Sam: 0:00

Last year, GPs in England delivered over 380 million appointments, and the pressure is on to deliver even more. So making each appointment work better is a priority. But maybe the bigger opportunity isn't just optimising the consultation. It's rethinking the relationship between a person and their GP. What happens before they walk in and what happens after they leave. Today's guest calls this the wider consultation, and he's seeing it from both sides as a practising GP and as the person leading digital transformation across London's primary care. 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 Menter, founder and 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. So, in today's conversation, I'm talking to Shankar Vijay about how to move beyond the 10-minute appointment, the reality of AI in general practice right now, and the digital front door. Shankar, thank you so much for joining us today. How would you describe the big problem you're trying to solve?

SPEAKER_01: 1:25

Maybe in just one word, frustration. And when I say the word frustration, I see it from both sides. Patient's frustrations, it's not easy to get access to general practice. And from the staff's perspective, it's frustrating because we just feel we don't have the resources or the time to deliver the care that we would want to get if we were the patient too.

Sam: 1:45

And when you look across London or the NHS more broadly, what tells you the system isn't working as it should for patients and for GPs?

SPEAKER_01: 1:54

I think we can see it everywhere. We can see it in the patients' experiences, whether you look at social media and people's experiences when they can't get access to things or where things go wrong in their care delivery. And then when we look at the statistics with our staff, it's difficult to recruit staff. Staff are retiring and they're reporting burnout. Staff satisfaction is going down in terms of their roles. So the frustration is quite clear to see.

Sam: 2:19

You're in quite a unique position because you're still a practicing GP and you're also leading regional transformation. Do you see your role more as a kind of a translator or a bridge? Or how would you describe your role?

SPEAKER_01: 2:33

Do you know? I think it's a bit like my role as a GP. Sometimes we are a jack of all trades. I see myself doing a bit of everything. When I look at the role of transformation, you can't predict. So sometimes I'm fixing, sometimes I'm designing, sometimes I'm a communicator. Sometimes I have to try and inspire people when they're really not keen on what we're proposing to look at as the issue. So I do think you have to navigate and be agile in your approach to all of that.

Sam: 2:56

Take me back to the beginning and what drew you into general practice. What were you curious about as a young person and what led you towards medicine?

SPEAKER_01: 3:05

First encounter I remember is I've only ever remember seeing a GP once, and I remember feeling really nervous in the waiting room as a kid, thinking, oh my God, who's that mysterious man? That sort of and I thought it was a powerful figure and what was going to happen when I go into that room. That never left me. So that's one childhood memory that pre-influenced me. But three of the other bits was what I used to get on in my free time. I loved programming. I had a BBC microcompute in those days. So yeah, that bit of programming. But in those days, IT wasn't really a career. I didn't really think of it as a career, didn't really know where that would lead me to. So that was one bit of childhood which was really important. And another bit was I was dragged in to do classical dancing. I got dragged off at weekends by my parents and did classical Asian dancing. And I didn't realize, but it would play a part later on in life.

Sam: 3:53

There seem to be lots of medical people who are also really good with computers, like beyond just being able to use computers, actually. They're programming and they're creating apps and things for their own use and that side of things.

SPEAKER_01: 4:04

I think it comes down to really what we're trying to do is as a doctor, we're sort of diagnosing problems usually. We're thinking systems, processing, logic. So there's a lot of parallels with logic making programmable code. So maybe there's some parallels about the type of people that go into medicine looking at problem solving and fixing issues, and the type of people that are interested in tech and digital.

Sam: 4:24

Do you think this also applies to social media? Because you were an early adopter of YouTube.

SPEAKER_01: 4:28

I do think it applies to using social media. I turned to YouTube in 2010. I was a GP in a practice in London, and I thought YouTube could help me fix everything. I made lots of little short videos and I had a couple of rules. The rules were that we had to keep it real. We didn't have time, so it was only one take, no practicing. My thought was if a patient walks into the practice and they get an unpolished version of a, you know, a consultation with one of us, why should it be any different when they watch us online? So I made hundreds of little clips. It was staff members giving health advice, patients telling their perspectives and experiences, and that was proven the most powerful thing. And I see it helped with our communication skills, team built-in skills, and it sort of brought up to a crescendo of having an idea of just doing a conga in Tesco's.

Sam: 5:24

Tell me more about that. What's a conga in Tesco's?

