October 20, 2024 • 42 mins
Dr. Lia Ali—consultant psychiatrist and clinical advisor at NHS England’s Transformation Directorate—joins host, Sam Menter from Healthia®, to explore the intersection of healthcare, human-centered design, and digital innovation.
Dr. Ali shares her unique insights on the bio-psycho-social model and how it aligns with user-centered design to create more personalised, effective health services. From using digital tools to improve patient outcomes, to exploring how the therapeutic relationship evolves in a digital age, this conversation dives deep into the role of design in transforming healthcare delivery.
With examples from Dr. Ali’s work at NHS England and her extensive experience in clinical practice, this episode offers valuable takeaways for anyone interested in the future of healthcare—whether you're leading service transformation, navigating digital health technologies, or simply passionate about improving patient care.
Tune in for practical, thought-provoking insights on how to shape the future of healthcare by putting people first.
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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Episode Transcript
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SPEAKER_01 (00:00):
Welcome to Problems Worth Solving, the podcast where
we explore transformativeapproaches in health and care
through the lenses ofhuman-centered design, service
design and digital.
I'm Sam Mentor, ManagingDirector at Healthier, the
(00:23):
service design and digitalinnovation consultancy.
Find us at healthier.services.
Join me as I speak with thepeople shaping the way health
and care is delivered.
Leaders and changemakers frompublic health, not-for-profit,
health tech, and life sciences.
We'll explore how putting peopleat the heart of service design
can drive impactful change.
(00:45):
In each episode, we'll shareinsights and inspiration from
real-world examples, like usingco-design techniques to improve
mental health services, ordigital tools that empower
patients to take control oftheir care.
In this month's episode, I'mjoined by Dr.
Leah Arley, Leah is a consultantpsychiatrist and she's a
clinical advisor at NHS Englandin the Transformation
Directorate.
(01:07):
So Leah, welcome and thank youfor joining Problems Worth
Solving.
Today we're going to talk a bitabout the overlap between design
and healthcare and look at someof the links between the
biopsychosocial approach thatyou're going to tell us more
about and user-centered design.
But before we go into thatdetail, I'd love to know a bit
more about your background andhow you came to be in this role.
SPEAKER_00 (01:26):
Hi, Sam.
Thank you very much for havingme.
It's really nice to be heretalking about myself.
That is always a favouritesubject.
So I'm a doctor.
I qualified.
back in 2002.
And I am sub-specialised.
I'm specialised in an areacalled liaison psychiatry, which
means that I look after patientswho are under the care of medics
(01:49):
or surgeons.
And it means I've always beenlooking after people or dealing
with people who have problemsthat kind of are the interface
of all those different issues.
And why did I get into thatfield of work?
I am a Croydon girl, veryproudly South London.
And in the area where I lived,the There was lots of different
things going on for me, lots ofdifferent things that I was
(02:10):
interested in.
And in particular, I had a veryearly interest in memory,
actually.
So when I left school, I went ona really quite special
experience.
I was lucky enough to go to DukeUniversity in the United States
and on a special program calledExploring the Mind.
And that program allowed you tostudy various topics like memory
(02:32):
and language from multipleperspectives.
So from neurobiologicalperspectives from linguistics
from philosophical perspectivesand from cultural
anthropological perspectives soreally quite a lot frankly for
an 18 year old freshman livingin a new country but really
interesting I really enjoyed itand it really gave me an
(02:54):
appreciation of the differentsorts of things that might be at
play in somebody's experienceand that really does relate to
the sort of things I wasinterested in really quite early
on so when I was little, I usedto want to be an astronaut, but
I didn't just want to be anastronaut.
I wanted to be a fashiondesigning astronaut.
(03:15):
So it's like a Neil Armstrongmeets Vivian Westwood sort of
love child type thing.
I don't really know.
And I'm talking about when I wasabout six here.
And one of the things that kindof really inspired that was I
went to Houston in the States toNASA headquarters.
And we went to, in NASAheadquarters, they had the
(03:35):
cinema experience, Cinematicexperience where you could see
the earth rising so it's thatreally famous image where
pictures were taken from themoon of the earth rising and you
see that beautiful blue planetand I can really clearly
remember it right now of beingstruck by just how beautiful
that was and what has come to meas I've reflected on the sort of
(03:56):
work that I've done is that itwas something about the beauty
that you could access that wasrelated to the technology, the
incredible engineering, theseincredible feats of innovation
that actually got people to themoon and allowed us to look back
on the earth and appreciate thiskind of beauty.
And at the same time, I wasmassively into my Barbie dolls
(04:18):
and my Cindy dolls.
I actually had more of a Cindydoll than Barbie dolls.
And I used to make clothes forthem.
And I used to really enjoythinking about colour and shape
and putting things together so Ihad this real sort of mix of
love of bit of science and thenloving these kind of creative
aspects of things and went downa route like a lot of people
(04:40):
didn't really go down any kindof creative route and went down
that science route and it wasn'twhen I was at Duke and doing
that special program some ofthat really came back to me that
kind of joy of really fantasticideas coming from when you look
at things from all differentperspectives and particularly
utilizing the creative part ofyour brain so when i came back
(05:04):
to medical school in the uk iwas on the usual standard track
of medical school at imperialcollege and i did a piece of
research that was around eeg andconsciousness so we were
recording electrical waves frompeople's brains as we got them
to do a task that encouragedthem to be in different types of
(05:24):
memory states.
And there was somethingdifferent about what they were
recollecting when they werehaving their EEGs measured.
And it allowed us to reallyexplore What could you see in
these deep processes of thingsthat were going on for people?
And that led on later in mycareer to working on Alzheimer's
disease and doing functionalneuroimaging in Alzheimer's.
(05:47):
And again, looking in real time.
What can you understand?
How do you measure what is goingon?
And how does that relate to theexperience that somebody's
having?
And in that particular piece ofwork, the Alzheimer's research
work, that was particularlylooking at ways that we might
test drugs early for Alzheimer'sdisease.
(06:08):
So putting together all thesedifferent kind of strands of
technology and how we use thatto be able to have an impact on
people's experience wassomething that was really
important to me.
I also do need to confess thatI'm a bit of a sci-fi geek.
I have always loved films andstories that are about our
futures.
And as I progressed through mymedical career, And into this
(06:30):
field of liaison psychiatry, Ialways carried with me that
interest of what can technologydo to help us understand
people's experience better?
And what can we do in terms ofinnovation to actually improve
that experience as well?
SPEAKER_01 (06:48):
And what does your work involve now, Leah?
SPEAKER_00 (06:50):
So my work now is a mixture of daily clinical
practice.
So I do work at the South LondonMaudsley in neuropsychiatry,
which means that I work with theneurologists in the acute
physical health hospital andhelp them with management of
people who might be presentingwith all different sorts of
(07:11):
neurological symptom and helpthe clinicians understand all
the factors that might be atplay in somebody's presentation.
And I can talk a little bit moreabout that because it comes very
much into this thing called thebiopsychosocial model.
The other aspect of my work isat NHS England where I work as a
clinical advisor in thetransformation directorate.
(07:33):
So that means working at apolicy level on various programs
of work that are related todigital within healthcare
services.
For example I advise around someaspects of the NHS app and also
around pieces of technologicalinfrastructure structure that we
have for example somethingcalled the shared care record
(07:53):
program it's called the nationalprogram is called the conga
program and i advise on some ofthe clinical and actually the
clinical design aspects of someof those things in terms of
serving the population indigital health care services
SPEAKER_01 (08:07):
so when we were talking before we were talking
about the biopsychosocialapproach and probably there are
people listening who are veryfamiliar with that who work in
health care and know all aboutit but i'm hoping there'll be
people listening coming athealth care from a design
perspective and have lessclinical backgrounds.
So I wondered if you could givea bit of a summary of what the
biopsychosocial approach is andhow it relates to user-centred
(08:28):
design, because I think you'vetalked about lots of parallels
between those two things.
SPEAKER_00 (08:32):
Sure.
So the biopsychosocial approach,as the name suggests, it's made
up of biological, psychologicaland social.
And it really relates tothinking about somebody from all
of those different perspectives.
So to give an example, someonewith, say, rheumatoid arthritis
which is an autoimmunecondition.
(08:52):
That means it's a conditionwhere your immune system is
attacking itself and causessymptoms, for example, like
joint swelling and stiffness.
That's the biological componentof rheumatoid arthritis.
However, we also know thatpeople who experience rheumatoid
arthritis have a psychologicalcomponent to what they're
experiencing.
So pain is a key component ofsomething like this condition.
