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Robin Coupland

Medical Advisor to the ICRC
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Robin Coupland is a medical adviser in the International Committee of the Red Cross (ICRC).

He joined the ICRC in 1987 and worked as a field surgeon in Thailand, Cambodia, Pakistan, Afghanistan, Yemen, Angola, Somalia, Kenya and Sudan. He has developed a health-oriented approach to a variety of issues relating to violence and the design and use of weapons.

A graduate of the Cambridge University School of Clinical Medicine, UK, he trained as a surgeon at the Norfolk and Norwich Hospital and University College Hospital, London. He became a Fellow of the Royal College of Surgeons in 1985. He is the holder of a Graduate Diploma in International Law from the University of Melbourne in Australia.

As part of his current position he has focused on the effects of violence and weapons both conventional and non-conventional. He has developed a public health model of armed violence and its effects as a tool for policy-making, reporting and communication.

His current work has two tracks: first, the feasibility of an ICRC operational response in the event of use of nuclear, radiological, biological or chemical weapons; second, improving security of health care in armed conflicts. He has published medical textbooks about care of wounded people and many articles relating to the surgical management of war wounds, the effects of weapons and armed violence.


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joined 12 years, 8 months ago

Henry Dowlen

Surgeon Lieutenant

Henry works as a Doctor in Emergency Medicine, and as a National Lead for Health Informatics. He has served with the Royal Navy and Royal Marines, mainly concentrated in Afghanistan where he worked alongside the Afghan Government in assisting the reconstruction of community medical provision. He is currently a Deployable Civilian Expert for the UK's Stabilisation Unit and an officer in the Royal Marines Reserves.


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joined 12 years, 9 months ago

Alan Gelb

Senior Fellow, Center for Global Development

Alan Gelb is a senior fellow at the Center for Global Development. His recent research includes aid and development outcomes, the transition from planned to market economies, the development applications of biometric ID technology, and the special development challenges of resource-rich countries. He was previously director of development policy at the World Bank and chief economist for the bank’s Africa region and staff director for the 1996 World Development Report “From Plan to Market.


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Mike Farrar

Independent management consultant

Mike Farrar is an independent management consultant and former Chief Executive of the NHS Confederation. He joined the organisation in May 2011.

Mike was chief executive of the North West England SHA from May 2006 to April 2011. He was previously chief executive of West Yorkshire and South Yorkshire Strategic Health Authorities, chief executive of Tees Valley Health Authority and head of primary care at the Department of Health.

Mike was also a board member of Sport England, and in August 2009 was appointed as National Tsar for Sport and Health. Mike was also awarded the CBE in 2005 for services to the NHS and is an honorary fellow of the University of Central Lancashire.


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Michael Marmot

Professor of Epidemiology and Public Health at University College, London and Director of the UCL Institute of Health Equity

Sir Michael Marmot is Professor of Epidemiology and Public Health at University College, London and Director of the Institute of Health Equity (UCL Department of Epidemiology & Public Health).

Professor Marmot has been awarded honorary doctorates from 14 universities and has led research groups on health inequalities for 40 years. He was Chair of the Commission on Social Determinants of Health (CSDH), which was set up by the World Health Organization in 2005, and produced the report entitled: ‘Closing the Gap in a Generation’ in August 2008.


At the request of the British Government, he conducted the Strategic Review of Health Inequalities in England, which published its report 'Fair Society, Healthy Lives' (aka The Marmot Review) in February 2010. This was followed by the European Review of Social Determinants of Health and the Health Divide, for WHO Europe in 2014. He chaired the Breast Screening Review for the NHS National Cancer Action Team and from 2011-2004 was a member of The Lancet-University of Oslo Commission on Global Governance for Health. He is currently Chair of the PAHO Commission on Equity and Health Inequalities in the Region of the Americas.


He set up the Whitehall II Studies of British Civil Servants, investigating explanations for the striking inverse social gradient in morbidity and mortality. He leads the English Longitudinal Study of Ageing (ELSA) and is engaged in several international research efforts on the social determinants of health. He served as President of the British Medical Association (BMA) in 2010-2011, and President of the World Medical Association (2015-16) and he is President of the British Lung Foundation. He is an Honorary Fellow of the American College of Epidemiology, a Fellow of the Academy of Medical Sciences, an Honorary Fellow of the British Academy, and an Honorary Fellow of the Faculty of Public Health of the Royal College of Physicians. He was a member of the Royal Commission on Environmental Pollution for six years and in 2000 he was knighted by Her Majesty The Queen, for services to epidemiology and the understanding of health inequalities.


