#405: First Look: 'NHS 10 Year Plan' goes big on AI

0:02Hey really, this is a first look at the NHS 10 year health plan for England called Fit to the Future. If you want to know about that plan, but you don't want to read an enormous document, same. That's why I have Liam Cahill with me to talk about what this means for the health tech industry now what they've said broadly just so everyone knows is that the nhs is making three big shifts to how it works hospital to community analog to digital and sickness to prevention so those are going to be these core components of and what they're calling a new care model and to support that they're going to ensure that the whole nhs is ready to deliver through a new operating model, ushering in more transparency, creating a new workforce model to genuinely align staff with the future direction of reform.

1:08They're going to reshape an innovation strategy and they're going to take a different approach to NHS finances. All of this sounds wonderful and I did look at the executive summary and I did look at the analogue to digital section and i'm going to pull out a few few bits that i noticed in here that we're going to be discussing with liam over the course of this next goodness knows how long it'll be but um i enjoyed them calling it the the neighborhood health service so the nhs standing not for national but neighborhood the neighborhood health service uh moving more into the community they talked about bricks to clicks um made me think the whole thing had gone through chat gpt to be perfectly honest when i I saw that.

1:51I was like, that's okay. Giving patients real control over a single patient record. So getting into some health tech stuff now. So single patient record is mentioned. Transforming the NHS app was mentioned. Continuous monitoring for proactive management of patients being a new normal. So first signs of deterioration being noticed by tech to prevent emergency admissions to hospital. Sounds wonderful. building a health store for patients to access approved digital tools great uh think i've heard that before but we'll go into that no you haven't this has never been invented before of course of course uh a health data research service um that sounds interesting so and now we're getting to the real nitty-gritty making the nhs the most ai enabled health system in the world and this is a direct quote with ai seamlessly integrated into clinical pathways excellent genomics used in routine preventative care that was mentioned making wearables standard practice again direct quote by 2035 they're aiming for that new global institutes so we can lead on science and innovation to speed up clinical trial recruitment again a known area it's almost as if they've spoken to people who know what they're doing here expanding nices technology appraisal to cover devices diagnostic and digital excellent introducing multi-year multi-year budgets and requiring nhs organizations to reserve at least three percent of annual spend for one-time investments in service, streamlined procurement of technology.

3:38So all the things that people moan about kind of being addressed here. Make AI every nurse's and doctor's trusted assistant. All of these direct quotes of what is looking to be achieved, which as a vision for health tech, as a vision for the NHS getting better through health tech all of this sounds wonderful so Liam can we expect all this Disney isn't it I was gonna say can we just expect all of this by sort of my birthday in November is this gonna be a nice birthday present like all of this delivered by then well tell me obviously let's give a serious answer let's give a serious answer that right so one of the um so uh Kirstenmer sort of did his did his thing um and the 10-year plan dropped before he'd finished his speech.

4:32So obviously nobody heard the second half of what he said because everyone started reading it, right? And then the HStra jumped an article saying that the delivery plan, which was supposed to have been written for it, hadn't even been started. And so there's a lot of dates. Which is the how, right? Yeah, it's like, well, what are we going to do when? Who's going to do it? How are we going to do it? You know, like, because the 10-year plan is not a plan. It is a vision, arguably in the direction of a strategy, right? you know if you know a vision is hold on hold on a vision in a vision in the direction of a strategy that sounds like you've you've just you've just been locuming from mckinsey over here a vision is here's the future milk and honey all of the things that we read in the exact summary a strategy is how are we going to enable people to get there and what we're going to do and what's the direction of travel that we're going to move you know it's kind of the beginning of the roadmap so we can so we can consciously see where we're going to get to and a plan is how are we going to do it what we're going to do and what are the specific actions and parameters if you ask your plan so you know again i'm splitting hairs here but it's it's less a plan and kind of a little bit strategy okay but it's most it's mostly vision right um by the way on my favorite quotes can i read my favorite quote out from the whole thing right particularly around ai and can i do it in a movie trailer always right okay by liberating staff from bureaucracy ai can help bring the joy back to work and give staff more control over their precious resource time i'm really that was my favorite one in the whole thing right um because i think you know jokes aside there's a lot of loftiness and actually you know if you read what the hsj said like when it you know basically more or less pre-leaked everything like the hsj described it as a mess with lofty vision for ai right i don't entirely agree but there is there's a lot of like you know if we're tiny tim staring through the window on Christmas Eve right now.

6:24And, you know, there's candy canes and stuff like that. There's a lot of candy canes on the other side of that window, right? Describing it as a mess seems harsh. It didn't strike me as a mess. I don't know. What was their justification for that? What they felt is that there was a load of baseless claims around all of the things the NHS app was going to do that hasn't been developed, that AI was going to solve everything, genomics was going to solve everything. And to be honest, if you take it from a certain lens, there are some elements where you could kind of conclude right so for example like the the treatment to prevention feels weak it's really weak i want to talk about the good things as well but it feels really weak and treatment to prevention kind of almost largely suggests if we use all of this fantastic technology and we shift towards neighborhood models one plus two equals three and it's not really an independent like you know there's no there's nothing there's very little about money but there's a few things that maybe infer it but it isn't a standalone loan plan for prevention.

