#463: Real world evidence & the metrics patients care about in healthtech

0:02You see a patient every three or every six or every 12 months. That's just a snapshot in time that you're getting. And it's quite difficult to personalize a pathway on the basis of those discrete snapshots. Who else is interested in understanding the real story? Who else is interested in watching the movie instead of seeing a few still? What they really care about is, are they living their best life?

0:30Dr James Somauroo:nada founder of ampersand health welcome back to the health tech podcast how are you sir james thank you so much for having me again i'm great it's great to be here thanks so much you're very welcome um you've been on at least once before i feel like maybe even twice before i feel like you were maybe one of the originals that were on this way back in the day uh obviously this podcast begins it's 2019 so surely you've been on a couple of times no i've been on once but i think like many other things today i'm just gonna have to let you down on that only one time definitely not one of the originals but oh well you're definitely one of the originals in the space i mean we've been we've been going at this for probably longer than we care to to admit to be honest how long has ampersand been around now so ampersand as an idea sort of came to pass but from my co-founders boo and gareth obviously both doctors um you know in clinical practice in the NHS.

1:23They've been working on this probably since 2015. I sort of started interloping in their work in about 2017 or 2018. So, you know, still it's approaching kind of the eight to 10 year kind of horizon, as it were, that I've been doing this. And, you know, you always read about startups and somebody says, yeah, you're hyperscaling after like two months and like, oh, a year later, you've sold your company and it's just not it's not been my experience at all but no i did go to a i did go to a seminar recently um in which they alleged that the average scale up uh raises its scale up money after 10 years which gave me a little bit of hope yes you know interesting did a bit of runway yeah i think that was probably not necessarily a silicon valley stat most likely it was uh it was a it was a grow london event so i guess that speaks to to how we do it

2:23Dr James Somauroo:yeah they certainly skew the mean don't they those companies and if uh if harry stebbings is to be believed then you're basically worthless as a human and a ceo unless you've got to 100 million arr in what a year or two years or something that's just yeah something outrageous i i often find myself lamenting lamenting that uh comparison is the thief of joy nada and so i think unfollowing accounts that give you that sort of information is a fantastic start i'm pretty sure you're the only person i follow on social media so i don't oh that is funny that is funny for people that maybe don't know give us a bit of your background give us a bit of ampersand health overview orientate us in that and then and then yeah I can I can tell you what philosophical stuff I've been doing recently to or dipping my toe into because obviously you have that background yeah that's right well I mean I obviously studied philosophy at university and you know set out in life to do something useful that sort of started with a career in policy actually I worked in in foreign policy focused on Central Asia, the Middle East, Africa, and was sort of seconded into the foreign office early in my career to basically wither and die.

3:44And that it was actually a really interesting and important kind of experience to have to see how big institutions work really early in my career, partially because you learn a lot from organizations that have been around for a long time and I've had a lot of time to kind of continuously improve and to iterate and so on but also in an environment you know in a policy environment at least you also realize how competitive the world is I think I was surrounded by thousands of people far cleverer than me far harder working than me and we were all desperately trying to get noticed for our little policy ideas and you know after doing that for a couple of years you kind of think well maybe there's a maybe there's a quicker way to make the difference that I'm quite keen to make.

4:30And so, you know, in sort of 2000, maybe 2007 or 2008, I set up my first startup with my best pal. It was in the climate tech space. And, you know, in the course of a couple of years of doing what we did, I really realized that business properly oriented can be an amazing lever for social change as well. The speed at which you can do things in a private sector setting, the risks that you can take, the sort of different perspectives that different people are free to bring to the table in an environment where you're not kind of answering into a single rigid reporting line or having to be on message or those kinds of things.

5:15You just have a very different approach to change making in that kind of environment. And, you know, we were really lucky. We learned a lot and things ended up going surprisingly well for us. And I really got the bug to try to do that again. And so I made the kind of lateral jump from climate into digital health in 2011 and have set up a couple of companies along the way there. one moderately successful one terrible failure and percent health is number three and you know as we were talking about before eight eight years into it um i think this is you know this is the one that is really hopefully going to let me express that change making needs the most i feel there's a real kind of impact objective here and just to kind of maybe explain a little bit about what we think that impact objective is and how we came to this point.

