SPEAKER_00: 0:00

Hello, this is Problems Worth Solving, the podcast where we meet people transforming health and care through human-centred design and digital innovation. I'm Sam Mentor, Managing Director at Healthier, the collaborative service design consultancy. If you enjoy listening, you can subscribe to this podcast and the accompanying newsletter at healthier.services. So today I'm joined by Dr Jonathan Gregory. Jonathan is a cancer surgeon by background who worked in the NHS for over 20 years and held several management positions. He now works to improve patient care and outcomes using data, digital and AI via his consultancy Pivotal Health. He's National Clinical Advisor at Macmillan. He's digital theme lead at a national institute for health and care research and he's an honorary research fellow at Imperial College London. We've split this episode into two parts because we had lots to talk about. You're listening to part one where we explore Jonathan's background, what it's like working as a surgeon and practical experiences of health inequalities. We'll also dig into Jonathan's work to improve cancer pathways and the critical importance of getting the right balance between digital and human support. In part two, we explore Jonathan's work with Macmillan and using AI to improve patient communication. We'll also dig into his groundbreaking work to understand the experiences of cancer survivors in the community and discuss his vision for the future. Jonathan, I'm excited to have you here. Thank you so much for joining Problems Worth Solving.

SPEAKER_01: 1:44

Thanks, Sam, and thanks for the invitation to come and speak with you today.

SPEAKER_00: 1:49

To kick things off, would you like to share a bit about your background and tell me a bit about what drew you to medicine and surgery?

SPEAKER_01: 1:56

I think it's the mixture of human and science, sort of biology, psychologists, behavioral medicine. So I think that's why I was drawn in that direction. And the fact that relatively, certainly that point in my life, I was looking for very tangible outcomes from things I did. And so treating patients is a bit more tangible than perhaps research or other feelings like that. I think it's always a bit of serendipity and happenstance. So when I went into medicine, I very much thought I would work maybe as an anaesthetist or cardiologist. So much more in the medical side of using drugs and medications, given my degree in pharmacology. But my practical experience on the wards was really that Lots of time went past and not always much changed for the patients in front of you. The benefits from medical therapies often are weeks or months later. Whereas on the surgical ward, someone wheels off to theatre and they come back and there's something different. There's something being added or removed. And I think it was that sort of immediacy that drew me. And then it's serendipity. I was put on a placement at the Royal Bolton Hospital and was put into the orthopedic team there and they were just brilliant they were inspirational they were great teachers they involved you and I think that was it really I was sold and yet I think if you'd ever said to the me prior to that trauma and orthopedics I wouldn't have thought that would have been the direction I'd have gone so

SPEAKER_00: 3:31

it's about the immediacy

SPEAKER_01: 3:32

I think that's it and I think patients and trauma and orthopedics someone comes in with a broken bone And they go home having an operation and the bone, you know, is aligned. It's less painful. There's something very clear. Someone comes in with a dislocated shoulder or within 10 minutes, you've removed that pain from them. So I think there is an immediacy. It probably lent into my slight obsession with to-do lists and ticking stuff off. It's a little bit like that. And again, it's a sort of interface specialty because you've obviously got engineering and biology involved. and all the other bits. So some of it, I think, is the intersections that I always find enjoyable.

SPEAKER_00: 4:13

It must be immensely rewarding working as a trauma surgeon.

SPEAKER_01: 4:18

Yes, it is. I hesitate because I think all jobs, you acclimatise to it. And I think as you become a consultant, you tend, unfortunately, or certainly I did, to remember your mistakes and things that didn't go so well, perhaps more than the successes. Because the successes have gone out into the world and brilliant, they're getting on living their lives. Whereas your clinic is full of the people who, oh, that could have been better. There's a funny recall bias, I guess, that's going on there. So it absolutely is rewarding. And even to this day, I can look back on cases and think, we did something good there together. But also I can look back and I can picture exactly the people that perhaps things didn't work out as well for as I would hope.

SPEAKER_00: 5:03

What did you like most about working as a surgeon?

SPEAKER_01: 5:07

I'm really drawn to the beauty of the human body. So it's really the anatomy and the fact that when you've seen the nerves that maybe gives you sensation to the tip of your index finger or the inside of the shoulder joint or where the tendon of the biceps is, and you can relate that to how you move, how, you know, your own life. I think there's something... really are all inspiring there. I'm probably going to sound very strange now, but it was never lost on me when you made the incision into the skin, assuming it was the first time this part of the body had been operated on, and you're looking at the tissues. That is the first time they have ever been exposed to light, conceived and grow in utero in the dark. They've been sealed ever since. So you are the first person, the first set of eyes to ever witness that piece of creation. And that That sort of, yeah, it was never really lost on me, I don't think.

