March 11, 2025 • 49 mins
In this two part episode, we talk to Dr. Jonathan Gregory, a former NHS cancer surgeon turned healthcare innovator, to explore the intersection of data, digital tools, AI, and patient-centred design in transforming cancer pathways.
With over 20 years in frontline surgery and leadership roles, Jonathan now works. as clinical advisor for Macmillan Cancer Support, and in roles at Imperial College, and NHS innovation programmes to rethink how healthcare is delivered—from AI-powered end-of-treatment communication to understanding the lived experiences of cancer survivors. He also runs his own consultancy Pivotal Health working with the NHS, academia, startups, and third-sector organisations to develop and implement digital, AI, and data-driven tools.
In part one we explore:
- What it's like working as a surgeon
- Redesigning cancer pathways and why the NHS struggles, despite simple solutions being within reach
- Health inequalities in cancer care and how systems can be re-engineered to work for everyone
In part two we explore:
- Where the real power of AI lies—not in replacing doctors but to challenge bias and support better decisions
- AI's role in better patient communication
- A groundbreaking national research trial, which is rapidly becoming the largest of its kind
Jonathan’s insights will challenge how you think about healthcare transformation, showing how human-centred design, behavioural science, and digital innovation can unlock real improvements—if we let them.
If you’re interested in the future of healthcare, cancer treatment, health inequalities, or AI’s role in medicine, this is an episode you won’t want to miss.
Problems Worth Solving is brought to you by Healthia, the collaborative service design consultancy for health, care and public services.
Find out more about our work at healthia.services.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
SPEAKER_00 (00:00):
Hello, this is Problems Worth Solving, the
podcast where we meet peopletransforming health and care
through human-centred design anddigital innovation.
I'm Sam Mentor, ManagingDirector at Healthier, the
(00:21):
collaborative service designconsultancy.
If you enjoy listening, you cansubscribe to this podcast and
the accompanying newsletter athealthier.services.
So today I'm joined by DrJonathan Gregory.
Jonathan is a cancer surgeon bybackground who worked in the NHS
for over 20 years and heldseveral management positions.
(00:44):
He now works to improve patientcare and outcomes using data,
digital and AI via hisconsultancy Pivotal Health.
He's National Clinical Advisorat Macmillan.
He's digital theme lead at anational institute for health
and care research and he's anhonorary research fellow at
Imperial College London.
We've split this episode intotwo parts because we had lots to
(01:06):
talk about.
You're listening to part onewhere we explore Jonathan's
background, what it's likeworking as a surgeon and
practical experiences of healthinequalities.
We'll also dig into Jonathan'swork to improve cancer pathways
and the critical importance ofgetting the right balance
between digital and humansupport.
In part two, we exploreJonathan's work with Macmillan
(01:27):
and using AI to improve patientcommunication.
We'll also dig into hisgroundbreaking work to
understand the experiences ofcancer survivors in the
community and discuss his visionfor the future.
Jonathan, I'm excited to haveyou here.
Thank you so much for joiningProblems Worth Solving.
SPEAKER_01 (01:44):
Thanks, Sam, and thanks for the invitation to
come and speak with you today.
SPEAKER_00 (01:49):
To kick things off, would you like to share a bit
about your background and tellme a bit about what drew you to
medicine and surgery?
SPEAKER_01 (01:56):
I think it's the mixture of human and science,
sort of biology, psychologists,behavioral medicine.
So I think that's why I wasdrawn in that direction.
And the fact that relatively,certainly that point in my life,
I was looking for very tangibleoutcomes from things I did.
And so treating patients is abit more tangible than perhaps
(02:19):
research or other feelings likethat.
I think it's always a bit ofserendipity and happenstance.
So when I went into medicine, Ivery much thought I would work
maybe as an anaesthetist orcardiologist.
So much more in the medical sideof using drugs and medications,
given my degree in pharmacology.
But my practical experience onthe wards was really that Lots
(02:44):
of time went past and not alwaysmuch changed for the patients in
front of you.
The benefits from medicaltherapies often are weeks or
months later.
Whereas on the surgical ward,someone wheels off to theatre
and they come back and there'ssomething different.
There's something being added orremoved.
And I think it was that sort ofimmediacy that drew me.
(03:07):
And then it's serendipity.
I was put on a placement at theRoyal Bolton Hospital and was
put into the orthopedic teamthere and they were just
brilliant they wereinspirational they were great
teachers they involved you and Ithink that was it really I was
sold and yet I think if you'dever said to the me prior to
that trauma and orthopedics Iwouldn't have thought that would
(03:29):
have been the direction I'd havegone so
SPEAKER_00 (03:31):
it's about the immediacy
SPEAKER_01 (03:32):
I think that's it and I think patients and trauma
and orthopedics someone comes inwith a broken bone And they go
home having an operation and thebone, you know, is aligned.
It's less painful.
There's something very clear.
Someone comes in with adislocated shoulder or within 10
minutes, you've removed thatpain from them.
So I think there is animmediacy.
(03:53):
It probably lent into my slightobsession with to-do lists and
ticking stuff off.
It's a little bit like that.
And again, it's a sort ofinterface specialty because
you've obviously got engineeringand biology involved.
and all the other bits.
So some of it, I think, is theintersections that I always find
enjoyable.
SPEAKER_00 (04:13):
It must be immensely rewarding working as a trauma
surgeon.
SPEAKER_01 (04:18):
Yes, it is.
I hesitate because I think alljobs, you acclimatise to it.
And I think as you become aconsultant, you tend,
unfortunately, or certainly Idid, to remember your mistakes
and things that didn't go sowell, perhaps more than the
successes.
Because the successes have goneout into the world and
brilliant, they're getting onliving their lives.
(04:40):
Whereas your clinic is full ofthe people who, oh, that could
have been better.
There's a funny recall bias, Iguess, that's going on there.
So it absolutely is rewarding.
And even to this day, I can lookback on cases and think, we did
something good there together.
But also I can look back and Ican picture exactly the people
that perhaps things didn't workout as well for as I would hope.
SPEAKER_00 (05:03):
What did you like most about working as a surgeon?
SPEAKER_01 (05:07):
I'm really drawn to the beauty of the human body.
So it's really the anatomy andthe fact that when you've seen
the nerves that maybe gives yousensation to the tip of your
index finger or the inside ofthe shoulder joint or where the
tendon of the biceps is, and youcan relate that to how you move,
how, you know, your own life.
(05:30):
I think there's something...
really are all inspiring there.
I'm probably going to sound verystrange now, but it was never
lost on me when you made theincision into the skin, assuming
it was the first time this partof the body had been operated
on, and you're looking at thetissues.
That is the first time they haveever been exposed to light,
conceived and grow in utero inthe dark.
(05:52):
They've been sealed ever since.
So you are the first person, thefirst set of eyes to ever
witness that piece of creation.
And that That sort of, yeah, itwas never really lost on me, I
don't think.
SPEAKER_00 (06:05):
You don't ever get tired of that view.
You get that excitement ofseeing the inside of the body.
SPEAKER_01 (06:10):
I think you do when you're in the correct headspace.
I would say that, unfortunately,as you get more senior, you're
often operating with a cognitiveload of other things going on.
You obviously arrive in theatreto a head that's buzzing with
emails that have come through,problems, what have you, and As
(06:32):
you get experience, like anytechnical skill, there are
obviously still extremelydemanding operations, but quite
a few are a little bit morereliable.
I would never use the wordautomatic, but you can function
at low levels.
But I think that it was neverlost on me when you go and see
the patients first thing in themorning before their operation.
(06:54):
You know, they are trusting you.
They're trusting you, to beblunt, cut them up.
And that's quite a strongcontract to hold, really.
So that part I never took forgranted.
SPEAKER_00 (07:04):
There was an artist about, oh, I forget his name,
about 10 years ago who diddisplays of the human nerve
system.
Do you remember?
I
SPEAKER_01 (07:12):
do, yeah.
The Austrian artist, I think.
SPEAKER_00 (07:15):
Did you go and see that?
SPEAKER_01 (07:17):
I didn't, no.
Were you tempted?
No, probably not, actually.
Whereas I do like the HunterianMuseum at the Royal College of
Surgeons, accepting that there'scertainly...
historically at least parts ofthat museum I think that we
shouldn't celebrate but thereare things there that yeah are
interesting a wow are I thinkthat's one of the reasons I went
(07:40):
into a particular part of SergioI did because when you've
exposed like a whole limb or awhole blood vessel the
intricacies and the twists andthe turns and as I say I think
feels I suppose like acosmologist looking at the stars
it gives you a slight sense ofthere you are worrying about
your day to day Just look atthis.
It's amazing.
SPEAKER_00 (08:00):
What about some of the challenges when you're
working as a surgeon?
I
SPEAKER_01 (08:04):
found it very tiring in the sense of, in the cold
light, in the cold light,everyone, should we say outside
of healthcare, will believe thateveryone's pulling in the same
direction and the same drivers.
And that isn't the case at all,is it?
Humans are humans with their ownmotivations, desires and wills.
And so as a surgeon, you...
trying to motivate colleagues todo operations.
(08:26):
It's getting towards the end ofthe day.
People want to go home, butyou're aware that there's a
patient who's waited all day,starved, and they're going to be
cancelled.
And so I think there's an awfullot of push of needing to drive.
The system, shall we say,doesn't run of its own.
It doesn't have a naturalmomentum.
(08:47):
And so I don't these days missthat at all.
That slight driving into work atseven in the morning, six, seven
in the morning with a sense ofquite a hard 12 hours ahead.
And actually not often would itbe the actual operating that
would be the hard part.
It would be the systemnavigation that would be harder.
SPEAKER_00 (09:06):
When you were working as a surgeon, how much
did health inequalities, factorslike where people live, their
income or their backgroundaffect their outcomes?
SPEAKER_01 (09:16):
I think it, affected them a lot.
But I confess that I'm not sureI always realised how much it
affected them at that time.
I was part of a cancer servicein two hospitals and we covered
large cancer areas.
People would travel many hoursto come to that area.
So we were aware perhaps oftrying to support people with
(09:38):
travel.
If you're trying to get fromDevon to Birmingham, what time
of day have you got to set off?
And so those sorts of almostgeographical things.
And we'd be aware of people,perhaps it's a single parent or
retirees.
But I don't think we, Icertainly didn't have the
cognitive capacity and perhapseven the real grasp of health
(10:01):
inequalities to lean in furtherthan that.
That sort of piece around, I'dprobably, a lot of people think,
I just don't understand why thisperson's not giving up smoking
or why can't we get them toadhere to to this treatment.
And now through experience andlearning, I realize that there's
a multitude of reasons for that.
