SPEAKER_01: 0:00

Welcome to Problems Worth Solving, the podcast where we explore transformative approaches in health and care through the lenses of human-centered design, service design and digital. I'm Sam Mentor, Managing Director at Healthier, the service design and digital innovation consultancy. Find us at healthier.services. Join me as I speak with the people shaping the way health and care is delivered. Leaders and changemakers from public health, not-for-profit, health tech, and life sciences. We'll explore how putting people at the heart of service design can drive impactful change. In each episode, we'll share insights and inspiration from real-world examples, like using co-design techniques to improve mental health services, or digital tools that empower patients to take control of their care. In this month's episode, I'm joined by Dr. Leah Arley, Leah is a consultant psychiatrist and she's a clinical advisor at NHS England in the Transformation Directorate. So Leah, welcome and thank you for joining Problems Worth Solving. Today we're going to talk a bit about the overlap between design and healthcare and look at some of the links between the biopsychosocial approach that you're going to tell us more about and user-centered design. But before we go into that detail, I'd love to know a bit more about your background and how you came to be in this role.

SPEAKER_00: 1:26

Hi, Sam. Thank you very much for having me. It's really nice to be here talking about myself. That is always a favourite subject. So I'm a doctor. I qualified. back in 2002. And I am sub-specialised. I'm specialised in an area called liaison psychiatry, which means that I look after patients who are under the care of medics or surgeons. And it means I've always been looking after people or dealing with people who have problems that kind of are the interface of all those different issues. And why did I get into that field of work? I am a Croydon girl, very proudly South London. And in the area where I lived, the There was lots of different things going on for me, lots of different things that I was interested in. And in particular, I had a very early interest in memory, actually. So when I left school, I went on a really quite special experience. I was lucky enough to go to Duke University in the United States and on a special program called Exploring the Mind. And that program allowed you to study various topics like memory and language from multiple perspectives. So from neurobiological perspectives from linguistics from philosophical perspectives and from cultural anthropological perspectives so really quite a lot frankly for an 18 year old freshman living in a new country but really interesting I really enjoyed it and it really gave me an appreciation of the different sorts of things that might be at play in somebody's experience and that really does relate to the sort of things I was interested in really quite early on so when I was little, I used to want to be an astronaut, but I didn't just want to be an astronaut. I wanted to be a fashion designing astronaut. So it's like a Neil Armstrong meets Vivian Westwood sort of love child type thing. I don't really know. And I'm talking about when I was about six here. And one of the things that kind of really inspired that was I went to Houston in the States to NASA headquarters. And we went to, in NASA headquarters, they had the cinema experience, Cinematic experience where you could see the earth rising so it's that really famous image where pictures were taken from the moon of the earth rising and you see that beautiful blue planet and I can really clearly remember it right now of being struck by just how beautiful that was and what has come to me as I've reflected on the sort of work that I've done is that it was something about the beauty that you could access that was related to the technology, the incredible engineering, these incredible feats of innovation that actually got people to the moon and allowed us to look back on the earth and appreciate this kind of beauty. And at the same time, I was massively into my Barbie dolls and my Cindy dolls. I actually had more of a Cindy doll than Barbie dolls. And I used to make clothes for them. And I used to really enjoy thinking about colour and shape and putting things together so I had this real sort of mix of love of bit of science and then loving these kind of creative aspects of things and went down a route like a lot of people didn't really go down any kind of creative route and went down that science route and it wasn't when I was at Duke and doing that special program some of that really came back to me that kind of joy of really fantastic ideas coming from when you look at things from all different perspectives and particularly utilizing the creative part of your brain so when i came back to medical school in the uk i was on the usual standard track of medical school at imperial college and i did a piece of research that was around eeg and consciousness so we were recording electrical waves from people's brains as we got them to do a task that encouraged them to be in different types of memory states. And there was something different about what they were recollecting when they were having their EEGs measured. And it allowed us to really explore What could you see in these deep processes of things that were going on for people? And that led on later in my career to working on Alzheimer's disease and doing functional neuroimaging in Alzheimer's. And again, looking in real time. What can you understand? How do you measure what is going on? And how does that relate to the experience that somebody's having? And in that particular piece of work, the Alzheimer's research work, that was particularly looking at ways that we might test drugs early for Alzheimer's disease. So putting together all these different kind of strands of technology and how we use that to be able to have an impact on people's experience was something that was really important to me. I also do need to confess that I'm a bit of a sci-fi geek. I have always loved films and stories that are about our futures. And as I progressed through my medical career, And into this field of liaison psychiatry, I always carried with me that interest of what can technology do to help us understand people's experience better? And what can we do in terms of innovation to actually improve that experience as well?