SPEAKER_00: 6:05

You don't ever get tired of that view. You get that excitement of seeing the inside of the body.

SPEAKER_01: 6:10

I think you do when you're in the correct headspace. I would say that, unfortunately, as you get more senior, you're often operating with a cognitive load of other things going on. You obviously arrive in theatre to a head that's buzzing with emails that have come through, problems, what have you, and As you get experience, like any technical skill, there are obviously still extremely demanding operations, but quite a few are a little bit more reliable. I would never use the word automatic, but you can function at low levels. But I think that it was never lost on me when you go and see the patients first thing in the morning before their operation. You know, they are trusting you. They're trusting you, to be blunt, cut them up. And that's quite a strong contract to hold, really. So that part I never took for granted.

SPEAKER_00: 7:04

There was an artist about, oh, I forget his name, about 10 years ago who did displays of the human nerve system. Do you remember? I

SPEAKER_01: 7:12

do, yeah. The Austrian artist, I think.

SPEAKER_00: 7:15

Did you go and see that?

SPEAKER_01: 7:17

I didn't, no. Were you tempted? No, probably not, actually. Whereas I do like the Hunterian Museum at the Royal College of Surgeons, accepting that there's certainly... historically at least parts of that museum I think that we shouldn't celebrate but there are things there that yeah are interesting a wow are I think that's one of the reasons I went into a particular part of Sergio I did because when you've exposed like a whole limb or a whole blood vessel the intricacies and the twists and the turns and as I say I think feels I suppose like a cosmologist looking at the stars it gives you a slight sense of there you are worrying about your day to day Just look at this. It's amazing.

SPEAKER_00: 8:00

What about some of the challenges when you're working as a surgeon? I

SPEAKER_01: 8:04

found it very tiring in the sense of, in the cold light, in the cold light, everyone, should we say outside of healthcare, will believe that everyone's pulling in the same direction and the same drivers. And that isn't the case at all, is it? Humans are humans with their own motivations, desires and wills. And so as a surgeon, you... trying to motivate colleagues to do operations. It's getting towards the end of the day. People want to go home, but you're aware that there's a patient who's waited all day, starved, and they're going to be cancelled. And so I think there's an awful lot of push of needing to drive. The system, shall we say, doesn't run of its own. It doesn't have a natural momentum. And so I don't these days miss that at all. That slight driving into work at seven in the morning, six, seven in the morning with a sense of quite a hard 12 hours ahead. And actually not often would it be the actual operating that would be the hard part. It would be the system navigation that would be harder.

SPEAKER_00: 9:06

When you were working as a surgeon, how much did health inequalities, factors like where people live, their income or their background affect their outcomes?

SPEAKER_01: 9:16

I think it, affected them a lot. But I confess that I'm not sure I always realised how much it affected them at that time. I was part of a cancer service in two hospitals and we covered large cancer areas. People would travel many hours to come to that area. So we were aware perhaps of trying to support people with travel. If you're trying to get from Devon to Birmingham, what time of day have you got to set off? And so those sorts of almost geographical things. And we'd be aware of people, perhaps it's a single parent or retirees. But I don't think we, I certainly didn't have the cognitive capacity and perhaps even the real grasp of health inequalities to lean in further than that. That sort of piece around, I'd probably, a lot of people think, I just don't understand why this person's not giving up smoking or why can't we get them to adhere to to this treatment. And now through experience and learning, I realize that there's a multitude of reasons for that. And also the way the system is built naturally makes it harder for some people to participate in healthcare than others, not purely on the basis of geography. So I think I come slightly as a reformed character where I never knowingly didn't deliver equitable health care but now in hindsight I realized that I didn't always I think I thought that by treating everyone equally I was doing the right thing someone's sexuality their ethnicity their gender that didn't matter to me but I realize now that I really needed to lean into that more because actually it's more that some of those groups will have greater barriers to letting me help them with their health care working with them in their health care And so I needed to know so I could take a step forwards towards them and bring the service closer to them. Whereas I probably thought it's not my business. I'm not influenced by them negatively.

SPEAKER_00: 11:21

So when we were talking earlier, you talked about how health inequalities have become quite a focus in your work. Can you tell me a bit more about that and why that is?

