#443: The NHS has trust. AI doesn't. Now what?

0:02I think the NHS is perfectly positioned to come out with some messaging that enables a heck of a lot of AI usage. Young people that age 16 to 24 year olds, they tend to be a bit more sceptical about the impact of AI in healthcare. If you want to bring this function in place and you want it to be successful, you need to work with the public. hey everyone delighted to have Ahmed Binnishmal here with me today from the Health Foundation um previously got that wrong so this is the second take so I'm glad I got it right this time uh Ahmed welcome how are you doing sir I'm doing well thank you James thanks for having me you're very welcome man um you've got a really interesting background looking at your LinkedIn and a route into health tech and so definitely looking forward to getting into that with you and hearing all about that.

0:52And then obviously the work at the Health Foundation. You guys have done a lot of great work that we've actually talked about before on the Health Tech Pigeon podcast. Public attitudes towards tech, towards AI. It's all incredibly relevant for, I guess, just how we all navigate this new world of tech and AI, the expectations that we have on the public to understand this stuff, the expectations that we have on ourselves to understand this stuff. as people within the healthcare system. Like it's such a strange, crazy time of change. And I think organisations like the Health Foundation, and I say this genuinely, I've worked in policy and interacted with you guys on many occasions, but I think the reports that you guys do and put out help ground us all into what is the actual reality because we're all in our bubbles.

1:41We're all super and hyper focused on our specific areas and our specific bits. But I find reading your stuff helps me to zoom out of thinking, OK, what does everyone else in the sector actually understand and appreciate? And what is the direction of travel and all that side of things? So I think it's obviously great work that you guys do and looking forward to getting into some of the specifics of it. But first of all, let's talk about you, man. So I'm just going to say Transport for Wales is where all this begins, according to your LinkedIn and the University of York before that. But yeah, talk to you.

2:15Talk about your background and tell us all a bit about you and who you are. Yeah. So my background is economics. So I studied economics at the University of York. Did that up north, which is really nice. And I don't know whether you've encountered many people that do economics or studied economics. But my experience studying it, you kind of get caught in this bubble a little bit of you sort of think that sort of banking, financial services, that's kind of the vocation that you're going to actually. And a part of it, I think, is those organisations market themselves best, I think, to economic students.

2:43But I wasn't really aware too much of outside of that where economics could be used or applied. And anyway, post-university, I went back home to Cardiff. That's my hometown. Nice. And I worked for Transport for Wales. I was planning my fee, just deciding what I was looking to do, trying to find out what I was going to do next with my degree and what kind of career I was going to take. And whilst I was there in Transport for Wales, I kind of landed in an analyst role. and I worked in a couple of different analytical roles at Transport for Wales for about three, three and a half years. And it was great because it kind of showed me a different world of where economics, analysis could be used and it gave me a really good foundation for trying to, especially in the rail sector where you have a lot of technical language, how do you convey technical language analytically to an audience that doesn't necessarily speak that language?

3:32So it gave me a really good foundation and it was really interesting, but I wouldn't say necessarily my passion was in rail. And I think after a few years, I was interested to see what else I could do next. And I kind of felt like I had an understanding of what other areas I could apply to my economics. And I looked and I then joined the British Medical Association in 2022. They had just made at the time a new sort of economics function. And they wanted to sort of underpin a lot of the policy influencing and policy recommendations they were making with substantive and empirical evidence. And that's where I joined the team.

4:08And around the time that I joined, I was working on a few different things there. It was a bit of a bapton of a fire because shortly after or around the same time, there was that kind of wave of doctor strike action that was happening. So a lot of my work in terms of funding analysis was geared towards that. But I also worked on other things like the pension campaigns, working on sort of funding more generally, digital infrastructure, the estate infrastructure. And then towards my end of sort of my time at the BMA, I also worked in a sort of senior policy role, working closely with the General Practice Committee, working on the kind of contract negotiations that they were going through and sort of seeing how else we could support the general practice workforce and the conditions going forward.

4:48But then almost paradoxically, I wanted to sort of broaden out my understanding of health policy, but also specialize a little bit. And so I was interested in looking at health policy more broadly outside of sort of doctors, but also my sort of interest in technology began to sort of spark a little bit. And I wanted to see where I could sort of cultivate that interest a bit more. And that sort of takes me to the Health Foundation. And, you know, as you mentioned at the start, James, you know, technology, AI, it's growing, it's getting bigger and it's becoming more important. And whether it's government, organizations, private sector trusts, they all see technology and AI being a way to help with kind of a lot of the challenges.

5:27and a lot of the work that we want to do is we agree that technology and AI is super important but it's making sure that it's being implemented responsibly in an ethical way in a responsible way with people on boards that people trust it and have confidence in it so that when it's implemented it works well. Completely agree and I can remember that the last time that we spoke about this actually or it might have even been the time before that when we talked about some of your work that But one of the things that really stuck with me was this notion that ABC1s, i.e. the people in society with the best jobs, if I am to summarise that.

6:05I don't know whether that's an appropriate summary or not, but basically the people that are, you know, middle class, good income, good jobs, skilled labour, etc. Well-educated, blah, blah, blah. So that being a sort of category, ABC1s, they do so well in healthcare because so much of healthcare is built around them and it's built around them because they engage. and actually it's the people that aren't in the abc one category that don't engage with the healthcare system because they don't trust it and there's this vicious cycle of not willing to share their data with the healthcare system not willing to engage in the healthcare system no data is therefore surfaced of those people and they're the people for whom all of the algorithms downstream and the systems and the processes would help the most.

