Is the NHS ready for a digital future? Insights from the 10 Year Health Plan

Matthew Taylor

 Hello and welcome to the latest edition of Health on the Line produced by Health Comms Plus on behalf of the NHS Confederation. Before we get into today's episode, I want to mention a special webinar I'm hosting with NHS England chair, Penny Dash, on the 20th of August. 

We're bringing together a panel of experts involved in developing the ten-year plan and who are responsible for its implementation, to focus on how these changes, the changes in that plan, can be made in a way that empowers leaders and the broader health and care system. So if you are interested in that event, we're already getting into the nuts and bolts now, aren't we, of how we make this ten-year plan a reality, please go to our website, www.nhsconf.org, and the event section in particular to book your place. This webinar, by the way, has been funded through sponsorship by Boehringer Ingelheim Limited, and I should also emphasise that Boehringer Ingelheim has no influence on the content of the programme.

Before we get into our main topic today, I want to bring in my colleague from Confed, Annie Bliss. I want to talk to Annie because one of the kind of issues that's really has lot of importance to our members we're finding as we go out and we talk to them, as we do on a daily basis, is performance, oversight and particularly league tables.

So, Annie, welcome to Health on the Line. 

Annie Bliss

Thanks Matthew. 

Matthew Taylor

Tell us first about what you know about the government's plans to publish league tables. And can you tell me more about the date, which seems to be shifting around all the time?

Annie Bliss

Absolutely. So we first heard about the reintroduction of league tables back in November, and then with the Ten-Year Health Plan positioning easy-to-understand rankings as part of its plans to improve public transparency, voice and choice. 

So I think really the intention behind the league tables is firstly to increase public transparency, which was announced in the plan and a big focus there. But a secondary aim is also to tackle underperformance and make sure that no more rewarding of failure. So that was something that was announced at the NHS Providers conference. 

I think it's important just to make the point that, you know, lead cables are part of a wider oversight and regulatory landscape and see oversight and regulation play an important role in making sure that you can identify providers that are in need of support, ideally get ahead of the issues that are going to lead to poor performance and potentially safety issues. So it was really important that that is tackled in a robust way.

Publishing performance data in the form of league tables is kind of one tool within the context of performance management. That tends to focus more on immediate issues like operational and financial performance. So it's really important that they look at the right things. 

In terms of timescales, we are expecting the league tables to be published in the summer, most likely in September. 

We know that they'll cover acute mental health community and ambulance trusts, and it'll be linked to the recently published NHS oversight framework, which has a shortened set of metrics to support rapid recovery. 

So, my view, and I find the debate about league table fascinating because, you know, I've been looking at these kinds of ideas and debates for three decades as I've thought about public service reform and innovation. So the, the arguments are kind of well rehearsed. 

I guess my starting point on this is. They are simply inevitable. In fact, I was reading the Yorkshire Post the other day, or the York Evening Post, that's just the paper for York, and it had an article saying, best and worst GPs in York according to our readers.

So the fact is, people are able to generate all sorts of details. HSJ, you know, a week never passes without them publishing some kind of list that tells you who's the best and the worst. So, for me the starting money is, that this is inevitable. The question is not whether there will be lead tables and equally if you are doing well in a league table, people will assume you're a good leader. And if you're doing really badly, people assume you're not such a great leader. 

So it's kind of defying gravity to suggest that you kind of don't do this. But then equally, on the other hand, the gap between doing it well and doing it badly, doing it in a way that improves things for patients and doing it in ways which can actually lead to perverse outcomes, that gap is huge. So it's not whether you do it, it's how you do it. 

So Annie, tell us a bit about the Confed’s perspective on some of the key things we need to make sure we get right. 

Annie Bliss

Absolutely agree, Matthew. 

I think giving league tables the best possible chance of achieving what they're setting out to do. So encouraging some healthy competition, increasing local accountability. some sharpening the focus on national priorities. The way we do that is to kind of make sure that they're not set up in a way that is intended to kind of just name and shame. They need to be designed thoughtfully. I think it really, obviously it matters what metrics you use, what behaviours you're incentivising, what data's available to support that judgment, how the information's presented, as well. So, it's absolutely, how do you take forward this approach? 

For example, while it's important to have clear rewards for good performance, clear consequences for underperformance, this needs to exist alongside a programme of support, which is tailored to organisations that are struggling and who might lack the capability to drive improvements on their own. 

