บทถอดความฉบับเต็มของ Why is it so difficult to implement Evidence Based Healthcare?

actually in my job now. 50 00:05:16,010 --> 00:05:24,020 And so I do quite a lot of work with ministers providing policy advice as well as then implementing the consequences. 51 00:05:24,020 --> 00:05:29,090 And so it's from those three different perspectives that I'm going to try and pull together 52 00:05:29,090 --> 00:05:36,200 my reflections and hopefully stimulate some questions and some thoughts for you to take away. 53 00:05:36,200 --> 00:05:40,730 So since the beginning of January, I've been to probably four or five meetings, 54 00:05:40,730 --> 00:05:53,480 all of which have been at the paper that was published in The BMJ in January about the diabetes prevention programme has come up. 55 00:05:53,480 --> 00:06:01,340 I don't know some people in here who who work in the medical field will have will have seen this paper, which is essentially a discussion. 56 00:06:01,340 --> 00:06:07,100 No, it's it's it's an analysis of some data actually about whether the diabetes 57 00:06:07,100 --> 00:06:12,650 prevention programme is an effective intervention at NHS England and my employer, 58 00:06:12,650 --> 00:06:15,020 Public Health England and Diabetes UK. 59 00:06:15,020 --> 00:06:24,470 The charity have together come together to run a diabetes prevention programme in this country, and it's quite a high profile programme. 60 00:06:24,470 --> 00:06:28,790 It was signed off specifically by the Treasury, 61 00:06:28,790 --> 00:06:38,720 and the review concludes that the evidence based upon which this is based in the model that this programme is using is not yet there. 62 00:06:38,720 --> 00:06:45,020 It draws a contrast between two different approaches to how you might adopt prevention, what they call a screen and treat approach, 63 00:06:45,020 --> 00:06:50,060 and then a whole population approach and the screen and treat programme approach, 64 00:06:50,060 --> 00:06:56,180 which is the one that's the main focus of the diabetes prevention programme as they are looking at. 65 00:06:56,180 --> 00:07:02,420 It concludes that by itself, that isn't sufficient. 66 00:07:02,420 --> 00:07:09,290 And in these meetings with secondary care doctors, hospital doctors, primary care doctors, 67 00:07:09,290 --> 00:07:16,310 managers, policymakers, medical statisticians, local government politicians, 68 00:07:16,310 --> 00:07:18,770 in all of these different meetings, 69 00:07:18,770 --> 00:07:26,460 people have been mulling over what should we be doing in response to this sort at this sort of a problem, and it's not an unusual problem. 70 00:07:26,460 --> 00:07:32,370 It's quite a common problem. The people sitting around the table, I'm not haven't come together. 71 00:07:32,370 --> 00:07:40,340 We know to design a rubbish programme that has no evidence that isn't going to benefit patients, and he's going to waste taxpayer money. 72 00:07:40,340 --> 00:07:47,930 So how do you deal with this dilemma between establishing an intervention that

that's trying 73 00:07:47,930 --> 00:07:57,360 to be effective and then what is often some quite difficult and contrasting evidence? 74 00:07:57,360 --> 00:08:07,830 So that's why I'm interested in focussing at the overlapping point of these four circles, evidence based medicine and evidence based health care. 75 00:08:07,830 --> 00:08:13,110 I'm not going to dwell on the difference between those two things we might want to touch on it later. 76 00:08:13,110 --> 00:08:20,340 Evidence based practise, she's much more around the implementation and an evidence based policy, 77 00:08:20,340 --> 00:08:30,490 with my focus being around this challenge in the in the box to the side using the evidence to design a population level intervention. 78 00:08:30,490 --> 00:08:36,700 So not interventions about individual patients, but about at the population level that can be implemented. 79 00:08:36,700 --> 00:08:41,970 So they need to be practical and they lead to at a population health level. 80 00:08:41,970 --> 00:08:48,900 Some clear benefit. So Trish Greenhill, who's at the university here, has done a really interesting article, 81 00:08:48,900 --> 00:08:58,920 it's a few years old now that talks about the the difference between evidence based policy and evidence based medicine and health care, 82 00:08:58,920 --> 00:09:03,510 arguing that they're fundamentally different in the paradigms that they start from with 83 00:09:03,510 --> 00:09:09,720 evidence based medicine essentially be based within the positive based imperatives paradigm. 84 00:09:09,720 --> 00:09:17,010 Evidence based policy comes from a different school, much more interpretive stick, 85 00:09:17,010 --> 00:09:25,950 addressing specific issues about implementation and understanding the context within which things happen and understanding the value ladened of policy 86 00:09:25,950 --> 00:09:34,320 and what that actually means in practise and how we deal with people's different people's perceptions and values about what we're trying to do. 87 00:09:34,320 --> 00:09:37,950 But for many people, the thing that sums up the little populist bit, 88 00:09:37,950 --> 00:09:48,380 you won't be surprised when I say Who's who I'm going to quote now that managed to capture this was Tony Blair going back in time, and his face was. 89 00:09:48,380 --> 00:09:57,200 What matters is what works. And that created a whole set of interest in an evidence based policy, 90 00:09:57,200 --> 00:10:02,090 but it created also that interface between evidence based medicine and evidence based policy. 91 00:10:02,090 --> 00:10:07,130 Of course, what doesn't work is just as important as what does work. 92 00:10:07,130 --> 00:10:12,710 But I'm going to I'm going to explore this sort of an overlap. 93 00:10:12,710 --> 00:10:20,000 I'm going to start by thinking a little bit about the evidence, and we could go into enormous detail here about the nature of the of the evidence. 94 00:10:20,000 --> 00:10:25,820 I'm going to just give you a few little vignettes that will try and capture that. 95 00:10:25,820 --> 00:10:33,020 And this report from the Academy of Medical Sciences, which came out in the autumn last year, 96 00:10:33,020 --> 00:10:41,480 I think we will we will judge that this has been a really helpful and important report in trying to stimulate 97 00:10:41,480 --> 00:10:50,660 the debate about what research we should be doing about the public's health for the next decade or so. 98 00:10:50,660 --> 00:10:53,810 It's quite a it's quite a weighty document, 99 00:10:53,810 --> 00:11:03,680 and it talks about this new research paradigm that we suggests we need to adopt about the health of the public. 100 00:11:03,680 --> 00:11:12,020 And there's a specific recommendations in the report that relates to to my employer and to some of the partner organisations that we work with, 101 00:11:12,020 --> 00:11:17,870 which is which is up there. And we've decided that report is going to fit. 102 00:11:17,870 --> 00:11:21,170 That recommendation will appear prominently in our business plan for next year. 103 00:11:21,170 --> 00:11:33,080 This is a recommendation we want to pick up and run with and really try and pull it apart a bit just to test what sits behind. 