(09:17):
And pain has a huge...
psychological aspect to it weknow that there is this
confluence of things happeningfor somebody you might have
chemicals floating around inyour joints that's the
biological part which causes thejoint swelling and stiffness and
this causes pain but theexperience of that pain is very
(09:37):
much informed by yourpsychological makeup some of
that is in kind of your earlychildhood some of that is what
you're experiencing in thepresent moment and it can be
precipitated by certain thingsAnd this is where your social
context is really quiteimportant as well.
For example, we might managesomebody with rheumatoid
arthritis who is a concertpianist and who the impact on
(10:02):
their job of having jointstiffness in their hands is
quite different to somebody elsewho has a different type of role
and a different type of jobwhere their symptoms may affect
them differently.
This affects all of how somebodypresents with what they're
experiencing.
To give you another example, Weoften think about somebody's
presentation and how somebodypresents with what they come to
(10:24):
the doctor or the nurse or anyclinician in terms of what might
have triggered it.
And again, these factors can bebiological, they can be
psychological, or they can besocial.
We know, for example, thatstress is a huge precipitant of
flares of all sorts of long-termconditions.
We know there's a relationshipto heart attacks.
We know there's a relationshipto getting stomach ulcers, etc.
(10:47):
And we know that the actualexperience of that who is likely
to get that heart attack isaffected again by this
interaction between thesebiological, psychological and
social factors.
Take, for example, heart attacksand cardiovascular disease.
Yes, you might be in a stressfuljob, but if you are somebody
who's got a family history and agenetic predisposition to, for
(11:09):
example, lay down more blockageswithin your arteries and your
vessels, you are more likelythen to have that outcome of the
stressful situation be somethinglike an end point, like a
cardiovascular symptom, like aheart attack or a stroke.
We know that, for example, inpeople who experience diabetes,
(11:30):
that if we think about them interms of all of these different
biological, psychological andsocial factors in their makeup,
we're much more likely to beable to help them manage their
blood sugar levels better andalso stave off some of the
long-term outcomes of havingdiabetes where you get damage to
the end organs.
(11:50):
So there's a lot of power inthis biopsychosocial model.
One of the reasons we don't heara lot about it, especially in
Western cultures, is because weactually have a health system
which is really quitemedicalised.
we've tended to focus very muchon the biological component and
this is the bit where i getusually a little bit
philosophical and say it's alittle bit to do with descartes
(12:11):
and this idea that the mind andthe body are separate so the
descartes quote is i thinktherefore i am and what's
embedded in that phrase is thisseparation between mind and body
so for us who follow abiopsychosocial model it's this
split between the psychosocialand the biological and we know
(12:31):
that healthcare services thatonly focus on the medicalised
bit or the biological bit missout these major components of
people's experience.
And that's often what people areexpressing in user research.
So in the digital work that Ihave been doing in multiple
different pathways and wherethat touches on user-centred
design, I can often hear inhealth stories that come from
(12:55):
the UCD, the user-centred designperspective on things, that have
all of these components of thepsychological a social context
of somebody which hasn'tnecessarily been taken into
account into how that interplayswith someone's experience.
So for example, the example Igave you first around rheumatoid
arthritis, if when we'rethinking about how somebody
(13:17):
might interact with rheumatologyservices in a clinic and we
don't think about how they canaccess that or what might have
caused a particular flare forthem, what's going on, have they
lost their job, have they had totake sick leave, do they have a
comorbidly existing so anexisting at the same time
condition like anxiety anddepression which happens a lot
(13:38):
for people with certain types ofconditions actually about 30 to
40 percent of the people withrheumatoid arthritis alone have
also have an anxiety ordepressive disorder then we're
not going to be able to planthat care for somebody properly
and in some of the work thati've done particularly something
called the imparts program atking's health partners
integrating mental and physicalhealth research training and
(14:00):
service this is exactly theapproach we took to looking at
services and incorporating thatinto the service design so for
example in the rheumatoidarthritis pathway in the imparts
model the team instituted aservice design where we knew
from the evidence base 30-40% ofthose people were likely to have
(14:23):
this anxiety or depressivedisorder and it was all about
picking that up so the idea waswhen you're sitting in the
waiting room and you're havingyour blood pressure and your
upholstery checked, you shouldalso be having your kind of
mental health vital signs beingchecked at the same time.
And lo and behold, we surfacedthe 30 to 40% of those people
that do have those symptoms.
And we were able to flag thatand design that service so that
(14:46):
it flagged that to everyone.
The other users within thatpathway, which were the physical
healthcare clinicians, so therheumatology doctors, the
rheumatology nurses, who don'tnecessarily get formal training
in the full breadth of thepsychosocial factors.
So what this allowed us to dowas to help those teams of
people say, recognise thatsomething was happening and also
(15:09):
give them pathways to say, okay,the patient you're seeing is
experiencing, this suggests thatperhaps an anxiety disorder is
going on, or perhaps adepressive disorder is
occurring, you may need to referthem to your team psychologist
and this is how you do it.
Or you may need to talk to themabout emergency or crisis help
(15:29):
for their mental healthcondition.
So starting to treat all of thethings that somebody is
experiencing together.
And this often gets neglected inthe highly acute hospital
specialist structures.
It's part of this verymedicalised model that we have.
The other part that's reallyquite important to understand is
that when interactions are verytransactional and very
(15:53):
paternalistic, it's really hardto surface those biopsychosocial
experiences because the model isvery much geared towards just
surfing the biological piece andjust addressing the biological
piece.
Chronic pain is one of thebiggest examples of this.
So if you take something likeback pain, we know that the
(16:14):
majority of services are gearedaround and people's expectations
are geared around perhapsreceiving pain medication, a
tablet to fix it, or a surgicalintervention, for example, to
fix their back pain.
Actually, we know that thecauses of back pain are numerous
and they all fit within thesethree domains, biological,
psychological and social, andthey interplay.
(16:37):
So you can have somebody whomaybe has a particular
anatomical variation in howtheir back is constructed.
And if they are in a stressfuljob and they're holding
themselves in a particularposition then that is much more
likely to trigger off an episodeof back pain or a flare and that
actually the the treatment forthat it might include painkiller
(17:00):
medication but actuallyphysiotherapy is going to be
really important and keepingactive is going to be really
important for keeping you wellin the longer term but that
complexity of factors is oftenreally difficult to surface and
the system the medicalization ofthe system doesn't always allow
for that to really be exploredwhich is then where we get some
(17:20):
deficits.
SPEAKER_01 (17:21):
So the problem that the biopsychosocial approach can
solve is that we're only lookingat part of the problem through
our traditional medicalapproach.
SPEAKER_00 (17:31):
Yeah I often the one of the analogy I use especially
when I'm teaching medicalstudents and healthcare
professionals is it's like abeautiful Persian carpet and
that often people bring us sortof little threads of what's
going on for them and especiallyif they're in a distressed state
these are very jumbled up Andone of our jobs is to try and
see that.
(17:51):
It makes me think of that storyabout seeing the earth rising
over the moon is that the beautycomes out when you are able to
help somebody make sense of thatand you're able to help them and
empower them within what they'reexperiencing to understand.
Oh my goodness, when I amexperiencing stress in my role,
I am holding myself in aparticular way, which is
(18:14):
exacerbating that disc prolapsethat I had five years ago.
And oh look, my disc hasprolapsed again.
And it's not one thing, it'smultiple things going on for me.
So when I then think about how Ican address that, it's
addressing all those factors.
Some of them might be out of mycontrol.
I may not be able to change mywork situation, for example.
But one thing I can do is I canchange my response.
(18:35):
I can be aware of my I can makesure I'm hydrated.
I can do what I need to do tochange my work situation or my
psychological response to that.
These will all have huge impactson what my actual health
experience is.
SPEAKER_01 (18:48):
How does this approach link in with
person-centred care?
Is it all part of the same
SPEAKER_00 (18:52):
thing?
Yeah, so person-centred care isdefinitely another way of
describing a biopsychosocialapproach.
So in NHS England, in thepersonalised care directorate,
that personalised care policy isvery deliberately imbued with a
biopsychosocial focus.
And you tend to see abiopsychosocial approach from
(19:13):
the types of specialty, clinicalspecialty, which deal with that
full experience of people.
So people who work in palliativecare, for example, or certain
types of general practice, careof the elderly medicine in
frailty pathways, where we'relooking at all the interplay of
these factors.
SPEAKER_01 (19:31):
So user-centred design is all about putting the
person at the centre of thedesign of the system or the
service that you're designing.
One of the principles ofuser-centred design is also
around iteration.
Does that relate to what you'retalking about as well?
SPEAKER_00 (19:42):
Yeah, absolutely.
So I often talk about that asthe ability to sit with
uncertainty.
