Why Young People Are Bypassing the NHS | Dr Charlotte Refsum

0:00I was practicing medicine in a converted bedroom of a semi-detached house in a suburb of south-east London. No access to bloods, no access to x-rays. And the choice was either me here today with that, like practicing nothing at my disposal, or send you into A &E to go and get bloods. There was like nothing in between.

0:17Steve Roest: That was the choice. Yeah, the way that we have set it up at the moment. It was very much, it worked very well for 1948. It works so differently now. And I think they've tested us and found us wanting. We couldn't work out how to value them properly. We couldn't work out how to pay for them properly. We couldn't work out how to deliver them properly. Tied ourselves up in absolute knots about it. Essentially, they went to the public and said, we'd like to use your data. And the public very reasonably said, what for? And the NHS went, I don't know, planning? Maybe? And it's because people just went, well, no then.

0:51But why? It's something completely different to sit in a room and have somebody walk in and trust you with their deepest fears and their biggest problems and they trust in you to help them through that. It's a huge, huge honour to do that and start to apply predictive analytics to it. If you can predict, then you can prevent.

1:15Steve Roest: Hello and welcome to this week's episode of the Health Tech Hour. Each week we bring you the best news, views and interviews with the leaders, clinicians, CEOs, founders, journalists, investors, the list goes on, who are changing the face of healthcare in the UK and beyond. As regular listeners and viewers know, I am a CEO and founder of a health tech venture myself called PocDoc. PocDoc's Healthy Heart Check now has been done by people in every single UK postcode area as of August. And the Healthy Heart Check is the number one tool that the nhs uses to screen for cardiovascular disease outside of gp surgery and we are super proud of that and if you're interested to learn more about pocdoc please go to pocdoc.co and thank you as always to pocdoc for supporting the show thank you also for all of your listens your streams your views the show is on an absolute rocket at the moment we get downloads now in over 50 countries every single month and our monthly stream count is somewhere approaching a million streams a month across all platforms so thank you so much for for tuning in for watching we deeply deeply appreciate it thank you also for listening live on uk health radio johan and his team do an incredible job and we're so proud to be on uk health radio as the station check out all of the other shows there's some amazing presenters doing amazing things and obviously thank you if you're listening on demand on any of the podcast channels or on the health tech hour instagram or tiktok or on my own instagram or youtube there's quite a lot to get through but we've got through the show admin so um on to today's show the last couple of shows that we've had have been fantastic and we had penny dash uh the chairman the chair of nhs england on recently and then this week this week prior we actually had laura earnshaw who is the co-founder of something called My Happy Mind, which is a completely different concept to Penny Dash as the NHS England chair.

3:13Steve Roest: But it's a platform to help children with their mental health and resilience starting from age three. And it's actually the most popular app for mental health in children in the UK. So check out both those shows if those tickle your fancy. But on to today's show, we have one of my favorite people in the healthcare industry that I've ever worked with. Someone that I've got to know through PocDoc over the last, I think, couple of years, give or take maybe 18 months um a breath of fresh air in in the uk system uh dr charlotte refsum who is director of health policy at something called the tony blair institute now many of you will obviously know the name tony blair he's kind of a he was kind of a thing back in the day um and you know i think two or three years ago there was a big change in the uk health market in the uk sort of ecosystem if you like which was the launch of the tony blair institute um and since launch it's really cemented itself at the very forefront of think tanks um i've interacted with it and know about it from healthcare i think they do a lot more but that's not necessarily my area of specialty but it gives me great pleasure to introduce charlotte to the show welcome to the show charlotte how are you i'm very well thank you that's a lovely introduction well we try we do good intros on the show thank you so you are a gp or are a gp it was a gp was a gp yeah so you saw health care from the front line before you came anywhere close to doing what you're doing right now yeah i did and i have the first thing i want to say about it is it's a massive privilege and that's the thing i take with me from my time like it it's something completely different to sit in a room and have somebody walk in and trust you with their deepest fears and their biggest problems and that they trust in you to help them through that.

4:59It's a huge, huge honour to do that. But it was a really difficult job, like a really difficult job. And I felt a lot of the time, like it's sort of half the time I felt like, I don't know whether you need somebody with 10 years medical training to start you out with this problem. And the other half of the time, I felt underqualified so I felt half overqualified and half underqualified and the underqualified part I felt like god you know you don't need me you need like a cardiologist a geriatrician and a renal specialist preferably all in the same room and it kind of occurred to me at that point that GP the way that we have um set it up at the moment it was very much it worked very well for 1948 it works so differently now and um and actually i think that we can do better than a single offer now especially with technology and perhaps perhaps we can get onto that i suspect we will but i you know i think we can give very different service to somebody who has a minor illness or somebody who's older and frailer or to children and i think you can offer different services to different people um so anyway that was my experience of being a gp so