104 00:11:33,080 --> 00:11:38,180 What's quite a simple statement that it would be difficult to disagree with this. 105 00:11:38,180 --> 00:11:41,780 That's a different issue from putting it into practise and actually saying, 106 00:11:41,780 --> 00:11:54,190 How are we going to commit resources, time, energy and effort and energy to make this real? 107 00:11:54,190 --> 00:11:59,320 So when we come to think about the evidence that's going to inform that sort of a research paradigm for all 108 00:11:59,320 --> 00:12:06,310 the work that in the organisation that I'm part of do about improving and protecting the public's health, 109 00:12:06,310 --> 00:12:13,810 and that the paradigm is going to require us to think quite broadly about the evidence that we're going to use. 110 00:12:13,810 --> 00:12:21,110 Often when you see these sorts of tables, you think the two rows, the two sides, the two columns are actually in contrast. 111 00:12:21,110 --> 00:12:25,840 But here, in order to deliver on this paradigm, 112 00:12:25,840 --> 00:12:30,160 we need to consider the evidence that comes from both of these two columns to focus 113 00:12:30,160 --> 00:12:36,790 exclusively on what is only going to lead to a partial understanding about the issue. 114 00:12:36,790 --> 00:12:43,270 And I'm going to just focus on the ones that I've highlighted there in yellow 115 00:12:43,270 --> 00:12:51,430 about the nature of the causes of the problem that we're trying to address. 116 00:12:51,430 --> 00:12:59,380 We may touch upon the nature of the wicked, messy problem to use the jargon about about public health problems. 117 00:12:59,380 --> 00:13:04,300 And we've got a couple of people

in the audience who are real experts in this area around it. 118 00:13:04,300 --> 00:13:10,870 But there is not a simple, single linear cause for most of the issues about the public's health. 119 00:13:10,870 --> 00:13:15,400 But that doesn't mean we shouldn't be looking at things where possible in order to establish that. 120 00:13:15,400 --> 00:13:24,820 But it isn't sufficient and that we have this model in evidence based medicine that's very strong around cost effectiveness now on. 121 00:13:24,820 --> 00:13:33,040 And as you know, as Denise mentioned, I have an interest in health economics and you know this as a substantive body of material about how we 122 00:13:33,040 --> 00:13:38,440 do cost effectiveness analysis and how that's different from some of the other health economic analysis, 123 00:13:38,440 --> 00:13:45,180 cost benefit analysis. Cost utility analysis. Cost efficiency analysis. But. 124 00:13:45,180 --> 00:13:50,640 In the practical part of my job, most people just want to talk about the return on investment. 125 00:13:50,640 --> 00:13:56,460 So what's the relationship between cost effectiveness and the return on investment? 126 00:13:56,460 --> 00:14:04,590 And then the timescale around the evidence, how often we're looking at things that we have collected data on usually and ideally purposefully, 127 00:14:04,590 --> 00:14:11,040 we've set up a study, you know, to do this and looked at it and then we have the results of that. 128 00:14:11,040 --> 00:14:15,780 But in many of the areas that that I deal with in my day to day life of my colleagues deal with, 129 00:14:15,780 --> 00:14:18,540 we were actually talking about things that take such a long time. 130 00:14:18,540 --> 00:14:26,100 In order to be clear about what the consequences are, we need to establish a different way of collecting that evidence and using that evidence. 131 00:14:26,100 --> 00:14:34,170 And that can be really quite fraught with problems as I'm going to show around tobacco control. 132 00:14:34,170 --> 00:14:41,400 So just picking those three, the multi causal approach, I'm reading a fantastic the best thriller I've read for a long time. 133 00:14:41,400 --> 00:14:49,830 It stands up there with the The Girl with the Dragon Tattoo, so and it's called Saving Gotham. 134 00:14:49,830 --> 00:15:02,040 It's not about Batman. It is the story of Mayor Bloomberg and Tom Frieden, who was his public health, who led the Public Health Service in New York, 135 00:15:02,040 --> 00:15:09,690 and how they designed a population health level in a set of interventions across the city of New York. 136 00:15:09,690 --> 00:15:16,080 How they ban smoking in bars. If you go to New York, you know some of these things because they're part of the life that we now live, 137 00:15:16,080 --> 00:15:26,190 how they took on the retail industry around trans fats, how they had food labelling, a whole series of population health interventions. 138 00:15:26,190 -->

00:15:30,990 And it's it's a riveting read because the ups and the downs, 139 00:15:30,990 --> 00:15:39,120 the arguments with politicians remember the public with sectors of industry, the disappointment when rulings go against them. 140 00:15:39,120 --> 00:15:43,620 It's absolutely fascinating and very entertaining book. 141 00:15:43,620 --> 00:15:51,830 It's written by the person who was Tom's deputy. Tom is now the director of the Centre for Disease Control of the CDC in Atlanta. 142 00:15:51,830 --> 00:15:59,910 I. Moving on, just to think a little bit about the cost effectiveness and the return on investment. 143 00:15:59,910 --> 00:16:05,370 So this is becoming better understood and the link between the two is becoming more explicit. 144 00:16:05,370 --> 00:16:10,770 If we look at the work that the National Institute for Health and Clinical Excellence nice have done, 145 00:16:10,770 --> 00:16:20,820 they now put out a stamp on their public health studies both that cost effectiveness, our analysis and their return on investment analysis. 146 00:16:20,820 --> 00:16:31,980 And so just to pick a couple of numbers to just help illustrate at their work on cost effectiveness analysis shows that running a briefing today, 147 00:16:31,980 --> 00:16:38,370 a brief intervention around helping to stop people stopped smoking. 148 00:16:38,370 --> 00:16:45,540 And if you add some self-help to that, you have a highly effective cost effectiveness ratio intervention. 149 00:16:45,540 --> 00:16:53,670 It's better than if you do the brief intervention by itself that the numbers are sort of mind bogglingly small. 150 00:16:53,670 --> 00:16:59,800 When you think that we normally talk about some of these drugs having a 20 or 30 thousand pound cost per quality. 151 00:16:59,800 --> 00:17:06,060 Here we're talking about three hundred and seventy pounds cost per quality. 152 00:17:06,060 --> 00:17:13,440 But at the same time, they've done a return on investment model based around the borough in Manchester about bevvy. 153 00:17:13,440 --> 00:17:20,820 And that gives you then the length of the return that you have for every pound that you invest. 154 00:17:20,820 --> 00:17:28,710 Recognising that in Bury, the director of public health and the local authority, you're going to be sitting there thinking, you know, reducing budget. 155 00:17:28,710 --> 00:17:37,420 We need to know what is the point at which the additional pounds we choose to spend on this area is going to lead to a financial payback? 156 00:17:37,420 --> 00:17:44,500 It's about three to three and a half years is the it's the level, as you can tell from the numbers that are there. 157 00:17:44,500 --> 00:17:49,900 But that understanding that sophistication of having both cost effectiveness and the vigour that's gone into 158 00:17:49,900 --> 00:17:59,450 that and converting that into return on investment is a big struggle and is relatively rare across the system. 159 00:17:59,450 --> 00:18:08,540 And then and then finally, this issue about prospective evidence and what better example we got than the debate over e-cigarettes, 160 00:18:08,540 --> 00:18:16,910 where first to be absolutely clear about the public health benefit, the population health benefit that comes from e-cigarettes, 161 00:18:16,910 --> 00:18:22,640 we need to look into the future through our crystal ball, 162 00:18:22,640 --> 00:18:26,300 but through mixed methods through a variety of different analytical tools 163 00:18:26,300 --> 00:18:32,120 through collecting evidence that it's not just it's partly about surveillance, 164 00:18:32,120 --> 00:18:37,760 it's partly about toxicology, but is also about expert opinion. 