SPEAKER_01: 11:29

Yeah, I think as a lot of things in my life, it's a bit of serendipity meeting helpful and interesting people. As I transitioned out of the NHS. I remember going to a conference hosted by the King's Fund on health inequalities, and that sort of opened my eyes a bit. Working for Macmillan's obviously significantly opened my eyes to health inequalities and the issues around that. And then, you know, several books I've read or other things I've watched. So I would never claim myself to be an expert, but I think what worries me is often in conversations, I feel like I'm the person who seems to know most about it. I think in the UK, we have a political system and maybe a political ideology that slightly, very much puts weight on the rights and responsibilities of the individual. You know, that sort of, we mustn't have a nanny state sort of mentality. And as I say, I don't, I'm not particularly interested in getting into the political elements of that, but I think what that does though is it sort of, it suggests that every person is able to make the decisions that are right for them at that moment in time. And yet there's increasing evidence in the psychological literature that people's decision-making is compromised by the life around them. So it's not suggesting people don't have the mental capacity to make decisions for themselves, but if you're hungry, if you're worried about people around you, if you're in pain, This all narrows your ability to make decisions and choices that might be in your longer-term benefit. It's about getting through the next 24 hours or the next week. And I just don't feel that in the UK, and particularly in healthcare, we take enough notice of that. That sort of, oh, someone can log in to do this or can go there to request that. And that, of course, works well for a large number of people. But some people do, at that moment in their life, might need us to step closer to them. And I'm not convinced... We're always that good at doing that.

SPEAKER_00: 13:31

What does that mean for patient-centered care?

SPEAKER_01: 13:34

That's a very interesting question, Sam, because, yes, my points taken to extreme drive you to a very paternalistic mindset, and that isn't, of course, what I'm intending at all. I think it's about there's a group of patients who I think naturally are well-activated and able to participate in their care care and their decisions and so that's about designing services and delivering care in a way that's an equal partnership but then there's a group of people i believe that because of circumstances we've mentioned not least potentially fear english as a second language poor health literacy where it's much harder and i think there it's about designing services that the can meet someone so late, enable them to make decisions that are right for them in that moment. But I think in the sheer volume of patients being seen this year, in an orthopedic fracture clinic, you have five minutes per patient. It isn't really designed for those, you know, what I think some people would try and say are edge cases, but actually are far more common than being an edge case. What does it mean? I think it just means we need to redouble our efforts. But I think some of that's It's not just about the way we talk to people and, oh, I'm going to give you a choice of operations or a choice of treatments. It's how do we deliver that information and when? Because my cognitive overload in this clinic today means I might be hearing but not able to absorb. How are we reaching out to you in three days' time or a week's time to say, have you had any reflections? What do you think? And trying to sort of drip the conversation beyond the clinic, I think.

SPEAKER_00: 15:21

And is there a natural progression of that, that patient choice can't be the same choices for every patient, that it needs to be quite a personalised steer that you're giving to patients?

SPEAKER_01: 15:30

I intrinsically want to say yes, I agree, but then I'm nervous that I think it's more how we phrase it, how all of medicine should be a conversation really that is about explaining someone's condition in a way that they understand that is meaningful to them and can activate them. and risks and benefits explanation of different approaches. And really, what's the value proposition? What's in it for you to take this tablet? And I do think that probably a better explanation of what I'm getting at here is there's a sort of naive assumption, I think, that every person must just want to be well. And I don't think that's true in that sense. I think, of course, everyone wants to be well. But my priority today might just be getting to work and bringing some income in. It might be caring for my elderly mother. So it's not that I don't want to be well. It just isn't the priority today or tomorrow or a week's time. And so how do we deliver value proposition that is in that selling point? It's no good selling me, oh, there's less chance I'll have a heart attack in 10 years time if I can't imagine that I'm going to make it to the end of next week. But I don't think we've been good enough today to refining how do we allow people to make a choice. And that isn't about talking them into it. It's just saying the benefits that I think might be helpful to you at ABC, they're still entitled to go, I don't fancy that doctor. But at least I'm worried that a lot of opt out at the minute is probably because we haven't explained it in a way that shows the value to people.

SPEAKER_00: 17:17

So Jonathan, you've worked with many patients, thousands of patients I would imagine over the years. Have you seen social determinants of health inequality impact the choices that patients make?