6:14Steve Roest: talking about the underqualified piece yeah how much of that do you think was sort of imposter syndrome and how much of it was like real real i don't think it is imposter syndrome i think they're real constraints on what you can do in a gp practice and anybody's ever heard me speak before is going to roll their eyes and yawn at this because i say it every single time but i was practicing medicine in a converted bedroom of a semi-detached house in a suburb of southeast london okay no access to bloods no access to x-rays no access to unless you came back next tuesday sort of thing and the choice was either me here today with that like practically nothing at my disposal or send you into a and e to go and get bloods okay there was like nothing in between that was the choice yeah and it just felt so archaic do you know what i mean like that you that it hadn't um that the offer wasn't any better than that and so i don't think it was i don't think it was imposter syndrome although everybody has their fair share of that i think it's genuine constraints on on what you could do in a gp surgery at that time and um yeah that's what i think what and what when you go through gp training yeah when you went through gp training yeah does anyone talk to you about those type of things or is it very much about how to be it's about sort of acquiring knowledge and training specifically to the task at hand not necessarily some of these larger issues that you might confront i'm just curious they do i think there's something about the vocational training scheme which is the three years that you get is your gp training there is a lot about how to manage the practicalities of the job okay and managing risk and managing uncertainty because that's what we do a lot of in general practice um i think it's become harder to manage uncertainty actually because i think that the person sitting in front of you has much higher expectations than that and i think that the service is starting to realize or at least medicine starting to realize that it's not actually your risk to manage.

8:09It's their risk. So to sit there and say, well, I'm sorry, I don't have that test here or I don't have access to that specialist advice today or I don't have, it sort of starts to feel not good enough. And you are taught in those three years how to manage uncertainty and to do workarounds for that. But I just, I feel now you don't need to do that a lot of the time. So I think there's far more we can do to support um gps in their jobs yeah so one of the things that we talked about before the show was

8:42Steve Roest: this this shift or this idea around primary care which for that we're a broad church of people so primary care you would define as well i've got a new phrase yeah go on hit me with a new phrase i think i think primary care is a platform not a place yeah and um i have been doing some i'd been doing some thinking about what it means to be a GP and what primary care actually is. And actually, I think that primary care, when it was invented in 1948, was a really elegant solution to a problem. So the government had just promised health for all, it promised universal health coverage. But we had medical knowledge in the form of consultants that was scarce and expensive.

9:25And GPs were the perfect solution to that. They were trained to know a little bit about many things and they could manage most things from from their small sort of you know converted bedrooms in a semi-detached house and then um they could refer you up to the hospital if you needed an expensive test or an opinion but what happens now in the age of ai when medical knowledge is no longer scarce and expensive but abundant and cheap what is the role of a gp and i think that increasingly the role of a GP, which is a lot of tasks, like I think they do a lot of things. Essentially, they're trying to either prevent ill health before it arises, treat ill health when it does arise, or manage chronic ill health when you can't treat it.

10:11And technology is just expanding every single aspect of those three functions. And what you can do outside of a hospital and in a practice with support has just ballooned. It's bigger than what you can hold in your head as a GP looking after 2 ,000 patients.

10:27Steve Roest: And it's accelerating all the time. Yeah, exactly. And I think that there are technologies that can support to deliver that. But each of those technologies is only a tool. So you've got tools that either generate data. So you've got genomics, you've got your microbiome, commercial determinants of health. It either generates data, processes data, or acts on the insights of those data. But that only works if you pull all those tools onto a platform and start to create a new workflow. And that's why I think the role of the GP becomes very, very different in the AI era. I think the platform takes on that role of sort of designing new workflows and using all these tools.

11:12It's a very different prospect to, for example, giving a GP chat GPT.

11:16Steve Roest: and saying you know yeah is that what well they've got it now but is it turbo charging primary care i mean you'd know better than i will probably not you don't see it in the numbers yeah so i think that the opportunity of ai and of all of these new tools and technologies that we're getting you can't realize them until you start to reimagine workflows and start to do things differently and start to atomize roles into tasks and reallocate them between man machine and then reconstitute roles and just think about doing things completely differently um like one example sorry yeah this is this is great so one example i was um i was on the train the other day with my mum and she had like a dry patch of skin on her forehead and i said how long have you had that for and she said it's about two weeks it's not healing i said oh you should get that sorted out so i took a picture of it and googled online like skin and yeah blah blah and boots online came up And so I went on that and with her consent said, can I upload your photo?