6:56And we end up in this situation where unless we fix trust, then the whole thing becomes a lot more difficult to actually serve the people for whom the healthcare system really needs to serve. And I'm seeing this play out in so many different places. Like I'm seeing this play out in the prevention argument or the prevention space, sorry, in a huge way. The arguments there being around, yeah, okay, all these preventative healthcare clinics and services are popping up but ultimately this is just going to help the people that are already healthy get a bit more healthy a bit healthier and it seems that whatever price point you're putting on this prevention stuff that's the that's the fulcrum everyone to the left let's say suffers everyone to the right gets slightly better or it's and it's it's just a strange concept but I find reading your stuff, because it is so well researched, it makes such compelling arguments that are impossible, particularly for other organizations, to actually ignore.

8:00And actually the policy downstream that can be affected becomes a lot clearer, I guess, because of the recommendations that you guys then provide on other people to then solve the problems through policy. So it's a really interesting complex of stuff, but I definitely want to get into. But before I do, there's a few things in your background that I think are super interesting. The first thing I actually wrote down was first jobs. Now, there's a lot of people that are in their 20s that will be listening to this podcast or at university and all the rest of it. And I think there's so much pressure that people feel around not wanting to waste time and they just want to get the perfect first job that sets them on the perfect career and all that side of things.

8:42I actually think yours is a great background to highlight that this notion of not putting so much pressure on what the first job actually is, because your first job can actually be far more about what you don't like and learning what you don't like. Because ultimately, I was listening to a podcast the other day, I can't remember who it was, it might have been Scott Galloway or someone like that, saying that ultimately most people's first job is you're doing the work that no one else wants to do because you're the lowest in the ladder. So your chances of loving a first job are pretty low at the best of times, let alone when you add just a random factor of whatever job's available at that time.

9:17But at the same time, though, you know, tying in something that has a technical language, tying in something that, you know, gives you a framework of the thing that you did at uni, the economic side of things, and actually putting that into practice. like you can you can design some things but actually it feels like you know what you you learned a heck of a lot in that time and actually you pointed at health care after that and actually looking at health care with fresh eyes as an industry uh as a new industry is also quite important but um yeah what did you learn in that first job do you think that really set you up yeah it's a really great point and i did put a lot of pressure on myself you know in that third year of university did you yeah jobs and i wish i could go back and sort of try and take off some of that pressure a little bit and like you said say you know what it doesn't you know whether you're successful or not it's it's okay you know it's i think i probably want to sort of tell myself to kind of enjoy that ride a little bit more rather than kind of put so much pressure on but i think it's kind of the environment that you're in i think you know people in sort of whether it's university or you everyone's kind of in that kind of race a little bit to be like oh have you got have you applied to this place have you got a job um here in this kind of industry but I definitely think it was a blessing in disguise the way things panned out and so when I came back to Cardiff and I was trying to find my feet a little bit that first role was kind of in HR it was a temporary role whilst I was looking for other things but if I didn't do that I wouldn't have then gone into the kind of analyst role that I then did and yeah I completely completely agree I think without that kind of foundation I don't think I'd have sort of maybe been as good in my role when I came to do health policy something that I really like something I don't necessarily see myself leaving anytime soon but i think it really did give me that kind of foundation and like you said maybe a fresh perspective a way of doing things differently maybe kind of motivation and of doing things differently but um i i'm so glad for it and i think you the kind of general advice is like you say it's good to try try things and try to keep busy and sort of learn from something that you might not necessarily think that's yeah the area that you you want to be in i think there's a lot of pressure to get into health tech at the moment i think there's a lot of people that are wanted that feel like they're being pushed out by the care environment or they want to get i mean i've i've had dms from well since i can remember of people in other industries even like how do i get into health tech how do i get into health tech this seems to be such a hot topic at the moment and careers are long and life is long and i think if actually if you can if you can try and find a way to apply your skills in a different area you see a lot in management consultants actually that i've noticed is that the people that leave to go and do um management consultancy will actually often intentionally do nothing to do with health care in order to build the skill and not to rely on necessarily their experience thus far and actually build this that all the analytical skills that you will acquire as a management consultant to then apply later down the line in lots of different things and i think it's it's just an interesting an interesting mentality i guess um i want to talk about economics actually because the going going into the bma as an economic analysis i don't actually you asked the question i don't actually have many people that have done economics on here but health economics is such a huge part of health care and of health tech specifically you look at you know a lot of regulatory consultancies will have a health economics division because it's just such an obvious addendum to what they do of going okay well now you've got regulatory clearance we need to make the case for your device your software your tech to even enter the healthcare system and at what point what place where does it add value is that saving cost is that creating capacity is that putting dollars on the pounds on the pnl literally is it and how is that is that sacking people because you save time is that through some reimbursement pathways it's like it's there is so much economics work within healthcare that i don't even know what my first question is here because it's sort of like eating the elephant even to sort of get involved in this but moving into healthcare there's just this huge economic soup and by the way with with this almost like overarching question of like is i mean i feel weird saying this out loud is the nhs economically viable question mark so there's no shortage of work for economists in health care in my opinion but where did you fit in initially in the bma what what was the bma's i guess economic need for them as an organization where does the bma then fit in for the people that don't know into the rest of health care and yeah i'm interested just to sort of tease out any opinions that you have on uh economics in the nhs more broadly yeah great great questions uh james and very complicated ones as well yeah sorry about that this might this might be a while answering these that's okay uh i'll try my best uh and sometimes it'll be a prosaic answer and that more research sometimes is needed to kind of identify some sort of specific clients on the questions but so generally speaking in my role and what I was doing with the BMA.

