Roy Lilley, Founder, Academy of Fabulous Stuff
How can a future with no hospitals improve our health? Roy Lilley, Health Policy Analyst and Founder of the Academy of Fabulous Stuff, taps into his vast experience in Britain’s health and social care system to share his vision of the future of health care and how it can be implemented in both the U.S. and U.K.
Over 50 years ago Roy Lilley started his first enterprise from scratch, built it into a multi-million turn-over business and sold it to fellow directors and managers, in 1989. He has chaired everything from major boards, to hospitals, health authorities, voluntary organisations and charities.
He has been a policy advisor, a visiting fellow at Imperial College London, helped start the Health services Management school at Nottingham University and was a founder of the Federation of NHS Trusts… that became the Confed. In local government; for over 20 years a councillor, chaired all the major committees, became the leader of the Council and Mayor of Surrey Heath Borough Council.
He is the Founder of the Academy of Fabulous Stuff, the only free-to-access repository of best practice in the NHS, the developer of the Fab-O-Meter, a way for measuring morale in organisations, in real time, and for over ten years has written a discontinuous eLetter that, often, over three times a week, reaches the inboxes of 300,000 health and care managers in the UK and overseas.
Show Notes
Roy Lilley shares his journey in the health care field. [02:41]
An example of an efficient healthcare supply chain. [07:03]
Why don’t we have that efficient supply chain in place now? [11:35]
The real vision for 30 years in the future. [12:55]
How do we get to a place where there are far fewer or no hospitals by 2049? [13:29]
Why do we have health inequities? [15:53]
What are the three things that everybody wants? [17:41]
What makes a good leader? [19:28]
Where does that leadership come from–government, private sector, and/or healthcare system? [20:16]
Financial incentives for healthcare providers that focus on keeping people healthy. [22:14]
What role will advancements in technology play in 2049? [26:14]
The ethical dilemmas that we need to address with innovative technology. [27:17]
How will a future with no hospitals improve health? [30:05]
Transcript
Jason Helgerson: I'm Jason Helgerson and you're listening to health 2049.
Roy Lilley: And would we really have the supply chain designed the way it is if we really started with a patient, started with a customer and worked backwards? We don't do it because there's no incentive to do it. There's no money in the system to do it. And hey, the patient's time is free. Our time is important. Our doctors are important. Everybody's important in the system except the patient. So that's why.
Jason Helgerson: Today's guest is famous for being a straight talking commentator on England's National Health Service. He's often described as a voice for many, when few feel empowered to speak. He celebrates the system successes, but is also willing to raise important issues and is never afraid to speak truth to power. He boasts an impressive resume as a health policy analyst, having written over 20 books on health and health services management. Today he runs the Academy of Fabulous Stuff, which celebrates all the great things being done to improve patient care across his country, given his willingness to always say it, how he sees it, I can't wait to hear what he thinks health and social care will look like in the year 2049. I'm Jason Helgerson Helgerson and you're listening to health 2049. And it's my pleasure to welcome Mr. Roy Lilley to our program. Roy, welcome.
Roy Lilley: Jason Helgerson thank you. And it's a great pleasure to be part of your program and thank you for inviting me.
Jason Helgerson: Great. Well, Roy, can you tell our audience a bit more about your interesting background?
Roy Lilley: Well, yeah, fundamentally, I'm a businessman. I left school when I was 15 and by the time I was 16, I was running my first business. And this year I'll be 75 years old and I've run businesses for however long it is. From 16 to 75. I can't do the math and I don’t want to, I get spooked. But I’ve run a lot of businesses. And along the way, I got involved in politics. I was a local authority counselor. I was the leader of my local council for 20 years. So I ran a small local authority in between running a business.
And then I got involved in the healthcare sector, where I became the chairman of what we used to call the District Health Authority, the clue is in the title, it just runs a health service for the district. And when that came to an end, I got invited by the prime minister of the day, it was Margaret Thatcher and she invited me to Downing Street for afternoon tea and a conversation. I wasn't there long enough to drink the tea and she did all the talking, but I walked out the chairman of an NHS trust, a hospital trust. I didn't know what it was, but he sounded like a good opportunity. And effectively, it was running the board for a hospital. And I did that for a few years or then, it coincided really with my retirement. I sold my businesses to the managers who worked in them and that enabled me to retire fairly early.