And in a lot of very medicalisedspecialties, That's not really
what we're doing.
We have a particularmethodology, a scientific
methodology, null hypothesistesting, where you're doing
(20:03):
experimentation in a way thatdoesn't sit with uncertainty.
And it's one of the biggestthings I've seen as being a real
revelation to me on my designjourney, actually, is that
within processes that come froma creative origin, there is much
more of that willingness to sitwith uncertainty.
as compared to processes thathave a science or an engineering
(20:26):
origin.
And I see it as being reallyexciting when you do both.
You can really get into a spacewhere real innovation happens.
One of the other models that Ioften talk about that helps me
really think about thisparticular space is something
called the Kenefin model, whichis a model of information
management, actually, and how wedo decision making.
(20:47):
And the idea of that, as anorganisational psychologist
called David Snowden, and theidea of that is that you've got
this kind of two by two matrixand you've got information in
different domains within thattwo by two matrix you've got one
level simple where it's reallyobvious you know what you need
to do the relationships are verylinear then the one above that
(21:08):
on the sort of top right iscomplicated and this is where
scientific experimentation sitsit's where there's things you
don't know but you set ahypothesis you assume that the
relationship is linear and thenyou use your methods to test
that assuming a linearrelationship That's where most
of academic medicine sits,actually.
And that's where clinical trialsand all those sorts of ways of
(21:33):
looking at something sit.
Then next to that, you've gotthe complex space.
And this is much more where Isee the sort of design processes
and design research methodologysitting, actually, where you've
got that uncertainty and you usemore of that probe test respond
type way of looking at things.
(21:53):
And we don't tend to utilisethat enough, in my view.
view on the kind of academicmedicine driven side of things.
And this is again where I'veseen some really interesting
things happen where you start touse that, you start defining
provocations and experimentationthat actually allows you to
explore the uncertainty.
The problem we have in clinicalmedicine is that we have big
(22:16):
risks.
So it's always really hard to dothat.
If you say sit with uncertainty,that's really hard when you're
talking about that people mightdie or lose a leg or the
boundaries are difficult to dealwith.
And I think that's what hasallowed people to go down that
very conservative, the veryconservative line.
But I do think when we worktogether, we can probably find
(22:38):
ways to do that sort of testingsafely, but accepting that we
are going to have to accept adegree of uncertainty and to to
be able to get to the best fitanswers.
And the box below is the onecalled chaotic, where nothing
makes any sense and all theunknowns are unknowns.
You're in a whole world of pain.
That's generative AI.
SPEAKER_01 (22:58):
We won't get onto AI.
That's the next one.
Now, the approach you've justbeen describing is about the
intersection of design andhealthcare.
Is this an approach that'sbecoming more common across the
health system?
SPEAKER_00 (23:09):
I think it is becoming more common.
So what already has quite a lotof purchase is the kind of
continuous improvementmethodology.
So quality improvement andcontinuous improvement.
And what a lot of people aren'tnecessarily, on the NHS side,
aren't aware of, so I'm talkingit's quite UK centric in terms
of improvement methodologiesthat the NHS uses, is that
actually, specificallycontinuous improvement is one in
(23:32):
a whole bag of methods that sitwith the design research
umbrella and for me it's quitehaving been so I'm on a Masters
in Healthcare and Design at theRoyal College of Art and
Imperial and this is where I'vereally developed my
understanding of where thesemethodological differences are
between a designer and atechnology led approach and I do
see as people trying to tacklethese hard problems these wicked
(23:53):
problems the call for more ofthe more ways of actually trying
to get to the nub of what'sgoing on what I think is really
important is helping people tounderstand where there might be
fundamental barriers.
So it's things like acceptingthat the current system we have
is medicalised.
It's not biopsychosocial.
(24:14):
It's accepting it is prettypaternalistic.
It is not as collaborative as weneed it to be.
And so embracing, acknowledgingthat first and then embracing
new methodologies, I think leadsus to a really exciting place.
SPEAKER_01 (24:26):
You told me a really interesting story earlier when
we were speaking around a placethat kind of this approach had a
real impact in some of yourwork.
SPEAKER_00 (24:33):
So right at the beginning of my digital health
career, I was working as aregistrar in South London, a
psychiatry registrar, and I wasasked to give some advice on a
programme of work that was beingled by the Service User Research
Academic Group, so all peoplewho were experiencing mental
illness.
And they were working with thehospital IT department and they
(24:57):
were also working with, thegroup of patients they were
working with all have severemental illness.
Now, people with severe mentalillness have a really raised
risk of physical health issuestoo.
People with SMI, severe mentalillness, are at risk of
somewhere between 13 to 20 yearsof their life being lost
compared to the average personin the population.
(25:19):
And this isn't death by thingslike ending their life by
suicide, which is a commonconnection people make for
people with SMI.
This is all causes all types ofphysical illness so there's
something going on there aboutwhy people with SMI why their
physical health isn't beingaddressed and in this patient
group that we were working withwe had people for example with
(25:41):
severe mental illness such asbipolar affective disorder whose
history of contact with serviceswas very much one of being very
paternalistic sometimes verycoercive so people who had been
detained say two three times Iunder the Mental Health Act and
had their human liberties takenaway and who had to basically
(26:03):
come to hospital against theirwill to receive treatment when
having a mental illness andbeing very unwell.
And they also had physicalhealth issues.
So I'm thinking of particularpatients who had, for example,
raised blood pressure andworking with them to actually do
things like measure their bloodblood pressure to do a wi-fi
enabled blood pressure cuff andat the same time encouraging
(26:26):
them in a very psychologicallyminded approach to be looking at
symptoms of their mental illnessof their bipolar affective
disorder allowed certainindividuals to start to really
track what was happening to themand we had examples from that
work of people who for the firsttime ever in their lives took
(26:47):
themselves back to their GP andhad their blood pressure
measured measured and theirraised blood pressure treated
and at the same time were ableto see that actually perhaps
some of their mood scores weregoing off and perhaps they
needed their medication checkingfor the the medication that
helped to keep their mood stablepart of their treatment plan I
(27:08):
mean this is huge these arepeople who had just not wanted
to have any contact withservices at all actually being
able to take control and be muchmore empowered and active in
their and do things on theirterms.
So one of the kind of key hooksfor this work was understanding
and taking into that kind ofunderstanding the
(27:29):
biopsychosocial drivers forpeople was that the mental
illness and the symptoms that weas clinicians might recognise,
that wasn't a problem for aparticular individual.
What was the problem for themwas was their blood pressure and
that was something they werewilling to engage with and being
able to give them ways that theycould manage that for themselves
(27:52):
and restart their relationshipwith health services on a
different footing made probablymade all the difference to being
admitted or not under section atthe next time so really we're
talking really huge outcomespossibly for people and I often
that it was seminal that workfor me because it's really
driven home my feelings thatdigital is potentially an
(28:15):
enabler for a biopsychosocialmodel of care.
I talk about it as a bit of aTrojan horse.
We know that Trying to change avery medicalised system and a
paternalistic system is hard,but digital services sit right
next to the user.
And if we are taking a user-ledapproach to those services, then
this is absolutely the righttime to be able to change the
(28:38):
models of how we approach that.
SPEAKER_01 (28:40):
You've talked about the potential of digital to have
huge impact through thisuser-centred approach and
through aligning with thebiopsychosocial approach.
There's this risk that we losethe human touch a bit when
everything starts going digital.
Is that something that you'vethought about much?
And do you have ideas aroundways that we can mitigate that?
SPEAKER_00 (28:57):
Yeah, I think that's, again, really important.
And it's a big reason why Ithink we need to really
understand what that user needis and think about something
called therapeutic relationship.
So what I think is oftenunderplayed is the role of the
therapeutic relationship insomeone's healthcare experience.
(29:18):
And therapeutic relationship,very simply, is the relationship
that somebody has with anotherhuman who has some kind of
involvement in their healthcareprovision.
And as you just said, there is areal risk as we digitise
services that we remove thatentirely.
And I don't think we fully knowwhat it means yet if we do
(29:38):
remove that entirely.
On the one hand, there is thisvery real risk that we lose this
kind of key component of humaninteraction and actually we end
up with services that just don'tserve people as it should do.
There are also opportunitieshere to actually engage with
(29:59):
people in a different way.
(30:27):
system key performanceindicators for example
attendance at A&E or attendanceat GP surgeries etc numbers of
flares and in conceptualclinical conceptual terms one of
the ways we talk about that isthinking about patient facing
services as needing to haveembedded what we know works from
a supported self-managementperspective and that means
(30:49):
understanding somebody from abi-psychosocial perspective it
also means understanding what inyour service needs to be there
to drive the behaviour thatyou're trying to drive, whether
it's taking up certainappointments or engaging in an
exercise, whatever it is thatyou're trying to do.