14:37So the BMA is, you know, as I'm sure you know, James is a trade union, but also represents doctors, but also is a sort of lobby and it sort of looks to influence policy at that level. So when I joined, I joined the policy team at the BMA. And the idea was that there's, like you said, there's funding happening everywhere. There's funding for healthcare and then there's funding for specific aspects of healthcare, whether that's for the estates, whether that's for the digital infrastructure and lots of different parts, this funding with regards to the pensions, this funding with regards to Dr. Pay.

15:10And so my role coming in and working with my, we've just a team of two when, you know, and the team was made at the BMA. And the idea was that sort of grounding a lot of the policy recommendations with empirical evidence saying, okay, we want to, you know, for example, if you're saying - If you want to fund more for healthcare, how much more should we be funding? And that's the kind of, is the amount that's being funded at the moment, is that enough is that enough to deal with the kind of demand that's you know increasing over time that kind of stuff so if we were making policy recommendations the idea was to sort of round a lot of those recommendations not just qualitatively but with something that kind of either you can measure or that's something you can sort of agree or justify and that was the idea of where we've come from just kind of go towards the evidence base of we think that you should be funding x amount more for this specific part of health care um last year the estates or the the digital infrastructure received this much or over time historically it's received an average of this much over the last five years since you know whoever whoever's been in uh in government it's reduced by this amount what why shouldn't we go back to kind of the old way of uh fun you know the previous funding levels it's kind of making those those arguments or trying to sort of make sure the dialogue is is based on evidence and that's the kind of yeah so there's lots of like you mentioned there's so many different areas whether it's funding as a whole and then the way sort of general practices funded is very complicated and there's intricacies with that and whether we can support that it's not to say that all the issues would be solved by by more funding there are i'm sure areas where um whether it's management or other areas of innovation technology could support as well but um sort of funding was kind of a key area me as the economic analyst and economics unit support and just and just on that just on that how how do you like really practically how do you do that and the reason i ask is because i imagine there are so many people listening no i mean no matter what your job or area or organization i think everyone's trying to make a case for why they should exist or should have a job or should have this startup or organization within healthcare i think finding the answers to those questions around funding is incredibly difficult i think because there's a lot of incomplete knowledge on all of that stuff i can remember when i worked at the bmj which was in bma house um one of the things i was tasked to do was to uh to to find actually in like data and evidence on how much a bed day costs but to actually justify it why does a bed day cost x number of hundreds of pounds in the ward hdu itu because because my department at the time within the BMJ was able to then use that information to do lots of different things with economics and to make certain policy recommendations and all the rest of it so I can remember I was tasked with that but again even my job doing that was so unbelievably difficult and at some point you have to just sort of go I think it's probably this on balance there's a few things saying a few different things it's probably around this number and then i always used to worry about the error carried forward i used to worry about like okay that 10 pounds of difference there if that getting multiplied against another 100 pound of difference in this that the other and it can end up straying quite fast so how do you how do you square stuff like that off and how do you how do you think about doing that economic analysis and getting the information and i think that's useful information for people listening that might want to do something similar definitely and it's a really good question and it's a balance between i mean you study economics um one of the things that underpin a lot of the sort of methodology and equations they do is assumptions so a lot of it is right can you justify you're going to make it as you say you're working with incomplete data in a lot of instances whether it's rhetorical data whether you're looking to do comparisons across the united kingdom england data wales data in wales scotland and northern ireland it's not standardized a lot of the time it's different kind of data they report on different measures sometimes so a lot of what we're what you're trying to do is okay how can you kind of reconcile those differences in a practical way so you want to make recommendations and the idea is that you're trying to make healthcare better for people within the uk so the kind of philosophy why you're doing things is is there and positive and okay so if you want to make a suggestion or recommendation with incomplete data sets then you have assumptions that you have to make and it comes down to whether you can justify reasonably to an audience whether it's people that you're trying to influence or whether it's people that are on board with you, whether those assumptions that you've made economically are viable and feasible.

20:04And you sort of work within the team. You challenge each other's assumptions and you challenge each other's methodologies. And then you take that further and you sort of, you know, it's really helpful with the BNA because you have the different committees and they'll challenge the assumptions. They might ask questions and pose questions around maybe thinking of something in a different way. Have you thought about, you know, this inflation measure or should we be using this instead of, instead of in the GDP deflator in this instance or another instance. And you kind of make assumptions. And I think a lot of it is, can you justify why you've made those assumptions?