6:17So Boo and Gareth obviously treat patients with a condition called inflammatory bowel disease, also known as Crohn's and colitis. I have a sort of second person perspective close to home on the same condition area. And one of the things that you see is that it's a disease characterized by relapse and remission, like arthritis, like psoriasis and eczema, like multiple sclerosis, a number of other conditions, what characterizes these diseases is uncertainty. Out of that uncertainty arise challenges for doctors and also for patients. So where we started was looking at the challenges presented to clinicians, which is to say, if you have a patient whose disease trajectory is uncertain, where there are ups and downs that are, for reasons that are poorly understood, at relatively short notice, there's a real premium to place on flexible and personalized care.

7:12And so where Boo and Gareth came into this was thinking, well, our patients have constantly changing needs. How do we map our service provision accordingly? How do we deliver flexible, personalized care to patients, acknowledging that they need different things at different times. And fundamentally, the sort of bridge to the solution statement there is the recognition that a lot of what happens happens between appointments. So you see a patient every three or every six or every 12 months. That's just a snapshot in time that you're getting. And it's quite difficult to personalize a pathway on the basis of those discrete snapshots.

7:57So what we set out to do was to figure out how we could generate a kind of ongoing stream of decision support data for Boo and Gareth in their departments initially, and then later scaling to other hospitals as well. And in the course of doing that, I think the big sort of aha moment for us was realizing that when you lens things through the clinical lens, you're not really seeing the whole story. Actually, what was really important was to take ourselves out of that and to think, what does relapse and remission mean for patients? And actually what it means is not obvious. It's not just that the disease comes and goes.

8:35It's that along with the uncertainty comes a feeling of not being free to do the things you want to do. And actually when you ask people that live with these kinds of conditions, what they care about. What they care about is living their best lives. And that's not something that shows up in the clinical context at all, right? Clinicians typically look at where you are in your disease based on your level of inflammation or other kind of clinical markers, but that's not what patients are necessarily looking for. So we had to take some time to kind of understand what patients we're looking for it's really more about empowerment self-management the ability to take control of a disease that could actually leave you feeling disempowered if you don't do that and we do that through a behavioral health model that basically navigates patients from just before diagnosis to sustained remission focuses on lifestyle levers of wellness functional levers of wellness like you know your stress and your sleep your diet and your exercise your medication adherence, how you build a good record of what's going on in your life, how you share it with your clinical team, and then how you build a strong circle of care around you.

9:52So that's really kind of the genesis of the business was clinical. We've added a patient piece to it. And I guess more recently, we've started to look at other use cases for the between appointments data that we generate in particular around real world evidence for pharmaceutical companies and I guess maybe we can talk a little bit about that later as well so that's kind of broadly speaking what the company

10:18Dr James Somauroo:does and you know hopefully it wasn't too boring not at all an incredible explanation actually so one thing that I mean you said there that has always griped me it griped me as a clinician it griped me in intensive care, it gripes me now with where we're going with healthcare and new technology, is what are we optimising for? What are we building this tech for if you're a startup? What are we treating this patient for? And I mean that holistically rather than single disease, single drug, single treatment. Okay, fair enough. But what is it? What's the picture of health that we are imagining in this patient in this society for this product?

11:05Dr James Somauroo:Like, that is something that I am perhaps it's because I'm from the world of storytelling that I, I, I probably do perhaps over index for this. But I feel like as a community in health tech, the technology is just being thrown at us so quickly now with its advances that I don't feel that we have a direction in health tech. I don't know what perfect health care is. I don't know what vision all of the technology that's coming in is painting a picture of. So I feel like we've got it the wrong way round. we're in very much a faster horses situation in like let's get frankly i'll just say it ai l lms let's pack in as much of that as possible to optimize what we're doing but i don't know where that leads us and i think it's really interesting that you've you've really taken that to heart with how you've built ampersand because you've gone with and perhaps you've iterated into this i don't know but you've had to certainly position around all the technology things that are coming in i imagine patients can just vibe code versions of this that are rudimentary even now but you've decided that what we're optimizing for is a patient living their best life and actually that being a north star and and then the features fit around that the way that it works and the way that it monitors and the way the patient self-report and what that moves into and how they get their advice and the rest of it clearly has that i suppose north star built into it which is really nice i do wonder and i'd be interested in your opinion on this is do you feel that we've got that in healthcare as a whole and where do you think we're going in healthcare as a whole and maybe like and have I got that right actually of ampersand is that the idea is that guiding your product roadmap and and everything I'm interested in in where you sit on all of that yeah I mean that's a that's a really interesting observation and I think there's two ways that you can kind of come at it right one of them is saying do we need more top-down structure to make sure that innovation coalesces around common goals that we have as a society.