(10:21):
And also the way the system isbuilt naturally makes it harder
for some people to participatein healthcare than others, not
purely on the basis ofgeography.
So I think I come slightly as areformed character where I never
knowingly didn't deliverequitable health care but now in
(10:42):
hindsight I realized that Ididn't always I think I thought
that by treating everyoneequally I was doing the right
thing someone's sexuality theirethnicity their gender that
didn't matter to me but Irealize now that I really needed
to lean into that more becauseactually it's more that some of
those groups will have greaterbarriers to letting me help them
(11:06):
with their health care workingwith them in their health care
And so I needed to know so Icould take a step forwards
towards them and bring theservice closer to them.
Whereas I probably thought it'snot my business.
I'm not influenced by themnegatively.
SPEAKER_00 (11:21):
So when we were talking earlier, you talked
about how health inequalitieshave become quite a focus in
your work.
Can you tell me a bit more aboutthat and why that is?
SPEAKER_01 (11:29):
Yeah, I think as a lot of things in my life, it's a
bit of serendipity meetinghelpful and interesting people.
As I transitioned out of theNHS.
I remember going to a conferencehosted by the King's Fund on
health inequalities, and thatsort of opened my eyes a bit.
Working for Macmillan'sobviously significantly opened
my eyes to health inequalitiesand the issues around that.
(11:52):
And then, you know, severalbooks I've read or other things
I've watched.
So I would never claim myself tobe an expert, but I think what
worries me is often inconversations, I feel like I'm
the person who seems to knowmost about it.
I think in the UK, we have apolitical system and maybe a
political ideology thatslightly, very much puts weight
(12:15):
on the rights andresponsibilities of the
individual.
You know, that sort of, wemustn't have a nanny state sort
of mentality.
And as I say, I don't, I'm notparticularly interested in
getting into the politicalelements of that, but I think
what that does though is it sortof, it suggests that every
person is able to make thedecisions that are right for
(12:37):
them at that moment in time.
And yet there's increasingevidence in the psychological
literature that people'sdecision-making is compromised
by the life around them.
So it's not suggesting peopledon't have the mental capacity
to make decisions forthemselves, but if you're
hungry, if you're worried aboutpeople around you, if you're in
(12:58):
pain, This all narrows yourability to make decisions and
choices that might be in yourlonger-term benefit.
It's about getting through thenext 24 hours or the next week.
And I just don't feel that inthe UK, and particularly in
healthcare, we take enoughnotice of that.
That sort of, oh, someone canlog in to do this or can go
there to request that.
(13:19):
And that, of course, works wellfor a large number of people.
But some people do, at thatmoment in their life, might need
us to step closer to them.
And I'm not convinced...
We're always that good at doingthat.
SPEAKER_00 (13:31):
What does that mean for patient-centered care?
SPEAKER_01 (13:34):
That's a very interesting question, Sam,
because, yes, my points taken toextreme drive you to a very
paternalistic mindset, and thatisn't, of course, what I'm
intending at all.
I think it's about there's agroup of patients who I think
naturally are well-activated andable to participate in their
(13:57):
care care and their decisionsand so that's about designing
services and delivering care ina way that's an equal
partnership but then there's agroup of people i believe that
because of circumstances we'vementioned not least potentially
fear english as a secondlanguage poor health literacy
(14:17):
where it's much harder and ithink there it's about designing
services that the can meetsomeone so late, enable them to
make decisions that are rightfor them in that moment.
But I think in the sheer volumeof patients being seen this
year, in an orthopedic fractureclinic, you have five minutes
per patient.
It isn't really designed forthose, you know, what I think
(14:42):
some people would try and sayare edge cases, but actually are
far more common than being anedge case.
What does it mean?
I think it just means we need toredouble our efforts.
But I think some of that's It'snot just about the way we talk
to people and, oh, I'm going togive you a choice of operations
or a choice of treatments.
It's how do we deliver thatinformation and when?
Because my cognitive overload inthis clinic today means I might
(15:07):
be hearing but not able toabsorb.
How are we reaching out to youin three days' time or a week's
time to say, have you had anyreflections?
What do you think?
And trying to sort of drip theconversation beyond the clinic,
I think.
SPEAKER_00 (15:21):
And is there a natural progression of that,
that patient choice can't be thesame choices for every patient,
that it needs to be quite apersonalised steer that you're
giving to patients?
SPEAKER_01 (15:30):
I intrinsically want to say yes, I agree, but then
I'm nervous that I think it'smore how we phrase it, how all
of medicine should be aconversation really that is
about explaining someone'scondition in a way that they
understand that is meaningful tothem and can activate them.
(15:52):
and risks and benefitsexplanation of different
approaches.
And really, what's the valueproposition?
What's in it for you to takethis tablet?
And I do think that probably abetter explanation of what I'm
getting at here is there's asort of naive assumption, I
think, that every person mustjust want to be well.
(16:15):
And I don't think that's true inthat sense.
I think, of course, everyonewants to be well.
But my priority today might justbe getting to work and bringing
some income in.
It might be caring for myelderly mother.
So it's not that I don't want tobe well.
It just isn't the priority todayor tomorrow or a week's time.
And so how do we deliver valueproposition that is in that
(16:39):
selling point?
It's no good selling me, oh,there's less chance I'll have a
heart attack in 10 years time ifI can't imagine that I'm going
to make it to the end of nextweek.
But I don't think we've beengood enough today to refining
how do we allow people to make achoice.
And that isn't about talkingthem into it.
It's just saying the benefitsthat I think might be helpful to
(17:02):
you at ABC, they're stillentitled to go, I don't fancy
that doctor.
But at least I'm worried that alot of opt out at the minute is
probably because we haven'texplained it in a way that shows
the value to people.
SPEAKER_00 (17:17):
So Jonathan, you've worked with many patients,
thousands of patients I wouldimagine over the years.
Have you seen socialdeterminants of health
inequality impact the choicesthat patients make?
SPEAKER_01 (17:28):
Yes.
And again, often perhaps Ididn't realise at that moment
that was what was driving thechoices people were making.
I'm probably smart after theevent.
But I think if we just look atsmoking cessation, if you speak
to most people who smokecigarettes, They realize it's
bad for their health in thelonger term, but don't stop.
(17:50):
And I think that there's a sortof assumption that they don't
stop and can't be bothered,weak-willed.
There's a million reasons thatit's on them.
And for a number of people,maybe that's true.
But for a large number of otherpeople, as we said, it's because
it's important, but it's not apriority for today.
And we've got that inorthopedics.
(18:10):
Smoking is well known to delayfracture healing.
Particularly if you break yourshin bone, which is slow to heal
anyway.
The rate of that bone nothealing is much higher in
smokers.
If it doesn't heal, it leads tolong-term problems.
You can be off work for 12, 18,24 months.
You know, real life impactingchanges.
(18:31):
And yet, people would, even oncethey were getting problems,
couldn't get off the cigarettes.
And of course, there's addictionin there as well, but...
I think it's that part of, let'ssay, your health happens within
your life.
It isn't the sole focus of yourlife.
We see it with risk-takingbehaviours, where I say
(18:53):
non-adherence to treatment,where we know that adherence to
taking medication, say for bloodpressure, varies across
different patient groups.
And I think some of that comesdown to trust and understanding.
I think for many people, there'sa sort of implicit sense that
(19:16):
you can trust the NHS.
So if the doctors are sayingthis, that must be fine.
But actually, for significantnumbers of people in the UK, the
NHS isn't a brand or anorganisation they feel they
trust because of harms orproblems that seem to impact
their community.
So if we look at maternaldeaths, which is at last
(19:39):
becoming far more talked about.
You know, if you're a lady ofnon-white ethnicity in a lot of
towns and cities, your chance ofdeath in childbirth and death of
your child is far greater thanfor a white mum.
And if we say that, then trustand understanding in the NHS
between people and clinicalstaff has to vary across people.
(20:01):
And so I think until we repairsome of those bits, some of
these Some of the socialdeterminants of health
inequality relate tocircumstances of life, but at
least some also relate to theimpacts that the way healthcare
has been delivered over time andproblems that have happened.
And those don't fall equallyacross society either.
SPEAKER_00 (20:22):
So you're taking on a lot of risk as a surgeon.
You have people's lives in yourhands.
Did it feel that the systemisn't set up in a way that is
sharing that risk?
SPEAKER_01 (20:31):
Absolutely, yes.
It felt very much, and I think alot of my clinical colleagues,
you know, anesthetists holdpeople's lives in their hands
even more tangibly than asurgeon.
But I think bringing this backto design, so much of the
systems and practices in the NHSare not designed to help
(20:51):
individuals not make mistakes.
There's a lot of it is like theway it is for bureaucratic
reasons, for a variety ofreasons.
But at their core, they justexpose a risk of human error.
And that isn't designed out.
That isn't the starting point.
So in my practice, it'd have hipand knee replacements and they
(21:11):
all come in lots of differentsizes and different.
There's no universal guidance onthe labeling of the boxes in the
sense that they should all be,regardless of manufacturer, have
some sort of thing.
So you get a steady stream ofone bit of an implant being used
or two bits ending up opened andone wasted.
And all of this just relies onOh, two humans are meant to
(21:33):
check it before you put it in.
But this could be engineeredout.
It's like those tragic caseswhere we know people have been
injected with the wrongsubstance, sometimes fatally.
And because the bottles are thesame except for a tiny yellow
box or something very small.
So with your work, Sam, I thinkthere's so much to do in the NHS
about designing out chances forerror.
(21:57):
And I don't think that is apriority.
SPEAKER_00 (21:59):
Why do you think that is?
SPEAKER_01 (22:00):
I think unfortunately, because in the
NHS, whilst patient safety isimportant and patient experience
is important, the bottom line,when you try to sell something
or try and do something toprocure and it really comes down
to return on investment, is itgoing to be cash releasing
within the next 12 months?
It's very hard to even make abusiness case work that releases
(22:23):
opportunity cost.
So even if it's The doctor willonly have to spend five minutes
doing this, not 10, so they cansee an extra patient.
While someone around the roomwould go, oh, that would be
good.
That sort of level of benefitprobably doesn't cut through
enough.
It really needs to be, we needless staff or we've got these
(22:44):
vacancies we can't fill and thiswill replace those vacancies.
So I think, like I said, I don'tbelieve this is some, I don't
think it's the people around thedecision table at Absolutely
not.
It's just the metrics areskewed.
Like, you know, the books haveto balance within 12 months and
anyone from outside the NHSwould say, if you're trying to
(23:04):
transform something, you oftenare less efficient before you
become more efficient.
And the financial return may bein two, three years time.
And you'll be so much further onby that point.
But often the financialmodelling in the NHS doesn't
allow that sort of time horizon.