Then I did a bit in academia. I helped to set up the Health Services Management School at Nottingham University. I was a visiting fellow at Imperial College London, started writing about health and healthcare. I wanted to kind of make it more accessible for managers to understand. I then started writing what I call an e-letter, which is a push email that goes out to, it's free to subscribe to it, I get about 300,000 readers a week now. It's a commentary on what's happening in the NHS, and a lot of updates and stuff that people working at the front line normally wouldn't get access to. It's just the C-suite, they get all the guidance. I make it accessible for people.
Then I figured that the way we were going about healthcare was ridiculous. We have an inspection regime here called the Care Quality Commission. And of course, all they do is just stomp around, hacking people off, destroying their morale and looking for things that are wrong.
So I looked for an alternative and now I run the Academy of Fabulous Stuff. That's the up top, bottom of it. I started it. It’s a repository of best practices based on the concept of positive deviance. In any organization, there’s a line of performance below that is negative deviance, which is what inspectors and regulators look for. Above that, there’s positive deviance where good things happen. And that's what I look for. And I look for the good stuff that people do and say, share your good stuff. Because the only way that we will leverage quality is to share the good things. You will not improve if you just simply look for the worst, because people will game the system, they'll hide their worst stuff. So we run the Academy of Fabulous Stuff, we’re six years now, it's a global thing. We have thousands of people that share their things. We have annual awards and we just generally have a good time figuring out how to run things better. So that's a kind of thumbnail sketch of Roy Lilley.
Jason Helgerson: All right. Well, great. And I wish we had an Academy of Fabulous Stuff here in the United States. We don't do enough to celebrate the good things.
Roy Lilley: If you want to do it, I'm happy to share it. I would love to have a US partner to do it with. We do get stuff, things from overseas, Australia, New Zealand, South Africa, right across Europe. So we do get people sharing things. So yeah, if you've got good stuff, come find us.
Jason Helgerson: All right, so let's talk about the future, roughly 30 years in the future. What does health and social care look like in the year 2049?
Roy Lilley: I’m at the age now where I probably don't care what it’s going to be in 30 years time. Look, I wrote something the other day that I'm yet to publish, I'll probably publish it next week, but shall I read it to you?
Jason Helgerson: Yeah, that'd be great.
Roy Lilley: And then we can have a conversation. So here we go, the afternoon before my hospital appointment, my iPhone pinged with a new message. It was the outpatient service dropping me a link to download an app and a password.
In a couple of seconds, the app was live confirming that I was good to go tomorrow and a little message saying, hoping my appointment went well. I arrived at the hospital in good time. The app had linked to my GPS and it gives me a suggested route to avoid some new roadwork on the motorway. So I got there in good time, it directed me to the outpatient car park and the barrier recognized my registration number in the app and up went the barrier and they let me in. It had connected to my credit card and paid the parking charge, emailed me a receipt and a code to cancel the charge if I was disabled or a pensioner. I left the car and made my way across the car park and into the hospital. I ignored all the sign posting, the app gave me pedestrian directions to the department I was expected at.
The smiley volunteer on reception asked me for the app and zapped the QR code. It told her who I was, who I was to see and to line up my health record. The clinic was busy, but on time. And when my turn came, the doc asked me to authorize his access to my health records with my pin number, my records and test results snapped onto his screen.
I was in and out in no time. He asked if next time I'd like to have a consultation by video and I use my pin number to agree. And that was that, I haven't been back since. I use the gadgets, I plug into my iPhone to keep across the various tests, and speak FaceTime to the doc, when I need to.
Now, all I've just read to you is fiction. It isn't true, but what is true is the technology exists for everything I've described to happen now. There's no development required. It all exists and working in one form or another elsewhere in the economy, just not in a healthy economy. Amazon has the technology to recognize a customer walking into a checkout-free supermarket and collect payment for whatever they take out.