So I think for us, we probably have some sort of considerations around whether that is being taken forward in the most appropriate way. So, do the ratings provide a rounded and accurate view of organisation performance? Is it clear and transparent to the public exactly what they will and won't do? And also how do we look at past examples of league tables? What metrics give us the most meaningful measures? What metrics can we look at from outside the UK and how do we mitigate some of those unintended consequences, perverse incentives.

Matthew Taylor 

One other concern I have, which you didn't mention, is if neighbourhood health is going to work, if the left shift is going to take place, we are going to need organisations to work effectively together in the interests of the public. Is there a danger around lead tables that they reassert the importance of organisational performance and they miss out the importance of integration and collaboration between organisations?

Annie Bliss

I think that's certainly a risk and obviously the league table approach needs to align with some of the other levers for change that were in the plan. So, financial flows and national targets, some of the things you've mentioned there, and in particular, there's a drive towards a more devolved model based on autonomy. So how do we make sure it kind of aligns with some of that?

 I think the most important thing really is that they do improve public transparency and that they're also going to actually empower the public, within the context of a wider set of measures, to increase their agency and choice over their own health. I think that's one of the key things that we know the ten-year plan needs to do.

So how do we make sure that the information is communicated in a way that makes sense? That's understandable to the public. And also how do we make sure that the metrics are things that do matter to most of the public. 

So obviously it might be a reach to suggest that publishing a league table may change someone's choice if there is actually no choice in reality about what services people can use.

I think it's important that that communication is clear around what they can and can't do. I think there's some considerations, in terms of financial override, which sits within the oversight framework and how much that can be a consideration for the public in terms of what services they use.

As a member of the public, I don't necessarily care if the trust that I'm using as in financial deficit, but I do care if they're going to deliver high-quality care for me or for my family members, for example. 

Matthew Taylor

Yes. Well, I think that's a good point to end on because I think what bit of advice I would give to all policy makers is the more things you try to achieve with something, the less likely you are to succeed. And so if you've got league tables and you're trying to improve performance, you’re trying to increase transparency, you’re trying to inform the public. Well, fine, but some those things might pull in different directions, so it's better to do a couple of things and do them properly than try to do too much and end up with something which in the end doesn't do anything properly.

So a lot of work to be done. We are working closely with officials at the centre to try to help them to get it right. I think, it's right, isn't Annie, to say this first iteration will very much be a first iteration and these league tables will develop over time?

Annie Bliss

Absolutely. 

Matthew Taylor

Thanks Annie, so much for joining me.

As regular listeners to Health on the Line know, we're in the process, over a number of programmes, of talking about the implementation, the implications, the opportunities, the challenges of the ten-year plan. We've talked about that in relation to mental health. We'll be talking about it soon in relation to neighbourhoods.

But today, we're focusing particularly on technology, on data, on ai, on digital. So much ambition in the plan, so much possibility of change, but then well, so much scar tissue in the NHS in terms of how we've tried to get this stuff right in the past and we haven't succeeded.

Well with me to talk through all of this I'm delighted to have Dr Nnenna Osuji, who's CEO of North Middlesex Hospital and Andrea Winders, who's head of business development for Midas, which is the Inward Investment Promotion Agency for Greater Manchester. 

Welcome both to Health on the Line. 

Now, I know you both took part in sessions at our recent ConExpo conference in Manchester, looking at how the NHS can better use data, how it uses ai, how we achieve the third of the three shifts that Wes Streeting has been talking about which still run through the ten-year plan. 

So the ten-year plan, never short of hyperbole, says the ambition is to create the most digitally accessible health system in the world.

Now, I'm just going to recap for our listeners the kind of key elements of that. That's establishing the NHS App as the front-door for all healthcare services, the doctor in my pocket principle; wanting to allow anyone with an NHS number to access their health data via single patient record so they can self-manage their own care and ultimately live healthier lives. And then there's lots of ambition around ai, including the development of a strategic AI roadmap with clear ethical and governance frameworks alongside staff training.

So, there's a huge amount in this. We know that Wes Streeting as a great enthusiast for the possibilities for technological transformation. 

I'll just start both of you with a kind of big question. I'm going to ask you to kind of give me a kind of a headline answer to that, which is now you've digested the ten-year plan, in a sentence, Nnenna, I'll start with you, does it feel like it's pointing us in the right direction for where the NHS needs to be in the next decade. 