SPEAKER_01: 5:28

Yeah, okay. I know that sounds really crazy, but this is my idea. In the past, as a GP, you probably had more encounters with your patients, you're part of the community, and you would see them maybe in the local grocery shop. So the modern equivalent for me was our supermarket. So I just suddenly had this idea. What if we used it to help raise money for UNICEF, the children's charity? The idea was let's put everyone together and let's mix it up. So we had patients, we had health professionals, opticians, pharmacists, anyone around in the in the local health system, the mayor, the MP. We also had the big CEOs of our IT systems come down. So we thought we could just sort of even tell them about IT problems and they would actually hear it well, face to face in the Conga line. And what was the reaction to people doing this Congo? Oh, it was magical. You know, it really built like a community together. I mean, and it didn't really even need to be the YouTube bit, obviously. Even just doing a Congo down the fruit and vegetable island disco was enough. It brought us back to those basics of relationships and understanding each other. So yeah, it it had an impact that was unmeasurable. Did they think you were a bit mad? Well, I think they probably did. They didn't tell me, but um I'm sure they I'm sure they thought I was bad. I think everyone did be bad. And in fact, even staff members, they did say we weren't sure. Afterwards, they said, we thought you were a bit mad, but we could see that there was logic in it. So it all went well at the end.

Sam: 6:52

You've been a GP for over 20 years. How has the job changed since you you started? And how have you seen technology become more and more integrated with the way you work?

SPEAKER_01: 7:03

It's just becoming faster and faster. I do think you've got to think of GP as a Formula One racing driver. I literally look at that 10-minute consultation, is I've got to maximize every second. But if I look at the volume of work that's gone on over the years, it's just the shift of the workload and the complexity. I'm not going to stereotype, you know, 20, 30 years ago, you know, was it the you know, coughs, cold, you know, was a stereotype what we thought GPs were seeing. But that shift of a lot of that workload's gone to different places, like whether it's pharmacists, nurses, other practitioners are dealing with that now more increasingly. And the complexity of things that the hospitals started to do, we're doing more. I can still remember where a basic blood pressure medication would require a hospital mission when I started as a doctor, and now we start in 10 seconds in GP land. So that shift in complexity means we're just having to do more transactions, more messages, more tasks that have been fired to us, more emails, more reading, more keeping up to date. So the pace of change and the pace of our workload has dramatically increased.

Sam: 8:05

So you're getting more done, but that's not necessarily reducing the workload.

SPEAKER_01: 8:09

No. And in fact, what I would say is if we didn't make those changes, we would have collapsed by now. So some of those system changes, those digital, it's just trying to stop the system becoming unsustainable, but the workload hasn't necessarily decreased. It's still increasing. It's just that the rate of increase of the race impact may be far less with the use of digital transformation and and tools that we use.

Sam: 8:33

So I want to go back five years now and think a little bit about COVID. So that was a time when suddenly GPs were at the fore of the health system and there was immense pressure, and there were huge changes going on all around. And you know, it really disrupted the way that GPs work, and some of those changes have stuck, and some of them have rolled back. But I'd like to just explore COVID a little bit with you, if I may. So really it forced general practice to change overnight very quickly. What was your personal experience of that period?

SPEAKER_01: 9:05

It was definitely the most intensive period in my career, and I'll echo exactly what you just said. Things just changed overnight. And things that didn't seem like they would ever be possible or hadn't been possible in the years before just became possible overnight. I mean, one thing I remember one of my leaders, actually my boss, one of the senior GPs in area, said as a comment, as Kobe started around, she said, Shunker, you won't know how this is going to unravel, but this will become a bit like a war. Like we've never gone through a war, but suddenly everything will fall together, become like a command thing that things will just happen. And there was definitely an element of that. Things just happened, maybe because everyone felt lost, so people just followed what they were told to do rather than thinking sometimes. But it wasn't really just that, it was the sense of intense collaboration. Finally, for a period, all the silos, all the boundaries between separate organizations within the NHS and beyond just fell apart. And you could see how much that causes like restricts things that we try to do. And it also shows when you have a common goal, common purpose, anything is possible within the NHS.

Sam: 10:13

Can you remember a moment when the magnitude of the situation dawned on you?

