowed them to start to change the paradigm.

What you will see on the right hand side of this slide are quotes that have come from the industry, this, by the way, is taken from a piece in the Financial Times, two weeks ago only, what us the game-changer in the Salford Lung Study, a paradigm of aligned self-interest and this is critical, what is the future of the pharmaceutical industry, in the session immediately before this, I be us that question to Richard Irwin, the managing director of Roche UK and his answer was blindingly, he said "we don't know." The future, he would argue, is highly personalised medicines where drugs are manufactured for that individual against their genomic profile and other markers of their ability to respond positively to that medication. And so, those drugs are not going to be cheap. Those drugs are going to be hugely expensive. We are past the stage of the 0.5p aspirin tablet into something that will be highly expensive. Simon announced something that will be hugely expensive yesterday, hugely worthwhile but hugely expensive.

Industry's got to come up with this new approach. How do we have strategies that will prevent all that is preventable if health systems are to have budget capacity for higher cost personalised medicines, because we can't do both? So we start, I hope, to see the glimmers of an industry that turns itself around into a focus on wellness and the prevention and treatment of chronic disease, rather than focusing, as we al- ways have done, historically on curing when things have gone wrong. Secondly, as part of this paradigm, being able to demonstrate that the new products are going to provide good value for money for the NHS, and because, without that, the pharmaceutical industry has no market. I should emphasise that, the driving force for pharmaceutical industry to invest still in the UK in a post-Brexit world is not the extent to which we consume drugs, we are not very good at consuming drugs by comparison with the French, for example, who consume something like one third more medica- tions per Capita than we do.

Our total consumption is about 3-4% of the global consumption. No. What works here is talent. It's the talent that comes from our universities, it's the talent that's working in the National Health Service. And that is what we need to capture in our partnerships with industry to make innovation work well for the future. But let me then turn to that which was a novel model of partnership open and transparent and with GPs and the community involved, to a different model of partnership, the 100,000 genomes program. I declare an interest, I'm also a board director of Ge- nomics England Ltd but that is a company fully owned by the Secretary of State. Why do we do that? Set up a company. The answer is, I don't believe we could have done that from within the NHS. I don't believe we have the flexibility within a complex organisation such as NHS England to be fleet of foot, to be commercial enough and to go out and deal directly with industry, procure sequencing and the curation and interpretation of data. So we set up a company, we authorised it to do all of those activities, and we succeeded and will have succeeded by the end of this year in doing 100,000 whole genome sequences. This, by the way, was something they said to us, "you will never do it". That's the NHS. I would like today to play enormous tribute to the clinicians and mathematicians and Genomics England for actually getting us there. It was the first program to do this in a particular way.

Other nations have done whole genome sequencing. But they've done it in the context of what available data they have. That is in the context, for example, of the Mayo, that clinic in America has some good genome sequencing capability and we have taken their director and made him a non-executive director of Genomics Eng- land so we can get some Transatlantic experience. However, their capacity is only with a certain self-selected population. Ours is with an entire population.

So what we wanted to do was roll out genomics to every participating hospital in the country, over 100 participating in this from the beginning. We could have done it all in London or Manchester. No. Because we are laying the foundation stones for a clinical service across the whole country, add not just a research exercise conducted in one or two hospitals. 85 acute Trusts, 13 NHS genomic medical centres, and we have been dealing with 200 rare diseases, 15 cancer classes and 260 cancer pathways. That's great. But what's next? How do we take whole genome sequencing for which we now have proof of concept, proof of concept across rare diseases, for example, we can now bring to you parents of young children who previously had no diagnosis, a child born with some genetic illness which we didn't understand? A phenomenon which everybody understood was called the Odyssey, it would take six or seven years to get a diagnosis for this child. In some cases this diagnosis, by way, will not be curative but in many cases it gives the clinician an understanding of the condition, so they can provide some sort of treatment which will avert what is other- wise a foreseeable illness in the future and it may be cancer or liver disease, which is associated with a mutation.