165 00:18:37,760 --> 00:18:48,360 Then you can start to think, well, what might be the the the the effectiveness of it of e-cigarettes. 166 00:18:48,360 --> 00:18:54,540 As a as part of an integrated tobacco control plan in an idea, 167 00:18:54,540 --> 00:19:04,860 and you probably know that the report that Public Health England published concluded that any form of smoking is is not what we should be promoting. 168 00:19:04,860 --> 00:19:13,710 But if you are going to smoke, then e-cigarettes are 95 percent safer than smoking conventional cigarettes. 169 00:19:13,710 --> 00:19:18,510 And then we have just before Christmas, a report from the surgeon general in the states. 170 00:19:18,510 --> 00:19:23,160 It gives a very different perspective on the evidence about the dangers of e-cigarettes 171 00:19:23,160 --> 00:19:33,370 as essentially a gateway for young people moving into other forms of addiction. 172 00:19:33,370 --> 00:19:38,230 Around it, and we have two bits of evidence hanging there and there, the contrast, 173 00:19:38,230 --> 00:19:44,530 and we see these in quite a number of areas that probably some people in the room who are looking at the childhood flu vaccine, where again, 174 00:19:44,530 --> 00:19:49,900 it's another example of where the UK and the US have got very different evidence bases and we're 175 00:19:49,900 --> 00:19:55,240 dealing with that contradiction is the explanation for this in the nature of the context, 176 00:19:55,240 --> 00:20:00,610 is it the way in which the interventions have been designed and implemented? 177 00:20:00,610 --> 00:20:12,810 Is it because as a methodological flaw in the studies? We say all of those things. 178 00:20:12,810 --> 00:20:20,650 So that leads to think what's good enough evidence, and we need to be really clear about what our evidence is there for. 179 00:20:20,650 --> 00:20:25,330 What does in Tony Barr's face working, what does that really mean? 180 00:20:25,330 --> 00:20:34,030 It's very easy to say we want to have evidence about what works, but we have to define what working means, as well as what the evidence is. 181 00:20:34,030 --> 00:20:42,730 And so there are all sorts of quite tricky questions that we need to peel back in order to be clear

about how 182 00:20:42,730 --> 00:20:55,690 we reach the point that we have an evidence based policy that is also aligned with evidence based health care. 183 00:20:55,690 --> 00:21:05,920 I'm going to just reflect on that a little bit further by by another, and we have and so I was four for six months last year acting into another vote, 184 00:21:05,920 --> 00:21:11,740 which meant I got very involved in the debate around what became the childhood obesity plan. 185 00:21:11,740 --> 00:21:17,230 I think all of us, whether we're clinicians or social scientists, 186 00:21:17,230 --> 00:21:25,000 will recognise the issue about what a complex issue obesity is and how there are so many different aspects 187 00:21:25,000 --> 00:21:34,690 of our life that play into the in addressing the what we call the obesity challenge the obesity epidemic. 188 00:21:34,690 --> 00:21:42,400 And Tom was just reflecting really on the on the journey of the of the evidence into practise over the last few years, 189 00:21:42,400 --> 00:21:47,050 starting with a growing number of academic studies. I, you know, if I'd have had the time, 190 00:21:47,050 --> 00:21:53,140 I'd have gone back and just looked at the the number of papers that have been published over that and how that's a clear, 191 00:21:53,140 --> 00:22:00,640 I guess, exponential growth would be my guess. How increasingly that became more and more surveillance data when the government decided to 192 00:22:00,640 --> 00:22:08,410 invest somewhat controversially in invest in a programme to actually measure childhood weight, 193 00:22:08,410 --> 00:22:12,090 some sort of synthesis of all of that evidence coming together. 194 00:22:12,090 --> 00:22:21,370 And, you know, Cochrane published 2011 still essentially in an academic context, but then starting to move into the policy sphere. 195 00:22:21,370 --> 00:22:31,420 And we have the purple document at the top form, the government's advisory committee about that chaired by a professor from Oxford. 196 00:22:31,420 --> 00:22:37,810 But essentially being still. That's right at the threshold between evidence and and into policy. 197 00:22:37,810 --> 00:22:44,200 Moving into our report about sugar reduction, which is much more policy orientated, 198 00:22:44,200 --> 00:22:52,810 includes specific recommendations to government about a multi strand policy in terms of addressing obesity. 199 00:22:52,810 --> 00:23:02,290 The document that I can't show you because but it's been on the television widely because Channel four Dispatches programme on a whole programme 200 00:23:02,290 --> 00:23:07,390 contrasting the original document that was written and we're sitting with David 201 00:23:07,390 --> 00:23:11,470 Cameron before the referendum and the document that came out afterwards, 202 00:23:11,470 --> 00:23:15,490 which is the document and the far left hand side, which was the childhood obesity plan. 203 00:23:15,490 --> 00:23:20,230 So it moved from childhood obesity strategy to childhood obesity plan, 204 00:23:20,230 --> 00:23:32,710 but also spinning off into the decision that the chancellor took about the sugary drink levy, which we learnt about on the morning of the budget. 205 00:23:32,710 --> 00:23:40,750 And lots of people have been able to speculate quite widely about how the sugar levy managed to capture all the headlines around the budget, 206 00:23:40,750 --> 00:23:46,900 which meant that the amount of coverage about some of the other things in the budget was much less. 207 00:23:46,900 --> 00:23:56,050 So that long and winding road that really built up over many years is is a great little example of the journey that we go on with evidence and policy. 208 00:23:56,050 --> 00:24:02,980 Because what a huge day that might be quite might seem long and winding as you're in the middle of it. 209 00:24:02,980 --> 00:24:09,020 But that's a hugely simplistic portrayal of what what happens. 210 00:24:09,020 --> 00:24:15,130 Toby post-hoc rationalisation because in the middle of it, you just weren't aware of it. 211 00:24:15,130 --> 00:24:16,810 I was a good deal of muddling through, 212 00:24:16,810 --> 00:24:27,160 which is a phrase in the in the policy literature going right back to the 1950s from Lyn Bloom about how policy goals aren't clear. 213 00:24:27,160 --> 00:24:32,920 And there are all sorts of little loops that were happening and the real politic that goes on. 214 00:24:32,920 --> 00:24:43,860 So that nice, neat sort of logical line that I described before my view is it is helpful to us to keep this. 215 00:24:43,860 --> 00:24:55,770 The pure and inadequate but important way of thinking about it is the way in which we start the discussion. 216 00:24:55,770 --> 00:24:58,980 But we need to deal with some of the political reality. 217 00:24:58,980 --> 00:25:07,980 I've often wondered would any of this happened if Jamie Oliver hadn't decided to take the role that he took on and won a very strong campaign? 218 00:25:07,980 --> 00:25:13,260 He has a significant foundation behind him that enables him to achieve all sorts 219 00:25:13,260 --> 00:25:18,750 of things that are not just related to the power of his media personality, 220 00:25:18,750 --> 00:25:28,840 but related to a good deal that sits behind that. And then the practicalities, not just of getting the policy, the evidence into policy, 221 00:25:28,840 --> 00:25:35,050 but the practical issues about implementation and what does this mean? 222 00:25:35,050 --> 00:25:38,530 You know, with a set of policy interventions, some of which are about national policy, 223 00:25:38,530 --> 00:25:46,180 but most of which are about what happens that we make our own decisions about, that we make decisions for our families about that. 224 00:25:46,180 --> 00:25:51,130 We deal with our friends and our communities that all local authorities and local health 225 00:25:51,130 --> 00:25:56,320 service providers deal with