Internationally acclaimed, Professor Marmot is a Foreign Associate Member of the Institute of Medicine (IOM), and a former Vice President of the Academia Europaea. He won the Balzan Prize for Epidemiology in 2004, gave the Harveian Oration in 2006, and won the William B. Graham Prize for Health Services Research in 2008.


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How do you develop a patient centred healthcare system that serves vast numbers of transient poor people? India has an answer: Rashtriya Swasthya Bima Yojna (RSBY), which has won plaudits from the World Bank and the United Nations as one of the world's best health insurance schemes.

RSBY combines state-of-the-art technology and incentive structures. It is paperless, does not use cash and provides affordable health insurance to millions of people. The overwhelming majority of who, are illiterate, transient people living below the poverty line.

RSBY employs cost effective, scalable technologies to help satisfy the health needs of a significant proportion of India’s poor. Enrolment of families into the scheme, biometric smart card generation, pre-authorization of admissions, as well as claim submission and approval, all occur electronically. Beneficiaries can use their smartcards in any empanelled hospital across India and therefore travel is no barrier to receiving healthcare. Patient data are transferred electronically between empanelled hospitals and insurance companies and claims are settled automatically. The scheme lowers costs, increases efficiency and reduces fraud.

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A&E is the barometer of the NHS.  In 2012 some 22 million people attended A&E in the UK. A 50% increase in the last 10 years, while the UK population only increased 7% over the same period.

The Royal College of Surgeons has warned that the knock-on effect of this is last minute cancellations of planned surgeries. Official figures show that for the first three months of 2013 some 20,000 planned operations were cancelled.
 
Transferring resources out of hospitals
Minded of the seriousness of the A&E challenge, the Academy of Medical Royal Colleges, the NHS Confederation and the patient group National Voices combined to report that the NHS urgently needs to transfer resources out of hospitals and into the community by expanding GP surgeries, health centres, district nurses and social care.
Such a significant transfer might be helped by enhancing the ways that health providers engage people about their health, which is about improving communications while reducing face-time with health professionals. This is important if Matthew Parris is right. Writing in The Times, recently he warned that patients' allegiance to traditional health providers is weakening. Online communications technology has the potential of strengthening this.
 
Both health professionals and patients have embraced health technology as transformational. Doctors are in love with iPads, consumers are loading wellbeing apps onto their phones and patients with chronic diseases are using smartphone attachments to measure and monitor their vital signs.
 
Exploiting technological trends to improve healthcare
However, technology alone is not the answer. Technologists have an undying faith in technology, which they view as the primary driver of change.  This is mistaken because people select, install, develop and manage technology. It is therefore people and the choices they make, not technology, which is the primary driver of change.  

Already health professionals are making choices to help transfer healthcare out of hospitals and into communities. They are successfully harnessing the propensity for people to play games to improve patients' cognitive skills, especially after stroke or the onset of dementia. Health workers are exploiting telehealth to provide patients with remote access to healthcare professionals as well as using social networks to improve the connectivity of health workers and enable patients to play a more active role in their own healthcare.
 
What patients want
Communications between health providers and patients benefit by an understanding of patients' healthcare needs and preferences. In today's world of interconnectivity, we know what patients want. 
Sixty six per cent of patients want answers about specific disease states, 56% want information about treatments, 36% want to find the best place to be treated and 33% want information about payment.
Further, 80% of all patients search online for health information and, if they cannot get face-time with their health professionals, they prefer online video answers to their questions directly from doctors. Video has become the preferred medium for content consumption by patients.

However, we also know that 90% of all doctors provide patients with information in pamphlet form. While this difference describes a communication challenge, it also suggests the answer: more doctors should use online solutions to communicate with patients.
 
A new online solution for health providers
Currently, there is no easy solution for patients to quickly and easily obtain reliable online answers to their questions in video format.  Also, there is no easy solution for doctors to post answers to patients' questions in an online video format.

Dr Sufyan Hussain, a specialist registrar and honorary clinical lecturer in endocrinology at Imperial College London, has participated in a beta test of HealthPad, a new free and easy-to-use web-based communication solution for non technical health professionals to create rich media publications for their patients and colleagues: www.healthpad.net.