20:34And a lot of the time, whether your kind of work will be seen as methodologically robust or not is on the strength of your assumptions and whether you can feasibly say, we've made this assumption because X, Y, Z. And I think people working in this area acknowledge that there are limitations when it comes to, as you said, to data. And that's key. And I think provided you're not making sort of extreme assumptions that might have kind of, you can see the conflict of interest of why you might have made a certain assumption. And I think that kind of undermines your work by doing that. So I think from our perspective is we want our assumptions to be as strong as possible.

21:09And for anyone reading them to acknowledge that, yes, they made this for these different reasons. And it's interesting because when you study economics, particularly the kind of statistical side of things, you're so robust with the theory behind it. when you take things from into a practical perspective you have to be a bit pragmatic and accept that certain data sets or certain things aren't going to be available and how do you compensate for that and the bma more broadly where does the bma fit into health care again the reason i ask the question is because you you've obviously been there and you did some really specific economic work and policy work and as you say you know membership organization and but but also but also lobbies for policy and also tries to make a difference there and tries to stick up for doctors where it needs to um has been a very powerful organization i would say throughout time and throughout history um so yeah what what is the bma's role now when you were there like what was the what were they trying to achieve yes it's a great question and um i was there a few years you know a few years ago i left a few years ago so i'm sure there's constantly being updates in terms of where they see themselves in the world of health policy so i can't say necessarily speak um for them or they might um there might be more to add to it to anything i say but i'd say when i was there at the time like you said it's around making the quality the idea is you improve the conditions for doctors so they can help the patients in the public being us everyone else and i think that's that's essentially what underpins a lot of the policy um that the work within the bma it's can we improve the conditions because they can be connected i think the conditions of doctors and the public and if you improve the conditions for doctors they'll be able to prove the conditions for they'll be able to do the best uh their best work and i think you know you look at some of the when i was at the bma we published two reports one on sort of the estate infrastructure another one on the digital infrastructure and some of the kind of anecdotal stories you might hear in terms of the conditions from a practical perspective the hospitals that you know roofs falling apart and that you really empathize and they don't want to be working those conditions because they know that's a risk to to patients so i think it really comes down to that wanting to make those those things and those areas better so that um the public benefit the most and it's about improving sort of health health of the uk and it's interesting because it leads kind of to to the work you know we do at the health foundation as well in terms of wanting to build a healthy uk that's uh that's our mission and we we see there's so much impetus for people to bring technology and ai into their practice but a lot of the time if you speak to doctors you know they're sometimes still using fax machines and you're talking about wanting to bring in ai it's there's a kind of realism um aspect it was a huge disconnect yeah it's a huge disconnect i actually have a question on on the economics of this because this is something that has plagued me for for a long time whenever i'm asked you know if you can click your fingers and change something about the health care system that would make it better for often people say like tech adoption or whatever it is my my answer is always really the same which is that if you if you create better conditions for staff you watch everything else improve like genuinely because people want to be there they go the extra mile even more so than they do now there's they're not as tired there's no obligation to like blah blah the the challenge i think has always been that there's very few business models available to increase the quality of working conditions for staff because the staff are doing so much and giving so much of themselves already that is already the case and so to improve conditions you'd have to assume in some way that they would work less or blah blah now you can increase efficiency and all the rest of it and all these phrases that people use but ultimately it comes down to this right like how do you justify spending money to improve conditions for staff when the finance director or whatever isn't going to see a cash in hand saving of that and by the way again like there's no penalty for treating your staff badly there's no there's no sanction there's no i say this like quite often there's no like what i think would be really interesting if there was like a staff survey where you know the bottom 10 percent of like organizations then have something support i'm not saying like it needs to be like a bad thing and a slap on the wrist it's like well these are the people that need support these are the places that need support but i don't know like i'm interested in like the economics of of i guess what the bma would even be suggesting in terms of i mean they'll pick off certain specific things i imagine but more broadly i don't know is that anything from can you shed any light on the economics of business models that make things better for doctors as you mentioned speaking broadly about it i think the the big thing is whether it is technology or whatever it is you you're implementing that requires or finances or funding i think because of the sort of tight constraints the sort of nhs is working under doctors are working under you sometimes expect results almost instantly there's kind of a short-term perspective and with economics we we know that whether you know if you invest you know whether it's a pound in health in several years it might come back with returns but it might take time for you to reach that that stage and whether you're in technology but you know you mentioned adopting technology and that's part of the equation but then it's how you implement that technology evaluate it is it working correctly how do you make sure that whatever's not working correctly is mitigated that process takes time because people are so under pressure to kind of get results you don't necessarily you might kind of take one step back and you haven't hit the stage where you're going to get the two steps forward yeah and i think that kind of long-term thinking from an economic perspective i think is necessary and you know you have sort of five-year cycles with government sometimes even shorter so commitments sometimes you know when 10 years they get shortened or not evaluated again so i think the kind of the principle of economics is that things take time and if you want to see kind of return on something or evaluate it correctly then you you need you need that time and I think failure is isn't necessarily a bad thing either you sort of learn what doesn't work and I think that's just as important as something being successful and we've seen with our own sort of work here at the foundation that preceded by time here but there was like the kind of concept of the spread challenge and just because something worked in one specific area it doesn't mean it will work somewhere else and sometimes you need to consider the unique conditions in another area to allow that same solution to sort of be implemented and work successfully I think that's what you need you need you need time to see the kind of economic results of a lot of these things it's it's really interesting and i i can completely appreciate it i can also completely appreciate what you're saying that you might have taken this step back and then you've cancelled the thing so you've never seen the steps forward i my instinct says that i think we're seeing a lot of that play out right now i think also five-year political cycles does not help anything in that regard because people don't have patience beyond five years and so what do they say about people you know good good men or good people planting trees the shade of which they'll never sit under like all that sorts of stuff it's like with health care being politicized so aggressively like that that that isn't even an option it doesn't feel like it's an option unless you get cross parliamentary views on this to a point where we have i mean we do have like five-year strategy 10-year strategy like it it exists it just doesn't feel like i mean i'm talking broadly now it just doesn't feel like people's hearts are in that stuff you know when there's someone going to stand up at pmq kirsten was going to stand up at pmqs on on wednesday and ultimately get berated if this thing has taken a step back before it takes a step forward.