7:21If you took that out and just read that on its own, you'd be like, wow, this isn't very material. So, you know, I think, you know, I can see why they felt some of it was lofty. And a lot of it is like, you know, it's like, well, how's this going to happen? Like, you know, I'm like, we've had this clarion call around bureaucracy, right? And we're, you know, there's an exciting idea that we are going to move the system away from just paralysis in institutional bureaucracy with confusing layers upon layers. Like how many health tech companies have you spoken to over the year who've talked about the contradictory and dichotomous complexity of the NHS and all that?

7:58Like it's just, it's a known, right? And like they're asking everybody to navigate this. And so like the question is, well, how are they going to enable it? How are they going to get people to think differently and to feel safe individually and collectively to do this? And the answer, as in that slightly tongue-in-cheek quote that I just gave is we're going to liberate people from bureaucracy through AI and it's like well how do we get the AI in how do we help to take that radical change like it's it's it's a it's a cyclical thing right so there are some areas where I can see why they would say that you know obviously this podcast is not about us talking about what the HSJ talked about but I think you know given given it was everybody's expectation was said that was a mess i didn't think it was i didn't think it was a mess but it depends on which chapter you look at i when i read it so a bit of background so i worked at health education england for a year i did one of my fellowship years there and so and i had an organization that does not exist anymore um or very soon won't um and when these types of reports come out as you say there's vision there's strategy and there's delivery and you know this sort of thing comes out and then all the organizations that are mentioned either kind of clearly and obviously mentioned or kind of alluded to that obviously some of the stuff would fall to them everyone then kind of writes a response as to okay cool if this is the vision here's how our organization will fit in and they will write their plan, I guess.

9:40And what lacked here was that kind of list of recommendations that are then attributed to certain organizations. And I suppose that's coming, that will come in the plan of this. But anyway, I say all of that to suggest I have some understanding of what goes on behind the scenes of policy and arm's length bodies when this type of thing comes out. My reaction to it with that in mind is actually relatively positive because if you'd have mentioned AI and even, you know, if I'd have shown you back then the paragraph written about ambient scribes that is in the analog, the digital section, if I'd shown you that back then in whatever it was, 2013 or whatever, like, or 15 or whatever it was, you'd have been laughed at.

10:32The idea that a government organization would talk about AI listening in the background and writing notes and putting things straight into the care record was just unbelievable. It's unbelievable to think that we've actually come so far as to have a government arm's length body, NHS England, write this in a report without it being a joke. like this is actually real and and i think from my perspective when you've got nhs england and leadership at the center set just simply saying things like that it and this is the thing about leadership when it is said things move underneath people react to conversations differently there'll be there'll be things mentioned now in conversation where people are warmer to it than cold simply because this has been written simply because kia starm has done a foreword of a of a report that mentions ambient scribes in a positive light that they will come in and it will change and i think it that even if 20 15 10 of this actually then goes and happens in the in the way that it's laid out here for me this just feels positive that we're moving in this direction and perhaps my overall cynicism of the way that the center and industry collaborate is is kind of setting my sights quite low there but yeah that's that's sort of how i feel that this didn't need to be mentioned at all in a 10-year plan but seemingly so much of it is about tech that feels positive for me yeah yeah um like you know we've got to have this signaling like they've got to say one day we'll get a dog into space like you know something they've got they've got to say that to to help people believe it's possible right and you know i remember so you know i remember i was teaching digital courses to focus in the nhs um you know my uh so a course i set for them and i was talking about how i'm pretty sure that within five ten years i was a bit i was i over underestimated a little bit but like in about five ten years that we'd be recording every consultation in in healthcare right and they and we had this big debate as a group and they were like no that's not ethical and i was like it would just happen you know and like i guess one of the things that like ambient scribes it's great to see it there but it kind of felt like an easy win because that's just a runaway train as it is at the moment like what we're going to do is do this thing that's already spreading really quickly across general practice because it's a no-brainer and we can then claim the credit for something that was kind of done anyway right like i think single patient record if they do it and they do it well is an area where they can probably take a bit more credit for it but you know there's some areas where they like to say well what's going to happen anyway Let's say it's going to happen and then we can say we made it happen, you know.

13:18So, yeah. But no, you're absolutely right. I don't want to disagree here that I think, like, you know, we've got to recognize a national strategy that everybody, you know, I know lots of leaders and trusts and areas and they're not all sitting around going, oh, we're waiting for someone to tell us what to do. Like they've got their own views and their own realities anyway, right? And generally, I think the view will be what's the impact of this on us? What do we have to change? But I think there is a really important thing around having the most tech positive demand signaling that we've ever had in strategy.