that of employers in terms of what they offer us at lunch time. 226 00:25:56,320 --> 00:26:09,440 The practical realities of implementation. It's going to reflect on it on another example. 227 00:26:09,440 --> 00:26:13,610 As Denise said, I'm originally a geographer from Oxford. 228 00:26:13,610 --> 00:26:21,860 We have a prime minister who's a geographer from Oxford. So she will have had she was considering a few years before me, I hasten to add, 229 00:26:21,860 --> 00:26:31,940 but I can be absolutely sure she will have had a very good grounding in health inequalities from her undergraduate training at this this institution. 230 00:26:31,940 --> 00:26:36,920 And so therefore, on the steps of Downing Street in her four and a half minute talk, 231 00:26:36,920 --> 00:26:44,330 she decided that the majority of that was going to talk about inequalities in our in our country. 232 00:26:44,330 --> 00:26:49,670 Although the way in which she became prime minister was a unique set of events. 233 00:26:49,670 --> 00:26:54,840 She won't have made that speech lightly and there will have been some very clear thought about what was behind it. 234 00:26:54,840 --> 00:27:01,020 I. What does that mean for policy? 235 00:27:01,020 --> 00:27:08,670 So we're in that middle stage now with a statement of political ambition and intent, 236 00:27:08,670 --> 00:27:14,920 but a lack of clarity about what that actually means by a neat irony. 237 00:27:14,920 --> 00:27:18,840 We a lot of the statistics that we produce in Public Health England, 238 00:27:18,840 --> 00:27:23,520 all the statistics that with the Office of National Statistics that sit behind that 239 00:27:23,520 --> 00:27:29,160 and this is one of Dennis especially stab you saw recognising the expertise in the. 240 00:27:29,160 --> 00:27:35,550 But when we really start inequality figures, we actually have the whole from a professor of geography on our advisory committee. 241 00:27:35,550 --> 00:27:40,710 And he is quoted prominently, you know, in our press release, 242 00:27:40,710 --> 00:27:50,520 and we're now starting to think through, how can we say, what are the evidence based interventions? 243 00:27:50,520 --> 00:27:56,040 Well, that's not coming from nowhere because there was a major report commissioned by 244 00:27:56,040 --> 00:28:00,210 the Labour government published just a few months before the 2010 election, 245 00:28:00,210 --> 00:28:05,340 and its commission was about the evidence about addressing health inequalities. 246 00:28:05,340 --> 00:28:10,800 But the issue for us? I just wanted to open up was this issue about are we interested in the evidence base? 247 00:28:10,800 --> 00:28:13,110 But are we interested in best practise? 248 00:28:13,110 --> 00:28:21,180 Because at the same time, the team that had done a lot of the work working with Sir Michael Marmot produced its best practise guide. 249 00:28:21,180 --> 00:28:29,170 And these are a material difference between best practise and best evidence. 250 00:28:29,170 --> 00:28:33,970 I'm going to now just pick up the accountability issue. 251 00:28:33,970 --> 00:28:41,650 And obviously there the word accountability is part of our everyday speech and we use it in a number of different ways. 252 00:28:41,650 --> 00:28:47,570 But it also has some very precise meanings. It has a meaning in the in the management world. 253 00:28:47,570 --> 00:28:55,690 I've drawn on it from the project literature here about the the individual who is ultimately answerable. 254 00:28:55,690 --> 00:29:00,380 But it also has a big meaning in the public policy sphere. 255 00:29:00,380 --> 00:29:13,860 And there it tends to be much more in a wider context about who holds whom to account and for what sort of a relationship. 256 00:29:13,860 --> 00:29:19,470 And so in the new public health system that was designed in two thousand and thirteen, 257 00:29:19,470 --> 00:29:28,320 what we had is a number of different lines of accountability within the system. 258 00:29:28,320 --> 00:29:37,950 If we tried to define what is the public, the activity that happens for the public's health and it it manifests itself through 259 00:29:37,950 --> 00:29:43,080 a number of different lines of accountability reporting up to the government. 260 00:29:43,080 --> 00:29:47,130 And I'm just looking at it from a top down perspective here. 261 00:29:47,130 --> 00:29:54,000 We have a specific sum of money that sits with NHS England for national public health interventions that need to happen. 262 00:29:54,000 --> 00:30:01,140 Similar in the same way across the country. Screening and immunisation being the best examples. 263 00:30:01,140 --> 00:30:08,340 We have a lot of what happens from the clinical commissioning groups as being the local commissioners of NHS services, 264 00:30:08,340 --> 00:30:12,840 but much of that is not explicit. It's difficult to know exactly what they do. 265 00:30:12,840 --> 00:30:22,410 That is clear. Public health and that boundary between clinical care and public health becomes very, very much of an issue for them. 266 00:30:22,410 --> 00:30:30,600 We have what most people think of as the bulk of the public health spending in this country now sits with the upper tier local authorities. 267 00:30:30,600 --> 00:30:33,960 The $3.4 billion, that was money that was in the NHS. 268 00:30:33,960 --> 00:30:43,280 It's money that's voted to the Department of Health, but is allocated through Public Health England to local authorities. 269 00:30:43,280 --> 00:30:51,710 And then there's a well, I can quite safely say it's a tiny sum of money relative to the others that comes to to my organisation to do what we do, 270 00:30:51,710 --> 00:30:54,740 which a lot of which is about advice about the evidence, 271 00:30:54,740 --> 00:31:03,840 but also running a number of things that run through the whole system around information, data and responding to emergencies. 272