SPEAKER_00 (23:24):
I'd like to move on now to talk a bit about your
work around cancer pathways.
So cancer treatment pathways arecomplex and can run for multiple
years.
Not every pathway is the sameand it can vary depending on
condition, location, personalhealth and of course how well
(23:45):
someone engages with thediagnosis and treatment.
You told me about a piece ofwork you'd been doing that was
looking at ways pathways can beimproved and how they can be
improved.
I wondered if you could tell mea bit more about this and what
was the trigger for that work?
What did you do and what werethe results?
SPEAKER_01 (24:00):
The service I was part of, as I received referrals
from across the country, and I'dreally had the same processes in
place for many years.
And it worked for the consultantteam who were there.
But as I joined, there wereseveral people retired and there
was a lot of turnover within thedepartment.
So should we say, thoseunwritten rules everyone knew
(24:22):
went out the door with thosepeople.
So we were suddenly seeingproblems in terms of the time it
was taking to diagnose people, ageneral feeling of slight chaos,
of an awful lot of human effortbeing needed just to keep the
ship afloat, and at the sametime probably not delivering a
brilliant patient experience.
(24:43):
So what we did was, working as ateam, is really strip it all
back.
So I mapped the entire pathwayfrom the moment a referral lands
at that point on a fax machineto say, we see this patient.
We walk the department.
What was happening?
Where were the handoffs?
What was the value being addedat that point?
(25:04):
And from memory, there's about30 handoffs, but there was only
11 adding value.
And so what we sought to do wasredesign the system to strip
that out.
We refined and reviewed some ofthe roles and fundamentally
tried to have a blank piece ofpaper.
And I mentioned at this point,the non-clinical manager I was
(25:28):
working with at that time, shewas incredibly supportive doing
this and really did allow us tonot allow ourselves in our
thinking to be constrained bywhat might be possible.
It was like, what do we want itto be like?
And then let's see if we can dothat.
So we scoped out a variety ofthings.
And I remember a fateful momentwhere one of my consult
colleagues, he said, we were alltrauma surgeons.
(25:50):
And every morning in thehospital, there's a trauma
meeting where we talk aboutpeople with a broken wrist and a
broken ankle who were admittedto hospital the day before.
For people with broken bones, wemeet every morning and talk
about it.
But we don't do that for peoplewith cancer.
And it was a light bulb moment.
He said, yeah, so the solutionis we should meet every morning.
(26:12):
Now, if you'd said that to anyof us before, we'd go, no
chance, never happened.
But we went with that premiseand it soon stacked up because
we were receiving, I think,about 3,000 referrals a year.
So actually, there was about 20cases a day to discuss.
So we designed a system based ona whole different, rather than
(26:33):
that batching that happens inthe NHS, we tried to have almost
a constant flow.
In the end, I think we did agood piece of work.
We took about six days out ofthe time taken for a patient to
be diagnosed with cancer.
We allowed a third of patientsto be telephoned, have the mind
put at ease, and never needed tocome to our hospital for
(26:55):
anything.
And the majority of patients,towards 80%, were phoned within
three days of their referral andus discussing it to be given
their management plan.
So, To be told it's not cancer,but we still need to see you or
we're worried about this.
So we're going to see you nextweek.
And at that clinic appointment,we'll do this and this.
(27:18):
And bearing in mind, we weredealing not only with adults,
but also children with cancer.
You know, I'll never forget,there was one patient all the
way over in Lincolnshire.
So three hours or so.
And they were told on the Mondayby their local hospital, we
think your child's got cancer.
And by Wednesday, we were ableto phone them and say, no, they
haven't.
And you don't need to come fromLincoln.
(27:40):
And that to me is a responsiveservice delivery value.
And I think what's interestingas well there is I had a
moderate do not attend rate atclinic.
And that was put down to thelarge geography and people don't
want to come.
But actually, I challenged that.
So it means the value of comingis not enough.
So actually, by redesigningclinics so that you've got more
(28:04):
things done for your visit, soyou would come have a scan.
In clinic, you'd be told theresult and you'd go and have a
preoperative assessmentappointment.
You'd meet your specialistnurse.
That did not attend, rate fell.
It didn't go to zero, but itchanged.
And so again, it challenges thatsort of, there's that belief
that everyone must just wanthealth.
It's actually, you need to go abit further than that and give
(28:27):
them something that allows themin their life to feel that this
is a priority for today,tomorrow, this week.
SPEAKER_00 (28:34):
And how did the work involve listening to patients
and how did the insight frompatients feed into the
recommendations and the changesthat you were making?
SPEAKER_01 (28:42):
Being really honest, it didn't feed in enough.
I think some of that, infairness, was because we were
struggling so much that we hadto move quickly.
And I think some of the changeswere obvious.
We obviously reviewed all thecomplaints and they were part of
a driver.
So we'd looked at some adverseevents and some of the things
(29:05):
around decisions we'd made.
You know, we noticed in some ofour meetings we weren't
consistent.
So one week for a patient in aparticular set of circumstances,
we'd make one clinical decisionand another week it would be a
different set.
And that was workload.
Sometimes in our weeklymultidisciplinary team meeting,
we'd be having 140, 160 peopleto discuss in three hours.
(29:27):
It's not possible.
So we fed in patient narratives.
But I would love to sit here,Sam, and say, oh, yeah, we had a
patient group who worked withus.
We didn't in that official sortof sense.
We tested it out.
There's a couple of thespecialist nurses who obviously
(29:47):
were very patient-facing.
We test ideas with them.
They might have informalconversations with people.
So, yes, it wasn't aco-designed, co-produced with...
patients, what I would say is Ido think it was co-produced and
co-designed with every member ofthe department, from the admin
(30:10):
clerks and secretaries, thesurgeons, the pathologists, the
radiologists.
So it was perhaps at a differentlevel.
SPEAKER_00 (30:18):
And lots of insight that those people would have
about the patients becauseyou're interacting with those
patients all the time.
SPEAKER_01 (30:22):
Yes.
And I think what was interestingwith all these things is, of
course, at the start, it wasvery challenging.
But you often recognize thatthere's a couple of key people.
And I remember one radiologistwho I think needed a bit of
convincing.
They knew things needed tochange, but they perhaps weren't
(30:43):
convinced that my proposals wereright.
But after a while, he started tomeet me halfway and in the end
became the biggest driver andadvocate for the change
possible.
Absolutely.
It wouldn't have succeededwithout them.
So it's a very interestingchange over time that it sort of
(31:03):
opened.
Once you get that sense, I thinkthat, okay, John genuinely wants
to work with us to change thisrather than do something to us.
Then the door opened and theradiology department were
absolutely brilliant andcouldn't have done more to help.
So I think it's that thing,isn't it?
We often think a bit aboutadoption of technology or
(31:26):
willingness to change.
but there's something even inthe people who are putting their
shoulder to the wheel to helpyou to change.
SPEAKER_00 (31:32):
I find it interesting that every FTSE
company, every big commercialorganisation, they will have
teams of people who areconstantly engaging with the
public and with their customersto measure the customer
experience, to work out whatneeds to change, to work out how
they can improve things, becausethere's a financial reward to
doing that, and that's why thecompany exists.
Yet here, the purpose of thecancer pathway is surely
(31:55):
phenomenally higher thanfinancial reward.
reward and yet it's really hardto actually do that measurement
and that kind of continualimprovement.
SPEAKER_01 (32:03):
Yes, I agree Sam.
I think it's also that metricsare collected but they aren't
telling people what they thinkthey're telling them.
So there's the National CancerPatient Experience Survey and
that's run on behalf of NHSEngland and hospitals will look
at those results and that willdescribe things like patients
indicated where they feltsupported, had enough
(32:23):
information.
But people don't go back andlook at who's participated in
that survey.
And non-white ethnicity isunderrepresented.
People under the age of 50,underrepresented.
People from, you know, you cango across it all the way.
And so it's telling you theexperiences of a group of people
that is entirely valid for thatgroup.
(32:46):
But you can't use that to designservices that deal with people
outside of that respondentgroup.
SPEAKER_00 (32:53):
There's often this kind of perception that we do a
survey, so we're gettingfeedback from people.
Yes.
But the difference between doinga big piece of quant versus
sitting down and talking toindividuals about their
experience of a particularpathway, understanding the way
one particular interactionworked or the way that one
particular part of the journeywas designed is chalk and
cheese.
They're completely differentends of the spectrum.
(33:13):
They both have their value.
They're both important to dothose things.
But I think...
Often it can be seen that you'vedone the quant, so actually the
qual side of things is not sonecessary.
SPEAKER_01 (33:24):
I think you're absolutely right.
I think this interview feelslike me just admitting to being
rubbish in the past.
But again, I think over timeI've had an increasing sense of
the value of qualitative work.
It's not that I didn't before,but I think medicine drives you
to be analytical in aquantitative way.
(33:46):
And I think over time I'vebecome better and better at
fusing them.
I would equally challenge that Ihave seen some pieces of work
that seem to be entirely drivenby qualitative.
And it's, you know, you have tounderstand where the groups
you've spoken to sit in thewider group.
It's not to dismiss it, but ifwe've spoken to six people about
a condition that affects fivemillion people, we do need to
(34:07):
reflect if we think that thosesix are representative.
And yes, I've seen it.
So I've seen errors on bothsides.
I would say we need both.
And they both have near equalweighting, bit of nuance
depending on what we're tryingto do.
And I think what thosequalitative insights, as you
say, it's a real low level.
They, I think, help you do, youknow, if we design for people
(34:32):
who need some adjustments, oftenwe're designing better for
everyone.
And so if that's members of thetrans community who find that
the atmosphere for screeningtests is different, not
welcoming or not supportive, orif we can lean into that, that
makes it better for them, itwill be better for everyone.
(34:54):
If we've got people inneurodiversity who find the
clinic letter difficult tounderstand, guess what?
People without neurodiversityfind them difficult to
understand.
But I think, as you say, in asurvey, that won't surface.
Whereas some targetedconversations, targeted
qualitative work, I think oftensurfaces things that are hidden
in the larger numbers.
SPEAKER_00 (35:15):
Where would you say are now the biggest
opportunities to improve thepathway?
SPEAKER_01 (35:21):
I think most of the opportunities are much more
simple than people would like toadmit.
I think, unfortunately,everyone's going so fast that
there's barely any capacity toreview processes, overhaul
processes, back to my pointsaround cognitive bandwidth.
So I'm just trying to getthrough clinic today to do the
(35:42):
operating list tomorrow We'retrying to get to the end of our
massive MDT meeting on theprojects I'm involved in at the
moment.
We're engaging with clinicalteams and I believe they all
realise the project will bebetter in the long term, will
reduce a bit of work in the longterm.