And understanding that deeplyand understanding which pieces
(31:11):
of that, in order to addressthat person's need, which pieces
of that are appropriate andethical to be replaced by a
fully digitised service andwhich pieces, is it much better
that we have an adjunct, we havesomething that improves
advocacy, for example, orself-advocacy, and then actually
allow somebody to engage withthe bits of the service that
they need.
(31:32):
And I think the more that weexplore that and the more open
we are to different ways ofdelivering care, the more
innovation we're going to havearound this and we'll come to
new ways of thinking aboutthings.
Within this, I do not think wecan ever get away, and I don't
think we should personally, fromunderstanding that people need
(31:53):
that human contact and that is akey part of that therapeutic
relationship, however you'redelivering it.
And I think it is a realresponsibility that we have to
design service is so they areblended and so that they can
provide to that becauseotherwise we run the risk of
just making things just not workfor people and that's not what
we want.
SPEAKER_01 (32:15):
Prevention is a big focus at the moment.
Do you have ideas around theways that digital and the
biopsychosocial model can beapplied in that context?
SPEAKER_00 (32:23):
Yeah, I think there are lots of opportunities here
because where we talk aboutsomeone's context being
important to what they'reexperiencing, we've got so many
ways of understanding what'sgoing on around us that's just
way more than me as a doctor ina clinic seeing somebody for 20
minutes or whatever or 10minutes.
I couldn't possibly have accessto all that information about
(32:45):
somebody that somebody mighthave from all the different
digital interactions that we nowhave.
So I think there is hugeopportunity there.
Everything from kind of ambientmonitoring through to very
specific things.
For example, I saw a piece ofwork around measurement of mood.
So I talked a little bit aboutin one of the pieces of work in
(33:06):
the Imparts piece of work, howwe use some mood scoring
surveys, questionnaires.
And like any questionnaire,There is an element of barrier
around that.
You have this time it takes forsomebody to do that.
It's a very specific thing.
And we are starting to have waysto be able to get that same
measure about somebody's mood,anxiety or depression experience
(33:30):
from, say, two minutes of speechusing natural language
processing models ofcharacteristics that are within
speech itself.
This is really exciting becauseit means that you're going to be
able to start start surfacingwhat could be a problem for
somebody.
It could be impacting, say,their joint stiffness, their
experience of their arthritis.
(33:51):
We talked about arthritisalready.
That they may not be aware of,that they're not even aware of.
So if you're not aware of it,you can't even start to find
help for it.
But if there are different waysthat we can start to help people
understand, be more connected towhat is going on for them, that
(34:13):
gives us lots of opportunitiesfor people to intervene early
for themselves.
That is prevention.
And I think there's hugeopportunities here.
SPEAKER_01 (34:21):
It sounds like you're really excited for the
future of health and care in oursystem.
SPEAKER_00 (34:25):
Yeah, it's that sci-fi geek in me coming through
again.
SPEAKER_01 (34:28):
Where do you see it going in five, ten years' time?
Can you see major changes?
SPEAKER_00 (34:33):
I don't know if I can see major changes.
I think we're seeing alreadythat the sort of digital
experience people are able tohave now is raising people's
expectations of what any digitalservice should provide.
And it is also empowering peopleI think, to take more control of
what is happening to them.
(34:54):
And as you know yourself more,as you know what happens to you
more, so I think very much ofthe kind of quantified self
group that I spoke to some ofthem many years ago who were
using the very earliest sensesand monitors to understand that.
I mean, we can do that, a bunchof that, through the watch on
our wrist now.
As we get better and better atunderstanding ourselves, what a
(35:17):
particular change means andcorrelating that, for example,
people with asthma who arewalking into an area where there
is greater pollution and willknow what their risk is and can
maybe take particular measures.
I think we're going to see moreand more creep of these using
the data more effectively topersonalise somebody's
(35:39):
intervention and somebody beingable to do that for themselves
and drive those behaviours forthemselves.
So I see it as being a veryconnected experience it's not
going to be one particular appit's not going to be one
particular sensor it is what wedo with all of that wealth of
information and why those thosearchitectures that we are
(35:59):
beginning to put in place nowaround that data needs to be
open enough to allow thatinnovation to come through
SPEAKER_01 (36:07):
can you tell me a bit about what you're working on
at the moment yeah
SPEAKER_00 (36:09):
Well, there's something that I was working on,
which I think is a really goodexample of where taking a
biopsychosocial approach has thepotential to really change how
we deliver care and do that in amore person-centred and holistic
way.
So in the spring budget lastyear, there was a call for
services that will run throughthe national digital channels
(36:33):
that provide access to servicesand digital tools that can help
people with musculoskeletalconditions and mental health
conditions.
And we started a bit of workaround musculoskeletal
conditions first, soparticularly thinking about
people with back pain.
And one of the things that'sreally important to understand
is What is the analogy toclinical care?
(36:57):
What does it mean when we aredelivering a service through a
digital channel where we aretrying to drive certain health
behaviours and where there mightnot be a human in the loop,
actually?
And what can we do there?
So one of the things that wedid, and I worked really closely
with Andy Bennett, who was theNational Clinical Director for
Musculoskeletal Conditions andsome of the National Channels
(37:20):
teams, we really tried to embedprinciples like a bias like a
social model of care within thethinking around the service
design.
So rather than simply thinkingabout, say, a jump off to an
external third partyapplication, what's also really
important to consider is whatthat service wrapper looks like
(37:41):
and how you think about whatsomebody's experience is who
might be looking for this typeof help, this type of service.
So in my clinical practice, Whatoften happens is that say
somebody who is seeking help forback pain, they'll go straight
to the medicalised answerbecause that's what they're
(38:01):
expecting.
That's what the system actuallyhas.
And we often have to go through,and this is the way, you know,
so if you talk to Andy and youtalk to physiotherapists who
work in this space, there is asort of, there is a clinical
role that we do where we helppeople understand their
biopsychosocial experience oftheir back pain.
(38:23):
which helps identify what causedit, what the triggers might be
and what's likely to perpetuateit, to keep it going.
If you translate that intodigital terms, what does that
mean?
That's what we were working on.
How do you try and create aservice that allows people to do
that bit of discovery themselvesand then actually helps them get
(38:45):
into the right service orintervention that is going to
help them take that forward?
It might be something aboutexercise, but it could ease also
for back pain, also be somethingaround sleep.
We know, for example, thatpeople who have some kind of
issue with their sleep, sayinsomnia, are going to be more
likely to get back pain becausethere's a relationship and
(39:05):
there's a loop there with howyou are repairing and renewing
your muscles and your ligaments.
And that makes you more likelyto have an ongoing pain syndrome
with an acute injury, forexample, or for an old injury to
flare up again.
It could be something to do withyour nutrition level or it could
be something to do with otherillnesses that you have if you
(39:29):
are somebody who has an anxietyor a depressive disorder we know
that treating the anxiety or thedepression also helps you with
your back pain so theresponsibility in a digital
service that we build like thathas to take that into account
and has to in order to be ableto really improve on people's
(39:50):
health outcomes and alsocrucially to um help with system
key performance indicators thatI talked about before it has to
take that approach ofconsidering all those factors
and incorporating that withinthe design that's something I'm
really quite excited about thatthat approach becomes more and
more of a way of thinking aboutwe're not thinking about the IT
(40:11):
piece as just a nice to have ora little add on it is the
service itself and it comes backto that discussion that we had
before when you take the humanout of the loop what things can
you replace What things can youdo differently?
What things do you have toaccount for because you can't
replace them and you need tomake sure that people have
access to that aspect of humaninteraction?
SPEAKER_01 (40:33):
What's next for you, Leah?
What are you excited about atthe moment?
SPEAKER_00 (40:36):
Oh, there's lots of things I'm excited about.
I am really excited about theway that in the pieces of work
that I'm involved in, we'rebeing able to do more around
this transdisciplinary mappingfrom the evidence base, the
clinical evidence base, to userinsights in various pieces of
(40:57):
work.
And that's starting to show realvalue in addressing need and
being able to inform the way wemight build services going
forward.
That's That's really excitingbecause it feels like we are
getting to a place where wemight really be able to deliver
person-centred care that istruly holistic and
(41:17):
biopsychosocial and where we'restarting to see collaborative
relationships around design ofproducts and services that are
showing us where there areopportunities to use the data
more effectively, to make surethings are useful and usable and
that actually really do impactpeople's health outcomes.
(41:39):
That's what I'm excited about.
It feels like a moment wherethese sort of worlds are
properly coming together.