00:31:03,840 --> 00:31:13,330 There's very little research about this system. David Hunter and Linda Marks up in Durham have got a grunt, and I had it. 273 00:31:13,330 --> 00:31:17,590 I was part of a detailed presentation that they gave just before Christmas. 274 00:31:17,590 --> 00:31:21,430 It's essentially a description about some of the dynamics that's happening in that. 275 00:31:21,430 --> 00:31:27,520 In that system, we've had a number of select committees that have done hearings into that. 276 00:31:27,520 --> 00:31:32,680 I'm told through evidence and had a number of contributions to it. 277 00:31:32,680 --> 00:31:42,520 I think by and large, they've been saying that whether you agree with the policy or not, the system has that. 278 00:31:42,520 --> 00:31:47,290 You can you can track some things in this system that it was impossible to track in the previous system. 279 00:31:47,290 --> 00:31:58,810 We had no idea how much money was spent on public health before 2013. Now there is a clear set of sums of money and clear accountabilities for those. 280 00:31:58,810 --> 00:32:05,320 But the Hunter and Mark's work is clearly showing that there are some real problems 281 00:32:05,320 --> 00:32:13,340 about aligning the different components of that to give a cohesive picture. 282 00:32:13,340 --> 00:32:22,040 So when we think about the evidence and the public health system where we're left with this with with a at a simple level, 283 00:32:22,040 --> 00:32:27,710 it's a high level this contrast between speaking with independents. 284 00:32:27,710 --> 00:32:31,460 And speaking to gain influence, 285 00:32:31,460 --> 00:32:41,450 how some people may not agree that these are contrasting issues that need to be balanced and there may be some inherent tension between them. 286 00:32:41,450 --> 00:32:52,900 But the practical reality sometimes that I've experienced is that you need to be able to manage both of these, those these two things simultaneously. 287 00:32:52,900 --> 00:32:57,490 And the government has obviously invested and wanted independent advice. 288 00:32:57,490 --> 00:33:00,700 I'm not talking about the NHS here, I'm talking just about public health. 289 00:33:00,700 --> 00:33:07,150 We've got four sources of independent advice, all created very explicitly and publicly by government. 290 00:33:07,150 --> 00:33:09,910 We have Public Health England, and I'll touch on this again in a minute. 291 00:33:09,910 --> 00:33:21,530 We have the Chief Medical Officer of O by Stat. We have joint committees and we have the National Institute of Health and Clinical Excellence. 292 00:33:21,530 --> 00:33:31,370 The issue of of accountability is a one that's very topical, it was a big issue when we created the debate in the House of Lords. 293 00:33:31,370 --> 00:33:39,920 The issue for us is. We feel we have and we're clear that we have the independence to speak to the evidence, 294 00:33:39,920 --> 00:33:46,310 the bit that we've agreed to do in the trade is when is that published? 295 00:33:46,310 --> 00:33:54,950 So it's the the timing, not the content, and that's the way of for us of ensuring that we do sit at the table. 296 00:33:54,950 --> 00:33:59,120 Being at the table is sometimes important. It would be very easy to be absent from table. 297 00:33:59,120 --> 00:34:06,880 So how do we strike that balance? I'm going to very quickly rattle through just the last three slides. 298 00:34:06,880 --> 00:34:14,440 The implementation issue is one that faces local government. How do local government put evidence into practise? 299 00:34:14,440 --> 00:34:20,560 They don't come from an evidence based medicine paradigm. And so far for it is much more of an issue for them. 300 00:34:20,560 --> 00:34:26,710 And this has been an issue for many directors of public health who've moved from the health service into local government. 301 00:34:26,710 --> 00:34:32,170 Perhaps the most likely route of this is around the peer challenge and sector led improvement approach to it, 302 00:34:32,170 --> 00:34:43,360 which retains the flexibility and the lightness of touch that you sometimes need in order to put the evidence the most topical evidence into practise. 303 00:34:43,360 --> 00:34:50,320 What we have from the NHS perspective is essentially a contrasting approach between the top down implementation, 304 00:34:50,320 --> 00:34:57,430 which says the evidence says you will assess this and you will go off and do it where the National Accountability Fund, 305 00:34:57,430 --> 00:35:07,540 likewise the local but potentially in the sustainability and transformation plans that the NHS is, has asked 44 footprints around the country. 306 00:35:07,540 --> 00:35:11,770 A whole debate about that accountability is saying You come up with what you think, 307 00:35:11,770 --> 00:35:19,330 the evidence base says, where potentially the local accountability far outweighs the national. 308 00:35:19,330 --> 00:35:23,050 And so I end up where I started really about this issue, 309 00:35:23,050 --> 00:35:32,410 about what is the evidence and what does it lead us to think about because in many areas that I work with, the evidence is not clear. 310 00:35:32,410 --> 00:35:39,580 The evidence is either partial because it taste comes through a particular lens or it doesn't yet exist. 311 00:35:39,580 --> 00:35:46,540 And very often I hear people say we want to innovate, and the evidence base doesn't allow us to innovate. 312 00:35:46,540 --> 00:35:53,320 So sometimes tying ourselves to evidence based medicine and evidence based healthcare acts as a restriction upon our innovation. 313 00:35:53,320 --> 00:36:01,810 But for me, I was the midwife for the academic health science networks, and we thought very hard about how we address that problem. 314 00:36:01,810 --> 00:36:04,750 And we did it through three mechanisms. 315 00:36:04,750 --> 00:36:11,890 Firstly, we made sure that the NHS

and had an accountability that was the primary accountability was to each other. 316 00:36:11,890 --> 00:36:15,280 It was about peer challenge, peer support. 317 00:36:15,280 --> 00:36:23,680 Secondly, where we needed to have national accountability, we made that very tight around doing specific things, 318 00:36:23,680 --> 00:36:29,230 which was a contract for implementing particular pieces of evidence. But thirdly, that isn't sufficient. 319 00:36:29,230 --> 00:36:37,570 We needed to allocate resources which enabled organisations to grow and nurture and to have flexibility and freedom to do their own work. 320 00:36:37,570 --> 00:36:46,770 And so we created a licence for the NHS ends, which was in effect a licence for them to operate, to do the things that they thought were right. 321 00:36:46,770 --> 00:36:54,630 And so therefore, in order to strike this balance, my personal view is that we should be looking at ever increasing ways of creating this 322 00:36:54,630 --> 00:37:00,840 horizontal accountability between peers as the best way of implementing evidence into practise. 323 00:37:00,840 --> 00:37:11,350 Thank you very much. Thank you enormously, Richard, 324 00:37:11,350 --> 00:37:21,250 that was the first a fabulous first lecture you set up so many of the issues that we're going to be addressing over the next few weeks. 325 00:37:21,250 --> 00:37:25,750 I'm going to pass straight across to Sue Dobson and then we'll open up for discussion. 326 00:37:25,750 --> 00:37:33,130 So Professor Dobson's research centres on leadership and transformational change in the public and health care sectors. 327 00:37:33,130 --> 00:37:38,470 And as I mentioned earlier, she is from the side business school. 328 00:37:38,470 --> 00:37:47,320 She is also I'm very pleased and proud to say, a governing body fellow here at Green Templeton College. 329 00:37:47,320 --> 00:37:56,290 Her work is informed and influence many government bodies, such as the Department of Health, Nice, the National Institute for Health, 330 00:37:56,290 --> 00:38:08,050 etc. and its influence their thinking in areas such as the dissemination of clinical evidence and to practise medical leadership. 331 00:38:08,050 --> 00:38:14,980 This is an area that she's particularly known for and the role of the support worker in the NHS so soon. 332 00:38:14,980 --> 00:38:24,890 You're very welcome. Thank you. I'm just trying. 333 00:38:24,890 --> 00:38:34,100 All right, Richard. OK. No, not you again. 334 00:38:34,100 --> 00:38:44,600 I am the one below you to see. OK, so thank you very much for that warm introduction. 335 00:38:44,600 --> 00:38:49,630 I'm indeed from the side business school and I spent gosh, 336 00:38:49,630 --> 00:38:56,500 I started with intermittent college some 28 years ago, was only 12 when I started my own long time. 337 00:38:56,500 --> 00:39:02,980 And I've always been very curious about health care and leadership in health care. 338 00:39:02,980

