Time present and time pastare both present in time future
JohnCooper
Utopia-DystopiaBinary choicesMapoftheEnglishCivilWar
loyalties
Brexitspread
Utopia-DystopiaBinary choices
Immeasurable changeTheFirstIndustrialRevolutionusedwaterandsteampowertomechanizeproduction.TheSecondusedelectricpowertocreatemassproduction.TheThirdusedelectronicsandinformationtechnologytoautomateproduction.NowaFourthIndustrialRevolution:characterizedbyafusionoftechnologiesthatisblurringthelinesbetweenthephysical,digital,andbiologicalspheres.TheFourthischaracterisedby:• Velocity• Scope• Systemsimpact
Thespeedofcurrentbreakthroughshasnohistoricalprecedent.Whencomparedwithpreviousindustrialrevolutions,theFourthisevolvingatanexponentialratherthanalinearpace.
Utopia-Dystopia
Probable fixes or near fixesMigratorypatterns
Urbanity
Travel
Patternsofsettlement
Humaninstitutions
Humanhealth
Humanneeds
Certainties for the healthcare future• AIwillhaveaprofoundlydisruptiveeffectonalllevelsoftheworkforce
• AIwillperformmanydiagnostictasks
• AIwillenablehugereductionsinimagingcosts
• Smartphonesenablerealtimepointofcarediagnostics
• Smartphonesenableremoteexamination
• Smartphonesenableremotemonitoring
• Networks:doctorswithdoctors,doctorswithpatientsandpatientswithpatients
Certainties for the healthcare future• Medicinewillbecomeincreasinglypredictiveandthereforepreventative
• Robotics
• Nanotechology
Remote possibility: end of scarcity
nanotechnology
My thoughts on the matter 1852
2013
The strange links
Self careMonitoringAutomated treatmentInformation and adviceNHS direct
Social carePrimary careOutreach careInformation and advice
Basic diagnostic servicesDay interventionsMinor injuriesNurse led inpatient careIntensive rehabilitationChronic care management
Planned interventionsEmergency careComplex diagnostic treatment & inpatient care
Home
Healthandsocialcare
centresupto10kcloseto
home
Communitycarecentres
100kheartofthecommunity
Specialistcarecentres250k,
500k,1000koncentralcity
sites
A lost decade: institutional torpor
2000 2005 2010 2015 2020
1950s
1970s
A lost decade: institutional torpor
Reasons: Procurement: commissioningbuildingsthroughtheconstructionindustry
Simpleeconomics:PFI
EvenasitsfutureremainsuncertainintheUK,PFIhasbecomeoneofBritain’s
mostsuccessfulexportswithcountriesfromCanadatoIndiaandAustraliainthe
processofrollingoutbillionsofpoundsworthofPFIschools,hospitals,roadsand
infrastructure.
“TheUKhascreatedamarketforBritishcompanieswithPFIexpertise,”says
RichardHowson,chiefexecutiveofCarillion,whichisamongthemoresignificant
companiesinthePFIsector,earningabout8percentofunderlyingoperating
profitsfrompublic/privatesectorpartnerships(PPPs)worldwide.
WithprojectsintheUKslowingtoatrickleasaresultofthegovernment’syear-
longreviewintothePFI’sfuture,contractorsincludingCarillionhavebeenbeefing
uptheiroverseasteams,particularlyinCanada,wheremorethan$7bnofhealth,
education,leisureandtransportprojectsweresignedofflastyear.
