The second point that is absolutely essential is that we foster really close partnerships between universities and healthcare organizations.
The background to this in the UK is that these two entities, two sectors, have drifted apart over the last few decades, for a variety of reasons (Slide 19). One is that the healthcare system has become very preoccupied with targets (nothing wrong with targets by the way); they’ve had a good effect in some ways, and led by management rather than clinicians (again, nothing wrong with good managers, they are very important people), but that means that the R&D agenda has been secondary rather than primary. Turning to the university sector, we have something in the UK called the research excellence framework (https://www.ref.ac.uk/), and it is easier to generate high-quality research in basic science and in animal models than it is in the clinical context, and so perhaps there has been a greater focus away from clinical research, and the financial pressures, again, tend to drive organizations to focus on their immediate priorities rather than on what is important in the long term.
Now, I don’t know whether this little joke is going to cross national boundaries, and so forgive me if it doesn’t. And I guess people here know of Winnie the Pooh and they’ve read stories in their childhood. Well, Pooh has a very, very good friend, and here they are (Slide 20) on a woozle hunt wandering around looking for a woozle. While the two friends wandered through the snow on their way home, Piglet grinned to himself thinking how lucky he was to have a best friend like Pooh. Now this cartoon came around the Internet at the time the swine flu virus was identified. And Pooh was thinking less charitable thoughts to himself, and forgive the language, it’s not mine, “If the pig sneezes, he’s fffing dead” (Slide 21). And so, the swine flu virus put at risk this very long-standing relationship. And I think our relationship between universities and healthcare in the UK, at least, has been under threat for those reasons that I have just mentioned.
For these reasons, the UK decided to launch a competition to designate a small number of academic health science centers (Slide 22). There are now six of these across the UK, and they are designed to bring universities and their hospital partners into a much more intimate relationship in order to drive high-impact innovation into improved clinical outcomes in the population.
Let me now tell you a little about the academic health science center that I lead (Slide 23). It is called King’s Health Partners, and it brings three hospitals together, Guy’s and St Thomas’ (GSTT), King’s College Hospital (KCH), and the UK’s leading mental health trust, South London and Maudsley (SLaM), with a university partner, King’s College London (KCL). In my view, to be a twenty-first century academic health science center, you need to tick three boxes as a baseline: Firstly, you need to provide excellence in clinical care, excellence in research, and excellence in education. Secondly, you need to be broad in your range of services and research, and thirdly you need scale.
I think we can claim all three of those. We certainly are large. We have 36,000 staff and have a turnover getting close to £4 billion per annum, with 5 million patient contacts and a very large research portfolio.
There are three hypotheses underlying what we are trying to do in King’s Health Partners, derived from the partners in this organization (Slide 24). So, if I’m talking to some innocent bystander at a bus stop, this is how I would explain what King’s Health Partners is about.
The first hypothesis is that by having two large acute hospitals, GSTT and KCH, in the same partnership, there must be an opportunity to reconfigure specialist services and link the relevant research and increase quality. It’s a lot easier to say than it is to do, as I am sure you well know. The second hypothesis is that by having a mental health hospital in this partnership, we should be able to do something to better integrate mental and physical healthcare. And the third hypothesis is that by having a university in this partnership, we should be able to create an academic culture and accelerate translation.
Let me briefly illustrate whether or not we are making progress with delivering on those three hypotheses.
Reconfiguration of Specialist Services
My presentation (Slides 25–27
) provides a diagram showing the specialist services delivered by GSTT. There are two hospitals, one organization on two sites, and KCH is three miles down the road. You don’t need to look at this very long to see that all these specialist services are duplicated. Now, if you were designing the healthcare system from scratch you would not design it like this, and that is why I call this a dog’s breakfast—it’s a mess. When we established King’s Health Partners, we saw an opportunity to do something more intelligent about it. Now, as I say, it’s an awful lot easier to say “Let’s reconfigure things” than it is to do it because nobody wants to give up what they have.
But over the last 10 years we have managed to make a lot of progress, and now we have committed consensually to developing a series of clinical academic institutes consolidating cardiovascular and child health at St Thomas’, cancer and dentistry at Guy’s, and neuroscience, diabetes, and hematology at Kings College Hospital. So, we are reconfiguring services. We’ve done this in a very fair and balanced way, and I think it has a lot of potential through driving improved clinical quality and translational research.
So that’s hypothesis one.
Integration of Physical with Mental Healthcare
Hypothesis two—I describe this as putting an end to Cartesian dualism. To understand that, you need to understand a little bit of philosophy. There was a French philosopher called Descartes who believed in the duality of the mind and the body—thought they were two separate things. Philosophy has largely moved on from that thinking, but our healthcare systems have not. And so, at Denmark Hill, KCH is on one side of the road, the SLaM hospital on the other side of the road, and the relationship between these two wasn’t very good in the past, and I’m told you needed a passport to cross the road when going from one hospital to the other!
This was not sensible. And this is something I’ve become passionate about since leading King’s Health Partners. The three drivers of this passion are shown on Slide 28, and I’m sure you know this.
First, by our own screening at King’s Health Partners, almost one-third of patients with long-term physical conditions are depressed. While rheumatologists are very good at looking after joints, they are not so good at detecting or managing depression. The same thing for diabetes and so on.
Secondly, 60% of patients referred to a cardiologist with chest pain have nothing wrong with their heart. That doesn’t mean they don’t have chest pain, but it means they get investigated inside and out until someone realizes that the problem is anxiety.
And thirdly, patients with long-term serious mental illness—and this is the worst scandal of all—have about 17 years taken off their lifespan. This is not suicide; this is the physical comorbidities that accompany their schizophrenia, and that’s partly due to drugs, partly due to lifestyle.
We need to do something about this, and this is a major theme across the whole of King’s Health Partners (Slide 29). We are looking to do everything we can to integrate across these boundaries, and so we now have 58 outpatient clinics which are co-staffed by a physician and a psychologist. We screen patients waiting in outpatients for mental health issues, we are training our mental health nurses to recognize insulin resistance and hypertension, and so on. I think this is immensely important.
Translation of Research into Clinical Practices
What about hypothesis three: are we managing to integrate the university into the healthcare system and generate an academic culture? Slide 30
shows the number of highly cited papers published by NHS employees in our hospitals. These are not university employees; they are NHS employees. King’s Health Partners was formed between 2008 and 2009. Slide 31
shows that publications have trebled in GSTT and doubled in KCH. I can’t prove that’s due to the Academic Health Science Center, but I am going to claim it as a credit.
Then if you look at clinical trial performance, which we measure across all hospitals in the UK, GSTT is now either first or second, KCH fourth and eleventh, and SLaM first or third (Slide 31). This is the clinical trial performance across the whole of the UK, and ten years ago, that was absolutely not the case. These are surrogate markers, but I hope you will accept that they do provide some encouragement—that we are generating a really academic research-orientated culture.