--> 00:39:13,480 And I guess over my career, I've been studying in somewhere on the, you know, lots of change in the health service and kind of have given up the 2010. 339 00:39:13,480 --> 00:39:21,310 But, you know, I've been a kind of in this space for four plus one was incredibly interesting is, you know, 340 00:39:21,310 --> 00:39:30,700 the kind of repetitive nature of the structures and the and frankly, the failure of the system to really learn from anything ever. 341 00:39:30,700 --> 00:39:34,540 I've really written or colleagues have written about why change is difficult, but anyway. 342 00:39:34,540 --> 00:39:38,830 But that's very that's very sad, very true. 343 00:39:38,830 --> 00:39:40,430 So I am interested in leadership, 344 00:39:40,430 --> 00:39:49,450 and I am particularly interested in how difficult leadership is in complex systems such as health care, not the only complex system. 345 00:39:49,450 --> 00:39:54,550 My favourite definition of leadership is actually disappointing people as a right they can cope with. 346 00:39:54,550 --> 00:39:59,590 But because I think it's such a hard, a such a hard gig. 347 00:39:59,590 --> 00:40:08,540 So in some ways, what I want to do in this, this very brief talk is talk a little bit about a couple of the projects that I've been involved in. 348 00:40:08,540 --> 00:40:12,620 One was indeed evidence based medicine, but I came out. 349 00:40:12,620 --> 00:40:18,760 It was really trying to understand what really motivated clinicians to either practise 350 00:40:18,760 --> 00:40:24,460 evidence based medicine and what really was going on in terms of their decision process. 351 00:40:24,460 --> 00:40:31,840 I've also lots more recently evidence based management, such as saying, right, and I'll say a little bit about about that. 352 00:40:31,840 --> 00:40:37,240 And there's some reoccurring themes that are about the nature of what evidence is and the 353 00:40:37,240 --> 00:40:43,330 complexity and the way in which it becomes something that grabbed hold of and shaped. 354 00:40:43,330 --> 00:40:48,580 So I have a real problem with the word translation in the sense that it becomes very rational. 355 00:40:48,580 --> 00:40:54,070 I think it's much messier than that, and I'll try and talk a little bit about why that is. 356 00:40:54,070 --> 00:40:57,700 But I wanted to present very brief vignettes or case study. 357 00:40:57,700 --> 00:41:02,620 Looking at a network, you mentioned networks and you and your tool, 358 00:41:02,620 --> 00:41:08,200 and we know that networks are very much seen as the vehicle for translation good ideas into practise. 359 00:41:08,200 --> 00:41:15,550 And I want to just showcase a little vignettes of one that me and my team studied for over five years, 360 00:41:15,550 --> 00:41:20,380 looking at the role of genetics, trying to get great science into practise in that space. 361 00:41:20,380 --> 00:41:24,310 And then I'll just make some final conclusions or observations about why, frankly, 362 00:41:24,310 --> 00:41:31,150 we need different models of change and why we need different models of leadership if we're going to make any progress at all. 363 00:41:31,150 --> 00:41:35,980 So that's roughly what I'm going to do in the next 15 or so minutes. 364 00:41:35,980 --> 00:41:46,360 So let me just say a little bit first, though, about this, the study that we did do where we did look at evidence based medicine and what it meant. 365 00:41:46,360 --> 00:41:51,730 So lots of my work and my team's work are just spending lots of time talking to people, 366 00:41:51,730 --> 00:41:56,570 doing quite in-depth interviews and asking people what really influenced their practise. 367 00:41:56,570 --> 00:42:01,240 So talking to clinicians about what influenced your practise? 368 00:42:01,240 --> 00:42:07,240 And of course, what we found, though for them, there was no such thing as evidence, necessarily. 369 00:42:07,240 --> 00:42:14,530 It was more complicated that it wasn't just the guidelines, but evidence to them was also one doctor when, 370 00:42:14,530 --> 00:42:18,610 when, when they had to have the first death and then they looked at it. 371 00:42:18,610 --> 00:42:26,830 It was experiential and they talked about experiences. So when we're talking about evidence, it's not just about Cochrane and the guidelines, 372 00:42:26,830 --> 00:42:31,210 it's also this blended approach about how people make sense of their own experience. 373 00:42:31,210 --> 00:42:38,500 So one theme of that work, and I'm really summarising quite a lot of work, is where there's no such thing as evidence in a very concrete way. 374 00:42:38,500 --> 00:42:42,220 It can mean all sorts of things. It's a malleable concept. 375 00:42:42,220 --> 00:42:46,630 And of course, we know in professional work there are hierarchies of evidence, and we need to understand that. 376 00:42:46,630 --> 00:42:51,670 Part of the reason is I'll show in a minute. What different professions find it hard to talk to one another. 377 00:42:51,670 --> 00:42:58,930 It's because they have different views about what is real data. And sometimes we just can't talk about it. 378 00:42:58,930 --> 00:43:07,900 And in that work also came the importance of opinion. It is you do get in systems, people who really are brave and mavericks, 379 00:43:07,900 --> 00:43:15,220 and they can cross boundaries and they can translate Evans and their model good practise by supporting those opinions. 380 00:43:15,220 --> 00:43:19,780 You can get good evidence into practise if they are supported. 381 00:43:19,780 --> 00:43:24,100 And I guess the final thing that I wanted to talk about that came up very strongly 382 00:43:24,100 --> 00:43:28,840 is that a theme in my work is the importance of leaders understanding context. 383 00:43:28,840 --> 00:43:35,290 Whatever you're doing, whether you're trying to get good ideas into practise or evidence into

practise or innovation to practise. 384 00:43:35,290 --> 00:43:40,270 We do not spend enough time as leaders thinking about context and want to come back to that. 385 00:43:40,270 --> 00:43:52,210 In the vignette. So. We have seen in that work that this kind of questioning the evidence is something that's very rational and tangible. 386 00:43:52,210 --> 00:43:59,770 It's messier than that. The second problem or subject that I looked at quite recently is this idea of evidence based management. 387 00:43:59,770 --> 00:44:04,990 And my goodness, if you work in a business, we're responsible for some of this stuff, right? 388 00:44:04,990 --> 00:44:10,210 So there's lots and lots of facts and ideas about management evidence that's out there. 389 00:44:10,210 --> 00:44:17,320 And the study that we looked at was again with with leaders in a range of health care settings. 390 00:44:17,320 --> 00:44:26,140 What was it that made them curious about evidence? What was it that made them curious about evidence and what caused them to engage 391 00:44:26,140 --> 00:44:30,760 with the stuff that I might write or the side business school might produce? 392 00:44:30,760 --> 00:44:32,680 So kind of interesting there. 393 00:44:32,680 --> 00:44:40,720 One thing we found by asking questions about what kind of evidence they draw on that you suddenly find that nobody reads any management stuff at all, 394 00:44:40,720 --> 00:44:46,690 actually. And the journals and all the stuff that we get most often are not really very influential at all. 395 00:44:46,690 --> 00:44:49,720 In fact, it is again personal experience. 