12:15I didn't need to register. I didn't need to do anything. And she said, yeah. So I uploaded the photo and it went. And in five seconds it went, here are five things it could be. Do you want to speak to a GP? It'll be 25 quid. But that is so different. That experience of care, that operating model is totally different to GP. It's not call a GP, make an appointment. GP signposts you to a digital tool. you use the tool the result comes to the it's totally different operating model and so i guess what i'm saying is that in order to be able to benefit from these new technologies and the opportunity they present for productivity and better care and quality you need to be able to accept that these new operating models that are kind of are going to emerge that kind of challenge

13:02Steve Roest: the status quo of how we do things well not just how we do things but how we fund things yeah yeah Which is a very, very sensitive issue in our country and quite rightly. But it's I don't know about you, but sometimes I like what you talked about there was a, you know, as we've seen through weight loss and all kinds of different things, the public sector and the private sector. Yeah. I'm really merging in different views. Right. So in that instance, your mom just needed an answer. Yeah. To that thing. And actually, at that moment in time, she would maybe pay£25. Yeah. Speak to a GP about it. and that is absolutely not the same as as what happens in the nhs for a gp but that gp may work in the nhs and not in the nhs so it may very well be the same provider one way or the other so it gets really really complex real fast i think what's interesting is that a lot of these new models of care that are emerging are emerging outside of the public sector and even sometimes even outside of healthcare altogether.

14:03And I'll give you an example. So you've got Ping An in China. You've got Apollo, well, Apollo is a health place in India, but you've got Amazon in the States. They've all developed these new models of care. And Ping An was an insurer before it ever became a healthcare provider. Amazon is a logistics company before it became Amazon Health. I get, my point is, is that what they all brought to the table was not new clinical knowledge. Like the clinical knowledge is there. They're bringing an understanding of how you manage risk or an understanding of how you sell to, you have a consumer mindset or how you link the use AI and AI agents as Amazon Health is doing.

14:49They all bring something different. And so I think that, for example, I'm not convinced that the new digital first prevention offer for young adults is going to come out of neighborhoods. I just don't think it will. I think it's going to come from, you know, whether it's Boots or PocDoc or, you know, it's not going to come, I think, from the traditional places we've always seen it.

15:15Steve Roest: No, I agree. And I think that there's, I don't know, I don't know how we, PocDoc, we spend a lot of time, we're very lucky to sit in the middle of the private healthcare, public health care and consumer space we're really proud that we can interact and and talk to the leaders in all of those things but we're very rare in being able to straddle those things normally you're either fully nhs public or fully private or consumer and actually we need to have a really open debate about this so glp1s for me is a classic example yeah you know absolute standout example where the private sector is what is it on like two million patients now what is it somewhere you know it's it's and then i mean it's it's it's clearly people have the propensity to pay for that and you can you can debate about whether they should be paying and and does it exacerbate health inequality and how many of those people you know go back come off of it and then put the weight back on you know all those different things but you can clearly see that there's a i think for the first time in terms of a licensed drug that's approved by nice for use in nhs populations the massive deviation in terms of private uptake versus what the nhs is even able to countenance affording yeah right and so i just don't know how that ever gets bridged it's a very i feel like it's sort of accelerating and this this gap is is widening yeah i think glp ones are they were the first test case with the nhs about how they're going to manage this new future of a very different class of medicines coming through that can help with prevention, a very new type of healthcare system that we need, actually.

16:56And I think they've tested us and found us wanting because I think they emerged and we couldn't work out how to value them properly, we couldn't work out how to pay for them properly, we couldn't work out how to deliver them properly, tied ourself up in absolute knots about it. What I find interesting is that NICE actually determines that they were good value for money and we ought to be rolling them out to 3.4 million people. It was NHS England that turned around and said, pulled the ripcord and said, well, we haven't got the capacity to do it. And because if you go and look at the details of how they were imagining rolling it out, it was through GP practices when actually the private sector's got 2.4, you know, it's 2.4 million people getting them off the internet.

17:36Now, I know that clinical governance isn't amazing on all of those companies, but there's got to be somewhere in the middle between. So I think it really did challenge each aspect of how we approach this new class of medication.

17:50Steve Roest: And I think that there's a really interesting debate here because, you know, on my travels and talking to different people, really senior people within the NHS, I hear quite often that people at a very senior level in the NHS are like, I wish we could find a way to copy what the private sector does well in terms of distribution of a good or a service. not not the money bit that's not what they're talking about they're not talking about charging people they're just talking about the private sector when it decides to do something generally does that thing really well right the market so why does it want to reinvent the the private sector they've done it why are you reinventing oh no they meant more in general i think they were sort of saying like aspirationally i guess my point is that i don't think you have to compete with the private sector i just think you have to work out a way how you can engage with them and deploy some of their models because they're the ones that are facing a consumer every day and trying to work out how to make their products.

18:50Steve Roest: Yeah, they have to make something that's acceptable to the consumer or they die. Yeah, I think that the opportunity that they have to do that probably sits somewhere either in NHS Online or in Health Store because I think those could be, like the worst thing it could be is if we simply digitize outpatients because that would be a waste of time. But if we used it as an opportunity to give people access to really completely different models of care and start engaging differently with the private sector so people could get private sector level service but reimbursed through the NHS. Because this is something else that I sort of discovered as I was doing my research is that young people are increasingly circumnavigating the NHS.