I have an app that knows where I am and pays my parking charges, Google Maps gives me directions. And my bank lets me give access to my money to a shopkeeper to buy something, appointments are dropped into my calendar and the cloud stores my information. Video technology keeps me in touch with everyone, fun, friendship, business, and family.
Roll that together and you get an app that takes care of my hospital visit and you can see, none of this is fanciful. Not as you might’ve thought, we don't have to wait 30 years, we could do it now. We can do this stuff and we should be doing this stuff, but we aren’t. Why? Well, there's no need. We don't have to. There's no driver. If people don't turn up or are late for an outpatient appointment, it's annoying, but, so what. If patients have to wander around a windswept car park in the pouring rain looking for change for the ticket machine, so what. If the public have to wait in a clinic that's over running, hospital time is more important than anyone else's time. And if their notes are missing, so what. If we have to go for three tests on three different days, it’s their time, not hospital time. If we do all that knowing we could do it perfectly while sitting at home, no one cares because no one's figured out a way to make the tariff reimbursement work and anyway, the patient's time is free.
If we got all our records into the cloud, we could have a password and give it like a pin number to any health professional we wanted to access, when we wanted to. The most common indicators we want to monitor can be done from a smartphone and a gizmo or two. So don't speak to me of innovation and don't talk of tech. Don't waste my time with vaporware and snake oil. Don't talk of digital transformation in the future. We don't need aspirants. We need achievers. No more governance. We need go do. No more artificial intelligence. We need some real brains with real intelligence to make real stuff work.
Jason Helgerson: Well, Roy, as I said, you are a straight talking commentator, on not just England's National Health Service, but on healthcare in general. And I think the technology you described all exists, but yet it is not applied to healthcare. So let's unpack a bit. Why isn't that better future you described the reality of today?
Roy Lilley: I think there's several things. Partly it's because the technology would save time and the patient’s time is free. So the efficiencies from the patient's point of view are hugely important to make them feel in charge, on top of what's happening, understanding, but it doesn't really matter to the system. The system exists to earn money. The system exists to, yes play lip service to looking after the patient and putting the patient at the center of everything we do and all that, it’s rubbish. But if we wanted to put patients at the center of everything we did, we'd start with the patient and work backwards.
And if we started with the patient and worked backwards, would we really have any of those things on the way? I mean, what I've just read out really is a kind of tarted up version of a supply chain. And would we have the supply chain designed the way it is if we really started with a patient, started with a customer and worked backwards. We don't do it because there's no incentive to do it. There's no money in the system to do it. And hey, the patient's time is free. Our time is important. Our doctors are important. Everybody's important in the system. Except the patient. So that's why, and really, you know, Jason, I don't believe it. I've written that about the future because you know, everybody wants to know what the future looks like.
I don't want the future to look like that. I really don't. I don't want people, even as slick and as good as that would be, if we did it, I don't want that. Because my real mission and what I really want to happen in 30 years time, is I really want to make the hospital history.
Jason Helgerson: All right. So let's talk about that, 30 years in the future, a world with no hospitals or a world with far fewer hospitals, how do we get from here to there?
Roy Lilley: Well, and that's the really interesting thing, isn't it? Because as the article I've just written explained something which is immediately doable, it is immediately doable for us to really consider making the hospital history. In my view, most of what we go to the hospitals for is either self-inflicted and by that, I mean our lifestyle, the way we live our lives, the things we eat, the exercise, we don't take the cigarettes we smoke, the booze we drink, all the things that we know are bad for us. We just do because most public health initiatives have failed. And because there is a conflict of interest between a government who wants to take the revenue from the cigarette companies and a bit of government that doesn't want us to smoke. I mean, you can't reconcile the two, you've got to decide if you want the revenue or do you want healthy people? And most governments say, well, we'll have the revenue. And then we'll kind of beat the customers up for smoking. So none of that makes any sense to me. It's lifestyle, partly our lifestyle. And it’s partly the way we run our societies.