But that benefit might be sixmonths away and they've got a
load of work to do today.
(36:03):
And so I think we are fightingthis transformational gap
because you've got to keepdelivering BIU as you transform
and that's incredibly hard mostI think non-clinical
organisations you almost mighthave a transformation team or
you have something that's doingsome of the lifting whereas it's
(36:24):
much harder I think with sort ofclinical work I mean I was taken
by one of your previous guestson the podcast Rochelle Gold and
she mentioned about being askedto see in clinic they wanted a
button a print button I think itwas on one of the screens and I
just think that's It is theperfect NHS example where I've
(36:45):
got this problem.
I need this problem solving.
I haven't got the time, space,capacity to go right back to the
root cause of that problem.
You know, a bit like the cancerpathway.
What actually is the aim of whatwe're trying to do here?
What value do we want todeliver?
Design a pathway that deliversthat.
We're often faced with justtrying to tweak what we're
(37:07):
doing.
to solve the biggest problem.
So I think for me, the biggestopportunities are if we can bury
capacity for people to do thatsort of root and branch review
of why is it like this?
What could it be like?
How do we do it?
So the changes I described, theydid cost money, but actually
they didn't involve a bigdigital infrastructure project.
(37:28):
They didn't involve lots ofthings that we didn't have a new
app.
We didn't have anything likethat.
It was perhaps rearranging thedeck chairs on the Titanic, but
we did at least manage to changethe speed of the Titanic heading
towards the iceberg that wouldbuy time to then digitize or
then bring in different sort ofsolutions.
SPEAKER_00 (37:49):
I find it quite frustrating sometimes the way
that transformation has becomesynonymous with technology.
Everything is a technologyproblem.
You can be solved withtechnology and, you know, right
up to the top.
That's kind of one of thepolicies of the new government.
And I'm absolutely an advocatefor technology in the right
place and the impact that it canhave.
But it feels that often that thechanges are, as you say,
simpler.
(38:09):
We did work on the autismdiagnosis pathway.
And one of the things that cameout of that was actually it
would be really good if peoplewere just given a leaflet when
they started the process so theycould understand what was going
to happen.
That's not rocket science andthat's not minimal investment to
actually make that happen.
But it feels like there's thistechnology kind of hammer that's
trying to solve everything.
SPEAKER_01 (38:27):
Yes, and I often, I think, jump from one side of the
fence to the other to try andsupport the team that's losing.
So if I'm in a meeting whereeveryone's saying, that's miles
too hard, technology can't solvethat, I find myself being a
slight tech advocate going, Idon't think it's as hard as you
think the technology to do that.
And then the flip side, as yousay, when everyone's trying to
say it needs technology, going,well, actually, as you say, if
(38:49):
we changed the form with aconditional question here or did
that there, that would bebetter.
If we just look at the letterswe send to patients, my wife's
had a couple of letters lately.
Between the two of us, we'vestruggled to understand them,
and I'm a doctor and she's ateacher.
So that tells you fundamentallythere's something wrong.
And what will have those peopledone?
(39:10):
Either not gone to theirappointment, phoned up
healthcare services to get theappointments explained.
All of these things are time andresources, and yet it's for want
of a better letter.
So as I say, I'd love to sithere and say, oh, these
opportunities right now, Sam,are some AI-driven this, that,
and the other, they will make adifference in time.
But right now, we could do anawful lot of things with just
(39:33):
redesigning our processes andour pathways.
SPEAKER_00 (39:36):
On the other side of things, how can technology help
the cancer pathway?
SPEAKER_01 (39:39):
I think I'm absolutely convinced it can.
I think the problem we have atthe minute is we have technology
getting in the way currently,and I think that's almost one of
the blocks to it.
So within cancer care, forexample, there's software that
collects data about thepatient's cancer diagnoses,
etc., called cancer registrysoftware.
And it's a brilliant example ofterrible design.
(40:02):
It was designed to solve aproblem, which was getting data
to NHS England.
It was designed to solve theproblem for the people who were
tasked with doing that, sothat's cancer managers in
hospitals.
But it had no input, certainlyno input from anyone who was
sensible, in hospitals.
what clinicians who wouldinterface with this would feel
(40:24):
was appropriate, could use.
And so you have this clunkysoftware that's extremely hard
to work, doesn't really, itdelivers what NHSE wants, but
data quality is a continualproblem because the software is
not intuitive.
You struggle to use it in realtime.
And it's that example really,isn't it?
The word users gets used, but inthe NHS, that's more vague.
(40:49):
There might be a nurse using itwith a patient, might be a
doctor using it on a patient.
The beneficiary might be apatient.
It might be the system or thehospital.
The payer might be the GPpractices.
It might be the hospitals.
So all these personas are split.
And very rarely in my experiencehave products and companies
really considered that properly.
(41:11):
What's the cost benefit, valueproposition, whatever it may be
across all the persona groups?
They just find one and hit it.
So I think one of the issuesregarding cancer care is that
some of the software that'spresently used is not great and
is a block to other changes.
But where do I see maybe it'sstarting to help more?
(41:32):
There's undoubtedly big shiftsin the world of radiology around
using AI-driven technologies tohelp with reporting, for
example, mammograms or chestX-rays.
That is not ready to beunleashed yet.
uncontrolled at the moment butwe've reached the point where
there are some very large trialsgoing now in multiple hospitals
(41:53):
so shall we say it's certainlygood enough at the moment that
it's not obviously terrible butwe've obviously got to just now
really refine is it absolutelysafe under what circumstances is
it appropriate or not similarlywith software to help
oncologists plan theirradiotherapy the software to
(42:14):
help with that, what's calledcontouring.
And that will save someoncologists, you know, could be
one to three hours a week atleast.
And that's time that can berepurposed.
So I think there was definitelythings coming.
But I suppose when I tell youthat fundamentally, if we were
in a cancer service today, wewould struggle to even map our
(42:37):
demand and capacity in the nextsix to eight weeks accurately.
Some of these verypatient-facing technologies are
great, but there's a lot ofback-office improvement that the
size of the prize isn'tobviously perceived to be big
enough for people to really wantto take on.
SPEAKER_00 (42:55):
Have you seen patient-facing technology that's
improving outcomes?
SPEAKER_01 (42:59):
For some people, potentially, yes.
I'm slightly guarded.
Particularly in cancer care,there's an awful lot of apps,
some of these perhaps to try andhelp people manage specific
symptoms.
After cancer treatment, fatiguecan be a real issue or sleep.
And so there's apps to targetthose things.
And the results would suggestthat a meaningful number of
(43:21):
patients get benefit from this.
There's lots of apps out therethat support people through
their cancer pathway.
Or it's a place for you to storeclinic notes, record your
symptoms and some of thesethings.
I think for some patients withsome clinical teams, they
probably generate a benefit.
But I would say that not allpatients can engage with those
(43:46):
technologies at scale, sothey're not helping everyone
equally.
And I'd also say that not allclinical teams are resourced to
do that.
There's a bit of a misconceptionthat, oh, you know, we've got
all these patients who canreport their symptoms in real
time.
Okay, but who's available tolook and deal with that?
And There's not a bank of nursesor doctors sat waiting for these
(44:11):
reports to come in.
And so until you can reallyleverage AI to triage all that
data to get the outcomes, whilstit relies on humans, you're
going to be very limited in whatcan be done.
So, for example, there are somesupport applications and they've
been adopted by smaller servicesor services perhaps in the
(44:32):
private sector where there's abetter ratio of nurses to
patients.
But I think, should we say, it'sa big, busy hospital.
I'd say most of the technologyat that point is really more
about perhaps, should we callthem patient portals or those
sorts of things where people canat least look at their results,
look at their clinic letters,that sort of level of
(44:52):
technology, but are notconvinced there's a really wow
technology out there that'sshifted the dial for patients.
There's interesting things likeVR to try and improve for people
who are having head and neckradiotherapy, for example, but
they're not in use at scale andare not sure.
(45:14):
I think that someone at onehospital might get it and
someone else doesn't elsewhere.
So as I sit here today, Sam, Idon't think we've really made a
big dent in that yet.
SPEAKER_00 (45:24):
Do you have thoughts about ways that we can achieve
the right balance between kindof digital support and human
support?
SPEAKER_01 (45:32):
Yeah, I think for me, technology...
We're up to tipping point.
So technology till now andthrough my clinical career
really was between me and thepatient.
It got in the way.
This sort of thing called thekeyboard, the screen slid into
the clinic room.
And early on, it was just for acouple of things.
(45:52):
And gradually it was all onthat, ordering everything on it.
And so we'll have all been in aconsultation where the doctor
seems to look at the screen andbe typing, not listening.
And that undoubtedly changes thedynamic of those conversations.
I think it makes it a bit moretick boxy.
So technology has been betweenus.
(46:14):
I think as we move forward, Iwould like to think that
technology can actually get helpfrom being between us and be
around us.
I think that we can use ithopefully to release us to be
more human.
We think probably overhypedexample would be ambient AI
technology.
But in time, I sincerely hopethat delivers because if we
(46:37):
could be having a consultation,Sam, and I haven't got to
request anything on the computerwhilst we're talking or dictate
a letter at the end because theambient AI is hoovering up our
conversation, synthesising it.
I said, we can just check yourbloods today, Sam.
We'll do this and this.
It's already filled the form in.
(46:58):
When we reach that point, thattransforms healthcare.
Because I'm released to be humanand to get back to doing what I
did, which was making eyecontact, which was using my body
language to reassure or help.
Whereas lots of subtleties likebody language are now lost
because as much as we don't wantto look over a desk, because
(47:21):
that's terrible for building arapport, how do I use the
computer and look at your x-raywhilst I'm talking to you?
So I am hopeful that technologywill undo the harms of
technology.
in the coming years, but youwon't get me committing to a
timeline for that.
SPEAKER_00 (47:38):
From a technology perspective, what you've
described is more or lesspossible from what's out there
now.
But from a kind of a system andan implementation and a policy
and all that other stuff, itfeels a long way, a long way to
go.
SPEAKER_01 (47:51):
I think so.
I think some of the technology,my understanding as a non-expert
is some of the ambient AI canwork really well in a
one-to-one, maybe a one-to-two.
but starts to struggle with morepeople.
And particularly in cancer care,you could have three, four, five
people in the room.
And at that point, so I'm notsure, but I think it's sort of
(48:14):
nearly there in some use cases,but not in others.
So it might be good for GPpractices before it is maybe
some hospital practices.
But I agree completely with youthat when I say this to clinical
staff, they look at me like I'mfrom Mars.
But I recognise that becauseuntil I left the NHS four years
(48:35):
or so ago, if you'd said AI tome, I'd have said, I can't even
log on to the system today.