19:37and if you think back to like um if we think about 10 years ago it would have been unthinkable to have a private gp and now it's like commonplace well that people are prepared certain people in

19:49Steve Roest: some places are prepared to pay one-off fees to solve things like like 10 years ago it was unthinkable that you might pay somebody a 25 or 30 service charge to go to co-op in the middle of the night because you forgot to buy toothpaste but that 10 years ago that was no one had ever come up with that idea yeah ever like if you explained it to someone they'd be like that's mental that's insane i'll just go to the shop tomorrow what are you talking about but the thing that's made it possible is technology yes because 10 years ago you couldn't have done a zoom appointment with it if you wanted a private gp you'd have had to gone to harley street they were very you know limited and it was but now you can you can get a zoom appointment and you can pay online and you can do it and technology has made it both affordable and accessible and what that means for the NHS is actually I think they're starting to realize for the first time that they're not the only show in town and actually there's an alternative and even if the NHS is free and the alternative costs a bit of money most people are prioritizing convenience particularly at certain age groups and I think that is what's coming that I think I'm not entirely sure the NHS has grasped that.

20:57I still think they think they're a monopoly and that people will always default to them. But I'm not sure that's necessarily the case.

21:03Steve Roest: Well, let's pick that up in the second part of the show. So I have to stop right now for our first commercial break. We will be right back after this short break with our guest today, Dr. Charlotte Refsome, the Director of Health Policy at the Tony Blair Institute. We'll be right back.

21:19Steve Roest: Welcome back to the second part of today's show with my guest, Dr. Charlotte Refsome from the Tony Blair Institute, Director of Health Policy at the tony blair institute um you guys at the institute really focused really early well i say this having i say this as an outsider so i don't know what happened on the inside obviously but it seemed like you picked a few very very specific theses to back and to go into real detail on that no one had really sort of approached before so i think one of them was in and around the concept of digital front door yeah and really what that really means beyond the the phrase that's been used for goodness knows how long what does that actually mean and then i think another one was around prevention i think and trying to actually layer in some real deep practical thinking beyond the well you know if you don't do it now it's going to be a lot of cost in the future which everyone's heard you know and so was that kind of deliberate was there a short list of these things and then you narrowed it down or like how did that sort of come to pass because you got a huge amount of impact off the off of by being so focused i think yeah i think they're just they're the things that occupy our as a as a team and as an institute it just occupies a lot of our thinking it's it's the institute the broader institute because you sort of referenced at the beginning and we do do a lot of work globally and we do work in other areas that aren't healthcare.

22:49I think the broader question that the Institute is answering is how do states, and I include the UK, how do states adapt to this new AI era? And it's not just transforming our ability to adopt technology. It's changing the kind of economics of everything around it. That NHS example is a really good example. The fact that technology is making healthcare outside of the NHS cheaper and more accessible means it's sort of challenging the status quo of the NHS as a national insurer and kind of undermining its sort of political consensus to be there.

23:24Steve Roest: Do you know what I mean? So it's not like, oh, how do we... The AI strategy of the company, of the country, is not how do I adopt and disseminate as much AI as possible. It's actually how do I preserve the concept of universal health coverage in an age where AI is making and technology is making healthcare outside of the NHS. more and more accessible so and that's a challenge across you know whether it's um not the same one but it's there's a challenge across defense and across um climate and across all these different areas so ai presents very different challenges and so the the institute is constantly thinking how do we support governments to negotiate these this new set of constraints that's that's what it is ai it's a new set of constraints and how do you optimize for them yeah and it's accelerated and we're only in the foothills yeah we're talking about yeah the thing that i doesn't concern me necessarily but it sort of i don't know i don't know what the right word is it makes me slightly worried in in the sense of how complex it already is for large national institutions to adapt to where we currently are yeah let alone where we might be in six months time or 12 months time or it just I don't I don't have a solution either I'm just saying it's you know it's just the curve is sort of steepening yeah and I don't know if we're keeping up it's part of the reason why we focus so much on digital and data because I think it allows the state to be agile I think one of the best things the NHS could do and I think there's an opportunity for it to do this if it is going to abolish NHS England and redefine the role of the centre of the NHS is to think about like what is what is the offer what is the nhs prepared to fund and then how can you engage with not for everything but but certainly for primary care i think how do you engage with different aspects of the public sector the private sector to deliver that and um so that you're not just locked into some monolithic delivery structure from 1948 you need that agility in order to be up with technology um yeah i mean i think for me the thing that which has nothing to do with pocdoc by the way so but is is i really hope happens and and seems to be happening regionally which i find slightly bizarre not nationally but it's a single patient record oh yeah now i'm again not my fight necessarily but obviously pocdoc and any other digital health business is going to benefit from this and sort of in downstream um but the whole country will anyway but what's your take on on why this is sort of dragging it seems to drag because we're not there yet are we or are we there i don't know where i don't think i think there is confusion about why we're building a single patient record and i think um i think we're in danger with the single patient record of creating if of creating a very expensive piece of digital nhs plumbing and well i i do because i think that i was looking into um some of the design criteria and it's considered a second order design criteria that it ought to be able to absorb you know wearables data or biome data or whatever from outside of the nhs at the moment they're just setting it up as a little intern i think the arguments that are used and i still hear them a lot are from they could have been made 30 years ago it's like this question's like oh but what happens if you live in scotland and you have an accident in cornwall how are they going to know your history it's like they'll work out for me the value of it is being able to um to have a single source of truth of this data that can absorb data from so you so you have your hip done in aspire hospital your blood pressure measured in boots you've been to a and e in a in an nhs hospital that all of that information can come together and you can then start to do real proper prevention because if you can pull all that data together um and start to apply predictive analytics to it if you can predict then you can prevent and so i think i think that it needs to be able to engage with the outside world i think at the moment it's being designed as some sort of hermetically sealed piece of apparatus for the nhs and i think it needs to engage with the ecosystem that is developing for the future or at least have the capability to right because you can build something that makes it impossible or you can build something that is theoretically possible but not activated or can be activated subject to some minimal amount of adaptation right because you definitely wouldn't want to just suddenly decide i'm lucky enough to be an advisor to the british and irish hypertension society which is a great society they do great work one of the discussions is around wearable data for blood pressure the cuffless blood pressure yes and it's a really non-tech question actually weirdly which is the entire primary care system is geared around either a single single blood pressure reading or two or three in a particular setting to get the standard deviation to do that right but they're single capture yeah measurements where if and there's no concept of what to do with wearable data to be able to do that piece or it's an ambulatory concept and you wear the halter for 24 hours um and it's even on a sort of data system ingestion concept they don't that there isn't really a way to put the wearable always on plumbing into the existing plumbing.