Nnenna Osuji

Thanks, and I'm, I'm focusing my answer mainly on digital. And we know that the status score is not sustainable. I love the commitment to bring digital currency into health, which feels the right direction of travel.

Of course, the devil is in the delivery and how it's translated with people, by people, for people. But in terms of ambition, definitely the right direction. 

Matthew Taylor

Andrea, what's your view? 

Andrea Winders 

Yeah, I'm pretty similar. I think the ambition is there. I wish it had gone a little bit further. if I'm really honest. I'm a disruptor, so I really want to see this being a little bit more disruptive. I wish it had contained more around the culture within the NHS and hadn't, hadn't generalised as much it as it has done because. Nnenna will know, that every trust is different and people is what makes the NHS tick and work. So I think it's a really great start. It's really ambitious, but I would question the deliverability and I wished it would've gone a bit further. 

Matthew Taylor

Let's get into that. So, Nnenna, if I can start with you. In your experience as a clinician overseeing a trust, you've got a really great sense of where the tech is working and also where it isn't; what the barriers are. 

So let's start with that barriers question first.

What continue to be the biggest barriers to us exploiting the full potential? You wanted to focus particularly on digital? 

Nnenna Osuji

Gosh. So I thought I'd be very careful with my answer here. I want to celebrate all that is good about the organisation I work for, but I want to recognise some of the limitations as well of the systems in which we work.

We are HIMSS level five, so we're not digitally naive in terms of our service. We've got an electronic health record, and we're an integrated organisation, so we've got community services. If I were to ask where we would want to go, I would want greater interconnectivity, both vertically and horizontally.

So when I say vertically, I mean in place so that when we talk about patients, we talk with the full purview of their health and social care in order to make better informed decisions with patients and with populations. I love that the NHS app looks like a single source of entry, a single portal for engagement of people. 

I'm really conscious that 60 per cent of our staff in this organisation come from our local population. And I know it's beholden upon us as leaders to then think about how do we train our own staff to make sure their first conversant? And also then sharing that opportunity. Staff will say infrastructure.

So we want to talk about new, exciting, technologies and innovation, but actually there's something about making sure before we go for clicks rather than bricks, that we get the bricks that we need for the clicks in place. And so simple things like Wi-Fi connectivity, making sure it's robust throughout the estate and in the community settings in which we work.

Elements around not looking at  that circle of doom. On a computer, you know that when you buy any form of technology, the second you walk out of the shop, it is already almost out  of date. So how do we maintain the currency of the hardware and software that we supply our staff with to make it work? 

Longer term, I'm thinking about environmental sustainability and not just the hardware and software, but also some of the digital space in which this will be secured and the cybersecurity element of this, which is something that we're more and more current, more and more concerned about where that can go differently. 

If I pick up two small other bits, there's something about how we get the basics right. So the NHS number, a single unique identifier, is absolutely the right standard and we know that with all our data solutions, what we put in is what we get out. I'm not sure that we yet, at a point as a system, as an ecosystem to have our NHS number, our wrist wristbands, our standards of our data in such a way that we can actually use it, harness it, and test it in the way we need to make digital solutions as effective as they possibly could be. 

So on the way, more to do around interconnectivity, both vertically and horizontally, a recognition of infrastructure and infrastructure is not just the tech, there's also something about the people. I want to make sure we have the subject matter expertise, and that's a level of expertise that is few and far between. That our staff, we have some who are fearful, some who are fearless. How do we make sure we have the training to bring everyone on the same journey? So, more for us to do for sure. 

Matthew Taylor

I noticed, I think yesterday an NHSE published data, might have been the Department, about the fact that there had been quite a significant uptick in the use of virtual appointments in primary care. That obviously it went up a lot in covid and then there was kind of questioning of it, and then there was some unhelpful political interventions. And it fell back again, but now it seems to be picking up and maybe picking up more, kind of more organically simply because it's what patients want and it's the best way in which the health service can offer access.

Where do you think we are in terms of that kind of story of digital access to the health service because it has been a debate that's gone we've had these kind of moments of exuberance and then disillusionment. Where do you think we are and where do you think we need to get to?

Nnenna Osuji

So I think it's part of a solution, but it's not the entirety of the solution. And digital is meant to augment, not replace what we do. It's difficult to make a blanket statement because I think there are different populations who engage in different ways, and some of that is about language. Some of that is about understanding. Some of that is about age. So nought to fives for example, tend to want to have their parents, of course, more face-to-face than necessarily virtual consultation. 