29:28That's just going to be called out. And so it ends up being mitigation for that and all the rest of it. I don't know, do you share the view on that? Does it feel like to you that that's where we are with a lot of policy? Or are you optimistic that longer term things are going on? I guess that's the point of the Health Foundation, right? If we want to drill down into that as well. Yeah, I think what you said, that kind of landscape exists. I think I'm also a bit optimistic in the sense that, like you said, we do see people, whether it's organizations, charities, doing sort of long term work and have the kind of capacity to do that long term work.

30:02You know, have that full cycle where you can assess whether something's been successful or not, whether it will be successful elsewhere. And I think we're seeing that more in the literature happen. For example, you know, our work, this Attitudes work, you know, we've run it for the third year. We're planning on running it continuously for the next few years off the back of some of the results of that. we're looking to do some deliberative qualitative research to understand like the why behind a lot of the what that we've discovered and i know we're not the only sort of people doing that i'm sure other organizations that are doing our policy team has their own sort of policy point that they've been doing for even even longer so it's it's great that that's happening and i think there is i think the value of doing that is being recognized more and more uh we get a lot of attention on the kind of these these uh these cycles and i think it's it's happening and i think it's encouraging to see it happening more and more often.

30:52And I think that's being recognised more. It's good to see there's a 10-year plan, like you said, that can be held of a degree of accountability. And as you said, there's lots within there that I think we can assess over a period of time so that we can say, okay, we're not necessarily going to see the results now, but we might see them later. But I think another part of that is the kind of trust and confidence you have with the public. If you have a kind of transparent and honest approach with the public, then that kind of commands the understanding that some things will take time and we see that we know we see in our survey there's a lot of trust when it comes to the NHS of course all demographics are something that's quite consistent they trust the NHS they trust the GP whether it's with the data and it's with the health information when it comes to other organizations including government unfortunately they're not as trusting so there's a lot of work that needs to be done to build that trust and confidence that like you said we have the license to think about things in a long-term way.

31:47And I think the burden of kind of responsibilities, government, organizations to work with the public to build that trust. It doesn't happen automatically. And sometimes where there have been instances where that trust is broken, there has to be extra work to build it back again. Let's talk about that then, because you've seen a huge amount of work on public attitudes when it comes to tech and when it comes to AI. And it's no surprise that the first thing we're talking about here is trust. The NHS has this amazing, amazing brand when it comes to being trusted. It's got a great brand, I think, nationally here for that.

32:28It's got a great brand internationally. And some of the work that we've done on this as well, the NHS brand internationally also means quality. It means a robustness. It means that if you've got through the NHS checks and balances, then that is something to be trusted. It's also of high quality and that brand is then used internationally to sell and do very interesting things for tech companies. The trust elements of the NHS, what do you think is driving that? like what what why why is the nhs so trusted is it a consistency over time is it because there have been as you as you again rightly point out there have been moments where you know cyber attacks and this and all that sort of stuff and perhaps that doesn't reach the public consciousness as much as we think it does maybe it's a connection to individuals in the nhs and people have built trust that way maybe it's the fact that it's a public system and it like it i don't know like I'm interested in what you guys found when you were looking at this about what were the drivers of that trust?

33:43It's a really good question. And it's one of the limitations of doing a quantitative survey is you sort of understand the what behind a lot of this stuff. So I don't want to be prosaic and say, you know, more research is needed, even though that is the truth. Research is needed to sort of understand why and sort of we need to focus groups and understand where different groups trust. I think we have other questions that might help guide us in terms of why they trust the NHS. And, you know, when we're talking about technology and AI in healthcare, one of the biggest concerns people have is infringing on the kind of human dimension of care.

34:12And of course, all demographics, people really value the kind of patient, doctor or clinician or NHS staff relationship, the human oversight. And they put a lot of weight on the kind of human dimension of care. You know, the human loop, the human dimension of care, those are things that are really important for the public. and I think that might help sort of maybe guide why they trust the sort of NHS so well because their relationship and experience with the healthcare system has been for a large part of their lives very positive and so it's interesting when we start splitting some of the results that we see with sort of attitudes and sentiment to tech and AI why there are sometimes differences in age groups for example and are those sort of differences in sentiment are they guided more by someone's experience of healthcare or whether they're guided more by their experience of technology.