29:11Steve Roest: It's not even about whether it should do or what decisions we can make. It's like a really basic, you have all this data and we just don't know how to put it in. Yeah. We just don't know what to do. It's a real kind of almost philosophical issue. But somebody out there does know what to do with it. So my point is, if you had a single patient record and all of your information was there and you chose to, as a citizen, share that with POC doc or share that with a provider of cardiovascular medicine or whatever, and they were able to ingest your wearables data, they could provide a service for you.

29:51the NHS might even reimburse on on your behalf but I guess my point is that at the moment it's just designed purely so that other NHS providers can deliver that care but I think increasingly whether it's payable by the NHS or not pay for it people will go outside so I think it's your right as a citizen actually to have a single patient record and one single place to store

30:12Steve Roest: all of that what other countries do it well single patient record do you know who are we looking up So we're looking to places like Estonia. Although, interestingly, if you speak to them, they would say, oh, we would have done it differently if we were going to do it again. Yeah. Is that right? Don't ask me any technical questions. No, I don't. But they've got like 1.3 million people. Do you think the size of the population matters in this instance? Does it make it harder? Or is that a bit of an excuse that people use? No, I think it does matter. And by the way, with a single patient record, we're not just talking about one database, you know, like one.

30:42And it can be something that the data can reside where it needs to reside and you query it and you pull it from where you need to.

30:52Steve Roest: It's one channel, but it could be from multiple sources. So we're not I'm not saying it needs to all sit in one warehouse, you know, but the ability to be able to source that from different places and for registered and accredited providers to be able to access it and to add to it and to take away. Not to take away, but, you know, to have read write access. um yeah that's what and what what do you think is sort of standing in the way what are the obstacles that we need to get out of the way to get this done like if you you know not naming names or anything like it's it's john john needs to you know but in general like what what or another way to put it is how far do you think we've got still to go before this thing is a reality in england because i i feel from having read the 10-year plan having listened to the previous health secretary the current health secretary you know i've got all the time in the world for them as individuals i love the plan we were lucky enough to contribute to the plan and you guys were heavily featured in well you know featured in but you definitely helped around the edges for sure and a lot of the the thinking and things like that and we were all honored to be in it but so much of that plan delivery relies on or is related to an ability to centralize data to be able to use it query it's critical like it's it it underpins everything and so you know how far have we got to go on this thing i'm i'm not close enough to tell you like gut feel probably quite far yeah that's what that's what i'm sensing yeah yeah i i the thing is i it's about clarity of mission and and and scope it doesn't need to be absolutely all things to all people i think that's one of the things i think that um you know kneecaps np fit or whatever it was i oh the other thing i think has really sort of jeopardized that we should learn from np fit was that what's np fit sorry i don't know that uh the national program for it so that was the big yeah that was the big one back in the day that yeah that went yeah um i think one of the challenges with that was that essentially they went to the public and the same with care.data they went to the public and said we'd like to use your data and the public very reasonably said what for and the nhs went i don't know planning maybe and it's because people just went well no then but what yeah i didn't realize that joke was that funny uh but but i think unless you make it yeah I can just imagine those conversations.