But I think we need to recognise that there is a demand out there for people who are as young as I am and younger, who want to have the immediacy and the synchronicity of a virtual contact, who want to have convenient healthcare.

And there's a cohort of patients where we look at things slightly differently. We look at transactions of care. That sort of quick fix opportunity that doesn't necessarily need to take up time. And by using virtual mechanisms and remote mechanisms, we then free up time to people who do require a little bit more complex.

I would always say as a clinician, there is no substitute for hands-on and sometimes in a moment of a consultation, you pick up something that you might otherwise not pick up. And so when we were looking at virtual solutions, even as simple as virtual clinics, it wasn't an either or, it was an ‘and’. So we would, for example, have patients come for two virtual clinics, but the third clinic had to be face to face.

So it's how we use the fullness of the, of the offer to make sure we respond to what people need, respond to what people want, and maximize the opportunity for us to do more for the most. 

Matthew Taylor

I'm interested in this exactly in that reply, which I think is absolutely critical, which is that we need to use the technology but not to use it in a way that forgets that we are human beings.

AI interests me a lot. I've got a personal perspective on this. My wife thinks deeply about AI and is somewhat of an AI sceptic and is forever, for example, pointing out articles that demonstrate that AI now seems, you know, using AI regularly seems to reduce people's kind of thinking capacities.

So, when you think about AI and the potential of AI and the inevitability of AI, how are we going to get the right balance of using this unbelievable force, but not doing in a way, which actually in some ways diminishes our humanity and our relationships? 

Nnenna Osuji

Gosh, that's a big question. And an important question and one in which we're actually living the reality of that question.

I am an AI advocate. I think you have to hold me back a bit in most cases, but I think that that diametric position between speed and control is one that we're living in. Many people want to almost close the gate, but actually the horse has bolted on AI. AI is permissive. It's everywhere in our lives and so many people are engaging with it.

I think that the way we engage with it is different and we'll need to recognise that and I'm really aware of the potential impact on people. So people who are operating at the top of their license can use AI in ways that actually help to augment and release more time to care and can look at productivity. Can question and test AI and use it as a starting point, but not the end point of the product. And I think that's really important because we always want the principle of human oversight on AI, even if it's not humans doing every aspect of the task. 

The second bit for me is that AI is absolutely necessary. And I say that because of the volume of data that is becoming normal in providing care. That's personalised data if we look at things like genomics; that's population data if we look at the size of the populations that we are responsible for. There's no way we can use human capacity alone in order to mine that data and provide the insights to make either personalised or population-based solutions.

So we absolutely need to use AI. The question is how we balance that governance and that speed in a way that allows us to move forward. There is something about the way we look at governance, which often looks at tangible products versus concepts, and I think we need to look at AI as conceptual governance and think about the way we manage that ethically, but realistically so that we have sufficient speed, but sufficient caution.

I'm really clear as well that in terms of moving forward with AI, there's something about the parochial, we spoke about the bricks for the clicks, but also the standards that are really, really important. We spoke about cybersecurity. I just told everyone to let that go so there's a parallel expectation as we move forward. 

And of course, from a commissioning point of view, we need to think about if we're replacing hardware from a capital point of view and the revenue implication. So what is a commissioning landscape in which we do this? 

Lastly, I really want to highlight people both in terms of subject matter, expertise, both in terms of our staff who need to engage with us in a different way, but also in terms of how we design equity by intention in what we do. 

We know many examples of where we've used AI and the inputs have been themselves skewed so that the outputs actually can potentially exacerbate inequalities rather than diminish that. So there's something about how we ensure parity and design and parity in the way we manage and monitor some of the AI outputs puts.

Matthew Taylor

Thanks Nnenna. And Andrea, I've got questions for you, but actually I'm first just interested in any response you've got to what you've heard from Nnenna.

Andrea

I'm fascinated by Nnenna’s response. I'm really pleased to hear that she's an AI advocate because I travel the world quite a lot and I see some great innovations that use AI to help clinicians or to help non-clinical staff, like pharmacists, for example. I've seen the AI stethoscope, which could be developed and be present in pharmacies so that if somebody goes in with an issue, the pharmacist isn't an expert, the AI stethoscope can step in and maybe help to either alleviate the concerns of the person or to help them to know to when to refer forward.