And I also have to remember fivepasswords for the different
systems just to run clinic.
So that is the reality and thedestination do feel a long way
apart for people who are workingin the NHS.
UNKNOWN (48:55):
Music
SPEAKER_00 (48:58):
You've been listening to part one of this
podcast with Dr JonathanGregory.
Stay tuned for part two where wewill explore Jonathan's work
with Macmillan using AI toimprove patient communication
and we'll also dig into hisgroundbreaking work to
understand experiences of cancersurvivors in the community and
discuss Jonathan's vision forthe future.
UNKNOWN (49:18):
Music
SPEAKER_00 (49:27):
Problems Worth Solving is brought to you by
Healthier, the collaborativeservice design consultancy for
transformation in health careand public services.
Find out more about how we canhelp you deliver user-centered
change at healthier.services.
Hello, this is Problems Worth Solving, the
podcast where we meet peopletransforming health and care
through human-centred design anddigital innovation.
I'm Sam Mentor, ManagingDirector at Healthier, the
(00:21):
collaborative service designconsultancy.
If you enjoy listening, you cansubscribe to this podcast and
the accompanying newsletter athealthier.services.
So today I'm joined by DrJonathan Gregory.
Jonathan is a cancer surgeon bybackground who worked in the NHS
for over 20 years and heldseveral management positions.
(00:44):
He now works to improve patientcare and outcomes using data,
digital and AI via hisconsultancy Pivotal Health.
He's National Clinical Advisorat Macmillan.
He's digital theme lead at anational institute for health
and care research and he's anhonorary research fellow at
Imperial College London.
We've split this episode intotwo parts because we had lots to
(01:06):
talk about.
You're listening to part onewhere we explore Jonathan's
background, what it's likeworking as a surgeon and
practical experiences of healthinequalities.
We'll also dig into Jonathan'swork to improve cancer pathways
and the critical importance ofgetting the right balance
between digital and humansupport.
In part two, we exploreJonathan's work with Macmillan
(01:27):
and using AI to improve patientcommunication.
We'll also dig into hisgroundbreaking work to
understand the experiences ofcancer survivors in the
community and discuss his visionfor the future.
Jonathan, I'm excited to haveyou here.
Thank you so much for joiningProblems Worth Solving.
SPEAKER_01 (01:44):
Thanks, Sam, and thanks for the invitation to
come and speak with you today.
SPEAKER_00 (01:49):
To kick things off, would you like to share a bit
about your background and tellme a bit about what drew you to
medicine and surgery?
SPEAKER_01 (01:56):
I think it's the mixture of human and science,
sort of biology, psychologists,behavioral medicine.
So I think that's why I wasdrawn in that direction.
And the fact that relatively,certainly that point in my life,
I was looking for very tangibleoutcomes from things I did.
And so treating patients is abit more tangible than perhaps
(02:19):
research or other feelings likethat.
I think it's always a bit ofserendipity and happenstance.
So when I went into medicine, Ivery much thought I would work
maybe as an anaesthetist orcardiologist.
So much more in the medical sideof using drugs and medications,
given my degree in pharmacology.
But my practical experience onthe wards was really that Lots
(02:44):
of time went past and not alwaysmuch changed for the patients in
front of you.
The benefits from medicaltherapies often are weeks or
months later.
Whereas on the surgical ward,someone wheels off to theatre
and they come back and there'ssomething different.
There's something being added orremoved.
And I think it was that sort ofimmediacy that drew me.
(03:07):
And then it's serendipity.
I was put on a placement at theRoyal Bolton Hospital and was
put into the orthopedic teamthere and they were just
brilliant they wereinspirational they were great
teachers they involved you and Ithink that was it really I was
sold and yet I think if you'dever said to the me prior to
that trauma and orthopedics Iwouldn't have thought that would
(03:29):
have been the direction I'd havegone so
SPEAKER_00 (03:31):
it's about the immediacy
SPEAKER_01 (03:32):
I think that's it and I think patients and trauma
and orthopedics someone comes inwith a broken bone And they go
home having an operation and thebone, you know, is aligned.
It's less painful.
There's something very clear.
Someone comes in with adislocated shoulder or within 10
minutes, you've removed thatpain from them.
So I think there is animmediacy.
(03:53):
It probably lent into my slightobsession with to-do lists and
ticking stuff off.
It's a little bit like that.
And again, it's a sort ofinterface specialty because
you've obviously got engineeringand biology involved.
and all the other bits.
So some of it, I think, is theintersections that I always find
enjoyable.
SPEAKER_00 (04:13):
It must be immensely rewarding working as a trauma
surgeon.
SPEAKER_01 (04:18):
Yes, it is.
I hesitate because I think alljobs, you acclimatise to it.
And I think as you become aconsultant, you tend,
unfortunately, or certainly Idid, to remember your mistakes
and things that didn't go sowell, perhaps more than the
successes.
Because the successes have goneout into the world and
brilliant, they're getting onliving their lives.
(04:40):
Whereas your clinic is full ofthe people who, oh, that could
have been better.
There's a funny recall bias, Iguess, that's going on there.
So it absolutely is rewarding.
And even to this day, I can lookback on cases and think, we did
something good there together.
But also I can look back and Ican picture exactly the people
that perhaps things didn't workout as well for as I would hope.
SPEAKER_00 (05:03):
What did you like most about working as a surgeon?
SPEAKER_01 (05:07):
I'm really drawn to the beauty of the human body.
So it's really the anatomy andthe fact that when you've seen
the nerves that maybe gives yousensation to the tip of your
index finger or the inside ofthe shoulder joint or where the
tendon of the biceps is, and youcan relate that to how you move,
how, you know, your own life.
(05:30):
I think there's something...
really are all inspiring there.
I'm probably going to sound verystrange now, but it was never
lost on me when you made theincision into the skin, assuming
it was the first time this partof the body had been operated
on, and you're looking at thetissues.
That is the first time they haveever been exposed to light,
conceived and grow in utero inthe dark.
(05:52):
They've been sealed ever since.
So you are the first person, thefirst set of eyes to ever
witness that piece of creation.
And that That sort of, yeah, itwas never really lost on me, I
don't think.
SPEAKER_00 (06:05):
You don't ever get tired of that view.
You get that excitement ofseeing the inside of the body.
SPEAKER_01 (06:10):
I think you do when you're in the correct headspace.
I would say that, unfortunately,as you get more senior, you're
often operating with a cognitiveload of other things going on.
You obviously arrive in theatreto a head that's buzzing with
emails that have come through,problems, what have you, and As
(06:32):
you get experience, like anytechnical skill, there are
obviously still extremelydemanding operations, but quite
a few are a little bit morereliable.
I would never use the wordautomatic, but you can function
at low levels.
But I think that it was neverlost on me when you go and see
the patients first thing in themorning before their operation.
(06:54):
You know, they are trusting you.
They're trusting you, to beblunt, cut them up.
And that's quite a strongcontract to hold, really.
So that part I never took forgranted.
SPEAKER_00 (07:04):
There was an artist about, oh, I forget his name,
about 10 years ago who diddisplays of the human nerve
system.
Do you remember?
I
SPEAKER_01 (07:12):
do, yeah.
The Austrian artist, I think.
SPEAKER_00 (07:15):
Did you go and see that?
SPEAKER_01 (07:17):
I didn't, no.
Were you tempted?
No, probably not, actually.
Whereas I do like the HunterianMuseum at the Royal College of
Surgeons, accepting that there'scertainly...
historically at least parts ofthat museum I think that we
shouldn't celebrate but thereare things there that yeah are
interesting a wow are I thinkthat's one of the reasons I went
(07:40):
into a particular part of SergioI did because when you've
exposed like a whole limb or awhole blood vessel the
intricacies and the twists andthe turns and as I say I think
feels I suppose like acosmologist looking at the stars
it gives you a slight sense ofthere you are worrying about
your day to day Just look atthis.
It's amazing.
SPEAKER_00 (08:00):
What about some of the challenges when you're
working as a surgeon?
I
SPEAKER_01 (08:04):
found it very tiring in the sense of, in the cold
light, in the cold light,everyone, should we say outside
of healthcare, will believe thateveryone's pulling in the same
direction and the same drivers.
And that isn't the case at all,is it?
Humans are humans with their ownmotivations, desires and wills.
And so as a surgeon, you...
trying to motivate colleagues todo operations.
(08:26):
It's getting towards the end ofthe day.
People want to go home, butyou're aware that there's a
patient who's waited all day,starved, and they're going to be
cancelled.
And so I think there's an awfullot of push of needing to drive.
The system, shall we say,doesn't run of its own.
It doesn't have a naturalmomentum.
(08:47):
And so I don't these days missthat at all.
That slight driving into work atseven in the morning, six, seven
in the morning with a sense ofquite a hard 12 hours ahead.
And actually not often would itbe the actual operating that
would be the hard part.
It would be the systemnavigation that would be harder.
SPEAKER_00 (09:06):
When you were working as a surgeon, how much
did health inequalities, factorslike where people live, their
income or their backgroundaffect their outcomes?
SPEAKER_01 (09:16):
I think it, affected them a lot.
But I confess that I'm not sureI always realised how much it
affected them at that time.
I was part of a cancer servicein two hospitals and we covered
large cancer areas.
People would travel many hoursto come to that area.
So we were aware perhaps oftrying to support people with
(09:38):
travel.
If you're trying to get fromDevon to Birmingham, what time
of day have you got to set off?
And so those sorts of almostgeographical things.
And we'd be aware of people,perhaps it's a single parent or
retirees.
But I don't think we, Icertainly didn't have the
cognitive capacity and perhapseven the real grasp of health
(10:01):
inequalities to lean in furtherthan that.
That sort of piece around, I'dprobably, a lot of people think,
I just don't understand why thisperson's not giving up smoking
or why can't we get them toadhere to to this treatment.
And now through experience andlearning, I realize that there's
a multitude of reasons for that.
(10:21):
And also the way the system isbuilt naturally makes it harder
for some people to participatein healthcare than others, not
purely on the basis ofgeography.
So I think I come slightly as areformed character where I never
knowingly didn't deliverequitable health care but now in
(10:42):
hindsight I realized that Ididn't always I think I thought
that by treating everyoneequally I was doing the right
thing someone's sexuality theirethnicity their gender that
didn't matter to me but Irealize now that I really needed
to lean into that more becauseactually it's more that some of
those groups will have greaterbarriers to letting me help them
(11:06):
with their health care workingwith them in their health care
And so I needed to know so Icould take a step forwards
towards them and bring theservice closer to them.
Whereas I probably thought it'snot my business.
I'm not influenced by themnegatively.
SPEAKER_00 (11:21):
So when we were talking earlier, you talked
about how health inequalitieshave become quite a focus in
your work.