Secondly, it allows counselling to be given to the parents. Given to the parents. Is this a condition which will affect any other child that's born or is this something unique to this particular child? So, rare diseases of which there are hundreds of

Raw transcript taken from live talks at Health and Care Innovation Expo 2018. Not for publication without consent from the NHS England Expo team. Needs checking and signing off prior to any subsequent publication, to ensure content is correct and accurate. Please contact [email protected] www.england.nhs.uk/expo @ExpoNHS thousands, millions of sufferers in this country, I can see now, a solid proof of concept. For cancers, it's still more difficult, but whereas in the past we have been using genetics and genomics in a way that dealings with single genes or panels of genes or an exome, an evident exome will give you 1% of the information a genome gives you. That contains much of the information that's needed to treat patients. The re- maining 99%, however, often with unexplained variants, things we don't yet understand, provides a wealth of information for future health care. That's why we want to drive this now out into the clinic. What we are going to do from October this year is re-design all the genetic laboratories in the country which will come to seven genomic laboratory hubs. They'll have responsibility for taking whole genome sequencing through the NHS, focusing one on rare diseases and certain classes of rare diseases, two on paediatric cancers, three on neonatal disorders, and four on certain blood cancers.

This is the opening wedge I think of a revolution in cancer care. There are, I think, a number of major steps to be taken, a number of funding decisions to be taken. A symbol of hope to do something that only the NHS of all world health care systems can actually do. So, everybody will stress that the genome is the first part, complex as it is. So the genome is, what takes place, if you like, under the bonnet. We have all got a genome, we can all be sequenced, and it would give us some indication of whether there are any variants in our genomic structure which might great creator or lesser propensity to certain sorts of conditions. The visionary thing for the future is not just the Jew gnome but it's how it works in relation to protein, transcriptome, me- ta-biome and things that look at what it is that externally can trigger the action within the cell towards it as we start to reproduce it abnormal lift Eric Topal said, "with personal technology, doctors can see a full continuously updated picture of individuals" and then it can be treated accordingly. Some say you can do the tests simply from a blood test every six months which gives you, like a Ministry of Transport test on your car, a read out of how things are going.

That's a little way in the future but it gives us an idea of the power of the technology, not only the technology to do the test, but the technology to read the data, to use it, not only that which is accumulated in this country, but if you had a child who had a rare disorder and we knew that there was a child with that same rare disorder in Texas, would we not want to compare those two genomes, then we might find one that was in Australia. There is a global exercise to be undertaken here in which we can interrogate data around the world of patients with very rare mutations. And to understand what that means for their medical care and treatment. So, let me look at partnerships within industry. That's a particular model of partnership in which the Genomics England works with the pharmaceutical companies, sequencing companies and provides intermediation between the NHS and industry. Certain other partnerships have been in the news.

Lord Paul Drayson, former Health Minister and now entrepreneur in Oxford. This is chaired by Sir John Bell as well. Many of the initiatives that I'll mention today are probably chaired by John Bell or have been designed with John Bell's intelligence.

He's an inspiring character. What is the commercial deal here? It's Oxford University, it's Oxford University Hospital's Foundation NHS Trust and a deal in which they can take discovery out of the hospital and take it out and commercialise it and they'll en- ter into similar sorts of deals with other participating Trusts. A Royalty fee, equity share and investment in local R&D. Royal Free. As everybody knows, it got involved in Google deep mind to develop a program called Streams which assembles data from various sources in hospital and allows clinicians and in the Royal Free to get early warning of a patient who may be heading towards a crisis in kidneys. Assem- bling all the information is really difficult here, particularly where there is a changeo- ver of clinician responsible for a large ward. This was not artificial intelligence, by the way, it was a model which was using a tree approach to diagnosis, which was already being used by the NHS. But we get to a position then where there is use of patients' data within the NHS and it's being used by Google Deep Mind to produce a product which will be of value to the Royal Free. But also of value globally as they develop the product.