Do the Maths
PFIBidCost: £4-5million
Averageprofitforatoptwentycontractor: say3%(actuallynearer1.5%)
Costofrecoupingbidcost: £130-150millioncontract
Ifyoumakea£45millionloss £1.5billioncontractrepaysthisloss
(60%ofthe8th largestcontractor’sturnover)
Do the diligence : commissioningdesignthroughthe
constructionindustry
Procurement: Business Cases
Thecost
£1.5- £3.0million
Procurement: Business Cases
£40millionspent– nothingtoshowforthis
£100millionspent(probably)acrossLondon
Example1
SmalltoMediumSizeTrust
• Turnover£272million
Commercialopportunity
• Aplotofsurpluslandcanbesoldfor£15million
Finances10days’Trustactivity
Financesa2500-3500squaremetrehealthcaredevelopment
Disposal based funding: do the Maths
Example2
LargeSizeTrust
• Turnover£650million
Commercialopportunity
• Aplotofsurpluslandcanbesoldfor£50million
Finances28days’Trustactivity
Financesa10-12000squaremetrehealthcaredevelopment
Disposals: Do the Maths
Briefing and planningwestartinthewrongplace
90%ofwhatspecialists
doisthesameyetwe
identifytheirspacesby
the10%difference
Meanwhile: tech change accelerates
Moore’s Law
2001- 2018 Information technologyTheextraordinaryandacceleratingadvancesthataretakingplace
Healthcaretalksaboutyesterday’stechnologyastoday’sandtoday’sastomorrow’s:
• smartphonetechnology
• algorithmictriageanddiagnosis
• telemedicine
• miniaturisation– realtimeremotediagnosis
• miniaturisation- imaging
• nano-sensors
• robotics
• pharmaceuticals/genomics
Smart phones• pharmaceuticals/genomics Monitoring
Examination
Networking
Communication
Telehealth
Remote monitoring
respiratoryrate
heartrate
bloodoxygenlevels
bloodglucoselevels
systolicbloodpressure
temperature
urineoutput
sleepandmovement
Realtimeagainstthepatient’srecordandthepatient’spersonalassessment
COPD
Asthma
Cardiacconditions
Diabetes
Mentalhealth
Monitoring
respiratoryrate
heartrate
bloodoxygenlevels
bloodglucoselevels
systolicbloodpressure
temperature
urineoutput
sleepandmovement
Realtimeagainstthepatient’srecordandthepatient’spersonalassessment
Wedevelopclinicallyvalidatedsoftwareapplicationspoweredbyartificialintelligenceincludingprescribeddigital
therapeuticsandhospitalsystemsforclinicalcare.Ourproductsconnectpatients,cliniciansandresearchers,generating
largedatabasesofphenotypicdata,enablingdiscoveryresearchandimprovingpatientoutcomes.
Networks: linkingpatients,cliniciansandresearchers
28% reductioninvisitstoseeaGP
17% reductioninhospitaladmissions
40% reductioninhospitalvisits
toseepracticenurses
EDGEisaprescribeddigitaltherapeuticformonitoringchronicobstructivepulmonarydisease(COPD)athomethatwas
developedbyOxfordUniversity(theInstituteofBiomedicalEngineeringandtheDepartmentofPrimaryHealthcareSciences),with
supportfromtheDepartmentofHealthandtheWellcomeTrustthroughtheHealthInnovationChallengeFund.
The dot com bubble risk
CambridgeUniversityColormetrix
Real time point of care diagnostics:
Theapp,developedbyresearchersattheUniversityofCambridge,accuratelymeasurescolour-based,orcolorimetric,testsforuseinhome,clinicalorremotesettings,andenablesthetransmissionofmedicaldatafrompatientsdirectlytohealthprofessionals.
Decentralisationofhealthcarethroughlow-costandhighlyportablepoint-of-carediagnosticshasthepotentialtorevolutionisecurrentlimitationsinpatientscreening.
TricorderPrize
Hand held technology
RequiredCoreHealthConditions(10):
Anaemia,AtrialFibrillation(AFib),ChronicObstructivePulmonaryDisease(COPD),Diabetes,Leukocytosis,Pneumonia,OtitisMedia,SleepApnea,UrinaryTractInfection,Absenceofcondition.
ElectiveHealthConditions(Choiceof3):
CholesterolScreen,Food-borneIllness,HIVScreen,Hypertension,Hypothyroidism/Hyperthyroidism,Melanoma,Mononucleosis,Pertussis(WhoopingCough),Shingles,StrepThroat.
RequiredHealthVitalSigns(5):
BloodPressure,HeartRate,OxygenSaturation,RespiratoryRate,Temperature
Hand held technology:TricorderPrize
Patient responsibility Thewinnerisactuallyasmallcollectionofspecializedandsmartmedicaldevicesthatinteractwiththeuser'stablet.
Thisincludesacompactspirometerthatcanmeasurethestrengthofapatient'slungs,aMonotestkit,medical-gradeheartrateandrespirationmonitors,anddevicesliketheDxtEROrb,whichdoublesasathermometerandstethoscope.
Thesedevicescan'tscanpatientsatamicroscopiclevellike StarTrek's device,butBasilLeaftechnologyco-founderGeorgeHarrissaysitimprovesontheshow'stricorderinonekeyarea:It'sdesignedforpatientstousethemselves.