SPEAKER_01: 6:48

And what does your work involve now, Leah?

SPEAKER_00: 6:50

So my work now is a mixture of daily clinical practice. So I do work at the South London Maudsley in neuropsychiatry, which means that I work with the neurologists in the acute physical health hospital and help them with management of people who might be presenting with all different sorts of neurological symptom and help the clinicians understand all the factors that might be at play in somebody's presentation. And I can talk a little bit more about that because it comes very much into this thing called the biopsychosocial model. The other aspect of my work is at NHS England where I work as a clinical advisor in the transformation directorate. So that means working at a policy level on various programs of work that are related to digital within healthcare services. For example I advise around some aspects of the NHS app and also around pieces of technological infrastructure structure that we have for example something called the shared care record program it's called the national program is called the conga program and i advise on some of the clinical and actually the clinical design aspects of some of those things in terms of serving the population in digital health care services

SPEAKER_01: 8:07

so when we were talking before we were talking about the biopsychosocial approach and probably there are people listening who are very familiar with that who work in health care and know all about it but i'm hoping there'll be people listening coming at health care from a design perspective and have less clinical backgrounds. So I wondered if you could give a bit of a summary of what the biopsychosocial approach is and how it relates to user-centred design, because I think you've talked about lots of parallels between those two things.

SPEAKER_00: 8:32

Sure. So the biopsychosocial approach, as the name suggests, it's made up of biological, psychological and social. And it really relates to thinking about somebody from all of those different perspectives. So to give an example, someone with, say, rheumatoid arthritis which is an autoimmune condition. That means it's a condition where your immune system is attacking itself and causes symptoms, for example, like joint swelling and stiffness. That's the biological component of rheumatoid arthritis. However, we also know that people who experience rheumatoid arthritis have a psychological component to what they're experiencing. So pain is a key component of something like this condition. And pain has a huge... psychological aspect to it we know that there is this confluence of things happening for somebody you might have chemicals floating around in your joints that's the biological part which causes the joint swelling and stiffness and this causes pain but the experience of that pain is very much informed by your psychological makeup some of that is in kind of your early childhood some of that is what you're experiencing in the present moment and it can be precipitated by certain things And this is where your social context is really quite important as well. For example, we might manage somebody with rheumatoid arthritis who is a concert pianist and who the impact on their job of having joint stiffness in their hands is quite different to somebody else who has a different type of role and a different type of job where their symptoms may affect them differently. This affects all of how somebody presents with what they're experiencing. To give you another example, We often think about somebody's presentation and how somebody presents with what they come to the doctor or the nurse or any clinician in terms of what might have triggered it. And again, these factors can be biological, they can be psychological, or they can be social. We know, for example, that stress is a huge precipitant of flares of all sorts of long-term conditions. We know there's a relationship to heart attacks. We know there's a relationship to getting stomach ulcers, etc. And we know that the actual experience of that who is likely to get that heart attack is affected again by this interaction between these biological, psychological and social factors. Take, for example, heart attacks and cardiovascular disease. Yes, you might be in a stressful job, but if you are somebody who's got a family history and a genetic predisposition to, for example, lay down more blockages within your arteries and your vessels, you are more likely then to have that outcome of the stressful situation be something like an end point, like a cardiovascular symptom, like a heart attack or a stroke. We know that, for example, in people who experience diabetes, that if we think about them in terms of all of these different biological, psychological and social factors in their makeup, we're much more likely to be able to help them manage their blood sugar levels better and also stave off some of the long-term outcomes of having diabetes where you get damage to the end organs. So there's a lot of power in this biopsychosocial model. One of the reasons we don't hear a lot about it, especially in Western cultures, is because we actually have a health system which is