SPEAKER_01: 17:28

Yes. And again, often perhaps I didn't realise at that moment that was what was driving the choices people were making. I'm probably smart after the event. But I think if we just look at smoking cessation, if you speak to most people who smoke cigarettes, They realize it's bad for their health in the longer term, but don't stop. And I think that there's a sort of assumption that they don't stop and can't be bothered, weak-willed. There's a million reasons that it's on them. And for a number of people, maybe that's true. But for a large number of other people, as we said, it's because it's important, but it's not a priority for today. And we've got that in orthopedics. Smoking is well known to delay fracture healing. Particularly if you break your shin bone, which is slow to heal anyway. The rate of that bone not healing is much higher in smokers. If it doesn't heal, it leads to long-term problems. You can be off work for 12, 18, 24 months. You know, real life impacting changes. And yet, people would, even once they were getting problems, couldn't get off the cigarettes. And of course, there's addiction in there as well, but... I think it's that part of, let's say, your health happens within your life. It isn't the sole focus of your life. We see it with risk-taking behaviours, where I say non-adherence to treatment, where we know that adherence to taking medication, say for blood pressure, varies across different patient groups. And I think some of that comes down to trust and understanding. I think for many people, there's a sort of implicit sense that you can trust the NHS. So if the doctors are saying this, that must be fine. But actually, for significant numbers of people in the UK, the NHS isn't a brand or an organisation they feel they trust because of harms or problems that seem to impact their community. So if we look at maternal deaths, which is at last becoming far more talked about. You know, if you're a lady of non-white ethnicity in a lot of towns and cities, your chance of death in childbirth and death of your child is far greater than for a white mum. And if we say that, then trust and understanding in the NHS between people and clinical staff has to vary across people. And so I think until we repair some of those bits, some of these Some of the social determinants of health inequality relate to circumstances of life, but at least some also relate to the impacts that the way healthcare has been delivered over time and problems that have happened. And those don't fall equally across society either.

SPEAKER_00: 20:22

So you're taking on a lot of risk as a surgeon. You have people's lives in your hands. Did it feel that the system isn't set up in a way that is sharing that risk?

SPEAKER_01: 20:31

Absolutely, yes. It felt very much, and I think a lot of my clinical colleagues, you know, anesthetists hold people's lives in their hands even more tangibly than a surgeon. But I think bringing this back to design, so much of the systems and practices in the NHS are not designed to help individuals not make mistakes. There's a lot of it is like the way it is for bureaucratic reasons, for a variety of reasons. But at their core, they just expose a risk of human error. And that isn't designed out. That isn't the starting point. So in my practice, it'd have hip and knee replacements and they all come in lots of different sizes and different. There's no universal guidance on the labeling of the boxes in the sense that they should all be, regardless of manufacturer, have some sort of thing. So you get a steady stream of one bit of an implant being used or two bits ending up opened and one wasted. And all of this just relies on Oh, two humans are meant to check it before you put it in. But this could be engineered out. It's like those tragic cases where we know people have been injected with the wrong substance, sometimes fatally. And because the bottles are the same except for a tiny yellow box or something very small. So with your work, Sam, I think there's so much to do in the NHS about designing out chances for error. And I don't think that is a priority.

SPEAKER_00: 21:59

Why do you think that is?

SPEAKER_01: 22:00

I think unfortunately, because in the NHS, whilst patient safety is important and patient experience is important, the bottom line, when you try to sell something or try and do something to procure and it really comes down to return on investment, is it going to be cash releasing within the next 12 months? It's very hard to even make a business case work that releases opportunity cost. So even if it's The doctor will only have to spend five minutes doing this, not 10, so they can see an extra patient. While someone around the room would go, oh, that would be good. That sort of level of benefit probably doesn't cut through enough. It really needs to be, we need less staff or we've got these vacancies we can't fill and this will replace those vacancies. So I think, like I said, I don't believe this is some, I don't think it's the people around the decision table at Absolutely not. It's just the metrics are skewed. Like, you know, the books have to balance within 12 months and anyone from outside the NHS would say, if you're trying to transform something, you often are less efficient before you become more efficient. And the financial return may be in two, three years time. And you'll be so much further on by that point. But often the financial modelling in the NHS doesn't allow that sort of time horizon.

SPEAKER_00: 23:24

I'd like to move on now to talk a bit about your work around cancer pathways. So cancer treatment pathways are complex and can run for multiple years. Not every pathway is the same and it can vary depending on condition, location, personal health and of course how well someone engages with the diagnosis and treatment. You told me about a piece of work you'd been doing that was looking at ways pathways can be improved and how they can be improved. I wondered if you could tell me a bit more about this and what was the trigger for that work? What did you do and what were the results?