13:47You know, even, you know, we were both around during the Hancock years whilst he was over a Chez Long sort of sending love to Babylon, you know, like, so like, you know, like we've seen we've seen a lot of tech positivity, but this is even more tech positive than we've ever seen before. Right. And that is it's definitely positive. but I do think that good leadership and good strategy is about helping people to know how to navigate it and not just shouting we will and to be honest when I look through this plan there's a lot of we will we will we will and I don't know like to me as someone who teaches strategy it's not it's not it's not the ideal way to do strategy you know so that is what I wanted to come on to next really which is really practically for the health tech founders the startups the innovators the people with ideas the evangelists of technology that are currently clinicians in hospitals that might be talking to tech companies as a you know to help them get into the hospital or whatever it is like our our ecosystem of people in health tech art the investors the the all of us right what does this mean for us what can we expect what can we do is there anything that we can glean from this other than broadly it's moving in the direction we thought it was yeah yeah let's let's no let's let's move the noise aside for one thing it's good but we've had lots of noise um there's a lot like you know james we know each other long enough to know that i'm obsessed with what are the material like what are the really specific things in it that actually make a big difference right and there are some things that make a really big difference in this right um and they might not be the things that everyone's talking about at the moment right but the thing which to me is the biggest before we start thinking about system changes the biggest biggest thing is like we have been doggedly sort of stuck with this short-term ism in this one-year planning cycle and nobody has had the guts to like really move us into longer-term planning cycles that is actually quite a political risk absolutely and i you know patricia hewitt proposed that she that was probably one of her single biggest things that she covered in 2013 that largely got ignored and you know i remember writing about it and being like that that they're not then the tories aren't going to do that and they didn't and labour has and you know what like i've got to applaud the fact that they for capital spending it's correct me if i'm wrong the wrong way around i've got my notes here but like for capital spending they've now got that from next year which isn't too far away that they're going to be thinking about four-year cycles which if you're a company trying to get there and you've got to win something get in integrate it deploy it and then prove it by the end of that financial year you've got like six months to make that happen and they want to know what's going to happen in three years by being able to have that extra runway that is seriously seriously important and actually if they start adding other things where they start apportioning so you know that you meant before we spoke you know mentioned the three percent here which isn't assigned to digital at the moment but that the three-year revenue cycle in the four-year capital cycle is hugely hugely important and actually i think it's one of the one of the biggest things in this plan because it will just in me these big central things we have to wait for stuff and someone's got to fix it and make it work and get from this one it will just quickly change things culturally it might take time for people to think differently but i think that is a really really big thing and i can't under emphasize how important that changes and so i'd be quite excited about that right because it's a forward thinking nhs not just in words but in financial intention yeah and actually thinking that through again very practically if i'm a small startup i'm i guess used to seeing the same people winning the same stuff the same contracts with the nhs because they've got some traction they've got some early wins they've got the means to deploy quickly they've got the means to deploy and prove that ROI very quickly.

18:04Is it fair to say this kind of then widens the field to people that are able to prove it over a longer time period? Is it fair to say that it helps, I guess, democratize the field a bit more? People will start looking at a few different things than they would have done because they can look at longer time to value. What do you think it actually means? yeah like you know if you if you're if you're a company that's doing prevention stuff that prevents right and every single time you know you're like in two years we'll improve i don't know ckd right you know um and you know you'll see these outcomes and you'll be able to see that this happens and they're like we need in-year savings because we have to think in one-year cycles right how do you ever manage to really prove that to really do that now there's two things within this firstly if you can say well look we'll work on this capital cycle you know maybe we'll think about incentives and maybe we can tear up payments or we can increase this and we can start to shift the different ways that you pay us over this period using your your longer term capital then it means that you can have more of a conversation we'll come to incentive soon i'd imagine but like um well i say imagine but let's let's come to it some point soon right but like you know you've got that and then the next element is that the trusts and the neighborhood you know the the the multi or single neighborhood um providers um also have been told they've got to put three percent towards transformation now that might money might not go towards the tech but one of the challenges they have is no one's got any capacity and time or the inclination to do it so actually if there's a bit of time that they can spend to get some support in and there might be some service might say you know if you're thinking about your your contract here it might be that you know a lot of tech providers you know for example the ambient describe ones almost work with like folks to help them get it in and you know you've got like service providers that go alongside it right so actually there is a bit more room where suddenly you can sit down and say we give us three years to do this you know we need enough to cover our bases and then maybe over this period you can we can scale up payments and stuff like that for that to work and then shift to revenue once we've proven that's been impossible absolutely unequivocally impossible so far and now in theory and again devil's in detail and let's see what comes the through it this is a strategy right but kind of um but like that is a that's a good sign for those who are actually trying and you know it does again support prevention because if we want to prevent we need to show things over a longer time period so we can't most digital technologies can't prove their benefits within one year you know i had a company that did a um that had a um a really really solid, proven and evidenced offering where they said, we can already prove that we can deliver really good results in year two and excellent results in year three.