33:23But unless you make it relevant to people, unless you link it to the NHS app, unless you make sure that the fact that they've got a single patient record means that they can access GLP-1s through an online provider or it means that they can now access digital physios through the app or make it meaningful. If you're just creating something behind the scenes that's really boring plumbing that makes no difference to people, then of course they're just gonna say no you need to make it relevant yeah and i think you need to

33:54Steve Roest: have that honest conversation with people yeah like which is not just people in the sector you know like how many consumers really patients read the 10-year plan none very few you know who don't work why are you doing this you know so i think that makes yeah that makes a lot of a lot of sense um so beyond the um the the prevention agenda and the this sort of stuff um how do you feel about the direction of travel in general towards the sort of vision that was laid out in the 10 year plan because there's there's some bits that are going well i think and going really positively so what are some of the things that you've seen that you're excited about um hopefully there are some well I think the commitment to prevention is really good and you you've mentioned the work that we've done at TBI on prevention and I didn't get an opportunity to talk about that some of that work because I think it's quite interesting because we did we have tried to flip the argument um on prevention um away from this kind of oh you should really do it honestly you're going to thank yourself in 20 years time spend the money now like it's it'll be great we sort of we've we We flip that because if you talk to Treasury and say, oh, if you spend this money now, it'll save you money in the future.

35:15They just don't believe you. It's a hard no. They just don't believe you.

35:18Steve Roest: Well, they've heard that story before, haven't they? Yeah. So part of what we were doing, some of the modelling we did with Professor Andrew Scott was to say, look, the prevention may not save you money for some time. Actually, what you can do is you can support people to live longer, healthier, more productive lives. and that changes the amount of time that somebody's in work, that changes your tax revenue, that changes GDP and so that was some of the modelling that we did there and I do think that some of that work is starting to filter through now and this idea of health as an asset, health as a national asset that we need to be investing in rather than health as a cost that we need to pay for.

36:01So I think some of that has really gone through But I do wonder whether we're still a bit behind on how we deliver some of this prevention. I just think I'm really encouraged that they're working with you. Because you are the future. That is exactly how we ought to be delivering. It's working with really innovative, agile providers that you can sort of work with to deliver on behalf of the NHS.

36:28Steve Roest: Well, the phrase that we've used quite successfully is that prevention is a lever of economic growth. Yeah. It's about adding to the GDP. You keep more people in work. You keep more people in the workforce for longer. Yeah. Happier people contribute more to the economy. And so it's not just about, well, you know, if you don't, because it's the fear message. The prevention, the prevention agenda, I think for far too long has been fueled by fear. Yeah. of people of well-meaning individuals clearly who have who are mission orientated and i get that and work super hard but their message has been one of if you don't do this the sky will fall in and i need money now to stop the sky falling in in the future and as national finances get tighter and tighter and tighter that's just a tougher and tougher and tougher message to land whereas one where you can definitively show and we actually used your your information about that gdp growth thing yeah it which is which is a really seminal piece of work actually by Andrew Scott to be able to demonstrate that invest investing in prevention now generates economic benefit now yeah that was the interesting thing actually that you didn't have to wait a generation to see the benefit actually you know within five years you can see an uptick in in GDP the the other interesting thought bit from that analysis that I really like that Andrew did was about the sweet spot the age like the age at which you get the fastest ROI for your investment so if you invest in um prevention for people in an older age group well there's a high incidence of disease but not many of them are working so it has very little impact if you invest in prevention for really young people well there's loads of people working but um not much incidence of disease but if you start investing in prevention particularly cardiovascular prevention for people who are in midlife who might be five 10 years away from a heart attack or a stroke whatever then you're going to start seeing your return on investment you know much much sooner and so it's that kind of forgotten middle and they're so neglected and i say this from my you know my days as a gp you're always worrying about the old person who's going to go off legs or the young person with a fever yeah nobody's thinking about the sort of middle-aged person who's basically well but like needs a conversation about their weight or about their cardiovascular risk and there just isn't kind of an offer for them no but they're the people where you get the biggest bang for your buck yeah modifiable risk factors yeah so we're going to do the last commercial break then we're going to come back and talk about this this lost middle and and a few other things but we'll be right back with the second part of today's show with my guest today dr charlotte refsum the um director of health policy at tony blair institute we'll be right back welcome back to the final part of today's episode with dr charlotte refsum on the health tech hour so just before the break we were talking about this idea of of the the sort of lost middle in the sense of um the the kind of people that are still very much in work have to be in work are active and arguably some of the least likely people to engage with the gp about their own health they're very likely to engage with the gp about their parents health or about their children's health but their own health um tends to get lost and they move from an amber where if they took action they could prevent something happening and every single year that they don't do anything they move further into the red um how do you feel like the best way is to try and deal with that because that's they're quite a tricky group to engage with historically yeah i i think what do i think i think that the i think it would be a slight mistake to go down the kind of we need a pure prevention offer and the reason I say that is because if your experience of the GP is that you know they're constantly sending you letters reminding you to get a smear constantly reminding you to come and get your vaccination constantly reminding you to do this but anytime you call them up and say I've got painful periods or I've got a headache they go I'm sorry I'm gonna have to see you in two weeks like they're going to stop engaging you need to meet people's expectations of a consumer service for acute needs like what do they think their gp is there for most people think the minimum viable product is that if i'm not feeling very well i get an appointment that day if i need antibiotics i get an appointment you know um so i i think you only get the right to do the prevention stuff if you're meeting people's acute needs so i think it and it's also i think it's wrong i don't i think prevention is kind of indivisible from standard care because so much of what we you know if you get admitted to hospital three times with something somebody needs to pick up that actually that could indicate that there's something so the acute service feeds into the preventive service so I think it's wrong to completely divide prevention and acute so I think I can't even remember what your question was now but I've got that It was great that was a great question it was more around like do you need to try and deliberately Yeah, more like, given the, I was just curious to get your thoughts on it.