The third one, a different model UK Buy a Bank, it was established about 20 years ago, largely using government money but also with investment from the Welcome Trust but with a commercial approach which is absolutely fascinating. The data is there, and the data is free to use. Not just to researchers in this country but to researchers globally. People with proper consent may come and use the data. It's de-identified patient data but also every participant and there are 500,000 in Buy a Bank, every patient has consented. There is, I think, maybe some thought about, what we do that now, would we not try to capture the economic value of that data in our dealings with industry? It might be that we would take a different approach now. But let me just mention the study that's on the right-hand side of the slide which it was published in Nature Genetics a couple of weeks ago about polygenic risk. By using data in Buy a Bank, instead of looking at risk factors through the lens of a single gene, they've been able to do polygenic risk looking at combinations of the way the genes interact and have come up with startling figures. For example, coronary artery disease in the UK, 8.5% of the population are greater than three times in- creased risk. More than five million Britons have triple the normal risk of heart disease. So we are starting to get the use of a non-commercial partnership, driving research which helps us to understand possibly how remove into a new model of population screening and a poly-genic population screening model which could be more accurate than population screening at the moment.

And then the fourth model here is the Moorfields Eye Hospital NHS Foundation truth and Deep Mind health. Forgive me if I spend a lot of time on this, because I love this. During my time at ICL, Moorfields has an institution of ophthalmology which was part of UCL and we worked together closely. At that time, Moorfields was not a strong performing hospital as it could have been. What we did was to reverse a procession of decline and the quality of the research understanding people, it's without doubt the leading eye hospital in Europe. The consequence of that is that they have a bur- geoning demand, not just because they're good and popular, but eye disease starts to multiply with an ageing population. Age related macular degeneration is a major

The this was not the first time that deep mind went to Moorfield, it was when the clinicians at Moorfields went to Deep Mind and said we have a problem, can you solve it for us. They made a Deep Learning model looking at 3-D scan, multi-layered and it gives a very accurate picture. It is the gold standard now for eye diagnosis in the first instance. Not just the gold standard but available into optometrists across the country and the world. Last year in America there were over five million OTC scans, just in Medicare which is the system that provides medical care for the older population. How Deep Mind went about is, is really original.

Other diagnostics have tried with pattern recognition, but to use it in a black box model, you run a million scans setting up the computer and it learns and learns and learns, but you don't understand what it is doing. This one did a two-phase process which is applicable across an entire range of diagnostics. First a deep segmentation work by which they did a tissue picture of the eye, so they delved into that, and for each eye that was scanned there is a tissue picture, and then a declassification network that takes that and builds on that into understanding what it is that now needs to be done as a result of that tissue picture. The reason why that's important is that we need to get away from black box use of AI, in mental health, because if we have black box it is very difficult for a clinician to second guess and say hang on, there is a point in this analysis that I don't agree with. The model at Moorfields allows the clinician to go back to the tissue segmentation and read it and try to understand what comes out of it. They have been able to device this for more than 50 common eye diseases, the most common macular degeneration and glaucoma and associated diseases. To evaluate the outcome from the machine against the gold standard, and the gold standard is how do clinicians get on with OCTs, the gold standard is how do they get on once they have all the subsequent information about the patient and not just the initial OCT scan.

How did they do? There we go. This is a paper again from Nature Medicine, two weeks ago, this is the gold standard. Here we have 96% diagnostic accuracy, which is equal to or exceeds that of the leading clinicians. In some of these scans their eight leading clinicians wouldn't agree what it was. This is not simple stuff and yet they have confidence that this is a remarkable change. 94% referral accuracy and all urgent patients were correctly classified. There are two variants you have to worry about this, what is the device doing the scan and how does that device vary even with devices by the same manufacturer, let alone other devices and by that segmentation they can make the device agnostic. It doesn't matter what your device is, that first section will correct for variants between the devices. The second variation is eyes are all different, there are different pathological manifestations of the disease in people's eyes, and that variant has been taken care of by the second of the segmen- tations. And so, just consider what this means?