SPEAKER_01: 24:00

The service I was part of, as I received referrals from across the country, and I'd really had the same processes in place for many years. And it worked for the consultant team who were there. But as I joined, there were several people retired and there was a lot of turnover within the department. So should we say, those unwritten rules everyone knew went out the door with those people. So we were suddenly seeing problems in terms of the time it was taking to diagnose people, a general feeling of slight chaos, of an awful lot of human effort being needed just to keep the ship afloat, and at the same time probably not delivering a brilliant patient experience. So what we did was, working as a team, is really strip it all back. So I mapped the entire pathway from the moment a referral lands at that point on a fax machine to say, we see this patient. We walk the department. What was happening? Where were the handoffs? What was the value being added at that point? And from memory, there's about 30 handoffs, but there was only 11 adding value. And so what we sought to do was redesign the system to strip that out. We refined and reviewed some of the roles and fundamentally tried to have a blank piece of paper. And I mentioned at this point, the non-clinical manager I was working with at that time, she was incredibly supportive doing this and really did allow us to not allow ourselves in our thinking to be constrained by what might be possible. It was like, what do we want it to be like? And then let's see if we can do that. So we scoped out a variety of things. And I remember a fateful moment where one of my consult colleagues, he said, we were all trauma surgeons. And every morning in the hospital, there's a trauma meeting where we talk about people with a broken wrist and a broken ankle who were admitted to hospital the day before. For people with broken bones, we meet every morning and talk about it. But we don't do that for people with cancer. And it was a light bulb moment. He said, yeah, so the solution is we should meet every morning. Now, if you'd said that to any of us before, we'd go, no chance, never happened. But we went with that premise and it soon stacked up because we were receiving, I think, about 3,000 referrals a year. So actually, there was about 20 cases a day to discuss. So we designed a system based on a whole different, rather than that batching that happens in the NHS, we tried to have almost a constant flow. In the end, I think we did a good piece of work. We took about six days out of the time taken for a patient to be diagnosed with cancer. We allowed a third of patients to be telephoned, have the mind put at ease, and never needed to come to our hospital for anything. And the majority of patients, towards 80%, were phoned within three days of their referral and us discussing it to be given their management plan. So, To be told it's not cancer, but we still need to see you or we're worried about this. So we're going to see you next week. And at that clinic appointment, we'll do this and this. And bearing in mind, we were dealing not only with adults, but also children with cancer. You know, I'll never forget, there was one patient all the way over in Lincolnshire. So three hours or so. And they were told on the Monday by their local hospital, we think your child's got cancer. And by Wednesday, we were able to phone them and say, no, they haven't. And you don't need to come from Lincoln. And that to me is a responsive service delivery value. And I think what's interesting as well there is I had a moderate do not attend rate at clinic. And that was put down to the large geography and people don't want to come. But actually, I challenged that. So it means the value of coming is not enough. So actually, by redesigning clinics so that you've got more things done for your visit, so you would come have a scan. In clinic, you'd be told the result and you'd go and have a preoperative assessment appointment. You'd meet your specialist nurse. That did not attend, rate fell. It didn't go to zero, but it changed. And so again, it challenges that sort of, there's that belief that everyone must just want health. It's actually, you need to go a bit further than that and give them something that allows them in their life to feel that this is a priority for today, tomorrow, this week.

SPEAKER_00: 28:34

And how did the work involve listening to patients and how did the insight from patients feed into the recommendations and the changes that you were making?

SPEAKER_01: 28:42

Being really honest, it didn't feed in enough. I think some of that, in fairness, was because we were struggling so much that we had to move quickly. And I think some of the changes were obvious. We obviously reviewed all the complaints and they were part of a driver. So we'd looked at some adverse events and some of the things around decisions we'd made. You know, we noticed in some of our meetings we weren't consistent. So one week for a patient in a particular set of circumstances, we'd make one clinical decision and another week it would be a different set. And that was workload. Sometimes in our weekly multidisciplinary team meeting, we'd be having 140, 160 people to discuss in three hours. It's not possible. So we fed in patient narratives. But I would love to sit here, Sam, and say, oh, yeah, we had a patient group who worked with us. We didn't in that official sort of sense. We tested it out. There's a couple of the specialist nurses who obviously were very patient-facing. We test ideas with them. They might have informal conversations with people. So, yes, it wasn't a co-designed, co-produced with... patients, what I would say is I do think it was co-produced and co-designed with every member of the department, from the admin clerks and secretaries, the surgeons, the pathologists, the radiologists. So it was perhaps at a different level.

SPEAKER_00: 30:18

And lots of insight that those people would have about the patients because you're interacting with those patients all the time.

SPEAKER_01: 30:22

Yes. And I think what was interesting with all these things is, of course, at the start, it was very challenging. But you often recognize that there's a couple of key people. And I remember one radiologist who I think needed a bit of convincing. They knew things needed to change, but they perhaps weren't convinced that my proposals were right. But after a while, he started to meet me halfway and in the end became the biggest driver and advocate for the change possible. Absolutely. It wouldn't have succeeded without them. So it's a very interesting change over time that it sort of opened. Once you get that sense, I think that, okay, John genuinely wants to work with us to change this rather than do something to us. Then the door opened and the radiology department were absolutely brilliant and couldn't have done more to help. So I think it's that thing, isn't it? We often think a bit about adoption of technology or willingness to change. but there's something even in the people who are putting their shoulder to the wheel to help you to change.