really quite medicalised. we've tended to focus very much on the biological component and this is the bit where i get usually a little bit philosophical and say it's a little bit to do with descartes and this idea that the mind and the body are separate so the descartes quote is i think therefore i am and what's embedded in that phrase is this separation between mind and body so for us who follow a biopsychosocial model it's this split between the psychosocial and the biological and we know that healthcare services that only focus on the medicalised bit or the biological bit miss out these major components of people's experience. And that's often what people are expressing in user research. So in the digital work that I have been doing in multiple different pathways and where that touches on user-centred design, I can often hear in health stories that come from the UCD, the user-centred design perspective on things, that have all of these components of the psychological a social context of somebody which hasn't necessarily been taken into account into how that interplays with someone's experience. So for example, the example I gave you first around rheumatoid arthritis, if when we're thinking about how somebody might interact with rheumatology services in a clinic and we don't think about how they can access that or what might have caused a particular flare for them, what's going on, have they lost their job, have they had to take sick leave, do they have a comorbidly existing so an existing at the same time condition like anxiety and depression which happens a lot for people with certain types of conditions actually about 30 to 40 percent of the people with rheumatoid arthritis alone have also have an anxiety or depressive disorder then we're not going to be able to plan that care for somebody properly and in some of the work that i've done particularly something called the imparts program at king's health partners integrating mental and physical health research training and service this is exactly the approach we took to looking at services and incorporating that into the service design so for example in the rheumatoid arthritis pathway in the imparts model the team instituted a service design where we knew from the evidence base 30-40% of those people were likely to have this anxiety or depressive disorder and it was all about picking that up so the idea was when you're sitting in the waiting room and you're having your blood pressure and your upholstery checked, you should also be having your kind of mental health vital signs being checked at the same time. And lo and behold, we surfaced the 30 to 40% of those people that do have those symptoms. And we were able to flag that and design that service so that it flagged that to everyone. The other users within that pathway, which were the physical healthcare clinicians, so the rheumatology doctors, the rheumatology nurses, who don't necessarily get formal training in the full breadth of the psychosocial factors. So what this allowed us to do was to help those teams of people say, recognise that something was happening and also give them pathways to say, okay, the patient you're seeing is experiencing, this suggests that perhaps an anxiety disorder is going on, or perhaps a depressive disorder is occurring, you may need to refer them to your team psychologist and this is how you do it. Or you may need to talk to them about emergency or crisis help for their mental health condition. So starting to treat all of the things that somebody is experiencing together. And this often gets neglected in the highly acute hospital specialist structures. It's part of this very medicalised model that we have. The other part that's really quite important to understand is that when interactions are very transactional and very paternalistic, it's really hard to surface those biopsychosocial experiences because the model is very much geared towards just surfing the biological piece and just addressing the biological piece. Chronic pain is one of the biggest examples of this. So if you take something like back pain, we know that the majority of services are geared around and people's expectations are geared around perhaps receiving pain medication, a tablet to fix it, or a surgical intervention, for example, to fix their back pain. Actually, we know that the causes of back pain are numerous and they all fit within these three domains, biological, psychological and social, and they interplay. So you can have somebody who maybe has a particular anatomical variation in how their back is constructed. And if they are in a stressful job and they're holding themselves in a particular position then that is much more likely to trigger off an episode of back pain or a flare and that actually the the treatment for that it might include painkiller medication but actually physiotherapy is going to be really important and keeping active is going to be really important for keeping you well in the longer term but that complexity of factors is often really difficult to surface and the system the medicalization of the system doesn't always allow for that to really be explored which is then where we get some deficits.