35:06But I think the kind of trust in the NHS, I think, is governed a lot by that relationship the public have with the staff and their experience of it in the past as well. Definitely. Why don't you talk through some of the other findings then? So obviously a huge amount of work has been done and the latest report that you've done as well is particularly around the NHS app as well. and so that's that's interesting because that's a new technology seemingly you know built by the nhs i'll put that in inverted commas but you know it's a product of the nhs i'm wondering does that end up taking on some of the cynicism from tech or does it predominantly take on the trust of the nhs like how do people perceive the app really really good question uh and really interesting And so just as a sort of barometer kind of just setting the scene, our overall results show that, you know, generally, broadly, the public and NHS staff, they're positive about the impact technology and AI can have in healthcare, slightly more positive towards technology, which might be understandable given that AI is newer and evolving.

36:12And so, you know, we see kind of how it's sometimes reported on as well. But big caveat is that it's not necessarily uniform as we've, and that's something that's a really sort of key point here. we see major differences across gender, age group, and socioeconomic group, which we already touched on earlier. So we find that younger people, this often surprises people, that younger people that age 16 to 24-year-olds, they tend to be a bit more sceptical about the impact of AI in healthcare. Women are a bit more sceptical. And then, as you mentioned, people in socioeconomic groups, D &Es, that's people who are on low or no income, they tend to be a bit more sceptical.

36:46And understandably so. I think you mentioned earlier that kind of engagement side of things with tech and AI. And I think the burden of responsibility when it comes to engagement is on developers and technology and people that are implementing it to find ways to engage with people that are more skeptical, aren't necessarily as trusting because the idea is you don't want these technologies that are often made with maybe disregarding or aren't made with sort of ethnic minorities or other genders in place. And they don't necessarily feel that they'll work for them as well. But we want to introduce tech responsibly and make sure it's not widening inequalities so back to that trust point is we need to find ways to engage with all all members of the public but bringing it back to the nhs app and that kind of idea of you know differences across a group that is consistent across a lot of the results but it's interesting on the nhs app so there was sort of within the government's 10-year plan a lot of emphasis on technology and on the nhs app to um be a bridge for for healthcare and so a lot of the proposed functions in there like booking hospital appointments booking vaccination appointments getting information by your treatments the public on the whole is supportive of using the app for these functions you know around three quarters 75 around 73 for some of these functions people are happy to to use the NHS app for that for that purpose but there's a really interesting one there's that kind of idea of the doctor in your pocket so using um AI for non-urgent care and that's the kind of function to be available 24 for 7 for people on the NHS app um so the idea of yeah you'd get health advice from an ai for non-urgent care and we see that we see quite a significant drop in support for using the app for that function from when we talk about you know the high 70s mid 70s 40 to 49 so 49 would be happy to use the app this way 32 would not and then a small percentage were so don't know or indifferent and so you still have more saying they would be happy to use the app this way but that kind of difference between the two is a lot a lot smaller so one in three saying they wouldn't necessarily be comfortable using the app um for that for that purpose so again when it comes to that kind of the other functions not necessarily ai related booking hospital appointments when it came to the ai specific function there was a bit more sort of reticence and hesitancy to using that so again it points to that kind of if you want to bring this function in place and you want it to be successful you need to work with the public to build their trust in that that the ai and we found specifically for that result people in socio-economic groups so people who are on low and no income, the majority of them, sorry, a high percentage of them would not want to use the app, would not want to use the kind of document than those that would.

39:21So again, there's more emphasis to work with the public to make sure it's being sort of rolled out responsibly. I actually think it's quite like, for me, it seemed quite high. It seemed quite high, the 49 % of people thinking incredibly positively about AI, particularly even in that use case, about ai doctor in the pocket giving health advice like half of half of people would be you know positive about that that for me actually feels really high which i think is a i think is a positive thing i i'm i don't know i just feel a bit on the fence about it though because i i feel that where i actually have no idea where we are with ai if i'm being completely honest i actually just generally now not necessarily in healthcare but like the quality of the models you look at claude's latest one opus the latest claude one or chat tbt 5.