Look how many appointments are taken up in outpatients, not only for the initial diagnosis but then for subsequent treatment. Understand how that can be transferred into a machine model of eye diagnosis, and what is the difference. The difference is for a leading clinician to read one of those scans is not a five-minute job, it could take hours. Particularly in a complex role. This model does it in about five seconds. So you have a suddenly accurate and a suddenly, extraordinary cheap and reliable model of diagnosis. The issue here is not just that here is something that has been developed in a major NHS hospital, but something that is applicable as the technology develops to other types of medical imaging, and diagnostics and to pathology. So why then do we not have a commercial agreement between Moorfield's and deep mind that returns 50% of all global profits from the product back into the NHS. That I think is a very serious question. This was experimental, it was an important break- through, it was driven by passion, by the clinicians.

But I would just like to commend very much what Lord O' Shaunessy I was promoting yesterday, which is a new Code of Practice for relationships with industry. If we miss this then we miss the value of the data and the intellectual property that lies at the heart of the NHS. Which we are not all that used to capturing, because we are, after all, a community interest venture. And the establishment of commercial princi- ples, by the way, in these terms, looks really right and interesting and good. In practise it is really difficult. In practise we do not want to have some sort of top-down prescription that you may not do this, this or this, without this and this consent, because that is not for innovation and experimental discovery. A fair share principle is right but who determines that. We have to move away from the use of NHS data given free to an industrial concern, but at the same time we have to ensure that the terms on which they can use it are terms which will return to the NHS and benefit in finance as well as in patient benefit. Equity sharing, royalty streams are a critical part of that for the future.

I made a point at the beginning, about what they heard, what do people want, how complex is it to get innovation spread in the NHS. And I had this slide devised simply to try to demonstrate that at the moment we have different pathways for different types of innovation, and the reason we do is because it is historical. In medicines, NICE is the pathway and around 75 instances per annum where NICE does an ap- praisal and the vast majority for medicines and there is a funding requirement for NHS to implement, but completely different for diagnostics and devices and digital products. On that middle line across, diagnostic and devices, it has been estimated of those three that then came into the innovation tariff there has been overall around a cost saving across the whole of the NHS and with some of them as much as 65% cost saving to introduce to the NHS. I think we should ask ourselves are we yet being sufficiently rigorous in uniform in how we assess the benefits to the NHS. And here's a telling diagram which says in relation to the uptake of the tariff, in some cases there has been as much as 50-60% uptake and in some cases it is still right down at about 3%. So there is a huge disparity by which we could say, well putting addi- tional money in is not the sole solution, important though it is. I wanted then just to

In the belief that there was a fundamental relationship between universities, the health service, and industry, that should be developed for the benefit of the NHS, and in those days, when I was a Vice Chancellor, I kept looking at this and thinking I don't get this for universities. Of course I have changed my mind completely now. But I could see what great benefit there would be to the NHS. The answer is fundamental, the stock of innovation and enterprise in the universities and the infrastructure of the universities, is fundamental to driving innovation across the NHS. Pre- cept, precept is something really quite simple, and it has come through one of our AHSN, it is an intervention that can prevent a child being born with, oh gosh, cerebral palsy, that's the one. I was hoping that he was still in attention, I was discussing it with Richard earlier. It is simple, it costs £1 per time but involves an injection of ammonium sulphate into a pre-term child during the mother's labour, a pound a time, of the seven cases where we know it has prevented a child being born with cerebral palsy, it has saved £5 million in lifetime costs. That is a crude utilitarian explanation, but it has saved families a lifetime of difficulties. We would expect that to be univer- sally adopted across the NHS instantly.