I've seen it being used in things like circulating tumor scans to speed up that process and to help the human eye to pick out issues. So I too am a strong advocate of AI and technology, but I carry the same concerns about making sure that everywhere's protected. 

In the past, I worked in smart cities and I saw what a data breach can do or a cybersecurity attack could do to a whole town.

It could be such a simple in attack that happens within a hospital, even down to a fish tank, dare I say, that isn't necessarily a piece of clinical equipment that could cause major issues that has ramifications beyond what we know. 

The NHS has got lots of opportunity to adopt and adapt AI and other technologies, and maybe something as simple as business process management to connect systems so they talk to one another.

There's a lot that can be done. 

Matthew Taylor

And actually, you go around the world, you have a background in innovation. I guess the question I want to ask is why is it so bloody difficult? What does the NHS seem to make such heavy weather of these changes? I mean obviously it didn't happen overnight. It took ten, 15 years, but you know, overwhelmingly people are online banking and accepting that's what they have to do and accepting responsibility for their part in making that kind of interaction work.

What's your sense of why this is so tough with the NHS? 

Andrea Winders

So this is an outside point of view. You know, I'm not working within a hospital, so if I say anything that's insults, do not take it to heart. I think it's just, it's a large ship and large tanks are very difficult to turn. And as I said earlier, people are at the heart of the NHS; people are what makes it tick.

It's managing that change that's difficult. I think there's the will to adopt and adapt new technology and new influences. But the actual practical way of doing it is just tremendously difficult, and it's also who owns the data? I have conversations with the ICB with the Health Innovation Network and others who say, oh, we own the data.

And actually, no, you don't. I own my data and it's my data. And I think there's a change of mindset needed about data and accessing data and how we manage that to put the citizen at the centre, as a starting point, rather as the end point. 

I love tech. I don't use the NHS App, I'm sorry. I don't use the NHS App, and I've given up trying to use it with my GP practice because it's just so difficult.

We've got some learning to do. 

Matthew Taylor

That's a sobering thought. Nnenna?

Nnenna Osuji

It. It really is. Actually, I was just sitting here thinking that that's a shame. So I would give examples of the NHS App where in clinical practice someone comes to see me and is able to share the trend of their results so that when I see them in that one consultation, I can give an opinion with them, explain to them, they feel reassured and they can walk away.

So I think the power of the app is there for sure. I love the fact that it is a patient-owned element and that we start the conversation, as you say, with the citizen, with the person. And I think that's going to change the way people engage with their healthcare. It's also going to probably protracted of our conversations before they compress the conversations because people start looking at every facet and become more curious.

But I do think it is a way, I think your challenge, Andrea, to how we make it more user friendly. How we make it interface with other elements. So we talk about my choices, we talk about my care. I think there's a lot that we can do in that. And within that provision something about how we make sure we speak all the right languages.

And I don't just mean whether you speak English or not English, I mean whether you speak medicine or not medicine, whether you speak NHS or not NHS and how we actually use it as a navigation tool as well. 

I'm hearing you say there's more we need to do to make it something that is more user-friendly, but the power and the patient and person-centric nature of what it can deliver is huge.

Matthew Taylor

I'm going to come back to you both with a kind of hypothesis about why this is difficult, which is not to say that should abandon hope, it is that we just need to understand and hold that difficulty. 

But just before I do that, Andrea, another kind of question for you when you're thinking about the work that you're doing with innovators and life sciences. I have to say that I think part of the problem in the NHS is that we have been fairly consistently sold things by the commercial sector with claims made which then are not fulfilled. And I'm not saying this is deliberate, that people mislead us. But obviously if you are selling a product, you'll sell the product with the full potential that you think that it's got, but you may underestimate the degree of time it'll take for it to start to pay off, the cultural changes that require for it to work, how other things have to work together. It is part of how we do technology innovation better a better quality of relationship between the health service and commercial partners?

Andrea Winders

I think that there needs to be a better relationship full stop between commercial partners and the health service. Almost every day I have somebody trying to sell to the NHS, saying we want to land in Manchester and we want to sell to the NHS. And my message to them is, stop. Don't think like that. It's Manchester Foundation Trust. Here in Manchester, I'm working with primarily their innovation team, and I put a challenge out to take a different approach to innovation, how we can actually start with a problem.

