Decision quality and the future of neighbourhood health: a US perspective

Matthew Taylor

Hello and welcome to Health on the Line, where I'm delighted to have a special guest that joined me in person last week from the other side of the pond, Al Mulley of the Dartmouth Institute's Global Healthcare Delivery Science Program. The program, that's the Dartmouth Institute's Program, is dedicated to forging partnerships around the world to build the capabilities essential to achieving sustainable healthcare economies.

We've had a fascinating conversation about issues like variation and clinical decision-making, how the NHS can implement the neighbourhood health ambitions contained in the 10 Year Plan. But before we get into that, I'm joined by someone a little closer to home, our very own Heather Moorhead, director of the Northern Ireland Confederation for Health and Social Care, or NICON as it's known.

I talked to Heather fresh from a wonderful NICON conference that I attended earlier this week in Belfast. 

Heather, welcome to Health on the Line. 

Heather Moorhead

Thank you very much, Matthew. I'm very glad to be on. I often listen, so it's nice to be with you today directly myself. 

Matthew Taylor

Yeah, it's a, it's a thrill having you on now, Heather, how I left your conference after you know about halfway through 600 people, a real buzz.

How did it go? 

Heather Moorhead

Yes, it was amazing. We'd 800 people there over the two days we’d the whole system in the room and everybody says ‘Best yet’. So that's deeply encouraging. And I think that was because we have one plan and everybody going the same direction, so there's a real sense of energy.

Matthew Taylor

I felt that, I mean, you know, Nikon is the second biggest conference we organise behind ConfedExpo.

It's a fantastic gathering. Now, exactly as you said, what I found was a real sense of shared purpose, and it's all around this reset plan that the Northern Irish government published, I think, in July. So just what are the kind of key features of that plan, Heather? 

Heather Moorhead

I think the, the reset plan, Matthew really follows a lot of the work that you're doing in a 10 year plan.

So in Northern Ireland, we've already got encompassing all our trusts, so that's health and social care because we've an integrated system. So that gives us a massive platform to really build out our digital work. So that's one thing that's massively exciting and everybody's really committed to. One of the other things is, is that we've just begun our work on neighbourhoods and we launched at conference our new primary care network, which is massively, you know, it's taken us a good long time to, to get that to happen.

And, and largely speaking, I love that because you prompted me to say, where's the primary care network in Northern Ireland? And we launched it. The other piece of work that we launched is we've got a People to Partners report, and we did that across the whole of government. So that health was working with all our government departments have really taken an asset space approach of really getting deep into our communities and do with approach.

So those are some of the key themes. Well, some of the other things that we were looking at was our winter plan, our flow and really rethinking about redesigning our design of our hospital services. 

So those are the the key things. 

Matthew Taylor

So one of the things that really struck me, Heather, was that it, it didn't feel like there was the same tension that I often find in England between kind of recovery things like, you know, getting the waiting list down, getting the money under control and reform.

It's all very difficult, but it all felt like it was, it was kind of part of one project and there has been a little bit of progress hasn't there? On waiting lists in Northern Ireland, albeit from a really unacceptable baseline. 

Heather Moorhead

Yes, massively unacceptable it has been a priority for our program of government to work on waiting list.

But there's been a concerted effort and we've made really good progress, which they were able to announce at conference. And that has been hugely welcomed by the whole of the system. And I think the other, the other thing that has been a sort of a cloud hanging over everybody is we began the year with a 600 million pounds deficit, and our system has saved almost half of that, I think nearly twice the amount of savings that the NHS was expected to make. So we're leaving conference with the executive announcing today that they've found the money for our pay increase. There's been a big concern that we'd end up with industrial action over the winter, and that was the big ask from our members, that we've made a lot of progress right across the system, that that would be stalled by going into the winter with industrial action.

Matthew Taylor

And then the other thing, I guess the thing that I found most exciting, Heather, about coming to NICON was that, you know, when you and I started working together a few years ago, you know, it was really hard for you to get a foot in the door of decision-making in Northern Ireland around health. And, that's gradually started to change.

And you and I, we agreed, didn't we, you know, two or three years ago that what we really wanted to do was to, to get away from a kind of master and servant way of working in Northern Ireland to one in which the people running the health service saw the chief executives of the health and care systems as partners in change.