20:55But year one is always a cost spend because you're spending the time doing it right. And we can release this money and no one's buying us because we can't release the money in year one. And, you know, I won't profile who that company was, but they were like, you know, that founder was really struggling. He was really worried about his business. Within this scenario, there is a different way that they can think about it and that's really really impactful right for getting all the national passports and stuff like that quite quickly that can be a game changer yeah so that's a really good market signal for me yeah and talking of prevention this one really stood out to me for its loftiness and i think it it's potentially so amazing but quite difficult is the wearables things so making wearables standard in preventative chronic and post-acute nhs treatment by 2035 so they've put a date on it as well now the the the fight for that the rfp for that the procurement for that the players that are going to try and get involved in that the you know if it was a corrupt system the backhanders the the ways of doing and it's absolutely not of course and there's nothing like that that ever goes on yeah like political political liaison organizations yeah no no there's no lobbying they're gonna have a great year ahead if they haven't already had just had a great year not naming anyone

22:30um sorry i'm just here to try and see if i can get you in the shit james there's uh hey the beauty of podcasts is that they're unregulated we can say what we want here um yeah and as i say not that any of that goes on because it's uh it's a completely clean system but um yeah making wearables standard in preventative chronic and post-acute and it's just true by 2035 gone it's not direct because i haven't written it down but basically wearables will be made available no wearables will be available to everyone and the nhs will even pay for it if people can't if people are in like in deprived areas so it's like well okay so if we just take that so wearables are currently already available to everyone there's no law saying that i can't go to argos and buy a wearable right so like that was a really interesting statement in that i wanted to pick into a little bit more and i get it like maybe they do it on the prescription system and that's kind of what they mean or something like that but yeah wearables are really we've really struggled with wearables to get any real traction you know like really you know apart from of course continuous glucose monitors um yeah which weirdly i think we talked about on the first podcast yeah yeah me and jess um and um frequent flyer mate um and like yeah like it's interesting i'll be honest so my take of the prevention if i if i kind of step back and see the wood for the trees is that they that neighborhood is really strong right like there's a lot in that that's really egos right um analog to digital feels very big tech it feels not for the little guy it doesn't really feel very startup friendly and a lot of the things create bottlenecks and concerns which maybe you want to come to right um not that i'm trying to guide you in your own podcast but maybe you will um and then prevention almost kind of feels one plus two equals three right and actually prevention was weak it was you know you know weak as a responsible parents like distribution of squash you know like it was really it was really i struggled to see anything material you know i'm about what's material i looked at that and it was like there's no money there's no apportionment and maybe there's a lot of things in other areas but they didn't like they didn't manage to present that in a way where they were like okay so they're they're laying stuff out and prevention feels solid but yeah so do you think then the analog to digital thing is just one big contract to microsoft

24:59coming it's already in the contract microsoft but um it feels microsoft copilot just being deployed everywhere um and they talked about um working with a world-class e-learning provider for workforce and who's that obviously going to be given microsoft is you know basically already entirely integrated like who else are they going to go to for that although of course they would go through a really good clear process, of course. But I'm going to be honest, my biggest takeaway from analogue to digital was there's a lot of stuff that looks promising, but as the little guys, and I think we're less about the big multinational corporations, right?