SPEAKER_00: 31:32

I find it interesting that every FTSE company, every big commercial organisation, they will have teams of people who are constantly engaging with the public and with their customers to measure the customer experience, to work out what needs to change, to work out how they can improve things, because there's a financial reward to doing that, and that's why the company exists. Yet here, the purpose of the cancer pathway is surely phenomenally higher than financial reward. reward and yet it's really hard to actually do that measurement and that kind of continual improvement.

SPEAKER_01: 32:03

Yes, I agree Sam. I think it's also that metrics are collected but they aren't telling people what they think they're telling them. So there's the National Cancer Patient Experience Survey and that's run on behalf of NHS England and hospitals will look at those results and that will describe things like patients indicated where they felt supported, had enough information. But people don't go back and look at who's participated in that survey. And non-white ethnicity is underrepresented. People under the age of 50, underrepresented. People from, you know, you can go across it all the way. And so it's telling you the experiences of a group of people that is entirely valid for that group. But you can't use that to design services that deal with people outside of that respondent group.

SPEAKER_00: 32:53

There's often this kind of perception that we do a survey, so we're getting feedback from people. Yes. But the difference between doing a big piece of quant versus sitting down and talking to individuals about their experience of a particular pathway, understanding the way one particular interaction worked or the way that one particular part of the journey was designed is chalk and cheese. They're completely different ends of the spectrum. They both have their value. They're both important to do those things. But I think... Often it can be seen that you've done the quant, so actually the qual side of things is not so necessary.

SPEAKER_01: 33:24

I think you're absolutely right. I think this interview feels like me just admitting to being rubbish in the past. But again, I think over time I've had an increasing sense of the value of qualitative work. It's not that I didn't before, but I think medicine drives you to be analytical in a quantitative way. And I think over time I've become better and better at fusing them. I would equally challenge that I have seen some pieces of work that seem to be entirely driven by qualitative. And it's, you know, you have to understand where the groups you've spoken to sit in the wider group. It's not to dismiss it, but if we've spoken to six people about a condition that affects five million people, we do need to reflect if we think that those six are representative. And yes, I've seen it. So I've seen errors on both sides. I would say we need both. And they both have near equal weighting, bit of nuance depending on what we're trying to do. And I think what those qualitative insights, as you say, it's a real low level. They, I think, help you do, you know, if we design for people who need some adjustments, often we're designing better for everyone. And so if that's members of the trans community who find that the atmosphere for screening tests is different, not welcoming or not supportive, or if we can lean into that, that makes it better for them, it will be better for everyone. If we've got people in neurodiversity who find the clinic letter difficult to understand, guess what? People without neurodiversity find them difficult to understand. But I think, as you say, in a survey, that won't surface. Whereas some targeted conversations, targeted qualitative work, I think often surfaces things that are hidden in the larger numbers.

SPEAKER_00: 35:15

Where would you say are now the biggest opportunities to improve the pathway?

SPEAKER_01: 35:21

I think most of the opportunities are much more simple than people would like to admit. I think, unfortunately, everyone's going so fast that there's barely any capacity to review processes, overhaul processes, back to my points around cognitive bandwidth. So I'm just trying to get through clinic today to do the operating list tomorrow We're trying to get to the end of our massive MDT meeting on the projects I'm involved in at the moment. We're engaging with clinical teams and I believe they all realise the project will be better in the long term, will reduce a bit of work in the long term. But that benefit might be six months away and they've got a load of work to do today. And so I think we are fighting this transformational gap because you've got to keep delivering BIU as you transform and that's incredibly hard most I think non-clinical organisations you almost might have a transformation team or you have something that's doing some of the lifting whereas it's much harder I think with sort of clinical work I mean I was taken by one of your previous guests on the podcast Rochelle Gold and she mentioned about being asked to see in clinic they wanted a button a print button I think it was on one of the screens and I just think that's It is the perfect NHS example where I've got this problem. I need this problem solving. I haven't got the time, space, capacity to go right back to the root cause of that problem. You know, a bit like the cancer pathway. What actually is the aim of what we're trying to do here? What value do we want to deliver? Design a pathway that delivers that. We're often faced with just trying to tweak what we're doing. to solve the biggest problem. So I think for me, the biggest opportunities are if we can bury capacity for people to do that sort of root and branch review of why is it like this? What could it be like? How do we do it? So the changes I described, they did cost money, but actually they didn't involve a big digital infrastructure project. They didn't involve lots of things that we didn't have a new app. We didn't have anything like that. It was perhaps rearranging the deck chairs on the Titanic, but we did at least manage to change the speed of the Titanic heading towards the iceberg that would buy time to then digitize or then bring in different sort of solutions.