They were a single team working together with mutual respect, all taking responsibility for their own organisations, but also for change across the whole of Northern Ireland. And that felt like a pipe dream. But You know, it's really happening, isn't it? NICON is really central to the conversation. You've got all of the trusts now working together, systems working together as a committee in common, and you've got Mike Farrah, one of my predecessors as Confed chief executive, not as the kind of boss of the system, but really as the kind of convener of that group all working together.

It really feels like a dynamic way of working. Heather. 

Heather Moorhead

I think that's absolutely right and these sort of things seem to arrive in public. But that was on the back of a lot of work and the, the reason that work happened was that Mike Farrah came during COVID and did some work for NICON with our chief executives as a development opportunity.

So he was meeting with them once a quarter. Helping them look up and out 'cause that's a big deal. Matthew, in Northern Ireland, we're small and we're a bubble, so our colleagues don't get time to really have their heads up and out. So we did that once a quarter so that they're working, looking to see what was happening in the rest of the world, what was happening in other types of businesses, but also building their relationships with each other and committing to each other.

So it was in that, that began to nudge, nudge, nudge, nudge, nudge. And slowly our chief execs were very much able to report at conference that they really were committing to be collaborative across. We've got six provider trusts and you could, you could see and feel the game change of that. 

And then obviously because Mike had been working with them. He knows them well and he's come in as very much a facilitative leader, and that's really changing the culture. Northern Ireland's very siloed because we have a different model of government, each different political party has a different ministry. And they tend to be very siloed. But Mike has really worked with not just his colleagues in health, but right across government. So there's a big theme of health and economy today and that again, and innovation and all of those things about how, the language that Mike uses is that health is a horizontal budget, and he's saying to other government departments, we can't continue to take money away from your budget. Can you work with us? And he's been really successful in doing that. So we’ve our executive office with us, we’ve the Department of Economy, with us. So it was a real whole of government approach and you could see and feel that tangible difference. And that's why I think my colleagues are really embracing that. Uh, we've Marmot with us, I should have said that earlier. 'cause that was a real fantastic place to start, to begin the whole conference really looking at, at health inequalities. So there was a real shift in my, just, just a shift in mindset about everybody really beginning to think, well, what makes a difference in health?

We can't keep going the way we're going so that we really have a sense of making a shift. 

Matthew Taylor

And, and Heather, there were so many positive things. You know, there were a lot of clinicians. I went to a fantastic session about performance variation. A lot of members of the community at the session I went to about the public as partners, even colleagues from south of the border coming and talking about how we can strengthen collaboration and understanding across Ireland.

Well, I, I hope. Listeners, these notions of, of kind of mission driven health policy in Northern Ireland of collegiate working have whetted your appetite because next edition, you will be hearing my interview on the stage at NICON that I recorded with Mike Farrah. Heather, thanks so much for joining me for this conversation.

Heather Moorhead

Thank you, Matthew. 

Matthew Taylor

Now returning to this episode, I was fortunate enough recently to catch up with Al Mulley at the NHS Confederation office in Westminster. I first came across Al’s work having listened to his wonderful podcast series, The Choice Securing the NHS for the next 75 years, and our mutual friend, Paul Corrigan, then put us in touch.

I was particularly keen to talk to Al about how the model of care and neighbourhood health needs to be different. Before his appointment at Dartmouth, Al was at Harvard in Massachusetts General Hospital, where he served as chief of general medicine for nearly three decades. But he was also a visiting fellow for The King's Fund, where he worked with the fund on how to transform the delivery of health services through innovations that produced better value for patients.

And in that, he looked at evidence from the UK and the us it, it was a wonderful conversation. So enjoy. 

So Al, just let's start by you telling us a bit about yourself, your background, your work as a clinician. 

Al Mulley

I'm happy to Matthew. Early on at university at Dartmouth, I became very interested in market failure. I read Garret Hardin's The Tragedy of the Commons, and I could see relevance to healthcare all over the metaphor.

Which, as you probably know, is sheep or cattle owned by multiple owners grazing freely on a common pool and what happens under those circumstances. So I chose to go to medical school, study policy and economics while in medical school so I could learn more about that and make a difference.

On the personal side, the reason I was already an admirer of the NHS is I grew up in the poorest community in New England, starting with parents who had very little education immigrating from Newfoundland and Poland. I had 17 cousins, 14 aunts and uncles. We had very little access to healthcare unless we were ill enough to be across the river to the MGH, which is just a few miles.