Can you tell me a bit more aboutthat and why that is?
SPEAKER_01 (11:29):
Yeah, I think as a lot of things in my life, it's a
bit of serendipity meetinghelpful and interesting people.
As I transitioned out of theNHS.
I remember going to a conferencehosted by the King's Fund on
health inequalities, and thatsort of opened my eyes a bit.
Working for Macmillan'sobviously significantly opened
my eyes to health inequalitiesand the issues around that.
(11:52):
And then, you know, severalbooks I've read or other things
I've watched.
So I would never claim myself tobe an expert, but I think what
worries me is often inconversations, I feel like I'm
the person who seems to knowmost about it.
I think in the UK, we have apolitical system and maybe a
political ideology thatslightly, very much puts weight
(12:15):
on the rights andresponsibilities of the
individual.
You know, that sort of, wemustn't have a nanny state sort
of mentality.
And as I say, I don't, I'm notparticularly interested in
getting into the politicalelements of that, but I think
what that does though is it sortof, it suggests that every
person is able to make thedecisions that are right for
(12:37):
them at that moment in time.
And yet there's increasingevidence in the psychological
literature that people'sdecision-making is compromised
by the life around them.
So it's not suggesting peopledon't have the mental capacity
to make decisions forthemselves, but if you're
hungry, if you're worried aboutpeople around you, if you're in
(12:58):
pain, This all narrows yourability to make decisions and
choices that might be in yourlonger-term benefit.
It's about getting through thenext 24 hours or the next week.
And I just don't feel that inthe UK, and particularly in
healthcare, we take enoughnotice of that.
That sort of, oh, someone canlog in to do this or can go
there to request that.
(13:19):
And that, of course, works wellfor a large number of people.
But some people do, at thatmoment in their life, might need
us to step closer to them.
And I'm not convinced...
We're always that good at doingthat.
SPEAKER_00 (13:31):
What does that mean for patient-centered care?
SPEAKER_01 (13:34):
That's a very interesting question, Sam,
because, yes, my points taken toextreme drive you to a very
paternalistic mindset, and thatisn't, of course, what I'm
intending at all.
I think it's about there's agroup of patients who I think
naturally are well-activated andable to participate in their
(13:57):
care care and their decisionsand so that's about designing
services and delivering care ina way that's an equal
partnership but then there's agroup of people i believe that
because of circumstances we'vementioned not least potentially
fear english as a secondlanguage poor health literacy
(14:17):
where it's much harder and ithink there it's about designing
services that the can meetsomeone so late, enable them to
make decisions that are rightfor them in that moment.
But I think in the sheer volumeof patients being seen this
year, in an orthopedic fractureclinic, you have five minutes
per patient.
It isn't really designed forthose, you know, what I think
(14:42):
some people would try and sayare edge cases, but actually are
far more common than being anedge case.
What does it mean?
I think it just means we need toredouble our efforts.
But I think some of that's It'snot just about the way we talk
to people and, oh, I'm going togive you a choice of operations
or a choice of treatments.
It's how do we deliver thatinformation and when?
Because my cognitive overload inthis clinic today means I might
(15:07):
be hearing but not able toabsorb.
How are we reaching out to youin three days' time or a week's
time to say, have you had anyreflections?
What do you think?
And trying to sort of drip theconversation beyond the clinic,
I think.
SPEAKER_00 (15:21):
And is there a natural progression of that,
that patient choice can't be thesame choices for every patient,
that it needs to be quite apersonalised steer that you're
giving to patients?
SPEAKER_01 (15:30):
I intrinsically want to say yes, I agree, but then
I'm nervous that I think it'smore how we phrase it, how all
of medicine should be aconversation really that is
about explaining someone'scondition in a way that they
understand that is meaningful tothem and can activate them.
(15:52):
and risks and benefitsexplanation of different
approaches.
And really, what's the valueproposition?
What's in it for you to takethis tablet?
And I do think that probably abetter explanation of what I'm
getting at here is there's asort of naive assumption, I
think, that every person mustjust want to be well.
(16:15):
And I don't think that's true inthat sense.
I think, of course, everyonewants to be well.
But my priority today might justbe getting to work and bringing
some income in.
It might be caring for myelderly mother.
So it's not that I don't want tobe well.
It just isn't the priority todayor tomorrow or a week's time.
And so how do we deliver valueproposition that is in that
(16:39):
selling point?
It's no good selling me, oh,there's less chance I'll have a
heart attack in 10 years time ifI can't imagine that I'm going
to make it to the end of nextweek.
But I don't think we've beengood enough today to refining
how do we allow people to make achoice.
And that isn't about talkingthem into it.
It's just saying the benefitsthat I think might be helpful to
(17:02):
you at ABC, they're stillentitled to go, I don't fancy
that doctor.
But at least I'm worried that alot of opt out at the minute is
probably because we haven'texplained it in a way that shows
the value to people.
SPEAKER_00 (17:17):
So Jonathan, you've worked with many patients,
thousands of patients I wouldimagine over the years.
Have you seen socialdeterminants of health
inequality impact the choicesthat patients make?
SPEAKER_01 (17:28):
Yes.
And again, often perhaps Ididn't realise at that moment
that was what was driving thechoices people were making.
I'm probably smart after theevent.
But I think if we just look atsmoking cessation, if you speak
to most people who smokecigarettes, They realize it's
bad for their health in thelonger term, but don't stop.
(17:50):
And I think that there's a sortof assumption that they don't
stop and can't be bothered,weak-willed.
There's a million reasons thatit's on them.
And for a number of people,maybe that's true.
But for a large number of otherpeople, as we said, it's because
it's important, but it's not apriority for today.
And we've got that inorthopedics.
(18:10):
Smoking is well known to delayfracture healing.
Particularly if you break yourshin bone, which is slow to heal
anyway.
The rate of that bone nothealing is much higher in
smokers.
If it doesn't heal, it leads tolong-term problems.
You can be off work for 12, 18,24 months.
You know, real life impactingchanges.
(18:31):
And yet, people would, even oncethey were getting problems,
couldn't get off the cigarettes.
And of course, there's addictionin there as well, but...
I think it's that part of, let'ssay, your health happens within
your life.
It isn't the sole focus of yourlife.
We see it with risk-takingbehaviours, where I say
(18:53):
non-adherence to treatment,where we know that adherence to
taking medication, say for bloodpressure, varies across
different patient groups.
And I think some of that comesdown to trust and understanding.
I think for many people, there'sa sort of implicit sense that
(19:16):
you can trust the NHS.
So if the doctors are sayingthis, that must be fine.
But actually, for significantnumbers of people in the UK, the
NHS isn't a brand or anorganisation they feel they
trust because of harms orproblems that seem to impact
their community.
So if we look at maternaldeaths, which is at last
(19:39):
becoming far more talked about.
You know, if you're a lady ofnon-white ethnicity in a lot of
towns and cities, your chance ofdeath in childbirth and death of
your child is far greater thanfor a white mum.
And if we say that, then trustand understanding in the NHS
between people and clinicalstaff has to vary across people.
(20:01):
And so I think until we repairsome of those bits, some of
these Some of the socialdeterminants of health
inequality relate tocircumstances of life, but at
least some also relate to theimpacts that the way healthcare
has been delivered over time andproblems that have happened.
And those don't fall equallyacross society either.
SPEAKER_00 (20:22):
So you're taking on a lot of risk as a surgeon.
You have people's lives in yourhands.
Did it feel that the systemisn't set up in a way that is
sharing that risk?
SPEAKER_01 (20:31):
Absolutely, yes.
It felt very much, and I think alot of my clinical colleagues,
you know, anesthetists holdpeople's lives in their hands
even more tangibly than asurgeon.
But I think bringing this backto design, so much of the
systems and practices in the NHSare not designed to help
(20:51):
individuals not make mistakes.
There's a lot of it is like theway it is for bureaucratic
reasons, for a variety ofreasons.
But at their core, they justexpose a risk of human error.
And that isn't designed out.
That isn't the starting point.
So in my practice, it'd have hipand knee replacements and they
(21:11):
all come in lots of differentsizes and different.
There's no universal guidance onthe labeling of the boxes in the
sense that they should all be,regardless of manufacturer, have
some sort of thing.
So you get a steady stream ofone bit of an implant being used
or two bits ending up opened andone wasted.
And all of this just relies onOh, two humans are meant to
(21:33):
check it before you put it in.
But this could be engineeredout.
It's like those tragic caseswhere we know people have been
injected with the wrongsubstance, sometimes fatally.
And because the bottles are thesame except for a tiny yellow
box or something very small.
So with your work, Sam, I thinkthere's so much to do in the NHS
about designing out chances forerror.
(21:57):
And I don't think that is apriority.
SPEAKER_00 (21:59):
Why do you think that is?
SPEAKER_01 (22:00):
I think unfortunately, because in the
NHS, whilst patient safety isimportant and patient experience
is important, the bottom line,when you try to sell something
or try and do something toprocure and it really comes down
to return on investment, is itgoing to be cash releasing
within the next 12 months?
It's very hard to even make abusiness case work that releases
(22:23):
opportunity cost.
So even if it's The doctor willonly have to spend five minutes
doing this, not 10, so they cansee an extra patient.
While someone around the roomwould go, oh, that would be
good.
That sort of level of benefitprobably doesn't cut through
enough.
It really needs to be, we needless staff or we've got these
(22:44):
vacancies we can't fill and thiswill replace those vacancies.
So I think, like I said, I don'tbelieve this is some, I don't
think it's the people around thedecision table at Absolutely
not.
It's just the metrics areskewed.
Like, you know, the books haveto balance within 12 months and
anyone from outside the NHSwould say, if you're trying to
(23:04):
transform something, you oftenare less efficient before you
become more efficient.
And the financial return may bein two, three years time.
And you'll be so much further onby that point.
But often the financialmodelling in the NHS doesn't
allow that sort of time horizon.
SPEAKER_00 (23:24):
I'd like to move on now to talk a bit about your
work around cancer pathways.
So cancer treatment pathways arecomplex and can run for multiple
years.
Not every pathway is the sameand it can vary depending on
condition, location, personalhealth and of course how well
(23:45):
someone engages with thediagnosis and treatment.
You told me about a piece ofwork you'd been doing that was
looking at ways pathways can beimproved and how they can be
improved.
I wondered if you could tell mea bit more about this and what
was the trigger for that work?
What did you do and what werethe results?
SPEAKER_01 (24:00):
The service I was part of, as I received referrals
from across the country, and I'dreally had the same processes in
place for many years.
And it worked for the consultantteam who were there.
But as I joined, there wereseveral people retired and there
was a lot of turnover within thedepartment.