25:42We're about, maybe they're not, you know, there's quite big little guys in our market, right? But they're the ones who aren't multinational corporations that are based in san francisco these are doctors like yourself who come out of the system and built something because they had a an idea and we know we know so many inspirational individuals in that area and i can't help but look at their plan the almost market decimating plan for parts of the nhs app their my this and my that and my the other that's going to kind of create this feature library and i'm already looking at i'm thinking in there's certain businesses out there that i'd be like that's kind of what they do and what they've been building up for years and it all feels very centralist like a centralist view of things and i it does make me worried about my clients and the companies that i represent and teach and stuff like that and that you know that you have on on your podcast a lot of the time it kind of almost feels a hammer blow to little industry and i kind of worry about whether the representation that has really pushed through the usual representative channels has over indexed those big companies and not fought enough for the smaller ones and if so that's bad for uk plc and it's a worry there are some things to be interested and excited about that like i don't think it makes it significantly worse but i just i just like yeah and again there's a particular saying um that i hated it made me really angry in the plan um which was we um we recognize the nhs doesn't have a monopoly on good digital technology um last time i checked the nhs hasn't really produced a lot of good digital technology right like i don't know about you but i've got i went through the catalog in my mind and i was like like if the best of the bunch is the app maybe e-referral like it's not exactly like that's not exactly shouting we built world-class technology right like actually we really need to rely on the market and it felt quite arrogant and true if i'm honest yeah and again for nice i kind of worried that that's sorry i'm totally going off on a rant here but like i worried that a lot of the stuff around the central you know the medtech pathway they proposed last year is back in um you know and you know we've already seen the plans for that and you know been through that of a tooth comb i imagine again that's for established things a lot of it is for things that are already kind of up there and relatively proven and i do worry that there's very little thinking in the 10-year plan about those who are trying to build up and they're trying to get their first and their second and their fifth and they're not at a point where nice is going well okay now we're going to put you across everywhere you've got to grow a certain amount to be ready for that and there's very little that improves their experience in that phase and i'll worry about that one thing that was interesting on the nice stuff was that they're going to be given a new role which is to identify outdated technology and therapy that can be removed from the nhs with the goal of freeing up resources for investment in what they call more effective ones yeah which doesn't necessarily support as you call it you know the little guy doesn't obviously support the startups and and that kind of thing necessarily however any thoughts on that what is that is that like a just a knee jerk to fax machines like i was just i was just thinking about fax machines i was just looking out the window looking at some poppies thinking about fax machines that feels like a knee jerk to that like they're sick of being like taking the piss out of basically because of fax machines and they've just gone like right here's a thing now that that that can't happen again like i'm sick of people talking about it i got got a thing that removes it i think i think the bigger the bigger element of this is that there's actually a huge number of medicines in this consistently growing growing portfolio this runaway train of the medicine spend which now they're going to have they're planning to have a single tariff which in the future will include digital as well which is they've been talking about for bloody years and never got even got close to the single national formulary i think removing what local formula is yeah um but um like to be honest we had a lot of medicines that are arguably the world's moved on and evident and i think on medicines that kind of makes sense but actually if we're trying to build for a disruptive environment where you know like there are certain technologies we see they're still bandying around and you're kind of like it doesn't really belong in the 2020s and yeah you know and yeah so i guess if you know if for example you know i don't know let's say the first versions of the continuous like actually let's look at glp1s right it's probably a really good example they mention it actually don't know where loads yeah um there's a there's a conspiracy line we can go down if you want um but like i mentioned glp1s and actually as we've seen the glp1 market there's certain ones that actually they would probably want to take away so they could do the new agents and given this is supposed to be a market like you know i'd imagine that manjaro at the moment within a handful of years they would probably want to discontinue that because something else has got better outcomes.

30:41And so it is quite logical to have that. But how they'd come around thinking about discontinuing technology, and actually the MedTech pathway that they had last year, they had like three tiers. And the first one was about getting to market and support to do that. The next one was around like central negotiation and streamlining. And then the third one was around review and discontinuation. So they've kind of been talking about that for like over a year now since the consultation came out. But I don't know. I feel maybe that's more for meds, mate. Okay. Makes sense. But it's good to have that in place to think about digital too, right?

31:17Yeah. Yeah. Innovator passports. Thoughts.

31:28Flipped in on this one. Okay. For people that don't know, by the way. yeah do you want to do the yeah so these brand new innovator passports are going to slash the red tape so that cutting edge tech and treatments can be rolled out across the nhs quicker under the 10-year plan so my understanding of this again just thinking about real examples that i've dealt with previously running accelerators and all the rest of it let's say someone does the information governance requirements for a big central london nhs trust one of the biggest frustrations for those innovators is that they now have to go through the same or very slightly different information governance requirements for the hospital down the road the hospital down the road of that the hospital in a different city the hospital down the like and it's pretty much the same stuff my understanding is that this innovator passport's idea will shortcut that so the idea that barts or guys and tommies or kings or whatever have said you know what you're good for deployment my understanding is that other hospitals can now very easily say you are also good for deployment or they can go around saying we are good for deployment and therefore you know other hospitals that do adopt them are not going to get a slap on the wrist um for not doing their own requirements that's my understanding but i don't know if you've got anything different on it so firstly apparently grapevine you know the the linkedin rumor mill and the whatsapp rumor yeah says that first it's only going to be medtech and the second element is it's going to be mostly trust focused right right which deletes quite a lot of the nhs and quite a lot of the health tech companies right right um now this is this is the perpetual story that always worries me in the nhs by medtech do you mean like hardware devices when you say that yeah yeah like mhra sort of you know find stuff that is you know is you know is in that area where it's obviously you know that making making medical clinical decisions rather than just the stuff that we put in you know yeah sure i've got a really good definition somewhere i just said it's been a long day right i've read read 141 pages of stuff so um um yeah like so you know i think there's always this thing that i think at the moment the center always thinks about sort of digital health therapeutics digital therapeutics and medtech and so on and that there is a whole rainbow of different technologies that are available that wouldn't naturally fall under that classification and there's always so you know the general story that has played out in the past if they've got this grand idea for something we want to do let's for example call it an innovation passport and then they look at it and they go oh, we can't do all of that.

34:12There's too many variables and too many different points. And how are we going to do it? So we need to make it cleaner and simpler. And then as a result of that, they pick a few areas and so on and they do those, but it never gets entirely completely finished. And then what happens is you end up with this halfway house where you've got one route where things go through and then they don't go through others. And so thinking about the timescales of a couple of years of this, my big concerns about the MedTech pathway and the innovation passport and so on is that what happens is we create something that bottlenecks and is selected for certain areas.