41:32I think it's, I think it's meeting their expectations of what they want out of a health service. And I think part of that is, so prevention is what they need, but they might not want it.

41:40Steve Roest: Well, no, no one wakes up necessarily thinking, oh, I should probably prevent something. Yeah. So I think meet their expectations of what they want from an acute service, but then also meet their expectations in terms of how they want to engage with that service. So it's a great, it's a great, a great example that I always give. So PocDocs Healthy Heart Check can be delivered in communities, workplaces, but also at home. So one of the groups I would say that was very sceptical, the NHS in general, I believe, is rightly careful about home screening. Yeah. Because it's patient led and there's not a clinician there.

42:16Steve Roest: And that just means that they're more concerned than they would be than if there was a clinician there delivering that intervention, which I think is completely sensible and natural and that type of thing. um so we were having a conversation with one of the regions where we worked um and there was a primary care network which is a collection of primary there's a collection of gp practice and they wanted to trial um our home testing offer so inviting people to do the test at home the healthy heart check at home and um the i'd say that the partners of the gp practice were quite skeptical because the idea came from the icb to do it and they were like and then we kind They were sort of humming and whoring and we said, well, look, why don't we just take who are the people on your books that are the most disengaged?

43:04Steve Roest: The absolute worst people, if you like, in terms of engagement on your list, because if we can show an impact there, then we all agree that there's no noise in that in that sample because they're silent. so they looked at this list of serial non-responders to the health check so people that for the previous five years had been invited multiple times a year for five years consecutively and had never responded letters text etc and they they thought we would get zero uptake so they sent all these people a single sms and in the sms it said you're overdue for your health check you've not responded click here to book an appointment or click here to do it at home with a home healthy heart check so we gave them the option in the message yeah we got 80 uptake off of a single sms of people that had never over multiple years responded to an invitation to come in that's phenomenal right and so they were blown away i mean we didn't realize it we knew it'd be good but we didn't know it'd be that good and i think it speaks to your point there which is it's about particularly for that middle finding the right intervention around the right conditions that actually engage with those people yeah because it's not that people don't want to engage there are some people that don't care about their health but it's not as many people as i think accepted wisdom would have you believe it is yeah and your point about fear really struck because we've used that as a system to kind of justify spending more on prevention but we use it on a very personal level as well if you don't give up smoking this is going to happen or if you don't do that don't lose weight and this is going to happen rather than the kind of aspirational like we're here to support you on your fitness journey your health journey your nutrition journey or whatever which is that that offer just doesn't exist but it exists in the consumer you know market but the i think the nhs feels fairly icky about it i think they think it's all a bit um i don't know i think there's definitely some narrative conflicts within the system about what they should say shouldn't say what they feel comfortable about saying for sure.

45:11Steve Roest: You know, don't want to go back to GLP-1s, but GLP-1s is a really good example where the system clearly, I think, feels much more comfortable engaging with or having people engage with digital weight loss, weight loss groups, than this idea that we're just letting people inject themselves with an arguably much higher, you know, outcome, better outcome. I think that's a difficult, that seems to me to be a difficult trade for them at the moment. Yeah. from a sort of personal ickiness I do just think the world is changing around them and how do they retain what it means to be the thing that people love most about the NHS I think in my view is that people know that you pay according to your means, you take according to your need and it's free at the point of use outside of that I don't think people give a you know who they get their health care off of annual as long as it works you know they don't mind going to a hospital for their hip down and i think that um i do i think there's historically been a lot of ickiness about engaging with that sector but increasingly they are the the ones with that consumer facing offer yeah uh and they know how to they spend their days thinking about how they engage people and get them to commit and because they have to yeah because if they don't then the the lights go out yeah exactly yeah it'd be interesting i wonder i mean i'm sure in my lifetime i'd be shocked if this happens but it would be really cool if as in other systems there is a reimbursable concept because i feel like if we had had that that might solve a lot of these issues because at the end of the day if the system reimburses a particular thing at a particular level then it's the provider's choice about whether to engage with that and offer that service or not it doesn't matter whether it's spire or bupa or anything yeah there are elements of that but my knees and hips right yeah a lot of the knees and hips is a bit of the big ones there are elements of that but i i think it it could go further in a way you know the nhs could set out really clearly and evaluate all the evidence and say that this is what we think a really good primary care offer looks like and describe it as a function rather than a service So this is what the NHS is here for.