Now, if we look at the US, for example, in the 2010 census half of the population of the US qualifies as poor or low income, and one in five millennials live in poverty. Now that's not just the US, I'm not just having a go at the US because in 2013, UNICEF said of the US, it's the highest relative child poverty rates in the developed world.
Now, if we look at the UK, we know better. In the same way that we have an image in the United States of Microsoft, Apple, the Oscars, glitz, Beyonce. We think of the UK as guardsmen, the royal family, the Beatles, all of that, but actually there are 14.3 million families living in poverty. That’s nearly 35% of our children and 49% of the 14.3 million live in persistent poverty. And these are all kids coming to school in your country or mine, where if we ask them, what did they have for breakfast, they’d probably say nothing. And if you ask them, when did they have a new pair of shoes? They couldn't remember.
So it's the way we run our societies. It's endemic. We engender because of the way people live, poor health, poor lifestyle, the whole approach to the way we live ends up with people backed up in hospital with cancers they don't need to have, with heart attacks they shouldn't be having, the whole approach to life and lifestyle gives us what we call health inequalities. Health inequalities in your country and my country and across Europe, any of these developed nations that call themselves wealthy, they are really not. Scratch the surface and you can see why we're getting sicker and sicker and things are going more and more wrong. So if you ask me in 30 years, how do I see the health system and what do I really want from a health system in 30 years is I want to make the hospital history.
And it's a big stretch I know, am I a dreamer? Well, I don't know, if you don't start with a dream, you don't get anywhere. Everything starts with a dream. So what am I saying? Well, what I'm saying is in 30 years, we have got the time and the imagination and the vision to bring up a whole cadre of new young people in a way that's healthy and in a way that stops them from their lifestyles, from getting sick, the air pollution, where they live next door to motorways, the cars they drive, because good health is a product of the way we live our lives. So when we educate kids, we train people to do jobs, are they the jobs we want them to do? I want people to learn for life, not learn for earning a living or learn for a job. We don't teach the kids right from day one how to live their lives in a healthier and happier way.
I mean, there are three things that everybody wants. They want a job, and in our two countries, we got people who don't have jobs. They want a safe place to live. And how much of our housing in our two countries is really awful and shouldn't be lived in. And they want to be free to love who they want to love. And those are the three pillars for me, a job, a safe place to live and being free to love who they want to love. If we can organize ourselves in our societies to do that, then we can start to be healthier. Then we can start to make the hospital history. Then we can put some of these big hospital corporations out of business.
And if you say, well, Roy, you're a dreamer, I'm not. When we introduced ourselves, I said, I've worked for myself every day since I was 15 years old. I had my first business at 16. I have not done that by being a dreamer. I've done that by having a dream. I did want to work for myself. I did want to employ people. I did want to create wealth. I did want to make businesses better. I did have an ambition to run a hospital. I did want to lead a council. I've done all that. I'm not saying I'm exceptional or different, but unless you have a vision, unless you have some idea where you want to go, you'll just wander.
And right now, I think with healthcare, we just kind of wander around landscape of healthcare, not really knowing what it is we want to do. We want a new cure for this, but we don't want to pay for it. We want a new pharmaceutical product for that, but it's too expensive. We want our hospitals to do this procedure, but the insurance companies don't want to pay for it. We want our hospitals to be run like the Hilton Hotel, but no one wants to pay for that, either. We wander around the landscape.
We need leadership, leaders are visible, have a vision and share it often. And those are the three things that you need to know about leadership. If we want to reduce illness and sickness we can, but we need the vision to do it and we need the leadership to say to people, we're going to change the way we do things. So that's what I really think.
Jason Helgerson: All right. So let's talk about where does that leadership and vision need to come from? Does it have to come from prime ministers and presidents, from members of parliament or members of Congress? Does it have to be led by sort of a central government? Or is it possible that that kind of leadership, that kind of vision could come from other sectors, whether it's the private sector or from the front lines of the healthcare system? Where do we need that leadership?