To be in A&E and admitted to an ICU. 

Matthew Taylor

Right, right. So you've been engaged with British colleagues for, you know, for a long time working to improve and sustain the NHS. How did you get involved in working with the NHS? 

AM Well, as I said, I always admired the NHS from a very early age. Right after we passed Medicare and Medicaid, I recognised that they were, uh, pale in comparison to what you did in 1948.

And what I learned at the Kennedy school studying policy and economics while in medical school gave me a focus on the quality of decision making. I learned a lot from economists about, uh, economic decision theory, game theory, uh, you know, that had me thinking about you never judge quality of a decision made in the face of uncertainty, bias, outcome.

It was all about how carefully you thought about the options and, and the outcomes from different choices that might be made. Probabilities of those options. And most importantly, don't stop there because your work's only half done. You have to try and quantify the outcomes in the lives of people who experience the consequences.

So, from the very beginning of my clinical career, I wanted to be a generalist spanning the breadth of medicine from primary care to ITU care. I did that and in the intensive care unit, I made the distinction between unwarranted and warranted variation in the early 1980s. The year after I made that distinction and, and reported it in a to a presidential commission, Jack Wenberg published a paper replicating the work that he had done, defining practice variation in New England.

In New England, the Midlands of England and Norway. I found that amazing because Clem McPherson was the first author, and Clem was from Oxford and at London School of Hygiene Tropical Medicine at the time. And he developed the standard coefficient of variation, which was able to demonstrate that variation in elective surgeries was condition-specific and essentially the same in these different countries, despite the fact they did enormously different ways of organising their health, the funding and provision of healthcare. 

Matthew Taylor

So, so let's get into some of these, these ideas, Al so let's start with this kinda notion of variation.

So we talk quite a lot in the NHS about variation, but we tend to be talking about variation in performance. Whereas I think your focus is more on variation in activity. That, you know, the proportion of people who are treated, what we actually discuss much, much less is that in your work with the NHS, this question of variations in the, in the number of the level, number of people who are, who are treated the way they're treated, is that something that you've found that people in the NHS are interested in wanting to talk about?

Al Mulley

Absolutely. When you do refer to it in the US as, as early as my introduction to working here in the mid eighties, um, you refer to it as the postcode lottery, with seriously negative connotations in implying that resources aren't sufficient in one area. They are in another and therefore there must be rationing going on and nothing increases demand for services like suspicion that things are being rationed and that's your problem. 

Matthew Taylor

And that's the problem that, because in, sorry to interrupt, but in, in the states when I've looked at this literature a bit, I, I've kind of assumed that these variations in, in the level of treatment reflect a market system where doctors were incentivised to treat people.

Al Mulley

Yes, but it's, it's much more than that, right? It's, there's no linkage between the clinical decisions made at the front lines, even though every clinical choice is a spending choice and the decisions made by people commissioning services in for future use for a population of people or for those making capital investments or doing workforce planning.

There's no linkage between the decisions made and the capacity that is being built. The most exciting aspect of the work that I started doing in 2016 with my partner also now in the faculty at Dartmouth, is that when we worked with frontline people and introduced them to the way we were thinking about decision quality as producing the critical intelligence that commissioners have never had, in order to invest in ways that don't spur more use of services that aren't necessarily the ones that are needed and wanted.

Matthew Taylor

So you spoke a few minutes ago about rationing. You would've thought that in, in as much as an element of kind of overtreatment might reflect the incentives in a market system where people are paid for activity. That wouldn't be such a problem in the NHS, but you find in the NHS similar kinds of variations.

Even though we have got a whole set of guidelines and institutions and NICE and all sorts of other things, which are there to try to, to reduce those kinds of unwarranted variations. 

Al Mulley

Yes. So just a little, a little bit of, of the history of variation in both of our countries. Jack discovered it in the 1970s in New England.

I told you about the international paper demonstrating that it was procedure-specific, not terribly affected by the form in which services were funded and provided in those three countries, vastly different. In 2001, five years after the first Dartmouth Atlas of healthcare, looking at variation across more than 300 regions, carefully defined with careful measurements of of administrative data.

Very dramatically for individual procedures, but also for hospitalisation and per capita costs of care. And in 1996, it was clear that we were spending three times as much per capita on people living in Miami, as on people living in Minneapolis. Now then the question becomes, what are we getting? Are we getting value for money?