So should we say, thoseunwritten rules everyone knew
(24:22):
went out the door with thosepeople.
So we were suddenly seeingproblems in terms of the time it
was taking to diagnose people, ageneral feeling of slight chaos,
of an awful lot of human effortbeing needed just to keep the
ship afloat, and at the sametime probably not delivering a
brilliant patient experience.
(24:43):
So what we did was, working as ateam, is really strip it all
back.
So I mapped the entire pathwayfrom the moment a referral lands
at that point on a fax machineto say, we see this patient.
We walk the department.
What was happening?
Where were the handoffs?
What was the value being addedat that point?
(25:04):
And from memory, there's about30 handoffs, but there was only
11 adding value.
And so what we sought to do wasredesign the system to strip
that out.
We refined and reviewed some ofthe roles and fundamentally
tried to have a blank piece ofpaper.
And I mentioned at this point,the non-clinical manager I was
(25:28):
working with at that time, shewas incredibly supportive doing
this and really did allow us tonot allow ourselves in our
thinking to be constrained bywhat might be possible.
It was like, what do we want itto be like?
And then let's see if we can dothat.
So we scoped out a variety ofthings.
And I remember a fateful momentwhere one of my consult
colleagues, he said, we were alltrauma surgeons.
(25:50):
And every morning in thehospital, there's a trauma
meeting where we talk aboutpeople with a broken wrist and a
broken ankle who were admittedto hospital the day before.
For people with broken bones, wemeet every morning and talk
about it.
But we don't do that for peoplewith cancer.
And it was a light bulb moment.
He said, yeah, so the solutionis we should meet every morning.
(26:12):
Now, if you'd said that to anyof us before, we'd go, no
chance, never happened.
But we went with that premiseand it soon stacked up because
we were receiving, I think,about 3,000 referrals a year.
So actually, there was about 20cases a day to discuss.
So we designed a system based ona whole different, rather than
(26:33):
that batching that happens inthe NHS, we tried to have almost
a constant flow.
In the end, I think we did agood piece of work.
We took about six days out ofthe time taken for a patient to
be diagnosed with cancer.
We allowed a third of patientsto be telephoned, have the mind
put at ease, and never needed tocome to our hospital for
(26:55):
anything.
And the majority of patients,towards 80%, were phoned within
three days of their referral andus discussing it to be given
their management plan.
So, To be told it's not cancer,but we still need to see you or
we're worried about this.
So we're going to see you nextweek.
And at that clinic appointment,we'll do this and this.
(27:18):
And bearing in mind, we weredealing not only with adults,
but also children with cancer.
You know, I'll never forget,there was one patient all the
way over in Lincolnshire.
So three hours or so.
And they were told on the Mondayby their local hospital, we
think your child's got cancer.
And by Wednesday, we were ableto phone them and say, no, they
haven't.
And you don't need to come fromLincoln.
(27:40):
And that to me is a responsiveservice delivery value.
And I think what's interestingas well there is I had a
moderate do not attend rate atclinic.
And that was put down to thelarge geography and people don't
want to come.
But actually, I challenged that.
So it means the value of comingis not enough.
So actually, by redesigningclinics so that you've got more
(28:04):
things done for your visit, soyou would come have a scan.
In clinic, you'd be told theresult and you'd go and have a
preoperative assessmentappointment.
You'd meet your specialistnurse.
That did not attend, rate fell.
It didn't go to zero, but itchanged.
And so again, it challenges thatsort of, there's that belief
that everyone must just wanthealth.
It's actually, you need to go abit further than that and give
(28:27):
them something that allows themin their life to feel that this
is a priority for today,tomorrow, this week.
SPEAKER_00 (28:34):
And how did the work involve listening to patients
and how did the insight frompatients feed into the
recommendations and the changesthat you were making?
SPEAKER_01 (28:42):
Being really honest, it didn't feed in enough.
I think some of that, infairness, was because we were
struggling so much that we hadto move quickly.
And I think some of the changeswere obvious.
We obviously reviewed all thecomplaints and they were part of
a driver.
So we'd looked at some adverseevents and some of the things
(29:05):
around decisions we'd made.
You know, we noticed in some ofour meetings we weren't
consistent.
So one week for a patient in aparticular set of circumstances,
we'd make one clinical decisionand another week it would be a
different set.
And that was workload.
Sometimes in our weeklymultidisciplinary team meeting,
we'd be having 140, 160 peopleto discuss in three hours.
(29:27):
It's not possible.
So we fed in patient narratives.
But I would love to sit here,Sam, and say, oh, yeah, we had a
patient group who worked withus.
We didn't in that official sortof sense.
We tested it out.
There's a couple of thespecialist nurses who obviously
(29:47):
were very patient-facing.
We test ideas with them.
They might have informalconversations with people.
So, yes, it wasn't aco-designed, co-produced with...
patients, what I would say is Ido think it was co-produced and
co-designed with every member ofthe department, from the admin
(30:10):
clerks and secretaries, thesurgeons, the pathologists, the
radiologists.
So it was perhaps at a differentlevel.
SPEAKER_00 (30:18):
And lots of insight that those people would have
about the patients becauseyou're interacting with those
patients all the time.
SPEAKER_01 (30:22):
Yes.
And I think what was interestingwith all these things is, of
course, at the start, it wasvery challenging.
But you often recognize thatthere's a couple of key people.
And I remember one radiologistwho I think needed a bit of
convincing.
They knew things needed tochange, but they perhaps weren't
(30:43):
convinced that my proposals wereright.
But after a while, he started tomeet me halfway and in the end
became the biggest driver andadvocate for the change
possible.
Absolutely.
It wouldn't have succeededwithout them.
So it's a very interestingchange over time that it sort of
(31:03):
opened.
Once you get that sense, I thinkthat, okay, John genuinely wants
to work with us to change thisrather than do something to us.
Then the door opened and theradiology department were
absolutely brilliant andcouldn't have done more to help.
So I think it's that thing,isn't it?
We often think a bit aboutadoption of technology or
(31:26):
willingness to change.
but there's something even inthe people who are putting their
shoulder to the wheel to helpyou to change.
SPEAKER_00 (31:32):
I find it interesting that every FTSE
company, every big commercialorganisation, they will have
teams of people who areconstantly engaging with the
public and with their customersto measure the customer
experience, to work out whatneeds to change, to work out how
they can improve things, becausethere's a financial reward to
doing that, and that's why thecompany exists.
Yet here, the purpose of thecancer pathway is surely
(31:55):
phenomenally higher thanfinancial reward.
reward and yet it's really hardto actually do that measurement
and that kind of continualimprovement.
SPEAKER_01 (32:03):
Yes, I agree Sam.
I think it's also that metricsare collected but they aren't
telling people what they thinkthey're telling them.
So there's the National CancerPatient Experience Survey and
that's run on behalf of NHSEngland and hospitals will look
at those results and that willdescribe things like patients
indicated where they feltsupported, had enough
(32:23):
information.
But people don't go back andlook at who's participated in
that survey.
And non-white ethnicity isunderrepresented.
People under the age of 50,underrepresented.
People from, you know, you cango across it all the way.
And so it's telling you theexperiences of a group of people
that is entirely valid for thatgroup.
(32:46):
But you can't use that to designservices that deal with people
outside of that respondentgroup.
SPEAKER_00 (32:53):
There's often this kind of perception that we do a
survey, so we're gettingfeedback from people.
Yes.
But the difference between doinga big piece of quant versus
sitting down and talking toindividuals about their
experience of a particularpathway, understanding the way
one particular interactionworked or the way that one
particular part of the journeywas designed is chalk and
cheese.
They're completely differentends of the spectrum.
(33:13):
They both have their value.
They're both important to dothose things.
But I think...
Often it can be seen that you'vedone the quant, so actually the
qual side of things is not sonecessary.
SPEAKER_01 (33:24):
I think you're absolutely right.
I think this interview feelslike me just admitting to being
rubbish in the past.
But again, I think over timeI've had an increasing sense of
the value of qualitative work.
It's not that I didn't before,but I think medicine drives you
to be analytical in aquantitative way.
(33:46):
And I think over time I'vebecome better and better at
fusing them.
I would equally challenge that Ihave seen some pieces of work
that seem to be entirely drivenby qualitative.
And it's, you know, you have tounderstand where the groups
you've spoken to sit in thewider group.
It's not to dismiss it, but ifwe've spoken to six people about
a condition that affects fivemillion people, we do need to
(34:07):
reflect if we think that thosesix are representative.
And yes, I've seen it.
So I've seen errors on bothsides.
I would say we need both.
And they both have near equalweighting, bit of nuance
depending on what we're tryingto do.
And I think what thosequalitative insights, as you
say, it's a real low level.
They, I think, help you do, youknow, if we design for people
(34:32):
who need some adjustments, oftenwe're designing better for
everyone.
And so if that's members of thetrans community who find that
the atmosphere for screeningtests is different, not
welcoming or not supportive, orif we can lean into that, that
makes it better for them, itwill be better for everyone.
(34:54):
If we've got people inneurodiversity who find the
clinic letter difficult tounderstand, guess what?
People without neurodiversityfind them difficult to
understand.
But I think, as you say, in asurvey, that won't surface.
Whereas some targetedconversations, targeted
qualitative work, I think oftensurfaces things that are hidden
in the larger numbers.
SPEAKER_00 (35:15):
Where would you say are now the biggest
opportunities to improve thepathway?
SPEAKER_01 (35:21):
I think most of the opportunities are much more
simple than people would like toadmit.
I think, unfortunately,everyone's going so fast that
there's barely any capacity toreview processes, overhaul
processes, back to my pointsaround cognitive bandwidth.
So I'm just trying to getthrough clinic today to do the
(35:42):
operating list tomorrow We'retrying to get to the end of our
massive MDT meeting on theprojects I'm involved in at the
moment.
We're engaging with clinicalteams and I believe they all
realise the project will bebetter in the long term, will
reduce a bit of work in the longterm.
But that benefit might be sixmonths away and they've got a
load of work to do today.
(36:03):
And so I think we are fightingthis transformational gap
because you've got to keepdelivering BIU as you transform
and that's incredibly hard mostI think non-clinical
organisations you almost mighthave a transformation team or
you have something that's doingsome of the lifting whereas it's
(36:24):
much harder I think with sort ofclinical work I mean I was taken
by one of your previous guestson the podcast Rochelle Gold and
she mentioned about being askedto see in clinic they wanted a
button a print button I think itwas on one of the screens and I
just think that's It is theperfect NHS example where I've
(36:45):
got this problem.
I need this problem solving.
I haven't got the time, space,capacity to go right back to the
root cause of that problem.
You know, a bit like the cancerpathway.
What actually is the aim of whatwe're trying to do here?