They've overlapped.
But actually, people arestarting to see the value of
when you do this workcollaboratively.
SPEAKER_01 (41:52):
Fantastic.
Thank you, Leah.
That's a really interestingdiscussion.
Thanks for taking the time tocome and talk to me.
SPEAKER_00 (41:56):
Thank you for having me.
UNKNOWN (41:59):
Thank you.
SPEAKER_01 (42:07):
Thank you.
Thank you.
Thank you.
Welcome to Problems Worth Solving, the podcast where
we explore transformativeapproaches in health and care
through the lenses ofhuman-centered design, service
design and digital.
I'm Sam Mentor, ManagingDirector at Healthier, the
(00:23):
service design and digitalinnovation consultancy.
Find us at healthier.services.
Join me as I speak with thepeople shaping the way health
and care is delivered.
Leaders and changemakers frompublic health, not-for-profit,
health tech, and life sciences.
We'll explore how putting peopleat the heart of service design
can drive impactful change.
(00:45):
In each episode, we'll shareinsights and inspiration from
real-world examples, like usingco-design techniques to improve
mental health services, ordigital tools that empower
patients to take control oftheir care.
In this month's episode, I'mjoined by Dr.
Leah Arley, Leah is a consultantpsychiatrist and she's a
clinical advisor at NHS Englandin the Transformation
Directorate.
(01:07):
So Leah, welcome and thank youfor joining Problems Worth
Solving.
Today we're going to talk a bitabout the overlap between design
and healthcare and look at someof the links between the
biopsychosocial approach thatyou're going to tell us more
about and user-centered design.
But before we go into thatdetail, I'd love to know a bit
more about your background andhow you came to be in this role.
SPEAKER_00 (01:26):
Hi, Sam.
Thank you very much for havingme.
It's really nice to be heretalking about myself.
That is always a favouritesubject.
So I'm a doctor.
I qualified.
back in 2002.
And I am sub-specialised.
I'm specialised in an areacalled liaison psychiatry, which
means that I look after patientswho are under the care of medics
(01:49):
or surgeons.
And it means I've always beenlooking after people or dealing
with people who have problemsthat kind of are the interface
of all those different issues.
And why did I get into thatfield of work?
I am a Croydon girl, veryproudly South London.
And in the area where I lived,the There was lots of different
things going on for me, lots ofdifferent things that I was
(02:10):
interested in.
And in particular, I had a veryearly interest in memory,
actually.
So when I left school, I went ona really quite special
experience.
I was lucky enough to go to DukeUniversity in the United States
and on a special program calledExploring the Mind.
And that program allowed you tostudy various topics like memory
(02:32):
and language from multipleperspectives.
So from neurobiologicalperspectives from linguistics
from philosophical perspectivesand from cultural
anthropological perspectives soreally quite a lot frankly for
an 18 year old freshman livingin a new country but really
interesting I really enjoyed itand it really gave me an
(02:54):
appreciation of the differentsorts of things that might be at
play in somebody's experienceand that really does relate to
the sort of things I wasinterested in really quite early
on so when I was little, I usedto want to be an astronaut, but
I didn't just want to be anastronaut.
I wanted to be a fashiondesigning astronaut.
(03:15):
So it's like a Neil Armstrongmeets Vivian Westwood sort of
love child type thing.
I don't really know.
And I'm talking about when I wasabout six here.
And one of the things that kindof really inspired that was I
went to Houston in the States toNASA headquarters.
And we went to, in NASAheadquarters, they had the
(03:35):
cinema experience, Cinematicexperience where you could see
the earth rising so it's thatreally famous image where
pictures were taken from themoon of the earth rising and you
see that beautiful blue planetand I can really clearly
remember it right now of beingstruck by just how beautiful
that was and what has come to meas I've reflected on the sort of
(03:56):
work that I've done is that itwas something about the beauty
that you could access that wasrelated to the technology, the
incredible engineering, theseincredible feats of innovation
that actually got people to themoon and allowed us to look back
on the earth and appreciate thiskind of beauty.
And at the same time, I wasmassively into my Barbie dolls
(04:18):
and my Cindy dolls.
I actually had more of a Cindydoll than Barbie dolls.
And I used to make clothes forthem.
And I used to really enjoythinking about colour and shape
and putting things together so Ihad this real sort of mix of
love of bit of science and thenloving these kind of creative
aspects of things and went downa route like a lot of people
(04:40):
didn't really go down any kindof creative route and went down
that science route and it wasn'twhen I was at Duke and doing
that special program some ofthat really came back to me that
kind of joy of really fantasticideas coming from when you look
at things from all differentperspectives and particularly
utilizing the creative part ofyour brain so when i came back
(05:04):
to medical school in the uk iwas on the usual standard track
of medical school at imperialcollege and i did a piece of
research that was around eeg andconsciousness so we were
recording electrical waves frompeople's brains as we got them
to do a task that encouragedthem to be in different types of
(05:24):
memory states.
And there was somethingdifferent about what they were
recollecting when they werehaving their EEGs measured.
And it allowed us to reallyexplore What could you see in
these deep processes of thingsthat were going on for people?
And that led on later in mycareer to working on Alzheimer's
disease and doing functionalneuroimaging in Alzheimer's.
(05:47):
And again, looking in real time.
What can you understand?
How do you measure what is goingon?
And how does that relate to theexperience that somebody's
having?
And in that particular piece ofwork, the Alzheimer's research
work, that was particularlylooking at ways that we might
test drugs early for Alzheimer'sdisease.
(06:08):
So putting together all thesedifferent kind of strands of
technology and how we use thatto be able to have an impact on
people's experience wassomething that was really
important to me.
I also do need to confess thatI'm a bit of a sci-fi geek.
I have always loved films andstories that are about our
futures.
And as I progressed through mymedical career, And into this
(06:30):
field of liaison psychiatry, Ialways carried with me that
interest of what can technologydo to help us understand
people's experience better?
And what can we do in terms ofinnovation to actually improve
that experience as well?
SPEAKER_01 (06:48):
And what does your work involve now, Leah?
SPEAKER_00 (06:50):
So my work now is a mixture of daily clinical
practice.
So I do work at the South LondonMaudsley in neuropsychiatry,
which means that I work with theneurologists in the acute
physical health hospital andhelp them with management of
people who might be presentingwith all different sorts of
(07:11):
neurological symptom and helpthe clinicians understand all
the factors that might be atplay in somebody's presentation.
And I can talk a little bit moreabout that because it comes very
much into this thing called thebiopsychosocial model.
The other aspect of my work isat NHS England where I work as a
clinical advisor in thetransformation directorate.
(07:33):
So that means working at apolicy level on various programs
of work that are related todigital within healthcare
services.
For example I advise around someaspects of the NHS app and also
around pieces of technologicalinfrastructure structure that we
have for example somethingcalled the shared care record
(07:53):
program it's called the nationalprogram is called the conga
program and i advise on some ofthe clinical and actually the
clinical design aspects of someof those things in terms of
serving the population indigital health care services
SPEAKER_01 (08:07):
so when we were talking before we were talking
about the biopsychosocialapproach and probably there are
people listening who are veryfamiliar with that who work in
health care and know all aboutit but i'm hoping there'll be
people listening coming athealth care from a design
perspective and have lessclinical backgrounds.
So I wondered if you could givea bit of a summary of what the
biopsychosocial approach is andhow it relates to user-centred
(08:28):
design, because I think you'vetalked about lots of parallels
between those two things.
SPEAKER_00 (08:32):
Sure.
So the biopsychosocial approach,as the name suggests, it's made
up of biological, psychologicaland social.
And it really relates tothinking about somebody from all
of those different perspectives.
So to give an example, someonewith, say, rheumatoid arthritis
which is an autoimmunecondition.
(08:52):
That means it's a conditionwhere your immune system is
attacking itself and causessymptoms, for example, like
joint swelling and stiffness.
That's the biological componentof rheumatoid arthritis.
However, we also know thatpeople who experience rheumatoid
arthritis have a psychologicalcomponent to what they're
experiencing.
So pain is a key component ofsomething like this condition.
(09:17):
And pain has a huge...
psychological aspect to it weknow that there is this
confluence of things happeningfor somebody you might have
chemicals floating around inyour joints that's the
biological part which causes thejoint swelling and stiffness and
this causes pain but theexperience of that pain is very
(09:37):
much informed by yourpsychological makeup some of
that is in kind of your earlychildhood some of that is what
you're experiencing in thepresent moment and it can be
precipitated by certain thingsAnd this is where your social
context is really quiteimportant as well.