The answer in 2001 was no. A very careful study published to much acclaim in United States showed that the people in Miami were less satisfied with their care. Their outcomes were no better and perhaps worse. So there was awful lot of of activity going on that represented waste and potential harm to patients.

That paper was discussed in 2002, I think here by Jack and my colleague Elliot Fisher, and that really lit a fire under people thinking about variation during the implementation of the early 2000s NHS plan. Shared decision making was recognised then. We had put it on the map in 1986, 1987, 1988.

It was embraced here by people at The King's Fund and by people at Oxford who knew Clem and his partner, Ann McPherson. They did something very similar with videos of patients so that prospective patients could get a sense of how they'd feel about different outcomes. So it was very much recognised as a source of learning.

There isn't anything we learn from, but variation. Sometimes we can control it in randomised trials. Sometimes we observe it. So there's a, there's a long history of this argument and there was a bit of a breakthrough when I was commissioned by the King's Fund to join up practice variation, shared decision making, engaging patients and understanding what they think they need and want and why.

Matthew Taylor

Yeah. 'cause this is what I wanted to get to as well. There's not an intuitive link for me between the notion of variation and the notion of decision points and the importance of decision points. So what is it that links these two ideas? We don't want needless variation 'cause it implies that some people are being treated who don't need to be and some people are not being treated who do need to be.

But what is the relationship between that and what's at the heart of the podcast really is, which is focusing on the point of decision between the, the clinician and the patient. 

Al Mulley

So you can't judge the quality of a decision made in the face of uncertainty only by the care with which one thinks about what the options are and the conversations that lead to the choice involving very much the expertise of the clinician, of course, but also the expertise of the patient about what matters to them at that moment in time, in the context in which they're living their life.

And what we've referred to is patient preferences. The breakthrough was about to describe is when I was commissioned to join-up variation, shared decision-making and commissioning, it gave me the opportunity to think and bring in some colleagues from Dartmouth to help me think in new ways and articulate that unless there were high-quality decisions being made and measurably high-quality decisions, there was no feedback loop to system leaders who were doing the commissioning.

Investing in capacity and investing in workforce, and that feedback loop generates the critical intelligence that is needed to know where to invest and where to disinvest. The distinction came from a moment when I was walking back to my research office where I was studying indications, interventions and outcomes of intensive care.

I’d just come from a family meeting and let's call the patient Mrs. Jones. She had been intubated in A&E nasotrichially. She wasn't getting very much better with the ventilatory support, so a decision had to be made about whether or not to do a simple operation and continue the support of tracheotomy or to remove the tube and do everything we could to support her without that. And if she couldn't improve, she would die. 

That was a common family meeting in intensive treatment units in this country and in my country, everywhere. And I was coming back proud of my trainees, including the medical students for the empathy that they expressed. I felt good about the decision made by Mrs. Jones, who was awake and alert with their family present.

And I was wondering how many cases like her I had in my database in order to narrow the confidence intervals around the probability of her having survived. If we did the tracheotomy and persisted with the mental support. And I had an epiphany, it really didn't matter. Probability might have been one in 50, one in 25, one in 10, but it was so low that the decision wasn't sensitive to the probability.

It was dominated by how Mrs. Jones and her family felt about where, when, and how she was gonna die. And Mr. Smith and his family across the corridor might feel very differently about where, when and how he was gonna die. I've been commissioned to work on intensive care decision-making for ethics committee that Jimmy Carter had pulled together, and I used that story to make the distinction between warranted and unwarranted variation.

So, so there's lots of variation in how patients feel about exactly the same outcome. There's lots of variation in how patients feel about exactly the same risk, and there's lots of variation in how patients feel about making some kind of quality of life sacrifice now in order for a better future.

Matthew Taylor

So what I wanted to do is to explore what the barriers are to this, as it were, investment of time and energy in the decision point in order that from that we can derive the information that we need, that commissioners need in order to understand our best to commission the services that we want. So I guess one would be, an obvious one would be we don't give clinicians the time maybe, we don't even give them the encouragement to create the space for those kinds of kind of conversations That in a sense, and I've heard GPS in particular say this, a patient comes in, you don't have that much time with them. They kind of want a diagnosis and they want something to take out of the surgery with them. They want to take a prescription, they want to take an outpatient's appointment out of that process, and it becomes, therefore it becomes quite kind of transactional.

And with it built in, is the assumption that a successful interaction is one that leads to some further medical intervention. 