SPEAKER_01: 17:21

So the problem that the biopsychosocial approach can solve is that we're only looking at part of the problem through our traditional medical approach.

SPEAKER_00: 17:31

Yeah I often the one of the analogy I use especially when I'm teaching medical students and healthcare professionals is it's like a beautiful Persian carpet and that often people bring us sort of little threads of what's going on for them and especially if they're in a distressed state these are very jumbled up And one of our jobs is to try and see that. It makes me think of that story about seeing the earth rising over the moon is that the beauty comes out when you are able to help somebody make sense of that and you're able to help them and empower them within what they're experiencing to understand. Oh my goodness, when I am experiencing stress in my role, I am holding myself in a particular way, which is exacerbating that disc prolapse that I had five years ago. And oh look, my disc has prolapsed again. And it's not one thing, it's multiple things going on for me. So when I then think about how I can address that, it's addressing all those factors. Some of them might be out of my control. I may not be able to change my work situation, for example. But one thing I can do is I can change my response. I can be aware of my I can make sure I'm hydrated. I can do what I need to do to change my work situation or my psychological response to that. These will all have huge impacts on 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 is definitely another way of describing a biopsychosocial approach. So in NHS England, in the personalised care directorate, that personalised care policy is very deliberately imbued with a biopsychosocial focus. And you tend to see a biopsychosocial approach from the types of specialty, clinical specialty, which deal with that full experience of people. So people who work in palliative care, for example, or certain types of general practice, care of the elderly medicine in frailty pathways, where we're looking 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 the design of the system or the service that you're designing. One of the principles of user-centred design is also around iteration. Does that relate to what you're talking about as well?

SPEAKER_00: 19:42

Yeah, absolutely. So I often talk about that as the ability to sit with uncertainty. And in a lot of very medicalised specialties, That's not really what we're doing. We have a particular methodology, a scientific methodology, null hypothesis testing, where you're doing experimentation in a way that doesn't sit with uncertainty. And it's one of the biggest things I've seen as being a real revelation to me on my design journey, actually, is that within processes that come from a creative origin, there is much more of that willingness to sit with uncertainty. as compared to processes that have a science or an engineering origin. And I see it as being really exciting when you do both. You can really get into a space where real innovation happens. One of the other models that I often talk about that helps me really think about this particular space is something called the Kenefin model, which is a model of information management, actually, and how we do decision making. And the idea of that, as an organisational psychologist called David Snowden, and the idea of that is that you've got this kind of two by two matrix and you've got information in different domains within that two by two matrix you've got one level simple where it's really obvious you know what you need to do the relationships are very linear then the one above that on the sort of top right is complicated and this is where scientific experimentation sits it's where there's things you don't know but you set a hypothesis you assume that the relationship is linear and then you use your methods to test that assuming a linear relationship That's where most of academic medicine sits, actually. And that's where clinical trials and all those sorts of ways of looking at something sit. Then next to that, you've got the complex space. And this is much more where I see the sort of design processes and design research methodology sitting, actually, where you've got that uncertainty and you use more of that probe test respond type way of looking at things. And we don't tend to utilise that enough, in my view. view on the kind of academic medicine driven side of things. And this is again where I've seen some really interesting things happen where you start to use that, you start defining provocations and experimentation that actually allows you to explore the uncertainty. The problem we have in clinical medicine is that we have big risks. So it's always really hard to do that. If you say sit with uncertainty, that's really hard when you're talking about that people might die or lose a leg or the boundaries are difficult to deal with. And I think that's what has allowed people to go down that very conservative, the very conservative line. But I do think when we work together, we can probably find ways to do that sort of testing safely, but accepting that we are going to have to accept a degree of uncertainty and to to be able to get to the best fit answers. And the box below is the one called chaotic, where nothing makes any sense and all the unknowns 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 just been describing is about the intersection of design and healthcare. Is this an approach that's becoming more common across the health system?