34:41And then everybody won't talk to you because they go, we'll go for innovation passport, but you're not eligible for it. And then suddenly you're out in the wilds and no one will talk to you because you're not perceived to be in this thing that they've been told, you know. And we've had the same with NICE guidance, even though NICE guidance doesn't really materially impact at the moment whether people do or don't make a decision, right? Like, you know, EVAs and stuff, it doesn't really make any difference. It's helpful. So that concerns me. The bigger thing is it's got quite didactic language around using it.

35:09So, you know, if you do this, then they will not be able to. And if we take the other trend in the NHS, as they're talking about autonomy and local areas having much more autonomy on what they do and freedom to act, and there's almost a contradiction in terms between like, you're going to make these different health organisations more able to do what the hell they want and work without, to quote, micromanagement from the centre, but you're also telling them that they're going to do this. And so it does make me ask around decision making. I should be positive here and say that it is a logical idea.

35:40It's a good idea. And actually, like I chaired a workshop for the NHS Innovation Accelerator in May. I think that was two months ago now. And like, you know, a lot of the report that we wrote where we had industry and NHS people trying to share collective problems and see how we could fix it. And some of the biggest problems that we had was twofold. the first one was that every area guards and doesn't provide any information and they've got different processes but they won't show you what they are and you've it's all guesswork and you never know how to what they want and what they need and then the other one which is intrinsically linked to it is that they have variation and if you've worked with one organization you've only worked with one organization and they've all got a different way of doing things that like logically they like like dcbs like they should all have the same way of doing it and stuff like that so it does make a lot of sense but the questions are to sort of conclude who's included and excluded over what time scales how do we make sure it doesn't bottleneck market how do we make sure that we've got a parallel market and that we're doing it sensibly so it works in these kind of ways and how do we make sure you know like if we take for example that i'm jumping across concepts but like the medtech the medtech evaluation pathway like that whole pathway was going to be selected centrally by like you know sort of nice early value assessments and stuff and the question was always like well how do they pick is it political is it rational what groups who gets to input and lobby and there's all of these questions on who's in and who's out and i always i always feel slightly concerned when these mechanisms come in place and these kind of things aren't clear and so i don't want to shit on it because it is a good idea but i just don't want to see the mistakes of the past be repeated because this could wreck parts of our industry and so we've got to think better about this stuff i think that's the thing i think it can be read into like this this like cynicism can be read into as being i don't know either too reductive or or basically it's just too negative and blah blah actually i think that the cynicism is because you and i are both ideally really bullish about this space and if we can identify the areas where things aren't exactly and we care about it right and and that's because we can see the potential for good where things are deployed properly and i think that's the thing is that if we can identify the areas where we don't think things are gonna work because we've seen it before or because we've got an understanding and we actually deploy that or redeploy that energy onto the areas where you think it is gonna work then actually putting your pedal down on those and really pushing on those to make that 15 20 percent of whatever this is come true is actually a better way of spending that energy.

38:16I think that does move me on to my next question really, Liam, which is like, what is possible out of this? What are you excited about out of this? What do you think, assuming there is a plan that comes out of this and thinking we'll go into the plan, some of this will be deprioritized, some of this will be hidden away in a final chapter of, well, these things would have been nice, but actually, you know, they're not going to be difficult. What do you want up and, you know, front and center when it comes to a plan? What are the bullet points out of this where you're like, okay, yeah, we should focus on this because I can see it's possible.

38:57This will make a difference and I am excited by it.

39:03Obviously, cap and rev, I think is a really good thing and we should explore how we can really finesse this. Like the thing, the thing to know about an extra strategy is, you know, every nhs strategy will almost have consideration and review over the next year or so so you know right now whilst we're talking as people on linkedin calling it a failure calling it the best thing in the world everyone's like you've got something to say about as of we we're here talking about it right um but i think now is an opportunity as we work through these things to really have good conversations about the detail and try and really think about how do we get this right and when i say get this right i don't mean add layers of institutional thinking onto it so we become paralyzed like we have to move away from that but we do need to have like in the Tory years it was like it was always the everything is awesome dance right and that you know I was I was a relative outcast in the Tory years because I was someone who was speaking out quite harshly on things that it wasn't the done thing you know I like the fact in this environment that we had the Darcy moment that we've got this but I think the biggest thing that I would want to see is that this is done in the spirit of genuine collaboration and almost deliberative democracy and when i say i don't like i do mean with patience and but i actually mean if we want genuine partnerships they need to think of this as a starting point and then listen to the feedback that people like us and wider groups have to say well okay maybe it could be like this and this yes but what about this and how are you going to think about these people rather than just going off into because it's been it's been very closed so far right you know and you know the the suggestion that this has been the people's discussion is not true you know a bunch of leading questions in the change.nhs you know whole thing and so like i don't know i always come back to like if you me and a group of people had something really big to work through right something really hard because like this is exciting and it's going to happen if we're going into a digital industrial revolution it's happening you know you gave the example about digital scribes in 2013 versus now right like this is just like we're on this runaway train and it is going to happen but i think if we were in this room trying to work through something really difficult great discussion and positive tension is kind of what we need you know and and debate is what we need in terms of finessing this because some really exciting things in 10-year plan genuinely particularly around like the nod to like learning from the work that's happened in derbyshire and birmingham around neighborhood models is so progressive so exciting so interesting like that's the most interesting part what is that stuff so basically the the um hospitals community um you know is talking very much around sort of neighborhood health services and um derbyshire so um i was at the um electoral strategy summit involved in it um last thursday and i had the privilege of seeing jim austin talk about the amazing way that they are thinking in such a progressive way in terms of working with their communities and the great outcomes that they're having and he was also referring to a lot of stuff that's happening in birmingham that's really interesting as well and i've had conversations with the with the you know with the uh leaders at that as well around what they're doing and there's some really inspiring stuff going on that they are doing a nod to and i think the opportunity and maybe this is less for tech industry but i think the opportunity for more progressive, autonomous systems that are working with their communities is genuinely exciting.