Roy Lilley: It comes from a range of leaders, I think, but fundamentally it comes from national leadership. I mean, you've had difficulties in your country with leadership recently and it doesn't look to me like you've solved it now. We have trouble in the UK with leadership. We've got Johnson who, frankly, his response to the COVID pandemic has been woeful and now we've come out of the European Union, we’re struggling on other fronts, as well. National leadership is very important, but that leadership and that vision cascades into every other part of our society. We have our leaders, we have our members in parliament, you have the Senate and Congress, we have our leaders.
But there are community leaders, as well. There are leaders in the workplace. There are organizations that are leaders. There are some extremely good employers now that do have workplace leadership about the health of their workplace. So the leadership comes from all kinds of levels. It comes from national leadership, regional leadership. It comes from the employer in the workplace and it comes from the hospital system itself. Most hospitals are compensated and paid for the people they treat when they get sick. What would it look like if we pay them for the number of people they kept out of hospital and out of the system. So, leadership, I think comes from a number of levels.
Jason Helgerson: So let's talk about financial incentives and you talk about payments. There's a lot of energy here in the United States around what we often referred to as payment reform. The idea of trying to get the financial incentives right, so that providers of health and social care services are rewarded. They do better financially when people are healthy, not just on an individual level, but on a population level. How important is it to get those financial incentives right in order to achieve that vision that you laid out so articulately of a future in which we don't need hospitals?
Roy Lilley: Well, I think he's really important. I mean, think about driving your car, your car insurance is reduced if you don't have an accident. So we know that works. That's an incentive that works. Our two systems are very different. If you look at the system you've got, you’ve got a federalized system, you've got insurance companies, you've got some state intervention. I mean, it's a real mixed bag of incentives and that in itself looks to me, someone looking at it from a distance, from a sort of helicopter view, that looks to me like a real mess. And that leads somehow or other to be codified, coalesced with one central theme.
Now in the UK, of course we have our national health service, which is funded by our taxes. It's a socialized system. And I know a socialized system is anathema to a lot of people listening to this, perhaps in the United States. But we really suffer, for as much as our two systems are different, we suffer from the same problems.
Let me give you an example. Our hospitals are pretty much funded on the work that they do. Now during the COVID pandemic, it’s been horrendous for both our countries and God knows how many people have died and we've lost loved ones. But there are things that have been good during COVID. And the great thing about change is to respect the past and take the best into the future. And if we're going to take the best of COVID into the future, one of the good things that's happened here is that a lot of our outpatient appointments are actually now being conducted by FaceTime or Skype or in some way, a video system.
Now it's been years and years and years and years of trying to do that. I wrote a book 10 years ago on telemedicine. And when I wrote it, everybody said I was balmy. In fact, I must have been because nothing happened. We've had more change during COVID using technology than we've had in the last 40 years. And we had that in four months because we've had to do it. So a lot of people now have had their outpatient appointments conducted remotely. Now here's the problem, hospitals get paid quite a lot of money to do outpatient appointments. It’s on a sliding scale, depending on the complexity of what happens when you get there. But fundamentally they earn money from the fact that they're outpatient appointments. So guess what, they want quite a lot of outpatient appointments and they don't care how convenient it is for the customer because, hey, the customer's time is free.
So suddenly in COVID they couldn't do that anymore. Now, guess what? The patients absolutely love doing it. Guess what? The clinicians, once they got over the shock of it, suddenly realized that they quite liked it as well, because guess what? A lot of the clinicians doing the outpatient appointment clinics were working from home. They didn't go to the hospital either.
And so we've got this win-win. The lose-lose is the fact that now the pay is in our system, the people who commissioned our healthcare here don't want to pay the full dollar for an outpatient appointment because it's being conducted remotely. So guess what? We're seeing the amount of remote telemedicine appointments starting to reduce and we're going back to old ways. So the reimbursement mechanisms are really very important.