SPEAKER_00: 23:09

I think it is becoming more common. So what already has quite a lot of purchase is the kind of continuous improvement methodology. So quality improvement and continuous improvement. And what a lot of people aren't necessarily, on the NHS side, aren't aware of, so I'm talking it's quite UK centric in terms of improvement methodologies that the NHS uses, is that actually, specifically continuous improvement is one in a whole bag of methods that sit with the design research umbrella and for me it's quite having been so I'm on a Masters in Healthcare and Design at the Royal College of Art and Imperial and this is where I've really developed my understanding of where these methodological differences are between a designer and a technology led approach and I do see as people trying to tackle these hard problems these wicked problems the call for more of the more ways of actually trying to get to the nub of what's going on what I think is really important is helping people to understand where there might be fundamental barriers. So it's things like accepting that the current system we have is medicalised. It's not biopsychosocial. It's accepting it is pretty paternalistic. It is not as collaborative as we need it to be. And so embracing, acknowledging that first and then embracing new methodologies, I think leads us to a really exciting place.

SPEAKER_01: 24:26

You told me a really interesting story earlier when we were speaking around a place that kind of this approach had a real impact in some of your work.

SPEAKER_00: 24:33

So right at the beginning of my digital health career, I was working as a registrar in South London, a psychiatry registrar, and I was asked to give some advice on a programme of work that was being led by the Service User Research Academic Group, so all people who were experiencing mental illness. And they were working with the hospital IT department and they were also working with, the group of patients they were working with all have severe mental illness. Now, people with severe mental illness have a really raised risk of physical health issues too. People with SMI, severe mental illness, are at risk of somewhere between 13 to 20 years of their life being lost compared to the average person in the population. And this isn't death by things like ending their life by suicide, which is a common connection people make for people with SMI. This is all causes all types of physical illness so there's something going on there about why people with SMI why their physical health isn't being addressed and in this patient group that we were working with we had people for example with severe mental illness such as bipolar affective disorder whose history of contact with services was very much one of being very paternalistic sometimes very coercive so people who had been detained say two three times I under the Mental Health Act and had their human liberties taken away and who had to basically come to hospital against their will to receive treatment when having a mental illness and being very unwell. And they also had physical health issues. So I'm thinking of particular patients who had, for example, raised blood pressure and working with them to actually do things like measure their blood blood pressure to do a wi-fi enabled blood pressure cuff and at the same time encouraging them in a very psychologically minded approach to be looking at symptoms of their mental illness of their bipolar affective disorder allowed certain individuals to start to really track what was happening to them and we had examples from that work of people who for the first time ever in their lives took themselves back to their GP and had their blood pressure measured measured and their raised blood pressure treated and at the same time were able to see that actually perhaps some of their mood scores were going off and perhaps they needed their medication checking for the the medication that helped to keep their mood stable part of their treatment plan I mean this is huge these are people who had just not wanted to have any contact with services at all actually being able to take control and be much more empowered and active in their and do things on their terms. So one of the kind of key hooks for this work was understanding and taking into that kind of understanding the biopsychosocial drivers for people was that the mental illness and the symptoms that we as clinicians might recognise, that wasn't a problem for a particular individual. What was the problem for them was was their blood pressure and that was something they were willing to engage with and being able to give them ways that they could manage that for themselves and restart their relationship with health services on a different footing made probably made all the difference to being admitted or not under section at the next time so really we're talking really huge outcomes possibly for people and I often that it was seminal that work for me because it's really driven home my feelings that digital is potentially an enabler for a biopsychosocial model of care. I talk about it as a bit of a Trojan horse. We know that Trying to change a very medicalised system and a paternalistic system is hard, but digital services sit right next to the user. And if we are taking a user-led approach to those services, then this is absolutely the right time to be able to change the models of how we approach that.

SPEAKER_01: 28:40

You've talked about the potential of digital to have huge impact through this user-centred approach and through aligning with the biopsychosocial approach. There's this risk that we lose the human touch a bit when everything starts going digital. Is that something that you've thought about much? And do you have ideas around ways that we can mitigate that?