Here is a map which is a telling map. We have worked to establish a network across the country, because we see them as agents driving change across the entire country if they come together and they have been doing that immensely successfully. This is the first we have had an AHSN national report, you can see stage zero where there is no information and contact isn't established is one of the major areas. As we move along the bottom line to the left, so we see the gradual take-up. What I challenge you is watch these reports, every quarter, and let's see whether we are suc- ceeding through a national network of AHSNs in getting this stuff to work, I think this is an immensely valuable and important venture that we are involved in. This one, the programme level data for escaped pain, you will see a much bigger group of grown where it is taken up. Escape pain is a simple innovation, it is for people with osteoarthritis, the common treatment with osteoarthritis is medication. Escape pain involves a new model of physio therapy and intensive physio therapy and groups of people coming together, working together, and with dramatic results which means that we have a non-medicated outcome and process, and I'm glad to see the extent to which that is now being taken up across the NHS. It is important, isn't it, to get the knowledge, to get the context and the enthusiasm and the drive and to produce results which are of benefit to patients. So, what's the framework for the future. This has been something of a driver for personal enthusiasm and personal frustrations, where can we go for the future as a movement to ensure that we get the innovation into the NHS. I think first of all it is to understand research and innovation is not an end of itself. We have seen innovative products which aren't actually better for patients. I mean I think some of the novel anticoagulants, as compared to Warfarin, we would say they work well for some waits but they are not well attenuated Warfarin for blood purposes not an end in itself. But only when it demonstrably improves patient care.

Secondly, I think we need to be clear about what works for all types of innovations, as I showed in the earlier slide, the what works bit isn't yet co-ordinated. What works is really well done by NICE which is a global exemplar, in terms of what works and how cost effective it is when it works, as we saw from the slide it is not yet driven out across the whole of the NHS in relation to diagnostics, devices, digital products and pathway changes. Thirdly, new models of partnerships with industry. I think we need to spend an enormous amount of time working collectively with industry and getting this right. Many Trusts are nervous, many Trusts do not have commercial leadership within the Trust that enables them to pick up and have a solid discussion with industry. We need leadership from the department and Steve is in the room and has leadership for that in his jurisdiction. But we need also to be able to ensure that we retain the autonomy and the local flexibility and local freedom to deal with industry, and to overcome the feeling that any non-executive on any Trust board will have, which is are we being screwed? Industry is going to make profits out of this, are we getting our share. I think professional advice, the creation of agreements which can ensure over time and the delivery of observable demonstrable returns to the hospital, to the AHSN, to the university and above all to patients and to the local community. I would say this is revolutionary, I think we are still very much in the early stages and there is an enormous amount of work to do.

And then I think a critical thing, how do we reflect the importance of developing or adopting innovations in all aspects of daily work in the NHS. Innovations isn't for the person who is called the director innovation. Innovation is actually for every clinician, and every clinician who I ever met is innovative but in different ways. The break- through that we see in places like the royal free and in places like Moorfield's and the Salford lung study and the engagement of that involves a mindset that is difficult often for people to develop in a time when they are working under immense pressure in the NHS and they are delivering high-quality care, and yet they know with some tweaking that have they could deliver better quality care and with development of industry of some new technique or some new advice that could be even better. How do we do it? Do we get it into job descriptions and career gateways, recruitment cri- teria, performance management networks and areas, it is a whole amount of structure within the NHS with huge enthusiasm and little focus and real opportunities to try to engender this as a driving force for everything we do? And then finally, how do we celebrate, we do need to celebrate stuff a lot more, we need to be able to say when you have done this well it shouldn't be a matter of being pursued down the street by the Information Commissioner, that should actually have been sorted and actually we should have some good, sensible rulings from the Information Commis- sioner about the use of patient data. What it has to be, however, is those that get that right and produce results that are of benefit to patients, have an ability and time to help replicate that across the NHS and indeed globally.

Richard:

Plenty of provocative material to chew on. So a few minutes before questions and we have got some roving mics, so please put your hands up if you would like to ask a question or make a contribution. Anyone waving at this point? Or drowning. Where are we? Yes, number two, please? Microphone heading your way.

Floor: I'm Lucy Morrison, I'm in the Strategy Team at Bart’s NHS Trust. I've been on a pan- el around creating value and industry around models and pathways of cares, as opposed around sight and translating medicines or devices et cetera. I wonder whether you see any role for that type of approach in this as well in terms of looking at how we operationalise things better, how we look at pathways and things in a very holistic but different way as well within industry?