So as opposed to having the door open to everybody and anybody coming in and trying to - if I get told about a mental health app again, you know, I must see two a day. Look at what the problem is and not what the solution is. So I'm challenging MFT to come up with problems, not solutions, so that then we can maybe do call outs to businesses to work globally to get solutions to come in. 

So flipping the lid on that Matthew, so that the NHS isn’t being sold to, is having a problem resolved. I'm hoping that that's the way forwards, because like I say, every entrepreneur, every innovator obviously thinks that theirs is the best product ever.

Large pharma invests hundreds of millions of pounds in creating new solutions for drugs. We are not seeing that in digital. We're seeing the one-man bands. We're seeing the smaller companies coming up with innovations. So I think there's just a different way of approaching this that could improve outcomes for the NHS, but also could improve success for entrepreneurs.

I see something great in Leeds. Leeds Teaching Hospital has an innovation, I wouldn't call it clinic, it's not, that's not what they call it, but that is kind of do what we're talking about. They've got a problem statement. They invite entrepreneurs in, they've got a space called Nexus, which is the startup space, and then they've got the Health Innovation Network who help those entrepreneurs to get ready.

I think we need to start thinking differently like that, and it's to stop people selling to the NHS per se and start from the other way round. 

Matthew Taylor

I mean, I completely agree with that. In fact, I remember years and years ago, Hackney Council had exactly that approach, which is to pull their, I mean, it's easy in Hackney, there's a lot of entrepreneurs, but bringing their entrepreneurs in and, and start with defining the problem and telling them to go away and call up the solution.

Because so often commercial companies have a solution looking for a problem. 

I mean, Nnenna, for you as a leader, you have commercial partners knocking on your door every day saying, look, here's a solution to all your problems. What do you need different kinds of support, better support in terms of helping you to make the right commercial decisions?

Nnenna Osuji

So I love the way Andrea has framed that. I think that often we have solutions that are sold to us and they're solutions looking for problems rather than problems in search of a solution. And I think that's exactly where we need to be. 

I think the second bit for me is around, we talk about innovation as though it's always something new and bright and shiny. Sometimes innovation is adoption. How do we make sure some of the simple things that work well, that are digitally based and I would use Scan for Safety, as a really good example. You spoke about Leeds. North Tees and others have used this. How do we use the things that work well and ensure we scale them up? So, to your question, Matthew, there's something about how we avoid that sort of pilot paralysis that the sets us in the NHS. I don't need to pilot it on behalf of someone else who has piloted it elsewhere, particularly for something like AI where you know that  the user case is well test and all we're really doing is making sure we understand how it enters the organisation. 

So I think there's something about what is the footprint of a pilot that allows us to adopt it, but also what are the specifications and how can we agree those regionally or nationally so that we are looking at the same thing rather than each person losing time, money, productivity, and cognitive efforts trying to find bespoke solutions for small problems rather than saying this works, let's adopt this. 

Matthew Taylor

And there is, to be fair, some specific recommendations in the ten-year plan, particularly in some of those areas around kind of once, once the technology is proven that, that it should be much easier for other people to adopt it.

Let's go back to this question of why it's so difficult though and suggest a proposition to you. Starting with you Andrea, which is that the way that technological innovation takes place in the commercial sector is that there's a kind of letting go of control; there's a kind of willingness for people to test things out. There's a kind of, you know, fake it till you make it kind of culture, which has got all sorts of problems associated with it, but is in the end a thing that does create an environment where all sorts of innovation flourishes. And also in the commercial sector, if you're a commercial organisation, you don't have to provide a solution that works for everybody. You've just got to provide a solution that works for sufficient customers and then you can refine it and try and bring in more customers. 

In the health service neither of these things apply. We can't have a kind of fake it till you make it culture. And, and as Nnenna has emphasised, we need solutions which work for everybody because we're a universal service. 

So I guess the first part of my question is, is that right? Is that one of the things that makes this so difficult? And if that is right, is part of what we have to do to be a little bit more willing to accept risk and also be a little bit more willing, in a transitional period, to accept that sometimes there'll be solutions that won't work for everybody, but that'll work for some people, and then over time we can develop them so that they work for more people.

Is that the kind of change of thinking that we need? Andrea, I'll start with you.

Andrea

Absolutely, that's the kind of thinking that we need to change and part of the problem comes from all the different trusts so that within Manchester we've got five trusts alone. So it wouldn't necessarily follow that if one trust took on some a digital product that another one, even the same region, would take it on.