SPEAKER_00: 28:57

Yeah, I think that's, again, really important. And it's a big reason why I think we need to really understand what that user need is and think about something called therapeutic relationship. So what I think is often underplayed is the role of the therapeutic relationship in someone's healthcare experience. And therapeutic relationship, very simply, is the relationship that somebody has with another human who has some kind of involvement in their healthcare provision. And as you just said, there is a real risk as we digitise services that we remove that entirely. And I don't think we fully know what it means yet if we do remove that entirely. On the one hand, there is this very real risk that we lose this kind of key component of human interaction and actually we end up with services that just don't serve people as it should do. There are also opportunities here to actually engage with people in a different way. system key performance indicators for example attendance at A&E or attendance at GP surgeries etc numbers of flares and in conceptual clinical conceptual terms one of the ways we talk about that is thinking about patient facing services as needing to have embedded what we know works from a supported self-management perspective and that means understanding somebody from a bi-psychosocial perspective it also means understanding what in your service needs to be there to drive the behaviour that you're trying to drive, whether it's taking up certain appointments or engaging in an exercise, whatever it is that you're trying to do. And understanding that deeply and understanding which pieces of that, in order to address that person's need, which pieces of that are appropriate and ethical to be replaced by a fully digitised service and which pieces, is it much better that we have an adjunct, we have something that improves advocacy, for example, or self-advocacy, and then actually allow somebody to engage with the bits of the service that they need. And I think the more that we explore that and the more open we are to different ways of delivering care, the more innovation we're going to have around this and we'll come to new ways of thinking about things. Within this, I do not think we can ever get away, and I don't think we should personally, from understanding that people need that human contact and that is a key part of that therapeutic relationship, however you're delivering it. And I think it is a real responsibility that we have to design service is so they are blended and so that they can provide to that because otherwise we run the risk of just making things just not work for 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 the ways that digital and the biopsychosocial model can be applied in that context?

SPEAKER_00: 32:23

Yeah, I think there are lots of opportunities here because where we talk about someone's context being important to what they're experiencing, we've got so many ways of understanding what's going on around us that's just way more than me as a doctor in a clinic seeing somebody for 20 minutes or whatever or 10 minutes. I couldn't possibly have access to all that information about somebody that somebody might have from all the different digital interactions that we now have. So I think there is huge opportunity there. Everything from kind of ambient monitoring through to very specific things. For example, I saw a piece of work around measurement of mood. So I talked a little bit about in one of the pieces of work in the Imparts piece of work, how we use some mood scoring surveys, questionnaires. And like any questionnaire, There is an element of barrier around that. You have this time it takes for somebody to do that. It's a very specific thing. And we are starting to have ways to be able to get that same measure about somebody's mood, anxiety or depression experience from, say, two minutes of speech using natural language processing models of characteristics that are within speech itself. This is really exciting because it means that you're going to be able to start start surfacing what could be a problem for somebody. It could be impacting, say, their joint stiffness, their experience of their arthritis. We talked about arthritis already. 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 ways that we can start to help people understand, be more connected to what is going on for them, that gives us lots of opportunities for people to intervene early for themselves. That is prevention. And I think there's huge opportunities here.

SPEAKER_01: 34:21

It sounds like you're really excited for the future of health and care in our system.