SPEAKER_01: 10:18

Oh, very early on. There was the element of suddenly, it was like day turning to night, like a light switch in general practice, doors shut, the work changed, there was intense fear, intense concern, both in patients and staff. I can remember then there was one example where we were planning to roll out an online consultation product to our practices. It was something in the pipeline, but suddenly when it hit, it all became high-trapped. So I can remember sending an email to our practices, look, I know you don't know what this product is, I don't know what we're going to do, but look at this. I need to get this out and rolled out to you within like five days, and I will then figure out what I need to explain to you. So I basically had to go on really high-trap leadership to do a system change, and it worked. Like I would send that email out on a Sunday, and everyone just did it. Whereas normally no one would accept it without me trying to explain what it is that I'm actually asking them to do and what is this product. So, examples like that, we did also have things like COVID hub. So we worked, I literally practically worked seven days a week. So it was also like looking at different parts of the system, doing a hot work seeing patients that were unwell and having really regular calls with different parts of the system to think about what we can do differently. I can remember another example where there was an IT discussion about something as a solution, like as a work around, because we were all short of laptops and devices at initial stages. And I made a suggestion in a in a sort of like a Teams meeting, and I and I was told, Shankar, everyone in the room is looking at what you're saying and saying, this is a really, really bad idea. We can't do it. And then literally within days, we decided to do it because we just the speed of reacting and understanding what we need to do and shifting our normal positions became really, really transparent.

Sam: 11:56

Do you think you learned quite a lot through that process?

SPEAKER_01: 11:59

Yes, I did, I did learn a lot. I guess I saw a vision of an NHS that I think we would love to have there constantly. A vision of real, true teamworking across all possible boundaries. This camaraderie of just feeling this common goal, feeling like you're really doing what those values of the NHS are all about, trying to deliver the care that patients need. And also just not fearing what you thought was impossible, learning about your own personal self-limiting beliefs of thinking, well, that won't happen, and then actually making it happen. It can leave you with a legacy that you suddenly think that everything is is possible and maybe become too optimistic. But yeah, I really hope that we don't have to keep having events like COVID to make sure we keep as close as possible to that spirit that we had.

Sam: 12:44

Some of the changes that happened during COVID, like on online consultations, have become permanent and others haven't stuck so much. What determines which of those changes you actually were able to carry forward?

SPEAKER_01: 12:56

Um, I think lots of factors. I think sometimes fatigue, and I'll give you one example of video consultation. I think it rose really high initially, then it dropped off. Not saying it hasn't got a complete benefit, but maybe even users as GPs think, oh gosh, I don't want to have to do it as a video thing. We don't even necessarily have that sense check dialogue with patients about what do they prefer. Sometimes it's due to resources or tech that things that were funded are no longer funded because of funding constraints that can dictate things. Sometimes it's behavioural change. We are, as humans, sometimes difficult to change our own behaviour and to change other people's behaviour.

Sam: 13:31

So lots of change happened during COVID. But what's it actually like being a GP in 2026? Can you describe that to me?

SPEAKER_01: 13:38

I think you can be pulled in two directions. You can feel at times that you are actually very privileged doing a really, really great job in a great setup and making a difference. Or there's at times you really want to quit and you just can't face another day. You can literally bounce between those two. And it could even be that you bounce between those two extremes within a morning at work to see a whole set of patients. Some of that can be the system frustrations that you're dealing with a patient where the problem isn't probably the part in general practice, it's the rest of their encounters with, you know, maybe specialist cares, hospitals, and you're you're struggling to influence it. Some of it can be workload pressures that you just feel like it's increasing, that there's expectations that are beyond what you feel you can deliver. And then there's the frustration about constant change. There is endless change in what you're having to do, either from a clinical guidance perspective or from a technical perspective, from a contract perspective, a changing workforce perspective, and change can be exhausting.

Sam: 14:40

What do you find most rewarding?

SPEAKER_01: 14:42

The most rewarding moments are usually the moments with a family or a patient where there is no rule book how to manage it. The big challenge with being a GP is you deal with patients who are often having multiple different conditions, and usually guidelines are just designed for one particular condition. So there may be actually no perfect decision. The joy of just navigating that decision making process with the family and the patient to try and agree an outcome, and you feel like you're a trusted maybe extension of that family at that point in time, I think are the most precious moments. Some of those moments I think sadly come towards the end of life. It could be like palliative care cancer type situations where they're really difficult situations, and you know that you're playing a part with making that decision-making process in a very difficult time.