Doctors post short and easily understood video answers to frequently asked questions about the prevention, symptoms, diagnosis, treatments, side effects and aftercare associated with different disease states and also about wellbeing. The videos are aggregated and stored in a cloud, linked to biographies of contributing doctors on HealthPad and can be easily accessed by patients on smartphones and tablets at anytime from anywhere. 
To-date, Dr Hussain has accrued a substantial personal video content library, which addresses frequently asked questions from his patients who, "don't always have to attend a hospital for reliable information to help them manage their conditions".  According to Dr. Hussain, using HealthPad, "can reduce valuable doctor face-time with patients while improving doctor-patient relationships and patient compliance by helping them understand their condition and treatment better".
 
Video healthcare libraries
Video healthcare libraries, similar to the one Dr Hussain has created, play a significant role in the US to communicate premium, reliable and up-to-date health information to patients and their carers. An important difference with pamphlets and WebMD is that people feel an allegiance to personalised video content in a way that they do not for pamphlets and the written word.
 
Psycho-social benefits of video healthcare libraries
US evidence suggests that patients feel a greater allegiance to health professionals who provide them with sought after information in a format they like and understand and deliver it personally to their smartphones.

Dr Whitfield Growdon, a cancer specialist who teaches at the Harvard University Medical School and has a gynaecologic medical and surgical practice at the Massachusetts General Hospital also participated in HealthPad's beta test and, like Dr Hussain, accrued a significant video comntent library, which he now uses with his patients. "Videos", says Dr Growdon, "personalise medicine and have positive psycho-social effects. Patients feel that they know me before we have even met and are less inclined to be swayed by discordant and often incorrect medical information they encounter on the internet that can create misperceptions and fear".

Video healthcare libraries connect doctors directly with patients and inform about medical conditions and treatment options. They are cheap to create, cost little to operate and develop, they can be quickly and easily updated and accessed 24-7, 365 days a year from anywhere at any time.
 
Significant opportunity for UK health providers
Seventy per cent of patients who search online for health information become confused and frustrated.  

HealthPad, the new platform which Drs Hussain and Growdon contributed, aggregates premium reliable health information in a format demanded by patients and represents a significant opportunity for health providers to transfer medical knowledge out of hospitals and into the communities.
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Can a dancing elephant help the NHS?
 
In May 2013 Sir David Nicholson, the head of NHS England, announced his resignation. Nicholson was an insider's insider and his in-depth knowledge of the organisation served well his political masters, but he was unable to bring about much needed transformative change.   
 
Escalating costs, changing technology, the growth and spread of diseases and an ageing population all conspire to present the NHS with its biggest challenge since it was created in 1948.
 
Will the new leader be another insider appointed to continue the political chess game with our national health? Or, will the new CEO seize the opportunity presented by lessons from outside the NHS and lead the transformative change that the NHS sorely needs?
 
Lessons from outside the NHS
Twenty years ago IBM, once the most profitable company ever, faced a similar challenge to that confronting the NHS today. In 1993, IBM was on the brink of bankruptcy and considered by various commentators as, "a dinosaur and a wreck". IBM appointed Lou Gerstner, a business leader, to transform the Company. Nine years later, IBM had become one of the world's most admired companies. Gerstner described how he achieved the transformation in a book, Who Says Elephants Can't Dance?
  
What are the similarities between IBM and the NHS?
What lessons can the NHS learn from IBM?
 
Inward looking organisation resistant to change
By the early 1990s, IBM had become an inward looking mainframe manufacturer driven by internal systems rather than customer needs. The PC revolution gave IBM the equivalent of a severe heart attack and put computers in the hands of millions and shifted power and purchasing decisions to individuals.  
 
By 1993, IBM's annual net losses reached a record US$8 billion and it was on the verge of bankruptcy. Before the arrival of Gerstner the Company's reaction to its crisis was to deploy resources more effectively, improve outcomes, control costs, split its divisions into separate independent businesses and attempt to sell some of them.
 
Parallels with the NHS
The NHS is an inward looking public monoploly, funded by the UK taxpayers to the tune of £110 billion a year, high bound with its own standards and procedures.
 
Like the old IBM, the NHS is less sensitive to its rapidly changing external environment, which includes rising patient expectations, expensive new drugs, the impact of an ageing population and the escalation of chronic non communicable diseases.
 
The response of the NHS to its current challenges is similar to IBM's initial response before the arrival of Lou Gerstner. It is focused on cost savings, streamlining its services and privatising specific functions. Such a strategy did not turnaround IBM and will not turnaround the NHS. This is understood by both the National Audit Office and the Parliamentary Select Committee on Health, which have called for the NHS to engage in "transformative change".
 
Stepping through a time warp
Transformative change for IBM began in 1993 with the appointment of Lou Gerstner as CEO at a time when IBM, similar to the NHS today, was bloated with excess costs and bureaucracy and its people demoralised.
  