Technology is getting smallerMRI Technology
AI Algorithms:Embeddingdatainalgorithmsforcomputerapplicationtoproblemsolving
Examples:CancerandICU
Deep learning: recognising patterns in distinct layers
Theaccuracygapbetweenthehumananddigitaleyeisexpectedtowiden.Asdeep-
learningapproachesgaintraction,theywillcontinuetoadvancesuchdiagnosticfieldsas:
• radiology(CT,MRIandmammographyinterpretation)
• pathology(microscopicandcytologicaldiagnoses)
• dermatology(rashidentificationandpigmentedlesionevaluationforpotentialmelanoma)
• ophthalmology(retinalvesselexaminationtopredicttheriskfordiabeticretinopathyandcardiovasculardisease).
Catalytic changeMtech co-existencewithsystemfailureandapolarisingsociety– firstandthirdworldhealthprovisionwithinthesameservice
Theirabilitytoextendmedicine’sreachtotheexcludedorunderserved
Thechangeswhichtheywillcatalyseinthehealthprofessionsandthebuildingstypes
Thelikelihoodoftheirnarrowingorwideningthehealthgapbetweenrichandpoor
What has this got to do with hospitals?
Present :70% of the NHS budget is devoted to chronic disease management
40% of the NHS budget is devoted to people over 65
50% of medical beds are occupied by patients who could be cared for elsewhere
On average elderly patients spend 4 times longer in hospital than their consultants’ initial care plan
Current position:number of acute beds in England
142000acutebeds
114000inuse
Over65yearolds 50%ofthesebedscouldbe
treated
elsewhere
Current position:number of acute beds in England
142000acutebeds
114000inuse
Change: 50%ofthesebedscouldbetreatedelsewhere
Virtualwards
Preventativemedicine
Extracarehousing
Rehab/stepup/stepdownbeds
TheRoyalHospitalforIncurablesinPutneyLondon
Let us think back
Aren’t wetalkingaboutchronicdiseasemanagement
The need for new models for acute care
John Cooper / Director JCA
Brand
ED
0% 50% 100% 150%
Ou tp a t i e n t s e r v i c e s
Th e ra p i e s
Im a g i n g
T h e a t r e s
Components of change: now
ED
0% 50% 100% 150%
Ou tp a t i e n t s e r v i c e s
Th e ra p i e s
Im a g i n g
T h e a t r e s
Components of change: very soon
Pa t h o l o g y
0% 50% 100% 150%
I npa t i e n t s e r v i c e s
I CU
Te l e h e a l t h
Components of change: now
S y s t em d e v e l o pmen t
Pa t h o l o g y
0% 50% 100% 150%
I npa t i e n t s e r v i c e s
I CU
Te l e h e a l t h
Components of change: very soon
S y s t em d e v e l o pmen t
How do we make sustainable buildings
Goodbuildingsgetre-usedPoorbuildingsaredemolished
Badbuildingsgetdemolished
Design: Lariboisiere
Space
Ventilation
Light
Patientgroupings
Management
Lariboisiere Hospital
Design:
Space
Ventilation
Light
Patientgroupings
Management
Lariboisiere Hospital
Thomaswas34whenStThomas’opened– thefirstPavilionhospitalinBritain
Hospital in the city
Hospital in the City
New Necker Hospital
No hierarchy within
The re-usable hospital: maximsLocation
Chassis
Space
Ventilation
Light
Patientgroupings
Chassis
Residentialaccommodation
Theatres
Widthoffloorplate
The re-usable hospital: maxims
ICUoutpatientsinpatients
Nursing
home
nursinghome
extra-careflats
GPpractice
communityhub
The flexible building block
The flexible chassis
Eliminating hospital-landsuccess
Eliminating hospital-landfailure
Palestine’s Cancer Centre
Palestine’s Cancer Centre
Palestine’s Cancer Centre
Palestine’s Cancer Centre
Eliminating hospital-land
Eliminating hospitals like this
Eliminating hospital land
Re-using hospitals Servicedoffice/medicaloffices/
startupsspaces
Mixed use hospitals: de la Tour Geneva
Mixed use hospitals: de la Tour Geneva
Thank you
Challenge: howtouseoldbuildingsandhospitalestates
Model developments
Example One: West LondonAnew350bedhospital
Acommunityhealthcarehub
90stepdownbedfacility
650-780apartments
24townhouses
50courtyardhouses
60shelteredapartments
Retailopportunities
Healthplex gym
A new community for 2500
Workhouse conversionThesebuildingshavearchitecturalqualities
Workhouse conversionCoherentarchitecturalform
Carparking levelbeneath(exploitinghospital’sexistingbasement)
Conversion of Victorian core
30x80metregarden
30x80metregarden
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