SPEAKER_00: 37:49

I find it quite frustrating sometimes the way that transformation has become synonymous with technology. Everything is a technology problem. You can be solved with technology and, you know, right up to the top. That's kind of one of the policies of the new government. And I'm absolutely an advocate for technology in the right place and the impact that it can have. But it feels that often that the changes are, as you say, simpler. We did work on the autism diagnosis pathway. And one of the things that came out of that was actually it would be really good if people were just given a leaflet when they started the process so they could understand what was going to happen. That's not rocket science and that's not minimal investment to actually make that happen. But it feels like there's this technology kind of hammer that's trying to solve everything.

SPEAKER_01: 38:27

Yes, and I often, I think, jump from one side of the fence to the other to try and support the team that's losing. So if I'm in a meeting where everyone's saying, that's miles too hard, technology can't solve that, I find myself being a slight tech advocate going, I don't think it's as hard as you think the technology to do that. And then the flip side, as you say, when everyone's trying to say it needs technology, going, well, actually, as you say, if we changed the form with a conditional question here or did that there, that would be better. If we just look at the letters we send to patients, my wife's had a couple of letters lately. Between the two of us, we've struggled to understand them, and I'm a doctor and she's a teacher. So that tells you fundamentally there's something wrong. And what will have those people done? Either not gone to their appointment, phoned up healthcare services to get the appointments explained. All of these things are time and resources, and yet it's for want of a better letter. So as I say, I'd love to sit here and say, oh, these opportunities right now, Sam, are some AI-driven this, that, and the other, they will make a difference in time. But right now, we could do an awful lot of things with just redesigning our processes and our pathways.

SPEAKER_00: 39:36

On the other side of things, how can technology help the cancer pathway?

SPEAKER_01: 39:39

I think I'm absolutely convinced it can. I think the problem we have at the minute is we have technology getting in the way currently, and I think that's almost one of the blocks to it. So within cancer care, for example, there's software that collects data about the patient's cancer diagnoses, etc., called cancer registry software. And it's a brilliant example of terrible design. It was designed to solve a problem, which was getting data to NHS England. It was designed to solve the problem for the people who were tasked with doing that, so that's cancer managers in hospitals. But it had no input, certainly no input from anyone who was sensible, in hospitals. what clinicians who would interface with this would feel was appropriate, could use. And so you have this clunky software that's extremely hard to work, doesn't really, it delivers what NHSE wants, but data quality is a continual problem because the software is not intuitive. You struggle to use it in real time. And it's that example really, isn't it? The word users gets used, but in the NHS, that's more vague. There might be a nurse using it with a patient, might be a doctor using it on a patient. The beneficiary might be a patient. It might be the system or the hospital. The payer might be the GP practices. It might be the hospitals. So all these personas are split. And very rarely in my experience have products and companies really considered that properly. What's the cost benefit, value proposition, whatever it may be across all the persona groups? They just find one and hit it. So I think one of the issues regarding cancer care is that some of the software that's presently used is not great and is a block to other changes. But where do I see maybe it's starting to help more? There's undoubtedly big shifts in the world of radiology around using AI-driven technologies to help with reporting, for example, mammograms or chest X-rays. That is not ready to be unleashed yet. uncontrolled at the moment but we've reached the point where there are some very large trials going now in multiple hospitals so shall we say it's certainly good enough at the moment that it's not obviously terrible but we've obviously got to just now really refine is it absolutely safe under what circumstances is it appropriate or not similarly with software to help oncologists plan their radiotherapy the software to help with that, what's called contouring. And that will save some oncologists, you know, could be one to three hours a week at least. And that's time that can be repurposed. So I think there was definitely things coming. But I suppose when I tell you that fundamentally, if we were in a cancer service today, we would struggle to even map our demand and capacity in the next six to eight weeks accurately. Some of these very patient-facing technologies are great, but there's a lot of back-office improvement that the size of the prize isn't obviously perceived to be big enough for people to really want to take on.

SPEAKER_00: 42:55

Have you seen patient-facing technology that's improving outcomes?