Jason Helgerson: So one more topic I want to cover is technology. A lot of our guests on this show like to talk about technology and the role it will play 30 years in the future. Things like gene editing that could potentially be available by that point, curing chronic illnesses, extending life. What role do you see technology and advances in technology playing? Do you think that those advances will help get to your future state in which we do not need hospitals? How do you see that technology playing out?
Roy Lilley: I think that's very important. I don't want to give anyone listening to this the impression that I'm a Luddite and here I am speaking to you with a gas lamp, somewhere in London. I'm up for all the technologies that we've got and certainly around the diagnostics and forecasting. I mean, there are difficulties with this. Let’s not run away with the idea that the fact that someone's going to be ill later in life is free. It isn't because immediately the insurance companies are going to say, oh, well, maybe we need to raise your insurance premium because you're going to be ill later in life. So we do need to deal with the medical legal aspects of this and we do need to deal with the complexities that it brings.
But absolutely, I think these technologies are just going to … once you start, it's like an avalanche, isn't it? It's like a game of Jenga, you pull one stick out and that's the key to the one technology and suddenly the whole lot just kinda cascades in on you. So all of that is really very important. I mean, let's ask ourselves the question, if it was possible that, here we are in the maternity ward with this beautiful little baby that's just been born, if we could take a tiny spot of its blood and forecast how well or sick or not or what it's going to be in the rest of its life and that technology will be with us, if it's not with us already in the next 30 years, do we want to do that? And of course that leaves us with a lot of ethical or moral dilemmas about whether or not we should or could do it. A doctor's going to play God, all these very difficult questions that arise out of this.
But, I'm old enough to remember back in 1969, when the world sat on the edge of its seat and watched something happen that it couldn't believe being done by someone they'd never heard of, in a place they didn't know where it was. And I tell you what it was … it was at the Groote Schuur Hospital in South Africa. The surgeon was Christiaan Barnard, he was a heart surgeon and what did he do? He took the heart of a dead girl and put it into the chest of a very sick and poorly man. And that man lived for a week. There were complications and sadly he died, but within five years, heart transplants had become normal and now they're routine. But at the time, I do remember people saying, this is doctors playing God, this is an ethical dilemma. We shouldn’t do this, and of course, the other complication was that it was a young girl's heart, who died in a traffic accident that'd been put in the chest of a man. And even more complicated back then was the fact that it was a white South African girl, and in those days in the ugly language of what was called a Cape Coloured South African. So it was a white girl's heart in a Cape Coloured guy's chest. I mean, these days who cares, but in those days it was a huge, moral and ethical dilemma. So as much as we look at these technologies and we recognize there are moral and ethical dilemmas, they pile into yesterday. And of course these technologies are important. Of course we should use them. And absolutely yes, they will feed in to helping to make the hospital history.
Jason Helgerson: All right. So one final question for you, Roy, I'm asking you to take a step back from the health and social care system to look at the broader landscape. If your vision of a future with no hospitals is actually achieved, how will this make the world a better place? How will it fundamentally improve the human experience, if we are fortunate enough to achieve your future state by the year 2049?
Roy Lilley: Well, just think of older people, for example, how many years do they spend towards the end of their life in pain, in discomfort, not being able to do the things they did when they were younger. All of that could go. And in older years, where you sit on a mountain of experience and you're not working and how you can play with your grandkids and be part of their growing up and be part of their family, that’s important for the individuals. It’s important for the economy, because think of the amount of taxes, I mean, we're paying a 106 billion pounds a year here for our health services and that doesn't take into account social care, either. Think of what we could do with those taxes in terms of education and making life more pleasant to live and living spaces better and housing and we could make poverty history, as well as, we can make hospital history. So, all of the things that we enjoy in our younger years, our healthier years and our years where we're spirited and full of imagination, all of that could continue on into our later years where we add to that a great deal of experience and a lot of wisdom.
Jason Helgerson: All right on that optimistic note, we'll bring an end to this podcast. And that was Roy Lilley's vision for healthcare in the year 2049. As always thank you for listening to health 2049. If you enjoyed what you heard, please subscribe to us and share this podcast with a friend. Thank you and see you next time.