396 00:44:49,720 --> 00:44:57,880 And so the story here about why people grabbed a hold of some of these ideas was basically that they had a puzzle in a context. 397 00:44:57,880 --> 00:45:05,380 They wanted to solve it. They were brave enough to solve it. And they again grabbed hold of evidence and grabbed hold of bits of context 398 00:45:05,380 --> 00:45:09,760 and stitched together something that actually allowed them to implement it. 399 00:45:09,760 --> 00:45:19,540 So we came up with this idea that that leaders and managers in this space don't translate evidence in a very rational way. 400 00:45:19,540 --> 00:45:23,560 In fact, they transpose it. They mould it. They look at contacts. 401 00:45:23,560 --> 00:45:34,090 They use contacts. They grab it, they mould it. It's a transposition for me is a better word for really representing this complex issue. 402 00:45:34,090 --> 00:45:44,020 So can I then move on to looking at the case study where we begin to look at some of the more general challenges of getting great ideas 403 00:45:44,020 --> 00:45:53,560 into practise and why it's so difficult to work across these boundaries that we see in health care between the university and the NHS, 404 00:45:53,560 --> 00:46:01,360 between different professional groups. So we studied the genetics knowledge parks. 405 00:46:01,360 --> 00:46:06,010 These were pre your academic health sciences centres and so forth. 406 00:46:06,010 --> 00:46:12,070 But such May six genetics knowledge parts is set up in the UK. 407 00:46:12,070 --> 00:46:19,180 Quite a large sum of money I can't remember, but an outstanding amount of money. And we studied one of those. 408 00:46:19,180 --> 00:46:26,620 And what we always do when we when we look at our policy problem is we just where did the idea come from? 409 00:46:26,620 --> 00:46:35,140 And this this this quotation here could be any any of the places that I studied adequately. 410 00:46:35,140 --> 00:46:43,210 So the notion was the idea. So let me ask the idea of the genetics knowledge partners to get the university and the health care system 411 00:46:43,210 --> 00:46:50,440 to work together in order to get great science into practise in the same trust and translational challenge. 412 00:46:50,440 --> 00:46:58,120 So the idea for this appeared very late in the draught, even in part virtually just a sentence, just a throwaway sentence. 413 00:46:58,120 --> 00:47:04,720 It took everyone by surprise, and when the health secretary was questioned, you tell me, and then we had to develop some things, right? 414 00:47:04,720 --> 00:47:12,480 So we have here the basis of not very good, thoughtful change management, right? 415 00:47:12,480 --> 00:47:19,640 And in a sense, there was no real specification of what these networks were there to do problem. 416 00:47:19,640 --> 00:47:24,160 OK, so we studied one of these networks. 417 00:47:24,160 --> 00:47:34,740 And again, you know, in my world, when you go in to look at change problems, you have to begin to understand in detail the context. 418 00:47:34,740 --> 00:47:42,330 And I would argue that the more we can understand the complicated context in which we are seeking to intervene 419 00:47:42,330 --> 00:47:49,870 and get evidence to practise the more likely we are to be able to at least get some traction and some success. 420 00:47:49,870 --> 00:47:55,260 So this was the story here. So the Department of Health came in, they didn't know what they were doing. 421 00:47:55,260 --> 00:47:57,660 They gave the money out, but no idea what was going on. 422 00:47:57,660 --> 00:48:03,120 The Department of Trade Industry got involved because they thought genetics would have a commercial benefit. 423 00:48:03,120 --> 00:48:07,680 And they frankly had money left in the pot and they didn't know what else to do with it. 424 00:48:07,680 --> 00:48:13,220 So there we are. And then you get, you know, the crafting of the bit with the great, 425 00:48:13,220 --> 00:48:18,510 the good on this and they're all there at the beginning, but then you find them disappearing. 426 00:48:18,510 --> 00:48:24,030 OK? Over the first two years and you're left with a core of people. 427 00:48:24,030 --> 00:48:31,110 So I want to tell you a bit about the story. So when we looked at this, there are all sorts of

challenges. 428 00:48:31,110 --> 00:48:38,020 But again, part of understanding the story has to be linked to this. 429 00:48:38,020 --> 00:48:43,180 That if we really want to understand context, it's not just about who, what the groups are, 430 00:48:43,180 --> 00:48:48,040 but it's also, you know, their unit that their affiliation organisation. 431 00:48:48,040 --> 00:48:53,860 What does the organisation context allow them to do, how they incentivise, et cetera? 432 00:48:53,860 --> 00:48:57,730 But also, how are they trained? How do they see the world? 433 00:48:57,730 --> 00:49:04,180 We know that socialisation processes have huge impacts on how we think about evidence and how we use it. 434 00:49:04,180 --> 00:49:10,540 So in this story, the Genetics Knowledge Caucus, we have these communities of practise. 435 00:49:10,540 --> 00:49:22,550 Yeah. And each of whom have been trained in a different discipline, which shapes the way in which they think and feel and talk exceptional. 436 00:49:22,550 --> 00:49:29,000 And it makes a difference how these groups get on, depending on where they're situated. 437 00:49:29,000 --> 00:49:35,960 So even if you are trained in biomedicine, you if you're in a lab and nature's lab, 438 00:49:35,960 --> 00:49:39,960 you request a very, very careful testing if you are a research lab. 439 00:49:39,960 --> 00:49:46,430 You know, you in a sense, are looking for the papers to publish. So let me tell you a little bit about the story. 440 00:49:46,430 --> 00:49:51,410 So in the end, this is five years, six years of work, right? 441 00:49:51,410 --> 00:49:57,200 And genetic science scientists, we say nothing happens. So I'm like, You just all right. 442 00:49:57,200 --> 00:50:00,890 So, you know, you have to do other things while this stuff's going on, otherwise you go mad. 443 00:50:00,890 --> 00:50:08,510 But nonetheless, what you tend to find, what we found here is that, you know, these people were well-intentioned. 444 00:50:08,510 --> 00:50:13,910 Everybody wanted to work together to get away genetic science into practise. 445 00:50:13,910 --> 00:50:23,140 Everybody wants to try to there's no kind of nastiness. But we got conflicts all over the place, we got conflicts with the Department of Health, 446 00:50:23,140 --> 00:50:26,320 who after three years decided that they ought to measure what was going on. 447 00:50:26,320 --> 00:50:36,490 So we got lots of tick boxes for conflict. We got a conflict here in terms of the labs, I just to give you a bit of a quote on this. 448 00:50:36,490 --> 00:50:45,310 So there was a clash here between people who were trained in biomedicine, but they worked in the labs or they worked in the academic area. 449 00:50:45,310 --> 00:50:49,480 And you see here a sense of flavour of the conflict, right? 450 00:50:49,480 --> 00:50:55,180 The way we work in the research lab is to try and get everything as fast as possible because it's a compromise. 451 00:50:55,180