SPEAKER_01: 42:59

For some people, potentially, yes. I'm slightly guarded. Particularly in cancer care, there's an awful lot of apps, some of these perhaps to try and help people manage specific symptoms. After cancer treatment, fatigue can be a real issue or sleep. And so there's apps to target those things. And the results would suggest that a meaningful number of patients get benefit from this. There's lots of apps out there that support people through their cancer pathway. Or it's a place for you to store clinic notes, record your symptoms and some of these things. I think for some patients with some clinical teams, they probably generate a benefit. But I would say that not all patients can engage with those technologies at scale, so they're not helping everyone equally. And I'd also say that not all clinical teams are resourced to do that. There's a bit of a misconception that, oh, you know, we've got all these patients who can report their symptoms in real time. Okay, but who's available to look and deal with that? And There's not a bank of nurses or doctors sat waiting for these reports to come in. And so until you can really leverage AI to triage all that data to get the outcomes, whilst it relies on humans, you're going to be very limited in what can be done. So, for example, there are some support applications and they've been adopted by smaller services or services perhaps in the private sector where there's a better ratio of nurses to patients. But I think, should we say, it's a big, busy hospital. I'd say most of the technology at that point is really more about perhaps, should we call them patient portals or those sorts of things where people can at least look at their results, look at their clinic letters, that sort of level of technology, but are not convinced there's a really wow technology out there that's shifted the dial for patients. There's interesting things like VR to try and improve for people who are having head and neck radiotherapy, for example, but they're not in use at scale and are not sure. I think that someone at one hospital might get it and someone else doesn't elsewhere. So as I sit here today, Sam, I don't think we've really made a big dent in that yet.

SPEAKER_00: 45:24

Do you have thoughts about ways that we can achieve the right balance between kind of digital support and human support?

SPEAKER_01: 45:32

Yeah, I think for me, technology... We're up to tipping point. So technology till now and through my clinical career really was between me and the patient. It got in the way. This sort of thing called the keyboard, the screen slid into the clinic room. And early on, it was just for a couple of things. And gradually it was all on that, ordering everything on it. And so we'll have all been in a consultation where the doctor seems to look at the screen and be typing, not listening. And that undoubtedly changes the dynamic of those conversations. I think it makes it a bit more tick boxy. So technology has been between us. I think as we move forward, I would like to think that technology can actually get help from being between us and be around us. I think that we can use it hopefully to release us to be more human. We think probably overhyped example would be ambient AI technology. But in time, I sincerely hope that delivers because if we could be having a consultation, Sam, and I haven't got to request anything on the computer whilst we're talking or dictate a letter at the end because the ambient AI is hoovering up our conversation, synthesising it. I said, we can just check your bloods today, Sam. We'll do this and this. It's already filled the form in. When we reach that point, that transforms healthcare. Because I'm released to be human and to get back to doing what I did, which was making eye contact, which was using my body language to reassure or help. Whereas lots of subtleties like body language are now lost because as much as we don't want to look over a desk, because that's terrible for building a rapport, how do I use the computer and look at your x-ray whilst I'm talking to you? So I am hopeful that technology will undo the harms of technology. in the coming years, but you won't get me committing to a timeline for that.

SPEAKER_00: 47:38

From a technology perspective, what you've described is more or less possible from what's out there now. But from a kind of a system and an implementation and a policy and all that other stuff, it feels a long way, a long way to go.

SPEAKER_01: 47:51

I think so. I think some of the technology, my understanding as a non-expert is some of the ambient AI can work really well in a one-to-one, maybe a one-to-two. but starts to struggle with more people. And particularly in cancer care, you could have three, four, five people in the room. And at that point, so I'm not sure, but I think it's sort of nearly there in some use cases, but not in others. So it might be good for GP practices before it is maybe some hospital practices. But I agree completely with you that when I say this to clinical staff, they look at me like I'm from Mars. But I recognise that because until I left the NHS four years or so ago, if you'd said AI to me, I'd have said, I can't even log on to the system today. And I also have to remember five passwords for the different systems just to run clinic. So that is the reality and the destination do feel a long way apart for people who are working in the NHS.

UNKNOWN: 48:55

Music

SPEAKER_00: 48:58

You've been listening to part one of this podcast with Dr Jonathan Gregory. Stay tuned for part two where we will explore Jonathan's work with Macmillan using AI to improve patient communication and we'll also dig into his groundbreaking work to understand experiences of cancer survivors in the community and discuss Jonathan's vision for the future.

UNKNOWN: 49:18

Music

SPEAKER_00: 49:27

Problems Worth Solving is brought to you by Healthier, the collaborative service design consultancy for transformation in health care and public services. Find out more about how we can help you deliver user-centered change at healthier.services.