For example, we might managesomebody with rheumatoid
arthritis who is a concertpianist and who the impact on
(10:02):
their job of having jointstiffness in their hands is
quite different to somebody elsewho has a different type of role
and a different type of jobwhere their symptoms may affect
them differently.
This affects all of how somebodypresents with what they're
experiencing.
To give you another example, Weoften think about somebody's
presentation and how somebodypresents with what they come to
(10:24):
the doctor or the nurse or anyclinician in terms of what might
have triggered it.
And again, these factors can bebiological, they can be
psychological, or they can besocial.
We know, for example, thatstress is a huge precipitant of
flares of all sorts of long-termconditions.
We know there's a relationshipto heart attacks.
We know there's a relationshipto getting stomach ulcers, etc.
(10:47):
And we know that the actualexperience of that who is likely
to get that heart attack isaffected again by this
interaction between thesebiological, psychological and
social factors.
Take, for example, heart attacksand cardiovascular disease.
Yes, you might be in a stressfuljob, but if you are somebody
who's got a family history and agenetic predisposition to, for
(11:09):
example, lay down more blockageswithin your arteries and your
vessels, you are more likelythen to have that outcome of the
stressful situation be somethinglike an end point, like a
cardiovascular symptom, like aheart attack or a stroke.
We know that, for example, inpeople who experience diabetes,
(11:30):
that if we think about them interms of all of these different
biological, psychological andsocial factors in their makeup,
we're much more likely to beable to help them manage their
blood sugar levels better andalso stave off some of the
long-term outcomes of havingdiabetes where you get damage to
the end organs.
(11:50):
So there's a lot of power inthis biopsychosocial model.
One of the reasons we don't heara lot about it, especially in
Western cultures, is because weactually have a health system
which is really quitemedicalised.
we've tended to focus very muchon the biological component and
this is the bit where i getusually a little bit
philosophical and say it's alittle bit to do with descartes
(12:11):
and this idea that the mind andthe body are separate so the
descartes quote is i thinktherefore i am and what's
embedded in that phrase is thisseparation between mind and body
so for us who follow abiopsychosocial model it's this
split between the psychosocialand the biological and we know
(12:31):
that healthcare services thatonly focus on the medicalised
bit or the biological bit missout these major components of
people's experience.
And that's often what people areexpressing in user research.
So in the digital work that Ihave been doing in multiple
different pathways and wherethat touches on user-centred
design, I can often hear inhealth stories that come from
(12:55):
the UCD, the user-centred designperspective on things, that have
all of these components of thepsychological a social context
of somebody which hasn'tnecessarily been taken into
account into how that interplayswith someone's experience.
So for example, the example Igave you first around rheumatoid
arthritis, if when we'rethinking about how somebody
(13:17):
might interact with rheumatologyservices in a clinic and we
don't think about how they canaccess that or what might have
caused a particular flare forthem, what's going on, have they
lost their job, have they had totake sick leave, do they have a
comorbidly existing so anexisting at the same time
condition like anxiety anddepression which happens a lot
(13:38):
for people with certain types ofconditions actually about 30 to
40 percent of the people withrheumatoid arthritis alone have
also have an anxiety ordepressive disorder then we're
not going to be able to planthat care for somebody properly
and in some of the work thati've done particularly something
called the imparts program atking's health partners
integrating mental and physicalhealth research training and
(14:00):
service this is exactly theapproach we took to looking at
services and incorporating thatinto the service design so for
example in the rheumatoidarthritis pathway in the imparts
model the team instituted aservice design where we knew
from the evidence base 30-40% ofthose people were likely to have
(14:23):
this anxiety or depressivedisorder and it was all about
picking that up so the idea waswhen you're sitting in the
waiting room and you're havingyour blood pressure and your
upholstery checked, you shouldalso be having your kind of
mental health vital signs beingchecked at the same time.
And lo and behold, we surfacedthe 30 to 40% of those people
that do have those symptoms.
And we were able to flag thatand design that service so that
(14:46):
it flagged that to everyone.
The other users within thatpathway, which were the physical
healthcare clinicians, so therheumatology doctors, the
rheumatology nurses, who don'tnecessarily get formal training
in the full breadth of thepsychosocial factors.
So what this allowed us to dowas to help those teams of
people say, recognise thatsomething was happening and also
(15:09):
give them pathways to say, okay,the patient you're seeing is
experiencing, this suggests thatperhaps an anxiety disorder is
going on, or perhaps adepressive disorder is
occurring, you may need to referthem to your team psychologist
and this is how you do it.
Or you may need to talk to themabout emergency or crisis help
(15:29):
for their mental healthcondition.
So starting to treat all of thethings that somebody is
experiencing together.
And this often gets neglected inthe highly acute hospital
specialist structures.
It's part of this verymedicalised model that we have.
The other part that's reallyquite important to understand is
that when interactions are verytransactional and very
(15:53):
paternalistic, it's really hardto surface those biopsychosocial
experiences because the model isvery much geared towards just
surfing the biological piece andjust addressing the biological
piece.
Chronic pain is one of thebiggest examples of this.
So if you take something likeback pain, we know that the
(16:14):
majority of services are gearedaround and people's expectations
are geared around perhapsreceiving pain medication, a
tablet to fix it, or a surgicalintervention, for example, to
fix their back pain.
Actually, we know that thecauses of back pain are numerous
and they all fit within thesethree domains, biological,
psychological and social, andthey interplay.
(16:37):
So you can have somebody whomaybe has a particular
anatomical variation in howtheir back is constructed.
And if they are in a stressfuljob and they're holding
themselves in a particularposition then that is much more
likely to trigger off an episodeof back pain or a flare and that
actually the the treatment forthat it might include painkiller
(17:00):
medication but actuallyphysiotherapy is going to be
really important and keepingactive is going to be really
important for keeping you wellin the longer term but that
complexity of factors is oftenreally difficult to surface and
the system the medicalization ofthe system doesn't always allow
for that to really be exploredwhich is then where we get some
(17:20):
deficits.
SPEAKER_01 (17:21):
So the problem that the biopsychosocial approach can
solve is that we're only lookingat part of the problem through
our traditional medicalapproach.
SPEAKER_00 (17:31):
Yeah I often the one of the analogy I use especially
when I'm teaching medicalstudents and healthcare
professionals is it's like abeautiful Persian carpet and
that often people bring us sortof little threads of what's
going on for them and especiallyif they're in a distressed state
these are very jumbled up Andone of our jobs is to try and
see that.
(17:51):
It makes me think of that storyabout seeing the earth rising
over the moon is that the beautycomes out when you are able to
help somebody make sense of thatand you're able to help them and
empower them within what they'reexperiencing to understand.
Oh my goodness, when I amexperiencing stress in my role,
I am holding myself in aparticular way, which is
(18:14):
exacerbating that disc prolapsethat I had five years ago.
And oh look, my disc hasprolapsed again.
And it's not one thing, it'smultiple things going on for me.
So when I then think about how Ican address that, it's
addressing all those factors.
Some of them might be out of mycontrol.
I may not be able to change mywork situation, for example.
But one thing I can do is I canchange my response.
(18:35):
I can be aware of my I can makesure I'm hydrated.
I can do what I need to do tochange my work situation or my
psychological response to that.
These will all have huge impactson what my actual health
experience is.
SPEAKER_01 (18:48):
How does this approach link in with
person-centred care?
Is it all part of the same
SPEAKER_00 (18:52):
thing?
Yeah, so person-centred care isdefinitely another way of
describing a biopsychosocialapproach.
So in NHS England, in thepersonalised care directorate,
that personalised care policy isvery deliberately imbued with a
biopsychosocial focus.
And you tend to see abiopsychosocial approach from
(19:13):
the types of specialty, clinicalspecialty, which deal with that
full experience of people.
So people who work in palliativecare, for example, or certain
types of general practice, careof the elderly medicine in
frailty pathways, where we'relooking at all the interplay of
these factors.
SPEAKER_01 (19:31):
So user-centred design is all about putting the
person at the centre of thedesign of the system or the
service that you're designing.
One of the principles ofuser-centred design is also
around iteration.
Does that relate to what you'retalking about as well?
SPEAKER_00 (19:42):
Yeah, absolutely.
So I often talk about that asthe ability to sit with
uncertainty.
And in a lot of very medicalisedspecialties, That's not really
what we're doing.
We have a particularmethodology, a scientific
methodology, null hypothesistesting, where you're doing
(20:03):
experimentation in a way thatdoesn't sit with uncertainty.
And it's one of the biggestthings I've seen as being a real
revelation to me on my designjourney, actually, is that
within processes that come froma creative origin, there is much
more of that willingness to sitwith uncertainty.
as compared to processes thathave a science or an engineering
(20:26):
origin.