40:18whatever and i and the chat tbt for health there's claude for healthcare now there's like all these things coming out right it's it's moving so fast and i know she said quite a lot and i was moving faster but the point is i honestly don't know like if ai health advice through the app doctor in your pocket is that any good i actually don't know so i feel like i don't know that then to go and get the public opinion on it seems like the second the second thing knowing that 50 percent of people where it is now or where we think they think it is now 50 are happy i think that's a really solid place to launch from if we can figure out as a health tech community what the heck are we actually doing with it and this is my i guess bugbear with where we are with ai and healthcare more broadly now and thinking about what your work could be influenced by at the health foundation so i'm just not clear on what we want healthcare to actually look like with ai like do like that's a use case right doctor in the pocket health advice through the nhs app you know replacing 111 in inverted commas with or adding a step before 111 which is you know type it into ai if it needs to connect you with someone it will like are we saying as a healthcare community that is something that we want to do i actually don't know like are we are we saying that's where we're pointed at because by the way if we are pointed at that and you guys think that's a good idea and or you're measuring sentiment and you think that that's possible bearing in mind where sentiment is well i don't know who the person is that signs that off as like that's the direction of travel for for nationally now like i i actually don't know who that is and i think without that vision and that guidance i'm i'm struggling to sort of see where the effort should be placed because if we can say definitively awesome we want to bolster the NHS out massively and actually you guys are feeding in data going the sentiments there we can probably get this done for a decent size of the population and the ones that don't we can cover them with this other thing if your information is feeding and saying that if other people's information is feeding and saying technically we know that these things are possible and we know that this is a really safe way of doing this thing then actually I think there's a lot of resources around us that can actually then start pointing at this but my my issue I think at the moment is that for me it feels like without that vision and guidance we're not pointed at specific use cases and so everyone is just it's it's so like I don't know it's just so fragmented that the effort is therefore fragmented and people are trying to justify their use case all over the shop and I just wonder if the work that you've been doing if you feel or if you know I'm not trying to put words in your mouth at all here like I'm interested in your opinion on it but but where do you land after doing a piece of work like this I've sort of labeled there's my frustration I see this and I'm like awesome sentiments there can we point some more resources at getting a thing done now and I'm not sure who needs to sign that off that's my frustration but after you do a piece of work like this what do you then feel i guess as an organization but also you personally like where does your personal like i don't know reaction land it's a really good point james it's interesting a couple of years ago at the foundation we published a piece that was a priorities for sort of an ai in healthcare strategy and the kind of sentiment of that is essentially what they're saying is that it's very fragmented and we need a direct strategy if you want we agree that technology can can help with a lot of the challenges that healthcare is facing and we just want to make sure that that technology is being implemented in a kind of responsible way in a safe way that's working for everyone and being optimized as well and as you mentioned not having that kind of direct strategy in in place makes it fragmented it makes it difficult and sort of use the technology well and then sometimes someone might say oh look we implemented technology and it didn't work out so well but or we adopted technology but it didn't work out so well so the technology wasn't great but maybe there's kind of a challenge with implementation or the evaluation mechanisms that were that were happening so if you have a kind of more formalized strategy it would help mitigate um those sort of risks then you could identify areas or implement things in a more in a more helpful way but i think the kind of strategy pointed to six priorities um that we could sort of think about sort of help um ensure ai is being used in in the best way possible one of which we've already touched on and and the pins a lot of our work is that it should be guided by public and staff attitudes there are other theories in terms of what you were saying that it's being deployed in the right areas there's also something on regulation as well and this is something that we did ask in our um our survey um last year was on sort of do to the public do they do they do they sort of given the choice between two options and not appreciating that the choice necessarily isn't always mutually exclusive but just provided the choice do you prefer regulation for sort of companies to be encouraged and sort of implement things more quickly.

45:37And public, you know, very considerably, you know, around 70%, 30 % would prefer regulation and sort of more stringent rules over that kind of encouraging things to be rolled out. So again, when we're thinking about how we bring AI into place, you know, having a kind of strong regulatory framework is really important. You know, there's the National Commission for AI with the MHRA at the moment. And the Huff Foundation is a research partner towards that. And that's when we're thinking about building a regulatory framework, bringing the kind of public along with us to ensure it's reflective of their views is really important.

46:13I think that comes under your broader point around rather than things being fragmented, we need a wider strategy. And I think a lot of these kind of points that we point towards, and I'm sure, you know, given that that was a couple of years ago, there are new points to think about would help guide that strategy. And I think having that strategy is key. I think then bringing it back to the NHS app and the sort of AI points, I agree. You know, you can look at it different ways in comparison to the other. Half full or half empty. That's the thing, isn't it? Exactly. It really is that. And, you know, relative to the other options, it's of course lower, but as a base, it's not too bad.

46:47But a part of that, as you said, might come back to that trust in the NHS. A part that, you know, I'm speculating here, so this isn't necessarily guided by anything, by any evidence, but maybe people's experience where they have to wait a long time to get advice might mean that they might feel more compelled to ask ai for advice because they've wait you know they might have to wait a really long time for an appointment and that might influence their decision as well but i think the kind of key point from it is that if we want it to work for everyone because it doesn't feel people don't feel that it's going to work for everyone then we need to sort of engage particularly those kind of concern and skeptical groups there's a point from your release that i actually just want to read out loud because i think this is this is really interesting to me and it relates to what you just said but crucially the public consistently prioritizes safety human oversight and robust regulation of ai over speed or convenience when presented with uh illustrative trade-offs related to the approach 70 prefer ai outputs checked by a human over speed of results 72 want strong evidence requirements even if this slows the rollout of new ai tools i think it's so interesting that really i think there's a comms job here there's a there's a comms and media job here of it i i think this is all in how it's brought in and what is said and the guidance that's given and treating the public actually with the intellectual respect that they actually deserve because we also think i i read that and i think well actually i i think that's a counter to messaging that they're probably getting elsewhere whereby tech companies which is everything's quicker everything's faster and and more efficient and like it's all of that type of speed messaging that i think most people are getting which is probably why this starts coming up and looking at the brand of the nhs being that robustness being that safety being that dependable that consistency all of that stuff it seems that But with AI, I think the NHS is perfectly positioned to come out with some messaging that then actually enables a heck of a lot of AI usage.

49:26Because all the public are saying here is stick this into a decent framework so that we know that a human's over it, that there's a real need to have it there. And then just communicate that with us and then we're all for it. that's sort of what I'm reading there, I guess, if you agree. I think on principle that that is a big part of it. Yeah. And I think that kind of communication point, I think, you know, we can't, I think more needs to go into that kind of communication. I mean, I'm biased there, Ahmed. I don't want to put words in your mouth. Of course, I run a media company. Therefore, I'm always going to say that.