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 already that the sort of digital experience people are able to have now is raising people's expectations of what any digital service should provide. And it is also empowering people I think, to take more control of what is happening to them. And as you know yourself more, as you know what happens to you more, so I think very much of the kind of quantified self group that I spoke to some of them many years ago who were using the very earliest senses and monitors to understand that. I mean, we can do that, a bunch of that, through the watch on our wrist now. As we get better and better at understanding ourselves, what a particular change means and correlating that, for example, people with asthma who are walking into an area where there is greater pollution and will know what their risk is and can maybe take particular measures. I think we're going to see more and more creep of these using the data more effectively to personalise somebody's intervention and somebody being able to do that for themselves and drive those behaviours for themselves. So I see it as being a very connected experience it's not going to be one particular app it's not going to be one particular sensor it is what we do with all of that wealth of information and why those those architectures that we are beginning to put in place now around that data needs to be open enough to allow that innovation 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 good example of where taking a biopsychosocial approach has the potential to really change how we deliver care and do that in a more person-centred and holistic way. So in the spring budget last year, there was a call for services that will run through the national digital channels that provide access to services and digital tools that can help people with musculoskeletal conditions and mental health conditions. And we started a bit of work around musculoskeletal conditions first, so particularly thinking about people with back pain. And one of the things that's really important to understand is What is the analogy to clinical care? What does it mean when we are delivering a service through a digital channel where we are trying to drive certain health behaviours and where there might not be a human in the loop, actually? And what can we do there? So one of the things that we did, and I worked really closely with Andy Bennett, who was the National Clinical Director for Musculoskeletal Conditions and some of the National Channels teams, we really tried to embed principles like a bias like a social model of care within the thinking around the service design. So rather than simply thinking about, say, a jump off to an external third party application, what's also really important to consider is what that service wrapper looks like and how you think about what somebody's experience is who might be looking for this type of help, this type of service. So in my clinical practice, What often happens is that say somebody who is seeking help for back pain, they'll go straight to the medicalised answer because that's what they're expecting. That's what the system actually has. And we often have to go through, and this is the way, you know, so if you talk to Andy and you talk to physiotherapists who work in this space, there is a sort of, there is a clinical role that we do where we help people understand their biopsychosocial experience of their back pain. which helps identify what caused it, what the triggers might be and what's likely to perpetuate it, to keep it going. If you translate that into digital terms, what does that mean? That's what we were working on. How do you try and create a service that allows people to do that bit of discovery themselves and then actually helps them get into the right service or intervention that is going to help them take that forward? It might be something about exercise, but it could ease also for back pain, also be something around sleep. We know, for example, that people who have some kind of issue with their sleep, say insomnia, are going to be more likely to get back pain because there's a relationship and there's a loop there with how you are repairing and renewing your muscles and your ligaments. And that makes you more likely to have an ongoing pain syndrome with an acute injury, for example, or for an old injury to flare up again. It could be something to do with your nutrition level or it could be something to do with other illnesses that you have if you are somebody who has an anxiety or a depressive disorder we know that treating the anxiety or the depression also helps you with your back pain so the responsibility in a digital service that we build like that has to take that into account and has to in order to be able to really improve on people's health outcomes and also crucially to um help with system key performance indicators that I talked about before it has to take that approach of considering all those factors and incorporating that within the design that's something I'm really quite excited about that that approach becomes more and more of a way of thinking about we're not thinking about the IT piece as just a nice to have or a little add on it is the service itself and it comes back to that discussion that we had before when you take the human out of the loop what things can you replace What things can you do differently? What things do you have to account for because you can't replace them and you need to make sure that people have access to that aspect of human interaction?

SPEAKER_01: 40:33

What's next for you, Leah? What are you excited about at the moment?

SPEAKER_00: 40:36

Oh, there's lots of things I'm excited about. I am really excited about the way that in the pieces of work that I'm involved in, we're being able to do more around this transdisciplinary mapping from the evidence base, the clinical evidence base, to user insights in various pieces of work. And that's starting to show real value in addressing need and being able to inform the way we might build services going forward. That's That's really exciting because it feels like we are getting to a place where we might really be able to deliver person-centred care that is truly holistic and biopsychosocial and where we're starting to see collaborative relationships around design of products and services that are showing us where there are opportunities to use the data more effectively, to make sure things are useful and usable and that actually really do impact people's health outcomes. That's what I'm excited about. It feels like a moment where these sort of worlds are properly coming together. They've overlapped. But actually, people are starting to see the value of when you do this work collaboratively.

SPEAKER_01: 41:52

Fantastic. Thank you, Leah. That's a really interesting discussion. Thanks for taking the time to come 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.