What value do we want todeliver?
Design a pathway that deliversthat.
We're often faced with justtrying to tweak what we're
(37:07):
doing.
to solve the biggest problem.
So I think for me, the biggestopportunities are if we can bury
capacity for people to do thatsort of root and branch review
of why is it like this?
What could it be like?
How do we do it?
So the changes I described, theydid cost money, but actually
they didn't involve a bigdigital infrastructure project.
(37:28):
They didn't involve lots ofthings that we didn't have a new
app.
We didn't have anything likethat.
It was perhaps rearranging thedeck chairs on the Titanic, but
we did at least manage to changethe speed of the Titanic heading
towards the iceberg that wouldbuy time to then digitize or
then bring in different sort ofsolutions.
SPEAKER_00 (37:49):
I find it quite frustrating sometimes the way
that transformation has becomesynonymous with technology.
Everything is a technologyproblem.
You can be solved withtechnology and, you know, right
up to the top.
That's kind of one of thepolicies of the new government.
And I'm absolutely an advocatefor technology in the right
place and the impact that it canhave.
But it feels that often that thechanges are, as you say,
simpler.
(38:09):
We did work on the autismdiagnosis pathway.
And one of the things that cameout of that was actually it
would be really good if peoplewere just given a leaflet when
they started the process so theycould understand what was going
to happen.
That's not rocket science andthat's not minimal investment to
actually make that happen.
But it feels like there's thistechnology kind of hammer that's
trying to solve everything.
SPEAKER_01 (38:27):
Yes, and I often, I think, jump from one side of the
fence to the other to try andsupport the team that's losing.
So if I'm in a meeting whereeveryone's saying, that's miles
too hard, technology can't solvethat, I find myself being a
slight tech advocate going, Idon't think it's as hard as you
think the technology to do that.
And then the flip side, as yousay, when everyone's trying to
say it needs technology, going,well, actually, as you say, if
(38:49):
we changed the form with aconditional question here or did
that there, that would bebetter.
If we just look at the letterswe send to patients, my wife's
had a couple of letters lately.
Between the two of us, we'vestruggled to understand them,
and I'm a doctor and she's ateacher.
So that tells you fundamentallythere's something wrong.
And what will have those peopledone?
(39:10):
Either not gone to theirappointment, phoned up
healthcare services to get theappointments explained.
All of these things are time andresources, and yet it's for want
of a better letter.
So as I say, I'd love to sithere and say, oh, these
opportunities right now, Sam,are some AI-driven this, that,
and the other, they will make adifference in time.
But right now, we could do anawful lot of things with just
(39:33):
redesigning our processes andour pathways.
SPEAKER_00 (39:36):
On the other side of things, how can technology help
the cancer pathway?
SPEAKER_01 (39:39):
I think I'm absolutely convinced it can.
I think the problem we have atthe minute is we have technology
getting in the way currently,and I think that's almost one of
the blocks to it.
So within cancer care, forexample, there's software that
collects data about thepatient's cancer diagnoses,
etc., called cancer registrysoftware.
And it's a brilliant example ofterrible design.
(40:02):
It was designed to solve aproblem, which was getting data
to NHS England.
It was designed to solve theproblem for the people who were
tasked with doing that, sothat's cancer managers in
hospitals.
But it had no input, certainlyno input from anyone who was
sensible, in hospitals.
what clinicians who wouldinterface with this would feel
(40:24):
was appropriate, could use.
And so you have this clunkysoftware that's extremely hard
to work, doesn't really, itdelivers what NHSE wants, but
data quality is a continualproblem because the software is
not intuitive.
You struggle to use it in realtime.
And it's that example really,isn't it?
The word users gets used, but inthe NHS, that's more vague.
(40:49):
There might be a nurse using itwith a patient, might be a
doctor using it on a patient.
The beneficiary might be apatient.
It might be the system or thehospital.
The payer might be the GPpractices.
It might be the hospitals.
So all these personas are split.
And very rarely in my experiencehave products and companies
really considered that properly.
(41:11):
What's the cost benefit, valueproposition, whatever it may be
across all the persona groups?
They just find one and hit it.
So I think one of the issuesregarding cancer care is that
some of the software that'spresently used is not great and
is a block to other changes.
But where do I see maybe it'sstarting to help more?
(41:32):
There's undoubtedly big shiftsin the world of radiology around
using AI-driven technologies tohelp with reporting, for
example, mammograms or chestX-rays.
That is not ready to beunleashed yet.
uncontrolled at the moment butwe've reached the point where
there are some very large trialsgoing now in multiple hospitals
(41:53):
so shall we say it's certainlygood enough at the moment that
it's not obviously terrible butwe've obviously got to just now
really refine is it absolutelysafe under what circumstances is
it appropriate or not similarlywith software to help
oncologists plan theirradiotherapy the software to
(42:14):
help with that, what's calledcontouring.
And that will save someoncologists, you know, could be
one to three hours a week atleast.
And that's time that can berepurposed.
So I think there was definitelythings coming.
But I suppose when I tell youthat fundamentally, if we were
in a cancer service today, wewould struggle to even map our
(42:37):
demand and capacity in the nextsix to eight weeks accurately.
Some of these verypatient-facing technologies are
great, but there's a lot ofback-office improvement that the
size of the prize isn'tobviously perceived to be big
enough for people to really wantto take on.
SPEAKER_00 (42:55):
Have you seen patient-facing technology that's
improving outcomes?
SPEAKER_01 (42:59):
For some people, potentially, yes.
I'm slightly guarded.
Particularly in cancer care,there's an awful lot of apps,
some of these perhaps to try andhelp people manage specific
symptoms.
After cancer treatment, fatiguecan be a real issue or sleep.
And so there's apps to targetthose things.
And the results would suggestthat a meaningful number of
(43:21):
patients get benefit from this.
There's lots of apps out therethat support people through
their cancer pathway.
Or it's a place for you to storeclinic notes, record your
symptoms and some of thesethings.
I think for some patients withsome clinical teams, they
probably generate a benefit.
But I would say that not allpatients can engage with those
(43:46):
technologies at scale, sothey're not helping everyone
equally.
And I'd also say that not allclinical teams are resourced to
do that.
There's a bit of a misconceptionthat, oh, you know, we've got
all these patients who canreport their symptoms in real
time.
Okay, but who's available tolook and deal with that?
And There's not a bank of nursesor doctors sat waiting for these
(44:11):
reports to come in.
And so until you can reallyleverage AI to triage all that
data to get the outcomes, whilstit relies on humans, you're
going to be very limited in whatcan be done.
So, for example, there are somesupport applications and they've
been adopted by smaller servicesor services perhaps in the
(44:32):
private sector where there's abetter ratio of nurses to
patients.
But I think, should we say, it'sa big, busy hospital.
I'd say most of the technologyat that point is really more
about perhaps, should we callthem patient portals or those
sorts of things where people canat least look at their results,
look at their clinic letters,that sort of level of
(44:52):
technology, but are notconvinced there's a really wow
technology out there that'sshifted the dial for patients.
There's interesting things likeVR to try and improve for people
who are having head and neckradiotherapy, for example, but
they're not in use at scale andare not sure.
(45:14):
I think that someone at onehospital might get it and
someone else doesn't elsewhere.
So as I sit here today, Sam, Idon't think we've really made a
big dent in that yet.
SPEAKER_00 (45:24):
Do you have thoughts about ways that we can achieve
the right balance between kindof digital support and human
support?
SPEAKER_01 (45:32):
Yeah, I think for me, technology...
We're up to tipping point.
So technology till now andthrough my clinical career
really was between me and thepatient.
It got in the way.
This sort of thing called thekeyboard, the screen slid into
the clinic room.
And early on, it was just for acouple of things.
(45:52):
And gradually it was all onthat, ordering everything on it.
And so we'll have all been in aconsultation where the doctor
seems to look at the screen andbe typing, not listening.
And that undoubtedly changes thedynamic of those conversations.
I think it makes it a bit moretick boxy.
So technology has been betweenus.
(46:14):
I think as we move forward, Iwould like to think that
technology can actually get helpfrom being between us and be
around us.
I think that we can use ithopefully to release us to be
more human.
We think probably overhypedexample would be ambient AI
technology.
But in time, I sincerely hopethat delivers because if we
(46:37):
could be having a consultation,Sam, and I haven't got to
request anything on the computerwhilst we're talking or dictate
a letter at the end because theambient AI is hoovering up our
conversation, synthesising it.
I said, we can just check yourbloods today, Sam.
We'll do this and this.
It's already filled the form in.
(46:58):
When we reach that point, thattransforms healthcare.
Because I'm released to be humanand to get back to doing what I
did, which was making eyecontact, which was using my body
language to reassure or help.
Whereas lots of subtleties likebody language are now lost
because as much as we don't wantto look over a desk, because
(47:21):
that's terrible for building arapport, how do I use the
computer and look at your x-raywhilst I'm talking to you?
So I am hopeful that technologywill undo the harms of
technology.
in the coming years, but youwon't get me committing to a
timeline for that.
SPEAKER_00 (47:38):
From a technology perspective, what you've
described is more or lesspossible from what's out there
now.
But from a kind of a system andan implementation and a policy
and all that other stuff, itfeels a long way, a long way to
go.
SPEAKER_01 (47:51):
I think so.
I think some of the technology,my understanding as a non-expert
is some of the ambient AI canwork really well in a
one-to-one, maybe a one-to-two.
but starts to struggle with morepeople.
And particularly in cancer care,you could have three, four, five
people in the room.
And at that point, so I'm notsure, but I think it's sort of
(48:14):
nearly there in some use cases,but not in others.
So it might be good for GPpractices before it is maybe
some hospital practices.
But I agree completely with youthat when I say this to clinical
staff, they look at me like I'mfrom Mars.
But I recognise that becauseuntil I left the NHS four years
(48:35):
or so ago, if you'd said AI tome, I'd have said, I can't even
log on to the system today.
And I also have to remember fivepasswords for the different
systems just to run clinic.
So that is the reality and thedestination do feel a long way
apart for people who are workingin the NHS.
UNKNOWN (48:55):
Music
SPEAKER_00 (48:58):
You've been listening to part one of this
podcast with Dr JonathanGregory.
Stay tuned for part two where wewill explore Jonathan's work
with Macmillan using AI toimprove patient communication
and we'll also dig into hisgroundbreaking work to
understand experiences of cancersurvivors in the community and
discuss Jonathan's vision forthe future.
UNKNOWN (49:18):
Music
SPEAKER_00 (49:27):
Problems Worth Solving is brought to you by
Healthier, the collaborativeservice design consultancy for
transformation in health careand public services.
Find out more about how we canhelp you deliver user-centered
change at healthier.services.
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