Sam: 15:32

I do that point, it sort of comes across as more of a calling than a job. Yeah. Actually, it's a human-to-human interaction supporting someone through a very difficult time. Yeah. If you're enjoying this conversation, you can hear more from Shankar at Digital Health Rewired at Birmingham NEC on the 24th and 25th of March. We'll also be hosting a live recording of Problems Worth Solving with the brilliant Tero Vananen, head of design at NHS England. Can you tell me about the day-to-day digital tools you're now using in your practice?

SPEAKER_01: 16:10

So the biggest tool is our GPIT system. So I'm using one of the big providers. It's actually called TPP, System One. So most of my working day is in that product. But we use lots of other products that plug into that product. And some of those products are around messaging, communicating to patients, online consultations. The other products at gain that plug into it are often around data. So things like can I look at results or records from different parts of the healthcare system from hospitals?

Sam: 16:39

What do you need technology to do that it's not doing for you yet?

SPEAKER_01: 16:43

I think the journey we're starting with AI probably is the most powerful one to go ahead. And the difficult area about clinical decision support. So when I'm seeing a patient in that 10 minutes, there's tons of data being framed to me. And beyond that, the patient may have come in with something different. It may be just that they want to just discuss that sore throat that's been going on for long. And I want to look at all the other issues that's been flagged to me in my system. It could be easy to miss things. So whether AI has a sort of starting to get into a world of clinical decision support where it's flagging things to me, trawling through all the data in their records or all-parts system, letting me know things that I might not spot. Yes, we've got to be really, really be really careful about the safety of AI. But when we look at errors by AI, we've also got to think about human errors. We've got to compare the two before. That could reduce my cognitive burnout. At the end of that day, I'm not absolutely exhausted from all the constant thoughts I'm having to make and decision making from the data that I'm reviewing.

Sam: 17:42

From a patient experience perspective, there's a pre-visit, there's booking a visit, there's actually going in, seeing the GP or having a virtual appointment with the GP, there's the post-appointment experience. Where is AI showing up in that process now? And how are you actually using it in the real world?

SPEAKER_01: 17:59

It's showing up in most of that experience now, but to variable elements. And when I think of general practice, we're highly variable. So it could be just those first followers at the moment. So if we look at the pre-appointment stage, so nowadays there are some practices that have things like AI avatars or chatbot devices on practice websites. So it helps you navigate, you know, your thought processes about what where you should be going to, who you should be seen. All we tend to have an online consultation product. So that first experience of collecting information, what is your need, trying to request either an assessment or an appointment is happening pre-appointment. We sometimes send patients like two-way interactive messaging where they can send us photographs, answer more questions through a questionnaire. That can happen pre-appointment or even during appointment or even after appointment. We often are then signposting, so messaging patients with links to different resources. That can help you, particularly even post-apointment, if there's information that they need to look up or follow up. And then you've got the NHS app almost like as our front door to all of that. That could play a part all the way through the journey from booking appointments, seeing their records, and then afterwards if they're looking for further help and advice.

Sam: 19:10

So it's almost like you have an ongoing dialogue with the patients supported by all these different technologies.

SPEAKER_01: 19:16

Yeah, I I I almost describe it as what I call the wider consultation. The consultation has to be wider than the actual consultation. So, like you just said, it has to start before and end afterwards. I sometimes think we probably focus not enough on the bit afterwards in particular. Like we've started to focus a little bit more about what we can do before the consultation, but not that after bit, about what happens after they leave that room.

Sam: 19:42

You mentioned AI supporting that decision-making process and that clinical decision-making process. What's been your experience of that so far and how is it being used?

SPEAKER_01: 19:52

I think it's really variable. The main concern is about safety. When you're starting into a world of clinical support and clinical decision making, it needs higher degrees of regulation, higher class of medical device. That offers barriers for companies or products that are trying to explore that. There's a lot of work that needs to go into it, it represents a lot of costs. But also, from a practice perspective, you need to pay a lot more due diligence in your review of the safety of it before you deploy it. And that's often beyond the realms of expertise of the average GP practice. So that can mean it's slow adoption at looking at that. But do you think that's a slow journey towards that? And one example is even in my own GP IT system, they've started to introduce things like suspected cancer type AI tools where it might suggest to you patients who might have suspected cancer you may not have thought about. It's early steps there, it's early development. I'm not saying it's the best thing yet, but it's a step into that world of clinical decision support.