Al Mulley

Yeah, no, that's exactly right. That's exactly right. The work that I described began with, with, uh, Vanguards CPS and, and pacs. We learned a lot co-developing with sexism across the country.

We then reiterated that in the poorest communities of East London and then in the black country and east of England, and after seven years, we dared in a black country meeting in Wolverhampton on an away day of the chief nursing officers and, and chief medical officers to put to them the galvanising question, how do we avoid the financial waste to the system, the personal harm to patients, and the moral injury to ourselves, the health professionals.

When we routinely substitute medical interventions for needed emotional or social support. And when you say that to a group of clinicians, they all nod knowingly. It's not uncommon for, I'm picking up on what you said. It's not uncommon to write a prescription for antidepressant 'cause your waiting room is full.

You're behind. You're trying to do your very best with the constrained resources you have, but you just didn't have time to learn that the dog died. Prescription for antidepressant for is already on the medications and there's a good chance she's gonna end up in A&E because of that ninth medication.

Matthew Taylor

So there, there's a great bit of practice. I think a couple of years ago from an ICB, I think it was in Sussex, they gathered together a large group of people who were on the musculoskeletal waiting list, brought them together for a day with clinicians of various kinds, I think voluntary sector organisations, various other people, and talked to them about a variety of options.

And at the end of the day. Quite a high proportion, I think, you know, 40 per cent or so these people maybe had said they didn't really wanna be on the waiting list anymore, that they could treat themselves, that they were gonna have some alternative way of dealing with it, or that actually they understood that the operation that they might ultimately have had wasn't really gonna do them a great deal of, of good.

So we kind of know that if we can engage patients in this way, they can see a range of alternatives. We give them a bit of time. The consequence is not, as I think we tend to assume, that I think there's an assumption often in the health service, which is the more time you give people, the more you'll end up having to do for them, whereas actually your argument is no.

If you give people more time, you probably end up having to do slightly less than or slightly less in a medical context.

Al Mulley

Not, not slightly less a great deal, less great deal. Not slightly less a great deal less, and, and there's evidence to demonstrate that what we focus on in, in the, in the podcast, just to try and simplify is, is five levels of decision quality.

Level one is doctor knows best, and that's what most patients have been taught to believe your entire lives. Level two is, well, you know, if you look at this variation, even within practices there, there must most often be more than one reasonable thing to do. At that point, people say, well, how do you narrow down?

And we say, no, no, don't narrow down. You have to expand the menu first. You, you have to recognise how complex it is to understand what brought a patient to the GP surgery, complaining of hip pain or back pain, or insomnia, or because those generalised symptoms are very often related to emotional or social needs that are much more embarrassing to talk about if the patient recognises that's the case and often they don't.

Much more embarrassing to talk about the fact that your banister broke and you're much more lonely than you've ever been before 'cause your daughter moved away and there's no one able to fix your banister. So you come in and say your hip pain is worse. You get the referral to the, that’s a true story.

There's a true story that we learned in our first iteration of these eight essential capabilities that, uh, we can talk about if you like. But in, in that case, the patient came back to the GP and said, I wish I'd known this was gonna be so difficult, the reenablement, I, I just couldn't get down the stairs comfortably view, because my banister broke.

How often do we replace hips rather than repair banisters because there isn't time to understand what is going on. Good GPs know that you ask the question, tell me your story and you don't interrupt. And when they do stop you hope you have the time to say, oh, that doesn't sound very good. Tell me more about what you're going through. And what you're doing there is trying to understand whether that insomnia is due to depression, which a lot of people can jump to because it's early morning awakening is a cardinal sign, or it's because of domestic violence or any other thing that needs a different kind of treatment.

Matthew Taylor

Let's think about your ideas in the context of two or three kind of topical questions for the NHS. So one is around the notion of neighbourhood health, and we've argued strongly at the Confed here that that neighbourhood health has to be about a different model of care and a different relationship with communities.

And we find that that argument, which goes to the idea of a more holistic offer, recognising that often the issue that people have is to do with housing or debt or all sorts of things, not necessarily needing a medical solution. And the notion of engaging more deeply with communities to try to understand what assets are available in those communities and what are the kind of assets we need to build.

