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An Overview of the UK Healthcare System Professor Reza Razavi Director of Research Kings Health Partners

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The NHS in England health and care system since April 2013 Recent changes to NHS core structures, introduced via the Coalition Governments Health and Social Care Act 2012, were designed to reform who makes decisions about NHS services, how these services are commissioned, and the way money is spent. http://www.nhs.uk/NHSEngland/then hs/about/Pages/nhsstructure.aspx

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An overview of the Health and Social Care Act 2012 A move to clinically led Commissioning An increase in patient involvement in the NHS A renewed focus on the importance of public health A streamlining of 'arms-length bodies Allowing healthcare market competition in the best interest of patients The Health and Social Care Act 2012: what the changes introduced mean: Primary Care Trusts (PCTs) were replaced by clinical commissioning groups (CCGs), led by groups of GP practices and other clinical professionals. CCGs now control the majority of the NHS budget, to buy care on behalf of their local communities. Highly specialist services and primary care services are commissioned by NHS England. Establishment of independent consumer champion organisation Healthwatch, to drive patient and public involvement across health and social care in England. Public Health England (PHE), an executive agency of the Department of Health created, to protect and improve the nation's health and to address health inequalities. Additional responsibility conferred on the National Institute for Health and Care Excellence (NICE) to develop guidance and set quality standards The Health and Social Care Information Centre (HSCIC) was also tasked with responsibility for collecting, analysing and presenting national health and social care data. CCGs can commission any service provider that meets NHS standards and costs. These can be NHS hospitals, social enterprises, charities, or private sector providers. Creation of a health specific economic regulator (Monitor). Monitor aims to promote competition, regulate prices and ensure the continuity of services for NHS foundation trusts.

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Understanding the new NHS

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Commissioning NHS services CCGs were designed to put purchasing power for NHS services in the hands of practitioners, and most specifically, GPs. more effective, patient-led decision GPs best placed to understand their local patient populations needs. CCGs commission most services, including: planned hospital care rehabilitative care urgent and emergency care most community health services mental health and learning disability services CCGs can commission any service provider that meets NHS standards and costs. These can be NHS hospitals, social enterprises, charities, or private sector providers. Highly specialist services and primary care services are commissioned by NHS England.

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Delivery of NHS services involves organisations predominantly known as trusts, which can be classified as NHS foundation trusts or NHS trusts Delivering NHS services Commissioned services include: Primary care services are delivered by a wide variety of providers including general practices, dentists, optometrists, pharmacists, walk-in centres and NHS 111. Acute trusts provide secondary care and more specialised services. Ambulance trusts manage emergency care for life-threatening and non-life threatening illnesses, including the NHS 999 service. Mental health trusts provide community, inpatient and social care services for a wide range of psychiatric and psychological illnesses. Community health services are delivered by foundation and non-foundation community health trusts. Services include district nurses, health visitors, school nursing, community specialist services, hospital at home, NHS walk-in centres and home-based rehabilitation

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Kings Health Partners Academic Health Sciences Centre one of five academic health science centres in the UK. brings together world leading research, education and clinical training and practice within an integrated environment. specifically focused on accelerating the translation of basic discovery science into experimental medicine and early phase clinical research, to speed up the delivery of new treatments and diagnostics for patient benefit. Kings Health Partners is a global collaboration between one of the world's leading research-led universities, Kings College London University, and three of London's most successful NHS Foundation Trusts, including leading teaching hospitals and comprehensive mental health services covering the London boroughs of Southwark and Lambeth. These are Guys and St Thomas, Kings College Hospital and South London and Maudsley NHS Foundation Trusts.

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The partners four highly-performing institutions Page 8 Hillingdon Harrow Ealing Brent Barnet Enfield Haringey Camden Hounslow Richmond Wandsworth Kingston Merton Sutton Croydon Bromley Lewisham Lambeth Southwark Greenwich Westminster Ken. & Chel. City Tower Hamlets Newham Hackney Islington Waltham Forest Redbridge Havering Barking Bexley Hammersmith Guys and St. Thomas South London and the Maudsley Kings College Hospital

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Kings Health Partners: Excellence, breadth and scale Hillingdon Harrow Ealing Brent Barnet Enfield Haringey Camden Hounslow Richmond Wandsworth Kingston Merton Sutton Croydon Bromley Lewisham Lambeth Southwark Greenwich Westminster Ken. & Chel. City Tower Hamlets Newham Hackney Islington Waltham Forest Redbridge Havering Barking Bexley Hammersmith - Excellence in clinical service Comprehensive portfolio of excellent quality innovative services International recognition: in renal and liver disease, dermatology, haematology, childrens, neurosciences, fetal medicine and mental health Excellence in research One of top 5 biomedical research universities in UK (2008 RAE) Five MRC Centres, three NIHR Research Centres and BHF Centre of Excellence Institute of Psychiatry and SLaM leading mental health research centre in Europe Excellence in education Unique breadth of education and training to 9,500 students At the forefront of innovation and exploiting new technology Capacity building for translational research Four highly-performing institutions Guys and St Thomas (GSTT) Kings College Hospital (KCH) South London and Maudsley (SLaM) Kings College London (KCL) 25,000 staff; turnover of ~ 2.5bn p.a.