--> 00:50:59,260 We need visible productivity to scrape over the surface for the big prise. 452 00:50:59,260 --> 00:51:03,980 The clinical genetics lab is incredibly compulsive, obsessive. They do everything you duplicate and love. 453 00:51:03,980 --> 00:51:09,400 Get it wrong. That's very reassuring. But the problem is that if you compulsive it, it takes too long. 454 00:51:09,400 --> 00:51:11,150 Yeah, baby, I lecture. 455 00:51:11,150 --> 00:51:19,150 Scientists feel that providing a service have been carefully weigh the risks until feckless people who wanted to let go of the thrill of the glory. 456 00:51:19,150 --> 00:51:29,410 Right? So now so we also know in these networks again, and this has benefited my career quite a lot, that they like social science in them, right? 457 00:51:29,410 --> 00:51:33,760 So that's great, OK? But you try working in this. 458 00:51:33,760 --> 00:51:38,800 So we've got this clash again between science and social science. 459 00:51:38,800 --> 00:51:45,400 Now, the economist interested me was able to get on better with the conditions because, 460 00:51:45,400 --> 00:51:49,100 well, it's nice because you've got the gates, you've got the science school. 461 00:51:49,100 --> 00:51:53,460 But this is not me, but it could be a sociology. 462 00:51:53,460 --> 00:52:00,940 Work is weird, I don't know, but this will always very black and white something when a sociologist talks to me about theories. 463 00:52:00,940 --> 00:52:05,920 It doesn't mean much to me story of my life, these weird sort of sociology people. 464 00:52:05,920 --> 00:52:10,450 We're just providing material for them to write interesting papers. 465 00:52:10,450 --> 00:52:17,800 And so it goes on. So at the point that I want to make here, I think, is just go back. 466 00:52:17,800 --> 00:52:24,130 This is the kind of work. That we need to do to understand the context. 467 00:52:24,130 --> 00:52:30,240 Before we start to use them as a kind of tried and tested change, management is critical. 468 00:52:30,240 --> 00:52:34,700 It is complicated work and I haven't seen it very well done. 469 00:52:34,700 --> 00:52:43,180 I mean, you can learn a lot from studying the history of the organisation historical analysis, but you really need to begin to do that. 470 00:52:43,180 --> 00:52:51,730 And there are no magic contacts. People talk about that famous there's no magic bullets and say this image contest, and now we inherit contacts. 471 00:52:51,730 --> 00:52:57,320 But also, I would argue that we can shake them. Leaders are a bit like farmers. 472 00:52:57,320 --> 00:53:02,000 Farmers don't grow crops. They create the conditions for crops to grow. 473 00:53:02,000 --> 00:53:06,710 And great leadership here could have nudged this system of thought about this, 474 00:53:06,710 --> 00:53:13,520 and it might have led to better translation of what was fantastic science. 475 00:53:13,520 --> 00:53:25,220 So I think one of my concerns really is to make sure that when we're thinking about change management and this is my kind of area of stuff, yeah, 476 00:53:25,220 --> 00:53:28,220 I'm not going to it's not an MBA lecturer, but you know, 477 00:53:28,220 --> 00:53:36,230 when we begin to think about change management where policymakers often think about it, I think this is changing. 478 00:53:36,230 --> 00:53:40,820 But certainly when I've been doing that research, it's about rational management. This is all good stuff, right? 479 00:53:40,820 --> 00:53:48,380 This is all good stuff and you need to do it. But we really need new models of change and I want you to come on to that. 480 00:53:48,380 --> 00:53:57,590 But just just thinking about your point that about wicked problems in leadership work, not enough time is spent by leaders analysing the problem. 481 00:53:57,590 --> 00:54:06,830 What problem is it that you want to solve? And Chief Bratton was a dear colleague of yours that we went somewhere else that he bought anyway. 482 00:54:06,830 --> 00:54:13,580 He did and talked about three kinds of problems that leaders face, 483 00:54:13,580 --> 00:54:20,330 and each kind of problem requires a different kind of approach to leadership and decision making. 484 00:54:20,330 --> 00:54:25,400 So there are times as a leader when you have to just tell him what to do and that's what you need to do. 485 00:54:25,400 --> 00:54:31,940 There are times when you're faced with team challenges where you have to go out and get, find best practises, try and bring them back. 486 00:54:31,940 --> 00:54:35,480 You still need to nudge it and messages that bring it back. 487 00:54:35,480 --> 00:54:44,750 But this kind of work about translating great ideas of good science and innovation to practise is, as you've said in that wiki space. 488 00:54:44,750 --> 00:54:58,520 It's very much in that working space. So my concern is really that we think about trying to innovate with new models of major change. 489 00:54:58,520 --> 00:55:05,860 And when you're dealing with wicked problems, you are in this space of asking questions, not telling people what to do. 490 00:55:05,860 --> 00:55:10,720 And some of the some of the lessons from our work around evidence based management 491 00:55:10,720 --> 00:55:17,620 and what what really seems to to work is the importance of being curious. 492 00:55:17,620 --> 00:55:20,780 What are the puzzles in the organisation? 493 00:55:20,780 --> 00:55:29,270 One of the puzzles in the organiser, she really beginning to stand back on high fits talks about the leadership guru. 494 00:55:29,270 --> 00:55:41,250 Good chat, though, and he says it's about standing on the balcony and beginning to really think in this kind of way about the complexity. 495 00:55:41,250 --> 00:55:46,140 What are the patterns here? What do you notice? What do you notice? 496 00:55:46,140 --> 00:55:53,210 And here the clashes were partly because they couldn't talk to one another. But it was also how they were incentivised. 497 00:55:53,210 --> 00:56:03,260 Publications or not? And what was interesting is that the university it was hard to move people around since the age 498 00:56:03,260 --> 00:56:08,600 old system in the university in the NHS is so different you couldn't move somebody around. 499 00:56:08,600 --> 00:56:12,410 It's not the i t didn't speak to another. 500 00:56:12,410 --> 00:56:21,050 So if you get on the balcony, you begin to ask questions of this star you begin to see, Oh my goodness, no wonder they can't work together. 501 00:56:21,050 --> 00:56:26,780 And that's the kind of work that we need to do. So we need to identify the contacts. 502 00:56:26,780 --> 00:56:32,030 We need to think very carefully about the challenge. And in our work, 503 00:56:32,030 --> 00:56:40,040 there's been lots of evidence which suggests that leaders who provide safe spaces for conversations to 504 00:56:40,040 --> 00:56:46,760 happen that wouldn't normally have fun are more likely to get translational work evidence into practise. 505 00:56:46,760 --> 00:56:55,040 They're more likely to do that. So part of it? How do you provide a holding space, a safe space for conversations that wouldn't normally happen? 506 00:56:55,040 --> 00:57:02,220 And that's how you begin to solve wicked problems. So I can give you a lecture on adaptive leadership. 507 00:57:02,220 --> 00:57:08,150 But but then I think the point is we need to have time for questions is really to make the point that we do 508 00:57:08,150 --> 00:57:17,160 need very different kinds of models of leadership and change an appreciation of the complexity of contacts. 509 00:57:17,160 --> 00:57:22,220 And people are part of that group, some part of that and how we know. 510 00:57:22,220 --> 00:57:30,340 And if we can nudge the context a little bit more, we may be more likely to get fantastic evidence. 511 00:57:30,340 --> 00:57:37,570 Takes practise. People to go through all sides, but I think that's probably enough to get a discussion going. 512 00:57:37,570 --> 00:57:44,678 Thank you.