So I think that's part of the challenge. And back to that pilot, I think somebody within our Health Innovation Network said we've got more pilots than BA. What we need to do is to adopt, adapt, and learn and move on. And have a system where if it's accepted in the NHS in one hospital and it works, don't pilot again.

Matthew Taylor

I think we can agree on that. And Nneena, to what extent do you think our quite appropriate worries about risk and commitment to inclusion can sometimes get in the way of being more entrepreneurial in terms of technological development and innovation. 

Nnenna Osuji

I think risk is a two-edged sword.

We spend a lot of time thinking about the risk of the things that we know about and that are in front of us. I would say there's equally a risk about the things that we are not paying attention to and that we need to think slightly differently about that. I think part of the reason we're all sort of once bitten, twice shy, we don't operate in a system that forgives risk or forgives failures in many ways. And the consequences of failures are quite extreme. We are talking about human life, so there's a good reason why people are cautious. But an abundance of caution can itself become a risk, and we need to be careful to find a balance.

And I think this comes back to the principles of governance. So how is it we maintain human oversight? How do we test and have appropriate audit of things that are AI driven or digitally driven so that we don't always release the reins completely. We maintain some element is scrutiny and oversight and in all our thinking, first do no harm.

But I do think there's something about how we adjust our risk appetite and how we think about the seen and the unseen elements of this. And I'd say lastly, when I use the word experimentation in the NHS, everyone looks at me with shock and horror. But there is something about how we experiment safely and how we just set the boundaries of what failure can be that is tolerated and that we move forward from that.

So I think that's a really delicate equation. It's one that we're grappling with. It's not an easy one, but it's an important one. I always remember a conversation around what if we get it wrong with AI as relates to populations? And I would say yes, but AI might allow us to identify a population that is not yet on our radar and actually what is their health impact?

So there is something about us having to have a very different relationship with risk, but a bounded relationship on one based on principles rather than product. 

Matthew Taylor

I think that's absolutely right, and I think the way we construct the narrative with staff and with the public here is really important.

So, exactly as you say, Nnenna, on the one hand, you know, when we talk about inclusion and technology, we can focus on the dangers of exclusion for people who, for example, don't have access to wifi or whatever. But we should also recognise that the technology offers enormous opportunities, as I've seen this in mental health, for us to provide services which people can access in new ways, who would find it difficult, and have found it difficult, accessing services in in traditional ways.

And equally, and this is a point that Joe Harrison from Milton Keynes is on the Confed board, often makes, whenever we talk about the risk of innovation, we should always start from recognising the risk that exists in the current system. You know, we're never introducing innovation into a risk-free system, we're changing the risk profile.

I want to end on a positive point where with both you, it's been a fantastic conversation. And, that's just what ultimately, Nnenna, I'll start with you, what do you think is the biggest game changer here of all? I mean, I think when I look at the ten-year plan, I'll answer my own question. I think individually-owned personal health record, the idea that we all own our own data. I do think that could be an absolute game changer. But, what for you is the single biggest game changer here? 

Nnenna Osuji

I like the question. I'm with you in terms of patient ownership, and I'm going to use data and insights that we can use to provoke change, to represent both parity, personalisation, population health and a future-proofed health and care system.

That, to me is the game changer.

Andrea Winders

Do you know what we're actually, we're doing a project in Manchester where we're actually bringing in a wellness wallet, so I'm with you as well on that one. So it's using data from all your wearables, connecting together, not replacing the NHS App, but coming from a different angle completely and with wellness at the heart. 

So I'm really excited about the prevention rather than cure. I've seen it in action in France. I went to France recently, spoke to somebody who'd moved there from the UK. They'd had a heart problem in the UK and had a couple of stents fitted. When they went to their clinician in France, they had more stents fitted because, and he asked the question why? They said, this is prevention. The others were curing your issue. This is preventing, and I love the fact that we're going to start changing our mindset around that. 

Matthew Taylor

Well look, who knows Andrea. And then if you work together on a wellness wallet or anything else, Health on the Line would've fulfilled its potential, not just to engage and entertain people, but to be the basis for new innovation. 

Thank you both so much for sharing your thoughts with us today.

And as I say listeners do keep an eye on our website where we'll be posting lots of opportunities for members to get involved in discussions about how we make this plan a reality. Thank you both.