Malcolm: Bart’s, you don't need industry there but it can be very helpful in helping digitise patients but there is a fundamental question as to why we have out-patients and one answer which is to train young doctors is actually a valid answer, but it doesn't relate to what benefit there is to patients and how much of the work done with out-patients could be done remotely and how much could then relieve pressure on senior and junior doctors in order to do the treatment of those who've come through-out patients, so I think first of all, Bart’s is taking a lead, along with the local Clinical Com- missioning Group, another major player in this. CCGs who I haven't mentioned in my speech, have to be also the drivers of change because they have to be the ones seeking better quality care at lower price from whom they commission health care. So far as industry is concerned, I think there is a wide variety of products already available that can help you and your strategy work, but also many industries are only going to flourish if they have a partnership with an organisation such as yours.

Richard: Next question, please? Yes, please, at the front, mic two is heading your way. That that hi, I'm Iain O'Neill from the Department of Health and social care. Your point about new commercial models and working with commercial organisations, where do you think we get the skills to understand that, are they skills that we already have, commercial seems to mean something different to us, buying, as opposed to what you are talking about, so do we have the skills or do we need to bring them in?

Malcolm: I think you need to bring them in and DHSE has done so to an extent. The critical question is that there is across the whole commercial world vast experience of this and how do you capture that and divvy up profits and what model of equity sharing you do. How do we ensure that industry in this country understands that a collabora- tive relationship with the NHS is hugely to their benefit? And that there are ad- vantages? What I wouldn't do is try to monetise the value of data. I think that's a mis- take. Simply to say you can use 100,000 patient records and it will cost you £3 million, I think that's too crude and too simplistic. We have got to be able to have something which isn't just a surface level agreement in which we give stuff away for a

Floor: Richard Stubbs. Thank you for raising the spread challenge which obviously is a big part of our work. There seems to be interesting comments from your comment about the tension between nationally derived maybe top-down directives about what to do and locally the devolved decision-making and in terms of the spread challenge where the answers lies on that spectrum.

Sir Malcolm: One of your colleagues came to a board meeting of NHS England and gave us an example of something which was a fail-safe device, the box. Potentially, preventative of fatalities in the operating room. My colleagues at the end of that said, why aren't we just saying you've got to do it, where is our powers and we looked at each other and thought, where's the board of NHS England, we have got all this money and Bruce Keogh was with us then and he sighed because that was his challenge of how we actually do it. Back to America - one of the features of America and there are many features of America that I would never want to import here. If you didn't do it you would just get sued. If this were now a practice which could be demonstrated could save a life and you fail to do it and somebody lost their life, you would get sued. In America, those legal actions generate huge volumes of overhead for the health care system. We are not far away from that. So I do worry that, as soon as a device or an approach or pathway or something is developed somewhere, that is demonstrably for the benefit of patients, and if we don't implement it, we are very vulnerable to, not only to facing the awful personable cost of disaster but also to legal action.

Richard: Thank you. Number three, please?

Floor: I'm an ophthalmology registrar in Oxford and deep mind and Moorfields was the most talked about that I can remember for a while in our department. The drugs take a long time to each us in the clinic, I was wondering if you knew how long it would be for it to reach us at a separate clinic in a separate Trust?

Moorfields have rolled it out in various subsidiaries which they have in other hospitals across the country. I would have thought that this was something where clinicians should be talking together because it's driven by Moorfields and their interest is not primary in generating huge revenue, but it's about spreading the product. So I would suggest that is the starting point. But of course, the control over the device, over the machine-learning with Deep Mind and they'll have a commercial interest in

Richard: Do you think there is more to be done there for the franchising of some of the leading institutions around the country to get innovation out more quickly?

Malcolm: Yes I do. This is part of what we expect the HSNs to be doing, developing new ideas and technologies through a national network are promoting the spirit. It's exactly what we want. The franchising issues are interesting because we have franchising, Moorfields are doing a front franchise model of eye treatment. They are concentrating resources and Salford and Pennines is a good example in this part of the country. The provider network situation is starting to change as well and that may well be a new gateway towards the spread of innovation.

Richard: Thank you. Can I thank Professor Sir Malcolm Grant for a fascinating address? Thank you.

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