50:03No, no, no. All problems are solved by media, Ahmed, honestly. No, of course. And I think that kind of, you know, communicate and transparency is so important to people. People want to know when tech or AI is being used as part of their healthcare. They really value these things. And I think even prior to that is when you're kind of developing these technologies, people want to feel like they've been involved in that process to sort of help shape how it's used. It's been demand driven rather than kind of, you know, it's supply driven where it's just, you know, we've got this product here, go and go sort of implement it within the framework of the NHS.

50:38You want people, we've raised that this is a challenge for us. You know, lots of people experiencing this kind of issue and people want to feel like they've been involved within that process from the beginning, not kind of just been told at the end, you know, oh, we're bringing, we're now bringing you in. And I think that's, that's a really key sort of part of that. And it's also, like you said, where do we implement AI and technology in a way that helps people? We know they're really concerned about the human dimension of care. So when you think about, and this is something that comes in within our results as well, is whether you're applying AI for patient care or AI for administrative purposes, people are a lot more receptive and open to AI being used in administrative areas where it's less likely to infringe on that human dimension of care.

51:22And that is a good way or potential way to build that confidence and trust where people can see AR being used in a way where actually might even improve the human dimension of care. We've seen VTs, I mean, voice technologies and the potential for that to sort of, you know, help improve the kind of experience you have with your clinician and NHS staff. And I think deploying it in the right way can help people see that it's being worked in a way that, again, works for everyone. and but also having that transparency and communication if someone's been told that navt is being used or maybe someone hasn't been told and they might feel a bit concerned but again if they they've been told there's a human sort of oversight there's they've been engaged in the process with regards to how this technology has come about that helps build that trust and confidence and then like you said i i think that is the most important point what you just said there that is the most important point that's what this work has shown for me i think that's the biggest learning point for health tech companies that exist that exist selling be it to the nhs or be it to you know b2b2c or private clinics or whatever it is i think this work has shown that actually if you do the work to show the public the things that they care about most and it's in black and white here they prioritize safety human oversight and robust regulation so the question for the health tech companies listening or the entrepreneurs listening that are thinking and building here is how are you showing those end users the patients safety human oversight and robust regulation how you like that really if you've got anything that that if you've got if you've got any solution product piece of tech or whatever that has those people as a powerful group even either because they lobby for it or that they just buy it those that that's where your messaging should be to get them on board if you've got a comms campaign or media campaign whatever it is like to those that's it's right there like you've done the data you've done the research you need to show them safety human oversight and robust regulation there's your three posts a week that's that's that's what you're doing um the other thing is you mentioned this a lot meaningful engagement with the public it's it's in the release your quoted as saying you know it's essential to get right what does that actually look like what does meaningful engagement with the public actually look like and again the reason i asked the question i see this so often in the space a version of of tokenism here a version of ticking the box a version of oh we've done the focus group it showed this and no kind of sustained by the way a lot of this because of resource and a lot of this is well-intentioned by the way of like we just need to get the thing to market we just need to make sure the thing is done or we need to you know the most efficient use of capital is blah blah blah and all the rest of it but what what does that actually look like do you think for for people building in health tech what what's what's like a best case scenario what's a gold standard what should people aspire to in in developing this kind of meaningful engagement with the public it's a great question i think you you've made a really good point around like you say you need to stop the meaningful engagement isn't kind of a tick box exercise at the end saying i was spoken to xyz at the end and we did a we supported the king's fund with a piece of research last year i think uh they they did and it was around how do you make digital services more inclusive, essentially.

55:00And it's kind of within that piece that answer a lot of the questions that you're asking. What does meaningful engagement actually look like? And there are lots of recommendations within that. You know, for example, like we've already mentioned, the NHS is a very well-trusted organisation. So engagement from the NHS is more likely to be successful, more likely to be meaningful, more likely to get people involved in that kind of engagement if they're kind of leading that or, you know, using trusted organisation, trusted communities. there were other recommendations for example like meeting people where they are so in places that they feel comfortable that they feel safe to be able to sort of communicate so quite literally meeting them where they are exactly quite literally yeah those are things that can make massive impact on on the level engagement you receive particularly from those demographics we mentioned that tend to be a lot more a lot more concerned or less willing to engage sometimes so how do you set the conditions to make it more comfortable for them for them to engage and it this really interesting graphic i i can't remember if it was in the publication or not and it it was produced by company for the life man can't remember the the name of it i think they're a charity um like i think they were called life or something life and soul or something i said i'm it's annoying that i can't remember the name but anyway they have this really really um useful graphic and it shows what engagement is like and has kind of a circle and within that you have tiers and level what is good engagement and sort of you know coming at the very beginning and you're engaging with people at the start and getting their opinions and then working together with them, that's what good engagement is.

56:27But then when you're sort of more towards the other end of it, where you're kind of like you said, just coming to them at the end, that doesn't constitute real good engagement. And sort of getting that right is really important if that's what we want it to look like. And one of the interesting results from our survey from 2024 was around would people be willing to sort of take part in a workshop, for example.