Interestingly, Gerstner was neither an insider nor an industry expert, but was recruited from Nabisco, an American biscuit manufacturer and had had previous experience at American Express and the consultancy firm McKinsey & Co. Gerstner likened his arrival at IBM to stepping through a time warp. The world had moved on while IBM stood still. This resulted in a significant mismatch between market needs and IBM's offerings. 
 
When Gerstner took the reins at IBM, the conventional wisdom, both from industry pundits and IBM insiders, was that the only solution for saving IBM from eventual disaster was to cut costs, increase efficiency, divisionalise and sell-off parts. 
 
Complete integrated solutions
Gerstner was determined to keep IBM together and convinced that the only way to do so was to change its culture: away from an inward looking bureaucracy to a responsive service company in-tune with customers' needs. Gerstner recognized that IBM's enduring strength was its core competency to provide integrated solutions for customers with complex problems. This, Gerstner judged to be the unique IBM advantage.
 
Gerstner's approach was to drive the Company from the customer view and, "turn IBM into a market-driven rather than internally focussed process-driven enterprise". And it worked. According to Gerstner, keeping IBM together and changing its culture, "was the first strategic decision and, I believe, the most important decision I ever made, not just at IBM, but in my entire business career".
 
Will the new leader of the NHS have Gerstner's strategic clarity, rottweiler focus and determination to execute?
 
Importance of culture
During his customer focused transformation, Gerstner learnt not to be fooled by bogus measurements and data associated with customer satisfaction and targets. "People"Gerstner said, "do what you inspect, not what you expect".
 
Gerstner's most important and proudest accomplishment was cultural change that brought IBM closer to its customers by inspiring employees to drive toward customer defined success.
 
"Until I came to IBM, I probably would have told you that culture was just one among several important elements in any organization's makeup and success; along with vision, strategy, marketing, financials, and the like I came to see, in my time at IBM, that culture isn't just one aspect of the game, it is the game. In the end, an organization is nothing more than the collective capacity of its people to create value".
 
Lessons for the NHS
In, Who Says Elephants Can't Dance? Gerstner describes three important insights, which helped transform IBM and could help the NHS:  
 
1. A service intergrator controls every major aspect of an industry
2. Every major industry in today's network-centric world is built around open standards
3. It is important to abandon proprietary development, "embrace software standards" and "actively license technology".  
 
In 1993, many people criticized IBM for their selection of Gerstner because he was neither an insider nor a technologist. You can hear something similar were the NHS to appoint a CEO from outside the healthcare industry.  Based on IBM's transformation and the insights described in Who Says Elephants Can't Dance? Gerstner was the right person for the job.
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Africa is sick. Ninety per cent of the world’s cholera cases occur in Africa. Meningococcal meningitis is epidemic in most African countries. Yellow fever is endemic in 23 African countries. Africa has more than 28 million HIV/AIDS cases and 75% of the world’s AIDS population live in sub-Saharan Africa. Of the one million annual malaria deaths, 90% occur in the same region. Measles are common throughout Africa and result in high levels of morbidity and mortality. Lassa fever accounts for about 0.4 million deaths each year and avian influenza is endemic in many African countries.

This is not the whole story. In addition to being plagued with infectious diseases, Africa has a neglected epidemic of chronic non-communicable disease (NCDs). Over the next decade the continent is projected to experience the largest increase in mortality rates from cardiovascular disease, cancer, respiratory disease and diabetes.

Although, international health agencies and national governments are beginning to recognize and confront the significant global burden of NCDs, its awareness in Africa is still relatively low and political leaders there have not shown much interest in NCDs and this has been reflected in the allocation of health budgets. This neglect compounds Africa’s healthcare and development challenges, since the projected rise in NCDs throughout the continent is expected to occur on a compressed timeline compared to high income countries and Africa has restricted capacity to respond to the magnitude of its disease burden.

International organisations have flagged the magnitude and the urgency of the challenge. Healthcare advice from numerous non government agencies in the developed world on ways to deal with Africa’s escalating disease burden is forthcoming. This has been especially the case over the past decade when humanitarian aid budgets have peaked. Agency recommendations have been high on overall strategy and low on cost effective and scalable means of delivering such strategy. 