I often tell the story of being in Birmingham talking to the neighbourhood team there, and I said to them, you know, what was the one resource you'd like more of in terms of referral? They said befriending. So not a medical service, not really a statutory service, you know, provided by the voluntary sector. So, I dunno if you've got involved in this conversation about neighbourhood health, but what would you say is essential if we're going, if, if we're gonna capture the idea that it's contained within neighbourhood health, which is that it's a much more kind of holistic, proactive, empowering model of care.

Al Mulley

Let me go back to my personal story for just a moment before I address your question about what we've seen in the UK and our work. When, when I was a student in training at Massachusetts General Hospital, it was viewed as one of the most technically, scientifically sophisticated institutions in the world and leadership there, the general director and the chief of medicine decided that they were not gonna compete to do the first heart transplant. This was in the early 1960s when that transplant was done for the first time in South Africa, not to very much benefit for the patient. It was the same year, 67, 1967 that the MGH opened a community oriented primary care centre in the Irish immigrant community just north of the hospital.

And my mentors there recognise the importance of understanding cultural context and cultural intelligence, as well as emotional and social intelligence in addressing both decision quality at the micro level and at the macro level. What does this person need? Is it medical or is it emotional? Is it social support?

And at the macro level, how do we engage the schools so that we're, we're dealing with one of the segments the chapter two parents and children, right? How do, how do we engage others in the community? So, you know, I am incredibly grateful for having, you know, arrived at Harvard when they are announcing a new PhD program in public policy.

And when the MGH was announcing a new training program that you had me learning, um, not only from the best consultants, some of the best consultants in the country, but also from advanced practice nurses who led our outpatient rounds four days a week. And on Friday, outpatient rounds were led by a social worker.

So, so there's that background. And working here with the vanguards, I recognised how unusual my experience. I started writing the first text book of primary care at a time when I was still training, and it was published when I was attending in the intensive treatment unit. So being able to talk to people in the acute trusts and in Middlesbrough for instance, about decision quality in a and e and in in primary care is something that has opened doors to helping them see that the people they're accountable to don't understand the complexity of decision-making at the front lines. They're focused on system functions of primary care – access, most importantly, because a problem with access is visible to patients who are voters. They're not aware of the complexity of medical diagnosis and treatment, psychological diagnosis and treatment.

We've already talked about how those are intertwined, supporting patients from all backgrounds and all phases of illness, treatment decisions, explaining prognosis. All of those things are really very complex, and they all involve learning from variation in order to avoid underuse in the neighbourhood.

Making prevention impossible, often, or overuse in the neighborhood causing clinical cascades that lead right to A&E into the hospital and ICUs. 

Matthew Taylor

So it's, it's so fantastic talking to you. I could talk to you for hours, but I'm gonna just ask two further questions. The first is, in terms of general terms of GPs, in terms of those people who wanna argue about the importance of GPs and investing in primary care, but particularly in in GPs. I think you've got one thing to say, which is kind of comforting with that argument, but one thing that's a bit more challenging. So I think the comforting thing is I think you recognise the importance of continuity of care. Although we need to be clear about what is continuity of information, continuity of person, continuity of care.

But on the other hand, it doesn't actually have to be a GP does it? The GP needs to be there to be called in, but it doesn't have to be the GP who has the conversation. 

Al Mulley

Right. And ideally they're not even called in. Right. But let me get back to your question about what we're talking about, I think is essential for people building neighbourhood care systems.

The opportunity to make the right decisions in neighbourhoods with the left shift in the community is the opportunity to make the NHS sustainable. We stopped at level three, broaden the menu of decision quality. Level four is get rid of all the biases, including the biases that come from uninformed commissioning decisions.

Because they don't have that feedback loop, which is the aggregate of the needs and wants revealed by high-quality decisions. So you get rid of all of those biases. And then the fifth brings you to the ultimate, the pinnacle of decision quality. And that's raising the voice, giving power to the patient.

You have to get them away from level one,

Matthew Taylor

…away from assuming a single medical solution. 

Al Mulley

No. The sense that the doctor knows what best, right? That you're a machine and this is a mechanical problem. You're much more complex than a machine, so you need to find ways to engage patients.

You need to find ways to help clinicians engage patients. And that's why we talk so much about listening capacity. The, the, the goal of any service provider in health and social care should be to make people feel known and cared for by someone they can trust. 

Matthew Taylor

So, so continuity does matter. 

Al Mulley

It does, 

Matthew Taylor

But it doesn't have to be a clinician who provides that continuity.