Sam: 20:50

AI scribes are getting quite a lot of attention. So this is the concept that there's an AI listening and it creates notes that you then approve and add to a system. Are they catching on now? Because there seems to be a real buzz around them.

SPEAKER_01: 21:01

Do you know what? The fact that I didn't even mention that and you did shows you how well they're catching on. It started to become probably the most commonly thought of thing about AI in general practice. There are multiple providers of it. I think most practices have definitely heard of it and have at least tried it. There's probably a spectrum of how much it's been used, but it's definitely there.

Sam: 21:22

Have you been using them?

SPEAKER_01: 21:23

Yes, I have. And how's it impacted your work? It has impacted me with the cognitive reduction, but I actually think I'm not the typical person who gets the most benefit because I'm generally good with a computer. I'm a fast typer. The clinicians who are probably less tech savvy, slower typers, they would describe it as magic, that they feel that their transformation in their lives has been colossal.

Sam: 21:49

When I spoke to Rachel Hope, who's director of digital prevention for NHS England, she was talking about the difference between solutions that get dropped into pathways and services that can evolve over time. Because they have dedicated teams that are evolving these products and services so that they can continue to improve. Is AI being introduced as something that can adapt, or does it tend to be a product that's bought off the shelf and then plugged in? And what do you think should be the approach?

SPEAKER_01: 22:15

I think if the approach is it should constantly evolve and adapt. It has to keep improving. But you're right, I think we often look at it as buying it at this point in time, implementing it, and we're not thinking about the future. The hope, though, would be that market competition between different providers means that things constantly evolve and constantly change. The issue probably is more about do we keep up with it?

Sam: 22:37

What are you most worried about around AI and general practice?

SPEAKER_01: 22:41

There is a fear about jobs. That when we think about AI, even at an admin level, so we often think about clinicians, but people from admin level, thinking, you know, like we mentioned about AI scribes, does that mean we need less secretaries to type up referral letters? Do they fear their jobs? My response to that would be probably that jobs will have to change in terms of the role and the tasks that people are doing. Second, do we fix one problem but cause another problem elsewhere? If I use AI to help save me time typing up notes, will it mean that I see more patients do more workload and burnout in different ways? So I've just shifted the nature of the problem without really identifying that root problem about workload in its entirety. So my fear is that AI will be really helpful, but it may not resolve the overall direction with increasing workload.

Sam: 23:37

Twenty years ago, you would arrive at a GP appointment and you would know nothing about the condition, you would know nothing about kind of treatment. Then the internet came along and people started Googling their conditions and coming in with a bit of knowledge and a bit of understanding about what they might be facing and maybe kind of diagnosing something they didn't have. Now we're seeing people using GPT as a kind of personal health advisor. How has that changed the way people are showing up in clinics?

SPEAKER_01: 24:02

I feel it's just like an evolution of the Google search. Like initially we were fearful, saying, Oh gosh, you've done an internet search then, right? Okay. But actually, we just got used to it and actually realized the helpfulness of it. It's just another insight into what's going through the patient's mind about what they think is going on. I just see the AI as a further development on that journey. When you're doing your search, you suddenly that top return may be an AI overview. Maybe the only fear I have more about it is it's not so clear to even the patient what is the source of the information which led to that conclusion. So, whereas I could say, Oh, what site did you visit? And we could look at that site together, if they did an AI return, they may feel a bit more lost. So I think that's one of the early fears about the navigation journey.

Sam: 24:47

How does it affect the dynamic between the GP and the patient?

SPEAKER_01: 24:51

Maybe we all varied. I think initially we can be quite defensive and think, oh gosh, what have you done? Okay, let's be like we did with the Google searches. But I'm hoping that as time goes on, and as we also mirror the patient, we start to use AI more ourselves, we neutralize that dynamic and we just use it as a tool to spark the conversation of where do we start with what do we think this problem could be about.

Sam: 25:11

We've talked a lot about how AI is impacting your clinical work, but how is that feeding into your role as a transformation person in NHS England?

SPEAKER_01: 25:20

Oh, it's critical. I don't think you can transform without being connected to both the patients and the frontline because you have to balance those different dynamics. You have to really understand what it feels. You've got to understand the pressure points because usually it's the small things that are the big things. The small things are often what leads to it failing.

Sam: 25:40

And you're also involved in the NHS app. Can you tell me a bit more about your work with the app?