47:32And then just kind of let people decide where they want to get that from. And I think that that would allow some of these new models to emerge. At the moment, the way we contract for primary care is we've decided that primary care is general practice. And we contract for general practice. And we get general practice. Yeah. And and there's very little scope or wiggle room within that to deliver care differently. So I I do think that kind of agility that the NHS needs could be achieved by just really clearly setting out what what the offer is. You know, what is the offer for children? Actually, how does that differ for the offer for, you know, frail elderly people or people with learning disabilities or people in midlife who are basically well and need prevention?

48:19I think they look like very different things but at the moment general practice is 10 minutes you know in the middle of a working day with somebody it's just it's very one size fits all and I feel bad now because I feel like I've put down general practice and I love it they're

48:35Steve Roest: amazing they do an incredible job but they they have to work to what the contract says exactly that's the point I have a question it's a genuine question because I don't know the answer yeah is a GP practice that signs up to the NHS GP contract are they able to also be a private GP at the same time or are they sort of is that do you have to okay yeah i think you could theoretically yeah and it's a very tricky offering that i know and gps do charge fees for doing certain things like if if you ask them to write a letter or do a um if you wanted to go flying and you wanted to fit to fly note or something like that there are certain things that gps will do that are off the not reimbursed by the nhs if you like which they're allowed to charge feasible um but But yeah.

49:19Steve Roest: So one of the things that we realized over our work, which I'd love to get your opinion on, is that GPs, as far as cardiovascular disease prevention goes, they're not actually reimbursed for what's referred to as primary prevention. So it creates this very weird sort of model where, in one way, sort of the system seems to be sort of asking GPs to do more to prevent things. But actually, there's not really reimbursable because the GPs contract... I didn't even know that. Yeah, yeah. So the COF points are only for people that are already on a risk register because they had some kind of cardiac event.

49:57Steve Roest: Or there's the NHS health check, but that's commissioned very specifically by local authorities. So there is no reimbursement for finding untested, untreated, high risk patients and initiating statins, for example. So that's not reimbursed. That's wild. It's crazy, isn't it? That is wild. Yeah, it's kind of, it's sort of in the weird horse trading around the GP contract. Yeah, but do you see how like, it's just not set up for prevention in the way that we're going to need it in future. It's not set up to, if you think about prevention, sort of break it down, you need to be able to identify risk early.

50:38You need to consume all this data from different places and understand someone's personalised risk. they need to process that risk and understand it and then you need to offer an intervention so glp1s and alzheimer's drugs are part of the story but there there's lots of things that can support with um you know identifying risk and then processing and then targeting targeted interventions before you even get on to the new drugs that are coming down the the line and and the system just isn't set up to to trawl through the data find um so what can we what what are some

51:11Steve Roest: of the things that you guys or you personally or you what are the sort of the two or three sort of pragmatic things that we that you think could be looked at or be done you know what i mean not not wave of magic wand territory but more like you know what is it what are we going to do because i think in primary care what they could do is take the opportunity of abolishing nhs england and of redefining the role of the centre, I think they could think really clearly about what the primary care offer is and what primary care is and isn't there for and set it out. And then I think that they could start to contract for that in a very different way that meant that you didn't have to be a GP to do some of that.

51:56Steve Roest: I think there are a lot of services that are now so, in a way, cheap and safe that you don't need a GP referral for them. and they could become self-access. And I think they do have a model to access that through things like that. They're trying to through Health Store and through NHS Online and things like that, but I think they could broaden that much more widely. And then I think that in order to make that work, you need a digital backbone. So the digital backbone is essentially the data sharing that you need to make that work to contract safely with the private sector. So you need a system to be able to identify somebody and determine their eligibility for a service.

52:37You need a health record, a single source of truth so that you can treat them safely. You need a shared understanding of risk because they'll be taking on a risk bearing contract, especially if they're doing prevention. So that's probably through the FTP. And then you need a way to reimburse somebody. And if you had a digital backbone and we really sorted out the data, so if you had an offer, a new contract or some new contracts and a digital backbone, I think you could transform the way that we do prevention. You know, there must be hundreds of companies, software companies now knocking on the door of every single GP going, I've got an amazing piece of software.

53:15I'm going to troll your data. I'm going to find all of your osteopenic patients, all of your latent heart disease. And then, but what's the benefit for GP? it's exactly as you said they're not reimbursed for it so why would they invest in that technology we need to make it worthwhile for people to be able to um to do that good work cool well look

53:35Steve Roest: on that note charlotte thank you so much for coming on thank you where do people go if they want to find more out about what you guys do where do they find it tony blair website tony blair website tony blair institute is it tbi.org what is it probably probably tbi well look anyway and thank you very much to everyone for listening we'll be back again next week thank you thank you