Al Mulley

Based on my experience trying to general, I was chief of general medicine for nearly 30 years at the MGH. I tried to reform, improve healthcare in five different ways. They all worked but marginally. When I came to Dartmouth, a condition of my moving, one condition of my moving was to start from scratch with a new model of primary care.

I'd spent a lot of time with Chris Trimble, who was a co-producer of the, of the podcast, and a co-author of Patient Preferences Matter and starting from scratch gives you lots of advantages that, that most GP services don't have. But if you follow his advice, you, you can actually do it. Starting from scratch, what I said to the chief executive over the time was that you're self-insured, you're a clinician.

You understand healthcare. Self-insured means the insurance company is justified in administrative services. It also means you're the policymaker if you wanna double the proportion that’s spent upstream. If you wanna create that kind of left shift, no one can stop you from doing it. And if you wanna capitate it, so you have more like British GP incentives, you can do that as well.

The only condition you should hold these colleagues that I introduced them to, you should hold them to in the operating model is that people will spend less than 50 per cent of time they currently spend one-on-one with a doctor or a nurse. They will be delighted more than ever before by the care they receive and that model, instead of having four GPs.

So the Dartmouth employees had two, instead of two nurses had one, instead of four receptionists, there were no receptionists, there was a behavioural coach and 10 general health coaches recruited in the community, only half of whom had experience in primary care. They recruited for their relational skills, their ability to affirmatively listen.

After a year, the net promoter score was 93. 

Matthew Taylor

That's such a powerful lesson as we think about our model of neighbourhood health. Final question. There's a lot of emphasis on digital. AI. One of the big announcements at the Labour Conference that we had recently was more outpatient appointments to be undertaken virtually.

We can see the upsides of all of this. In terms of the upsides and the downsides, given the emphasis you have on human relationships and human decisions, how do you feel about the idea that more and more of these conversations will be taking place virtually or potentially algorithmically?

Al Mulley

I'm currently proofing the chapter one of primary care medicine, um, which I'd just recently revised, and the major revisions were about corporatisation of primary care in the United States, and you don't want to go anywhere near that, but also the role of AI.

And I only had a few paragraphs to deal with this, and what I ended up stressing was the role of human values in medical decision-making. And I cited a number of papers that addressed that head on, both from here, from institutions like Oxford and others, Imperial, and from the US. I think that as long as people are paying attention to verifying the value of AI interventions that should be paid to diagnostic interventions and therapeutic interventions and hold AI to the same standard we’ll be okay.

Commercial interest won't do that. It's one of the reasons why I think the NHS has the opportunity to show the world what smart, intelligent regulation of these potentially wonderful innovations could do if somebody is looking out for the welfare of the patient as first priority. 

Matthew Taylor

Yeah, I mean, what worries me is this early evidence that AI seems to make people less intelligent, actually, the use of AI.

And I worry that the emotional intelligence, which you emphasise so much in terms of the decision point. That if we are over reliant on algorithms, if we are overreliant on systems almost distance the patient from the person who's advising. Then we, we will think it's making us more efficient. And it, and it won't be 

Al Mulley

No, no, it will never be able to be more than an advieor, in my view.

It can't be the decider. And it's because it. I don't see it being able to deal with the variation in utilities, risk attitudes, discount rates that we've talked about to use the technical terms, and I don't see it being able to bring the emotional, social, and cultural intelligence to decision points that is needed.

So not a decider, an adviser. One of the papers I paraphrase quickly in this chapter used the kind of decision theory that, uh, I was schooled on in at, at the Kennedy School in order to test AI. And what it did is it gave it all the same information, but gave that information to different stakeholders to a child's parents.

It was a question of early, short stature and, and do you treat it? So if, if you give the same information and you're allegedly posing the question to the child's parents, you get one response. If you're posing it to the clinician, you get a very different response. And if you're posing it to the insurer, you get an even different response.

A very clever way to highlight the risk of losing sight of human values in AI. 

Matthew Taylor

Al it's been an honour talking to you. This really, this episode of Health on the Line, it's just an extended trailer for your wonderful podcaster, The Choice Securing the NHS for the Next 75 years. So folks, if you've enjoyed this conversation immediately go and start listening to that podcast.

As I say, particularly relevant, I think now as we start to think about what is at the core of the neighbourhood health model. Al, thanks so much for joining us. 

Al Mulley

Thank you, Matthew. Very kind of you. Thank you. 

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