42:24And actually, part of this is, it's like we look at the different mechanics for industry and so on. But one of the most important things is that we have a system that works in these times that is an ode to the complex times that we're in and the challenges that we face in the system. And I think if we can lock some of those and get past some of these really entrenched things because entrenched groups have been forcing them to stay. I'm not going to talk about the power of GPs and doctors and the BMA and stuff like that, but there's a lot of elements where we can't move forward because the debate is just so contentious and we need to build the system to allow this to happen properly.

43:04And there's a lot of question marks on it, but that's what really excites me. But then my passion, as we discussed on the last time I joined you for this podcast, is around how do we build great communities and neighborhoods and democratic, like, you know, genuinely democratic enabled and empowered communities that work together. And like, if we want people to lean into prevention and to take on these diagnostics and think differently, we've got to work with them. And I think that's the most exciting area. And then the money. And then there's some really good ideas in terms of what they're trying to do around centralization, as long as it's not too dictatorial.

43:39So I'm not, I don't want to come across as being negative, but it's a mix. It's good and bad. You're a realist though, aren't you? I mean, but that's the, that's the thing. Like you're, you're a realist and you just want to see and know and talk about the areas that it is going to work. Yeah. I can't trust anything until I understand how it's going to work. Yeah. And I think, yeah. And look, the inevitability, the inevitability of something like this coming out, which is very visionary. of course there's going to be those questions because being so visionary answering so many of the questions that we had around are they going to are they going to talk about ai well actually they've said they're going to make the nhs the most ai enabled health system in the world seamlessly integrating ai into clinical pathways make ai every nurses and doctors trusted assistant not only if they mentioned it not only have they lent in but they have really doubled down on this is going to be the most ai enabled system ever and i think if i'm going to conclude my i guess feelings on it is that this definitely enables that dialogue that you've said needs to happen it forces people to talk about this because you can't go into a conversation now about health care legitimately without now talking about hey how is ai going to seamlessly integrate into these clinical pathways you have to now ask the question and you think about nhs england and who answers to nhs england where you talk about nhs trusts and or at least taking guidance from and all the rest of it so they are now going to have to think in these terms because they are thinking in these terms the senior leadership of those organizations is thinking in these terms the people that are reading those procurements and and running those procurements are now having to I think in these terms, therefore the people on the ground floor are going to somewhat have to think about things in these terms.

45:35The leadership that these documents will, I guess, create is conversation and dialogue. That's a reflection of this. So for me it's positive for those reasons. Yeah, go for it. I entirely agree because I think one of the challenges that we've had is, and a lot of the work that I've done in projects with the Health Foundation and stuff, has been that we've got this divide between people who think about care and ops and clinical elements and people who think about technology and technology folks are in their basement kind of their kind of technology like that you know like sort of moles if i haven't seen the light of day and they don't really they can't really have conversations and talk with each other and i spend a lot of time working with clinical services where like you go to teams they're just terrified of it because there's this backstory and i think like you know i think the key i don't know like i wrote something about recently just around where the key message almost needs to be that we need to move the conversation away from the technologists and mainstream, that transformation, the biggest leaps in care that change, kind of will come from technology in some way, shape or form, right?

46:39We've got, we've juiced enough of the lemon so far. But, you know, and I talk to a lot of boards and do a lot of board work and stuff like that with them. And I'm like, how are you not just going to lean on this one person and feel like a bunch of dinosaurs who don't know? How are you going to mainstream this in your thinking, in your organisation? how are you going to try and bring this in and you know i might be working with one trust exactly on this topic right like because it's we've got to get everybody to see the role that they play so they can understand the role that technology can play so they can think more strategically and relevant to a world where we're just going for it and i think hopefully this is a clarion call that says i as a leader have to go and really understand what this means for me and not just go we've got digital ned we've got a cio and a cnio and they're going to tell us what the thing is you know very practically that is the i think the benefit of this genuinely because i can remember at health education england like i remember jeremy hunt used to come out as health secretary at the time used to come into the office i think it was every monday and they used to go into one of the offices and a load of people used to go in there and and you know you'd have this like very cyclical like weekly anxiety and the run-up and then the the you know the post meeting and then it would all you know calm down towards the end of the week and then the anxiety pipe peaks again but you know it was all around jeremy likes this jeremy wants this jeremy cares about this and it was the gp numbers at the time it was it was there was there was one there was one metric and the only metric that mattered was how many gps like we just need gp numbers i just need to see the gp numbers the numbers need to go up then like that was that was the one thing that he and and and that propagates because every conversation that you have in the organization is then how does this relate to the gp numbers how can this increase that how can we spin this to matter to the gp like if it didn't matter to gp numbers it might as well not be happening so um and i'm exaggerating slightly yeah again very very like practically that's how this does filter down so when you have so much in there about AI, it can feel very pie in the sky.