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Page 10 The biomedical revolution

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Precision medicine and pan-omics The biomedical revolution

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Human genome 3.1bn bases 2003: 5 years and $3bn 2014: 24 hours and $1k UK 100,000 Genomes Project Personalised Medicine: Use of genetic and other information about an individual patient to guide treatment Nature

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Rising numbers of novel disease-causing genes identified

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Epigenome, metabolome (much better at predicting CV risk, for example), proteome, exposome (e.g. airborne particulates) Integration of multiple modalities to make the best treatment decision for each patient Personalised medicine: the future

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The biomedical revolution Precision medicine and pan-omics Regenerative medicine

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Regenerative medicine: functional insulin-secreting cells Pagliuca et al., Cell (2014) Generation of Functional Human Pancreatic Cells In Vitro

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Kidney organoid Takasato et al., Nature Cell Biology (2014) Regenerative medicine: functional organs

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Immune reaction Regenerative medicine: challenges Cancer Function & stability Sources, differentiation & manufacture Clinical Use

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Precision medicine and pan-omics Regenerative medicine The digital revolution The biomedical revolution

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The past....?

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Examples Long-term telemetry EEG before epilepsy surgery App for schizophrenia symptoms Activity monitoring Exposure monitoring Remote consultation and diagnosis Digital technology: remote monitoring and intervention Future: integration of multiple measures

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Real-time visualisation of brain activity (MRI or EEG) Allows patient to train themselves to modulate activity Potential in depression, addiction, schizophrenia, movement disorders Digital technology: neurofeedback

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Cancer surgery: real-time analysis of tissue Digital technology: iKnife

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Digital technology: image-guided surgery

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KHP Institutes

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Animation Cancer Institute

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Integrated Cancer Centre New Cancer Centre will include 15,000m of clinical and laboratory space dedicated to the introduction of novel, personalised therapies through clinical trials; 300+ researchers achieving 49m income (2012-13); Nearly 20,000 suspected cancer patients are seen per year; 6,500 newly diagnosed cancer patients are treated per year.

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Cardiovascular Institute

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KHP clinical: Many areas of high quality and innovation Primary PCI First 24/7 service in the UK Out of hours survival n=1120 consec PPCI Transcatheter valve intervention First TAVI in UK First-in-world procedures PCR London Valves Imaging-guided intervention First in world XMR Vascular, cardiac, EP procedures Heart failure Acute heart failure units 1 0 /2 0 /3 0 interface Device therapy Vascular surgery Complex endovascular intervention

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KHP academic strengths Percentage of the submission meeting: Overall rating 4*3*Total 4*/3* UoA1 Clinical Medicine: (Includes KCL Cardiovascular Division) KCL484593 Oxford533992 Queen Marys London 405090 Cambridge582987 Imperial483886 St. Georges293766 REF 2014 BHF funding (2011-14) Inter-disciplinarity Cardiovasc Imaging Infrastructure Technologies Training BHF Centre of Research Excellence

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All the building blocks for a world-class Institute Clinical volume and breadth Commercial Potential Academic Excellence World-class Clinical-academic consensus and enthusiasm

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Specialist CV centre Outreach Model of Clinical Care: Whole-system, patient-focussed, one team Leadership of the sector KHP cross-speciality services KHP cross-speciality services Community services Main hospital

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Specialist cardiovascular Cross-specialty services Community and outreach Cardiac assist Transplantation Minimally invasive interventions MR-guided interventions Advanced pulmonary hypertension Mental-physical Cardio-oncology Cardio-renal Inherited cardiac diseases Per-operative risk Pregnancy Heart failure Vascular risk Chest pain Arrhythmia Specialist clinics in feeder hospitals Videoconferencing Education New / improved clinical services

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USPs of a KHP Cardiovascular Institute Specialist Clinical Centre Basic + clinical research integrated with clinical care Inherited heart muscle disease Heart failure Basic discovery Devices, modelling Imaging-guided intervention Multimodality imaging Cardiac / Vasc omics, biomarkers Multi-disciplinary training Specialist training Centre of choice: Patients, staff, students, industry

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Commercial opportunities Academic: Interdisciplinary awards, networks, centres Clinical: Tertiary and quaternary work Educational: New clinical / non-clinical programmes Industry: Start-ups, incubator, partner of choice Private patients Philanthropy London location

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Healthcare is changing rapidly New era of precision medicine Health economic considerations increasingly important alongside improving clinical outcomes The NHS is changing and much more open to commercial partnerships There are opportunities both for investment and and building international clinical and academic partnerships Conclusion Page 36