And I see it as being reallyexciting when you do both.
You can really get into a spacewhere real innovation happens.
One of the other models that Ioften talk about that helps me
really think about thisparticular space is something
called the Kenefin model, whichis a model of information
management, actually, and how wedo decision making.
(20:47):
And the idea of that, as anorganisational psychologist
called David Snowden, and theidea of that is that you've got
this kind of two by two matrixand you've got information in
different domains within thattwo by two matrix you've got one
level simple where it's reallyobvious you know what you need
to do the relationships are verylinear then the one above that
(21:08):
on the sort of top right iscomplicated and this is where
scientific experimentation sitsit's where there's things you
don't know but you set ahypothesis you assume that the
relationship is linear and thenyou use your methods to test
that assuming a linearrelationship That's where most
of academic medicine sits,actually.
And that's where clinical trialsand all those sorts of ways of
(21:33):
looking at something sit.
Then next to that, you've gotthe complex space.
And this is much more where Isee the sort of design processes
and design research methodologysitting, actually, where you've
got that uncertainty and you usemore of that probe test respond
type way of looking at things.
(21:53):
And we don't tend to utilisethat enough, in my view.
view on the kind of academicmedicine driven side of things.
And this is again where I'veseen some really interesting
things happen where you start touse that, you start defining
provocations and experimentationthat actually allows you to
explore the uncertainty.
The problem we have in clinicalmedicine is that we have big
(22:16):
risks.
So it's always really hard to dothat.
If you say sit with uncertainty,that's really hard when you're
talking about that people mightdie or lose a leg or the
boundaries are difficult to dealwith.
And I think that's what hasallowed people to go down that
very conservative, the veryconservative line.
But I do think when we worktogether, we can probably find
(22:38):
ways to do that sort of testingsafely, but accepting that we
are going to have to accept adegree of uncertainty and to to
be able to get to the best fitanswers.
And the box below is the onecalled chaotic, where nothing
makes any sense and all theunknowns are unknowns.
You're in a whole world of pain.
That's generative AI.
SPEAKER_01 (22:58):
We won't get onto AI.
That's the next one.
Now, the approach you've justbeen describing is about the
intersection of design andhealthcare.
Is this an approach that'sbecoming more common across the
health system?
SPEAKER_00 (23:09):
I think it is becoming more common.
So what already has quite a lotof purchase is the kind of
continuous improvementmethodology.
So quality improvement andcontinuous improvement.
And what a lot of people aren'tnecessarily, on the NHS side,
aren't aware of, so I'm talkingit's quite UK centric in terms
of improvement methodologiesthat the NHS uses, is that
actually, specificallycontinuous improvement is one in
(23:32):
a whole bag of methods that sitwith the design research
umbrella and for me it's quitehaving been so I'm on a Masters
in Healthcare and Design at theRoyal College of Art and
Imperial and this is where I'vereally developed my
understanding of where thesemethodological differences are
between a designer and atechnology led approach and I do
see as people trying to tacklethese hard problems these wicked
(23:53):
problems the call for more ofthe more ways of actually trying
to get to the nub of what'sgoing on what I think is really
important is helping people tounderstand where there might be
fundamental barriers.
So it's things like acceptingthat the current system we have
is medicalised.
It's not biopsychosocial.
(24:14):
It's accepting it is prettypaternalistic.
It is not as collaborative as weneed it to be.
And so embracing, acknowledgingthat first and then embracing
new methodologies, I think leadsus to a really exciting place.
SPEAKER_01 (24:26):
You told me a really interesting story earlier when
we were speaking around a placethat kind of this approach had a
real impact in some of yourwork.
SPEAKER_00 (24:33):
So right at the beginning of my digital health
career, I was working as aregistrar in South London, a
psychiatry registrar, and I wasasked to give some advice on a
programme of work that was beingled by the Service User Research
Academic Group, so all peoplewho were experiencing mental
illness.
And they were working with thehospital IT department and they
(24:57):
were also working with, thegroup of patients they were
working with all have severemental illness.
Now, people with severe mentalillness have a really raised
risk of physical health issuestoo.
People with SMI, severe mentalillness, are at risk of
somewhere between 13 to 20 yearsof their life being lost
compared to the average personin the population.
(25:19):
And this isn't death by thingslike ending their life by
suicide, which is a commonconnection people make for
people with SMI.
This is all causes all types ofphysical illness so there's
something going on there aboutwhy people with SMI why their
physical health isn't beingaddressed and in this patient
group that we were working withwe had people for example with
(25:41):
severe mental illness such asbipolar affective disorder whose
history of contact with serviceswas very much one of being very
paternalistic sometimes verycoercive so people who had been
detained say two three times Iunder the Mental Health Act and
had their human liberties takenaway and who had to basically
(26:03):
come to hospital against theirwill to receive treatment when
having a mental illness andbeing very unwell.
And they also had physicalhealth issues.
So I'm thinking of particularpatients who had, for example,
raised blood pressure andworking with them to actually do
things like measure their bloodblood pressure to do a wi-fi
enabled blood pressure cuff andat the same time encouraging
(26:26):
them in a very psychologicallyminded approach to be looking at
symptoms of their mental illnessof their bipolar affective
disorder allowed certainindividuals to start to really
track what was happening to themand we had examples from that
work of people who for the firsttime ever in their lives took
(26:47):
themselves back to their GP andhad their blood pressure
measured measured and theirraised blood pressure treated
and at the same time were ableto see that actually perhaps
some of their mood scores weregoing off and perhaps they
needed their medication checkingfor the the medication that
helped to keep their mood stablepart of their treatment plan I
(27:08):
mean this is huge these arepeople who had just not wanted
to have any contact withservices at all actually being
able to take control and be muchmore empowered and active in
their and do things on theirterms.
So one of the kind of key hooksfor this work was understanding
and taking into that kind ofunderstanding the
(27:29):
biopsychosocial drivers forpeople was that the mental
illness and the symptoms that weas clinicians might recognise,
that wasn't a problem for aparticular individual.
What was the problem for themwas was their blood pressure and
that was something they werewilling to engage with and being
able to give them ways that theycould manage that for themselves
(27:52):
and restart their relationshipwith health services on a
different footing made probablymade all the difference to being
admitted or not under section atthe next time so really we're
talking really huge outcomespossibly for people and I often
that it was seminal that workfor me because it's really
driven home my feelings thatdigital is potentially an
(28:15):
enabler for a biopsychosocialmodel of care.
I talk about it as a bit of aTrojan horse.
We know that Trying to change avery medicalised system and a
paternalistic system is hard,but digital services sit right
next to the user.
And if we are taking a user-ledapproach to those services, then
this is absolutely the righttime to be able to change the
(28:38):
models of how we approach that.
SPEAKER_01 (28:40):
You've talked about the potential of digital to have
huge impact through thisuser-centred approach and
through aligning with thebiopsychosocial approach.
There's this risk that we losethe human touch a bit when
everything starts going digital.
Is that something that you'vethought about much?
And do you have ideas aroundways that we can mitigate that?
SPEAKER_00 (28:57):
Yeah, I think that's, again, really important.
And it's a big reason why Ithink we need to really
understand what that user needis and think about something
called therapeutic relationship.
So what I think is oftenunderplayed is the role of the
therapeutic relationship insomeone's healthcare experience.
(29:18):
And therapeutic relationship,very simply, is the relationship
that somebody has with anotherhuman who has some kind of
involvement in their healthcareprovision.
And as you just said, there is areal risk as we digitise
services that we remove thatentirely.
And I don't think we fully knowwhat it means yet if we do
(29:38):
remove that entirely.
On the one hand, there is thisvery real risk that we lose this
kind of key component of humaninteraction and actually we end
up with services that just don'tserve people as it should do.
There are also opportunitieshere to actually engage with
(29:59):
people in a different way.
(30:27):
system key performanceindicators for example
attendance at A&E or attendanceat GP surgeries etc numbers of
flares and in conceptualclinical conceptual terms one of
the ways we talk about that isthinking about patient facing
services as needing to haveembedded what we know works from
a supported self-managementperspective and that means
(30:49):
understanding somebody from abi-psychosocial perspective it
also means understanding what inyour service needs to be there
to drive the behaviour thatyou're trying to drive, whether
it's taking up certainappointments or engaging in an
exercise, whatever it is thatyou're trying to do.
And understanding that deeplyand understanding which pieces
(31:11):
of that, in order to addressthat person's need, which pieces
of that are appropriate andethical to be replaced by a
fully digitised service andwhich pieces, is it much better
that we have an adjunct, we havesomething that improves
advocacy, for example, orself-advocacy, and then actually
allow somebody to engage withthe bits of the service that
they need.