48:48It can feel if the HSJ thinks it's a mess and too much related to AI, okay, great. That might be the case for now. That might persist, but actually there'll be 250 ,000 conversations that happen about AI, 250 ,000 bits of feedback about how this can't quite work because, or half a million times that someone has critiqued the AI in their clinical system and given some decent response that leads to some small check i think all of that is potentially the downstream win of this yeah although we've got it we've got to make sure that we can rebuild goodwill in this right and you know there's some good stuff in the workforce plan that kind of covers but like you know jim mackie he said himself said that that morale and goodwill is at an all-time low right and to be totally honest the way that this whole strategy run-up has been handled has not said particularly you know for a lot of folks in icbs and all of these areas we appreciate you we value you right it's almost kind of like and there's a lot of people who are very angry and upset and we're now about to ask them to do a lot and to change a lot and to be part of that change you know like the very final page that we're streeting is sort of as like you know like you are the change and it's like i i i i feel upset for a number of individuals who've basically been shat on and then told that they're part of the change and it feels it feels very it feels very very clapping for the nhs doesn't it yes sort of downward sycophancy to the nhs and the people who work in it yeah and actually there's one thing that i read in the report that did make me feel like that i can actually remember uh quite viscerally in the ambient scribe section they talked about a 51 percent reduction in admin and i think it was that in this case that 13 percent more patients could be seen or productivity increase or something on those lines and then they said and this basically means that clinicians can now see 9 000 extra patients through a and e with the time that they save and it was like the very next chapter is about workforce and what you've done is you've gone oh we're going to save you loads of time and then make it way more stressful like uh that doesn't quite feel like you've nailed that so there was there was there was a really interesting article in the hsj the other day i can't remember the exact wording of it but it almost kind of said like they want to see clinical like clinicians and clinical teams like perform really well so they can get money for tech and it's like oh aren't you lucky you get some tech money that you and it's kind of like you kind of not understanding human behavior and incentives here right like that's a very like like that it feels like a very naive way of putting it right but like i just you know like my you know my end of year article i wrote after and sort of you know around what 2025 look was are just like the morale's threadbare and if we just then have like months of just like ruining it we're going to find that our most important resource has checked out and doesn't and it's just and doesn't care so i i wonder how many people in the nhs have read this of just like and just sighed and maybe they haven't they've looked at it a different way because because of the story that's happened in the run-up to it and these are the people who as we say we're supposed to be inspiring and putting messages to and stuff like that right like words are cheap if people receiving them it's beauty is in the eye of the beholder right i'm checking out the crappy charge phaser well nothing has to be justified in this one as you said at the start and so to finish what what are next steps then what what can we expect as a health tech industry the the next steps are going to be now um so apparently uh milburn hasn't written the delivery pan so that's apparently going to be they're talking about september and that's what's being reported so a few more months away in because you know like it'd be too easy otherwise um but september could easily become october november as they start to go into the detail on this um we really need to crack on like we really like it's been a year since the election like a very very senior individual kind of expressed their anger to me on whatsapp earlier of like how did they like they knew they were going to get in how did they turn up a blank sheet of paper and then take a year to give us something that isn't finished and like you know Darcy told us how messy things were sorry I'm moaning again aren't I um what happens next um we all have a big conversation and we see how they respond and um hopefully like you know let's be positive rather than negative um what happens next we all really embrace this and try and work out how we can improve the things that don't make sense give honest candid feedback and hopefully this signal they've said that they want to work with us as partners um means that they'll be receptive to that that's what we can so basically delivery plan is being written they're going to listen they're going to listen for signals in the market i assume um and therefore we need to talk about it and we need to figure out what is actually possible um hopefully they'll listen to your podcast on this so we've done our job a nice weekend now it's only thursday well thank you liam it's been a pleasure always a pleasure to uh hang with you mate yeah well um we'll jump on again when the delivery plan comes out we'll see what we'll see we'll see which we can we can sit we can even uh we can even poll it now like which organization do you think is going to come out the worst in terms of how much work they're going to have to do um seems like nice have been pegged to do quite a lot it seems like the MRHRA is a bit.

54:55I don't know. Can we have a summer first? You know, nice summer break. Right. See you in September, October, November. We'll see.