SPEAKER_01: 25:46

The first thing is the NHS app team often are on the same office as us, so we can often have interactions with them in an organic level. We're always keen in London to test and pilot new stuff and get involved early. So usually whenever something's coming on board or something's been developed, we relook at it. At the moment in London, we're getting involved with some AI pilots looking at the triage element. You might have seen that that was mentioned in the 10-year plan. Looking at different booking elements, like things like RSV vaccination booking through the NHS app. We're doing things with NHS app Metagin. So I've been involved in the early sort of pilots of rollout across more GP practices.

Sam: 26:24

And what are you seeing having the most impact in terms of the app's functionality?

SPEAKER_01: 26:29

I think in general practice, messaging is one that is hopefully going to have a big impact. And there's a cost element to this. So I'm just saying from a general practice then, because at the moment we're we're having to pay for every increase in SMS costs. So NHS app messaging is something that could really help reduce those costs, but also improve security. We may be able to communicate to a deeper level with more sort of sensitive information because it's going security in HS app than what we could do by sending text. So that's one thing from general practice element. I think the second element still is about some of the basics. So things like repeat prescriptions. I think it's really great that prescription tracking's been rolled out. So this, if you weren't aware, is that now not just that you can request your medication, you can start to see the whole journey with your prescription that has a GP practice issued it? Has my pharmacist got it in stock? Is it ready to collect? At the moment, about 18% of pharmacies are live with that. But as that rolls out even more, I think that reduces queries and frustrations. So again, they may seem like simple problems, but they can create a huge amount of workload.

Sam: 27:33

What's the role of general practice around prevention? Do you see that as part of your remit?

SPEAKER_01: 27:38

Oh, 100%. I think that should be core to what we're doing. It's obviously the direction of travel for the NHS. If we look at general patterns to move into neighbourhoods, it's increasing priority for that as well. And I do think the NHS app is going to play a pivotal part of that. So the digital cardiovascular check that's been designed, the health check through the NHS app, for me, the reason why I think that's also a great idea is the whole sort of inverse care law principle about health. That as a GP, it's not about the patients who come to me into my room and sees me. Hopefully, if I do a good job, they're sorted. It's all those patients who don't contact us, who registered or not registered with the GP practice, who have got health issues that maybe they don't even know. And if they can engage in a digital wealth with screening and with cardiovascular checks through the NHS app, that can only be a good thing. And it makes it more viable for a general practice from a workload perspective if we had those digital enablers.

Sam: 28:33

There could be a shift where citizens' relationship with their GP isn't just about appointments. It's about an ongoing relationship with various interactions through the app and other communications. So it becomes a two-way relationship throughout their lifetime.

SPEAKER_01: 28:47

Exactly. And the appointment should only be a small proportion of that care. So I agree with you. And it could even be basics and some mundane things, you know, whether they get prompts to update their latest weight or something through the NHS app, give blood pressure read-ins. So you know, you're just using that app to trigger things that are from a prevention agenda, or, you know, offering them services like those immunizations and blood tests. It feels like you're getting that experience.

Sam: 29:12

It's quite easy to actually tell someone to lose weight or to stop smoking, but it's much harder to design an intervention that actually changes their behavior that leads to those outcomes. What role do you think GPs should be playing in behavior change and what should be handed off to digital services or health coaches and community support?

SPEAKER_01: 29:32

I think that's a tough one because part of us would say, Oh, well, we don't have enough time for this, so it should be passed to everyone else. Part of us would say, Well, that's part of what makes a job good. And if you take that totally away from us, we become like robots clicking computers and measuring things. So I think there needs to be a balance. And if we also look at that relationship, you know, if that patient's relationship is different with different parts of the NHS and with different health professionals, we've got to leverage that. So if you do have a stronger relationship with your GP, surely they do have a big part to pay in that prevention. Because I mean, we're going back to that word trust that we mentioned earlier on. If you trust your GP and they just say something, sometimes that statement, or even if it's delivered badly, can have an impact because you've known them your whole life. If you've if you remember them as a kid growing up and your family does that, and you trust them because if they've navigated you through different experiences, that could have an impact. So I do think we need to look at it.

Sam: 30:25

We've been working with communities in Shubury on co-designing what neighborhood health services could look like. One of the things that struck us is how different the priorities look once you start designing with residents rather than around the organizational structures. The tenure plan puts a lot of emphasis on neighborhood health centers and co-locating services. But co-location isn't necessarily integration. What would it look like if we designed these centers around patient journeys rather than professional silos?