 

Most advice includes epidemiological surveillance, primary programmes that target healthy populations and secondary preventative programmes aimed at reducing complications in affected populations. All agencies agree that human resources are crucial to viable African health systems. Hitherto, human resources have been a neglected component of African healthcare. A common implementation strategy recommended and implemented by several non government agencies is to organise health workers from the developed world to spend time in African countries teaching the teachers. To assist such programmes, some agencies recommend that African governments build more roads to enable health workers to gain better access to rural areas where healthcare provision is poor or non-existent. Education is crucially important, but the key question is, how do you educate enough people to make a difference?

Africa has a population of over one billion; about 15% of global population,but only 2% of global GDP and its population is projected to double by 2050. Africa is exposed to multiple health risks combined with inadequate preventative healthcare and education. Projected trends of Africa’s disease burden and consequent rates of morbidity and mortality highlight the inadequacy of some popular traditional response to Africa’s healthcare challenge. In addition to the enormity of its disease burden, Africa, which has weak health systems, also has significant long standing structural, logistic, human and organisational barriers to the implementation of well intended traditionalhealthcare programmes many of which focus on teaching the teachers.

So, despite well intended traditional interventions, Africa’s disease burden continues to grow and its overall effect is likely to decrease productivity, lower competiveness, increase fiscal pressure, expand poverty and create greater inequity in most African countries. More scalable and effective solutions are required. These should build on Africa’s strength, which are her established and fast growing telecommunications networks and her relative absence of healthcare legacy systems. Current trends in disease prevalence and treatment costs will force African countries to make deliberate and innovative choices in order to address their disease burdens in sustainable and effective ways. Such choices are more likely to employ modern technology than to build more roads. In Africa, mobile penetration exceeds infrastructure development, including paved roads and access to electricity and the internet. According to the World Health Organization’s (WHO) Global Observatory for mHealth some 40 African countries are using mobile health services.

 

Africa is the fastest-growing mobile telephone market in the world and the biggest after Asia. Over the past five years the number of subscribers on the Continent has grown some 20% each year. By the end of 2012 it is projected that Africa will have 735 million mobile subscribers.The nature of Africa’s mobilemarket is also changing. Today, smart phone penetration rate in Africa is estimated to be about 18%: almost one in five and projected to reach 40% by 2015. While patchy, mobile penetration rates in Sub Saharan Africa, where the disease burden is greatest, are not low and the rate of smart phone penetration is estimated to be about 20%.

In 2007 Sarafaricom, a leading mobile phone network in Kenya, launched M-Pesa, a mobile phone‐based payment and money transfer service for people too poor to have a bank account. M-Pesa spread quickly and has become the most successful mobile phone‐based financial service in the developing world. Today there are some 17 million registered M-Pesa accounts in Kenya. It is only a small step to offer a mobile health information service for all M-Pesa account holders.

Africa’s new highways to carry healthcare information are virtual rather than physical. They already exist, they are extensive and, over the course of the next five years, are projected to rapidly expand and improve. With such an infrastructure one teacher can educate millions of people, which is significantly more cost effective and sustainable than traditional healthcare programmes.

Further, Africa will not be able to diagnose and treat its way out of its disease burden. Increasingly, healthcare programmes will need to emphasis prevention, alongside efforts to strengthen health systems to provide early diagnosis; targeted cost-effective and scalable treatments that are fiscally sustainable depending on countries’ epidemiological profile. Such solutions will need to fit complex, overstretched and under-resourced health systems; address the enormity of the escalating disease burden and bring about desired changes in specific African countries’ health systems. This cannot be achieved only by repeating traditional healthcare programmes delivered by non government agencies from developed countries.

According to the International Telecommunications Union there are some 5 billion wireless subscribers in the world today and over 70% of these reside in low and middle income countries. In 2011, Africa held its first mobile health summit in South Africa and firmly put mobile telephony at the centre of improving healthcare in poor countries. A 2011 WHO global survey of the use of mobile telephony in healthcare; mHealth, reported that commercial wireless signals cover over 85% of the world’s population. Eighty three per cent of the 122 countries surveyed in the Report used mobile phones for free emergency calls, text messaging and pill reminders.

Modern technologies have the scalability to provide the basis for Africa to develop country-congruent health policies that are locally applicable. Technological systems such as mobile telephony, the internet and biometric identification, which are appropriately implemented, have the capacity to empower individuals and encourage them to take care of their own health. Further, such technologies have the capacity to improve targeting, reduce fraud and increase access to healthcare. Technologically based healthcare strategies offer Africa an opportunity to leapfrog its ineffective traditional healthcare systems and begin to manage the enormity of its disease burden and, in turn, may benefit the whole world by demonstrating the benefits of patient centred healthcare.   

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