(31:32):
And I think the more that weexplore that and the more open
we are to different ways ofdelivering care, the more
innovation we're going to havearound this and we'll come to
new ways of thinking aboutthings.
Within this, I do not think wecan ever get away, and I don't
think we should personally, fromunderstanding that people need
(31:53):
that human contact and that is akey part of that therapeutic
relationship, however you'redelivering it.
And I think it is a realresponsibility that we have to
design service is so they areblended and so that they can
provide to that becauseotherwise we run the risk of
just making things just not workfor people and that's not what
we want.
SPEAKER_01 (32:15):
Prevention is a big focus at the moment.
Do you have ideas around theways that digital and the
biopsychosocial model can beapplied in that context?
SPEAKER_00 (32:23):
Yeah, I think there are lots of opportunities here
because where we talk aboutsomeone's context being
important to what they'reexperiencing, we've got so many
ways of understanding what'sgoing on around us that's just
way more than me as a doctor ina clinic seeing somebody for 20
minutes or whatever or 10minutes.
I couldn't possibly have accessto all that information about
(32:45):
somebody that somebody mighthave from all the different
digital interactions that we nowhave.
So I think there is hugeopportunity there.
Everything from kind of ambientmonitoring through to very
specific things.
For example, I saw a piece ofwork around measurement of mood.
So I talked a little bit aboutin one of the pieces of work in
(33:06):
the Imparts piece of work, howwe use some mood scoring
surveys, questionnaires.
And like any questionnaire,There is an element of barrier
around that.
You have this time it takes forsomebody to do that.
It's a very specific thing.
And we are starting to have waysto be able to get that same
measure about somebody's mood,anxiety or depression experience
(33:30):
from, say, two minutes of speechusing natural language
processing models ofcharacteristics that are within
speech itself.
This is really exciting becauseit means that you're going to be
able to start start surfacingwhat could be a problem for
somebody.
It could be impacting, say,their joint stiffness, their
experience of their arthritis.
(33:51):
We talked about arthritisalready.
That they may not be aware of,that they're not even aware of.
So if you're not aware of it,you can't even start to find
help for it.
But if there are different waysthat we can start to help people
understand, be more connected towhat is going on for them, that
(34:13):
gives us lots of opportunitiesfor people to intervene early
for themselves.
That is prevention.
And I think there's hugeopportunities here.
SPEAKER_01 (34:21):
It sounds like you're really excited for the
future of health and care in oursystem.
SPEAKER_00 (34:25):
Yeah, it's that sci-fi geek in me coming through
again.
SPEAKER_01 (34:28):
Where do you see it going in five, ten years' time?
Can you see major changes?
SPEAKER_00 (34:33):
I don't know if I can see major changes.
I think we're seeing alreadythat the sort of digital
experience people are able tohave now is raising people's
expectations of what any digitalservice should provide.
And it is also empowering peopleI think, to take more control of
what is happening to them.
(34:54):
And as you know yourself more,as you know what happens to you
more, so I think very much ofthe kind of quantified self
group that I spoke to some ofthem many years ago who were
using the very earliest sensesand monitors to understand that.
I mean, we can do that, a bunchof that, through the watch on
our wrist now.
As we get better and better atunderstanding ourselves, what a
(35:17):
particular change means andcorrelating that, for example,
people with asthma who arewalking into an area where there
is greater pollution and willknow what their risk is and can
maybe take particular measures.
I think we're going to see moreand more creep of these using
the data more effectively topersonalise somebody's
(35:39):
intervention and somebody beingable to do that for themselves
and drive those behaviours forthemselves.
So I see it as being a veryconnected experience it's not
going to be one particular appit's not going to be one
particular sensor it is what wedo with all of that wealth of
information and why those thosearchitectures that we are
(35:59):
beginning to put in place nowaround that data needs to be
open enough to allow thatinnovation to come through
SPEAKER_01 (36:07):
can you tell me a bit about what you're working on
at the moment yeah
SPEAKER_00 (36:09):
Well, there's something that I was working on,
which I think is a really goodexample of where taking a
biopsychosocial approach has thepotential to really change how
we deliver care and do that in amore person-centred and holistic
way.
So in the spring budget lastyear, there was a call for
services that will run throughthe national digital channels
(36:33):
that provide access to servicesand digital tools that can help
people with musculoskeletalconditions and mental health
conditions.
And we started a bit of workaround musculoskeletal
conditions first, soparticularly thinking about
people with back pain.
And one of the things that'sreally important to understand
is What is the analogy toclinical care?
(36:57):
What does it mean when we aredelivering a service through a
digital channel where we aretrying to drive certain health
behaviours and where there mightnot be a human in the loop,
actually?
And what can we do there?
So one of the things that wedid, and I worked really closely
with Andy Bennett, who was theNational Clinical Director for
Musculoskeletal Conditions andsome of the National Channels
(37:20):
teams, we really tried to embedprinciples like a bias like a
social model of care within thethinking around the service
design.
So rather than simply thinkingabout, say, a jump off to an
external third partyapplication, what's also really
important to consider is whatthat service wrapper looks like
(37:41):
and how you think about whatsomebody's experience is who
might be looking for this typeof help, this type of service.
So in my clinical practice, Whatoften happens is that say
somebody who is seeking help forback pain, they'll go straight
to the medicalised answerbecause that's what they're
(38:01):
expecting.
That's what the system actuallyhas.
And we often have to go through,and this is the way, you know,
so if you talk to Andy and youtalk to physiotherapists who
work in this space, there is asort of, there is a clinical
role that we do where we helppeople understand their
biopsychosocial experience oftheir back pain.
(38:23):
which helps identify what causedit, what the triggers might be
and what's likely to perpetuateit, to keep it going.
If you translate that intodigital terms, what does that
mean?
That's what we were working on.
How do you try and create aservice that allows people to do
that bit of discovery themselvesand then actually helps them get
(38:45):
into the right service orintervention that is going to
help them take that forward?
It might be something aboutexercise, but it could ease also
for back pain, also be somethingaround sleep.
We know, for example, thatpeople who have some kind of
issue with their sleep, sayinsomnia, are going to be more
likely to get back pain becausethere's a relationship and
(39:05):
there's a loop there with howyou are repairing and renewing
your muscles and your ligaments.
And that makes you more likelyto have an ongoing pain syndrome
with an acute injury, forexample, or for an old injury to
flare up again.
It could be something to do withyour nutrition level or it could
be something to do with otherillnesses that you have if you
(39:29):
are somebody who has an anxietyor a depressive disorder we know
that treating the anxiety or thedepression also helps you with
your back pain so theresponsibility in a digital
service that we build like thathas to take that into account
and has to in order to be ableto really improve on people's
(39:50):
health outcomes and alsocrucially to um help with system
key performance indicators thatI talked about before it has to
take that approach ofconsidering all those factors
and incorporating that withinthe design that's something I'm
really quite excited about thatthat approach becomes more and
more of a way of thinking aboutwe're not thinking about the IT
(40:11):
piece as just a nice to have ora little add on it is the
service itself and it comes backto that discussion that we had
before when you take the humanout of the loop what things can
you replace What things can youdo differently?
What things do you have toaccount for because you can't
replace them and you need tomake sure that people have
access to that aspect of humaninteraction?
SPEAKER_01 (40:33):
What's next for you, Leah?
What are you excited about atthe moment?
SPEAKER_00 (40:36):
Oh, there's lots of things I'm excited about.
I am really excited about theway that in the pieces of work
that I'm involved in, we'rebeing able to do more around
this transdisciplinary mappingfrom the evidence base, the
clinical evidence base, to userinsights in various pieces of
(40:57):
work.
And that's starting to show realvalue in addressing need and
being able to inform the way wemight build services going
forward.
That's That's really excitingbecause it feels like we are
getting to a place where wemight really be able to deliver
person-centred care that istruly holistic and
(41:17):
biopsychosocial and where we'restarting to see collaborative
relationships around design ofproducts and services that are
showing us where there areopportunities to use the data
more effectively, to make surethings are useful and usable and
that actually really do impactpeople's health outcomes.
(41:39):
That's what I'm excited about.
It feels like a moment wherethese sort of worlds are
properly coming together.
They've overlapped.
But actually, people arestarting to see the value of
when you do this workcollaboratively.
SPEAKER_01 (41:52):
Fantastic.
Thank you, Leah.
That's a really interestingdiscussion.
Thanks for taking the time tocome and talk to me.
SPEAKER_00 (41:56):
Thank you for having me.
UNKNOWN (41:59):
Thank you.
SPEAKER_01 (42:07):
Thank you.
Thank you.
Thank you.
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