SPEAKER_01: 30:54

I think you're right. So I think the first thing is don't we need to use more patience in that design? And what does that look like? We can come in from our end, and exactly what you said, sometimes co-location doesn't mean joint up services, it just means that they share a physical building. Maybe they just share the toilets for the patients, and it could be as that's as far as it gets. So truly breaking down those barriers, and sometimes that's contractual. It could be that people are pulling in different directions, that money flows and payment for service makes it difficult to work collaboratively. So you've got to look at contracts and flow. Second of all, fix thinking that we're so used to doing this as our service that we don't want to not do this. So we've got to redesign it. And we've also got to think about how to make it easier for the patient. You know, like they don't have to go for one appointment here, one appointment there. You know, how do we join things up together?

Sam: 31:45

Have you seen examples where design started around one patient rather than the organization chart?

SPEAKER_01: 31:51

One patient can make a difference. So it could be that, okay, that diabetic pathway or service is not great. It could be one advocate, one patient who champions it, leads through a design process. And sometimes I'm a great believer in that. We obviously need to represent a huge breadth of patient experience, patient variability, and what they think good looks like. But the risk is that we also never go anywhere. And having a one-patient champion can actually develop something that's more feasible. You can almost visualize it, touch it, design it, and then everyone can then chip in, break it, pull it apart, and shape it. So some service designs can have a one-patient champion.

Sam: 32:30

It feels like the shift is also very reliant on the VCSE community as well. And I wondered what the role you saw for them in that shift is and how we make sure we co-design change that works for those voluntary organizations as well as the NHS.

SPEAKER_01: 32:47

I think they play a critical part at this time in the NHS and have a really big role to play in neighborhood health. They are connected to the communities, they understand their different patient and population cohorts that they serve. They usually have a lot of range of motivations and are more holistic in how they approach something. So we can't separate health often from social and they interplay. We still, we know as GPs, we still focus more on the NHS health bit and maybe don't feel we can influence the social bit. So some of those voluntary agencies can span that breadth and cover all those things. Usually they also offer really good value for money and investments. The difficulty, though, is that they're precarious, often in terms of their finances, longevity, reliance on charities, which I think is even more of a reason to pull them into the NHS in terms of how we work collaboratively. And just to give you one example, and we were talking about the NHS app earlier at my borough. We have almost 70 practices. We wanted to do some training for them, like about how they could get the most out of the NHS app. Plan A would have been me running around to all of the practices and trying to do some team training. When someone pointed out that maybe I won't have capacity, plan B became AGUK. And we got AGK involved to go around and help train these practices. Now it's too early to totally evaluate it, but I think it's really fascinating, isn't it? Because this is where patients are training us effectively, or patient representation, training us on our technology. And we're actually hearing the users and the patient experience to challenge our thought processes as well. Surely we could roll that out as a bigger concept that we need to be challenged by patients on how we use digital.

Sam: 34:24

What qualities or mindsets do you think we need more of in the NHS to make change happen?

SPEAKER_01: 34:29

I think the biggest mindset change that we need is to realize small things can make difference and we've got to work collaboratively and we've got to work faster. And when I say faster, we've got to learn quickly, fail quickly, and change quickly to make the best use of our resources. And finally, what are you most optimistic about? I'm more optimistic about the fact that we still have a really great health service. We may think that there's things that we really dislike about it, but the fact that in five and ten years' time, I really do feel it's going to still be here and it's going to be different to what we had five or ten years ago. Um, the 10-year plan, there's lots of interesting things in that. And if even a small proportion of those deliver, that will be a good thing.

Sam: 35:24

Shankar, it's been a pleasure talking to you. Thanks so much for taking the time to join me today. What struck me most about this conversation is how many of the frustrations Shankar describes aren't technology problems. They're design problems. AI scribes, clinical decision support, app messaging, they're all making the current model faster. But faster isn't necessarily the same as better. The question I come back to is what would a GP practice look like in 2030 if it was designed around prevention with treatment as the exception? And maybe AI's real value isn't saving clinicians tens of seconds of typing, it's actually about the way it can reshape our relationship with the health system across our entire lives. That's not really an AI challenge, that's a service design challenge, and definitely a problem worth solving.services.