13:16And I at least hear a lot of people talking great game about preventative medicine, for example, as a kind of North Star for us collectively. I think that's really, really powerful. And I think that's really important if we're thinking about how do we make healthcare sustainable and in the interest of society as a whole. And I say that partially as an interested party who has health and who is going to have health needs in the future. But I also say it as a taxpayer and I say it as a person with an ethical approach to those kinds of things as well. In all of those cases, or through all of those lenses, you'd say that preventative medicine and focusing on prevention as a really key pillar of things is a policy lever that should be being pulled way more.

14:09And, you know, obviously, you know, more about it than I do. But you know, you see organizations like Neko Health, for example, I actually have my scan on Thursday, my wife had hers a couple of days ago, she hasn't stopped talking about it since, by the way. But, you know, my feeling is that there are these kind of pockets of, of bona fide innovation, that we all think of as being amazing. And the question then becomes how do we scale that and that's where I think the top down and the policy approaches clearly manifest funnily enough um I think you know another example of where top down a top down lever is kind of being pulled at the moment is with NHS online and I don't know if you come across that very much so yeah I mean you know for me the idea that we actually have a digital first NHS trust now in existence and find they're not taking patients for a little while yet.

15:06But that's a great example of a top-down kind of policy-led framework that can help innovators find their home and then scale what they're doing because the framework is kind of present and created. So I'm not saying that I'm a sort of top-downist, if that's a word. I do think there's a bottom up part of that as well, which is about how we help patients and people with health needs become more active contributors to the design language that we as a community of innovators respond to. right we you know i mean we've been so lucky i have to say in in my co-founders we had two people who really got it early and so we did things like for example partner with Crohn's and Colitis UK and Arthritis UK before we'd written the line of code to understand and to bring the patient voice into what we were doing.

16:14And that has been instrumental in terms of developing a picture of that North Star, as you called it, that's actually robust and rigorous and defensible. And I've got to say, you know, I know that there's a kind of component of these sessions that's about tips for CEOs. And I would say that that's one example of something that everybody who goes on the journey that we're on could do early and which gives you a critical lever for persuading people that your vision is a credible vision yeah when we point to all of the the sort of patient advocacy engagement that we've had all of the research that we've done you know the patient panel that we have around the company all of those things it means that even a skeptical clinician or even a, you know, I don't know, an IT or transformation individual in a hospital we might work with, they look at that and they're like, oh yeah, actually, we see why this fits, why this addresses an unmet need, even if it's not an unmet need that we had identified.

17:30So I think there's that bottom-up piece of it as well. You know, if we want to build innovation that has impact in addition to creating the right top-down framework we need to know what questions to ask of who as innovators to build that kind of robust foundation if that

17:47Dr James Somauroo:makes sense it does and actually it fits into something that you mentioned in your background as well so you you framed starting a you framed a business actually as the answer to a to a question of how do I create a force for positive change you actually framed that starting a business is the answer and I think a lot of people actually go the other way around and they just think for themselves personally they want to start a business and then try and look for a problem to solve and do it that way around it seems like whether it's your background in policy or your grounding from that perspective and seeing you you know you use the word leave is quite a lot and actually see seeing a lot of that and the business being the answer i think that's uh as i say it's just something i wanted to wanted to talk about because were you were you the kind of born entrepreneur that just wanted to do this and always saw your path this way or was it was it that is a business is just hold on a minute I can start this thing which allows me to raise money and put that into it and I can then do this and have contracts and a bank account and therefore that means I can get this thing done it's just a very interesting way to to talk about it because I don't hear it that that often yeah I mean look I think I've always felt and I've always been incredibly lucky and incredibly privileged and I've always thought that out of good luck comes a responsibility to do something useful.

19:14So I've always been looking for that in a way policy, the policy and work and working in the third sector, you know, I guess I still have a few irons in the fire in the third sector that are really meaningful and important for me in day-to-day life. That's where I thought I'd make the biggest difference initially. I am following the rubric, the selfish rubric that you described it's just that my selfishness is trying to alleviate my sort of guilt about feeling so lucky if that makes sense um so i think you know we're all at the end of the day we're all motivated by selfishness in some way or another what that selfishness actually is is probably different for different people yeah i think that's better or worse but that's at least you know how i've seen

20:02Dr James Somauroo:Understood. And your work in policy, foreign policy in the foreign office, interesting. That's hardly kind of, you know, lower level stuff. That's really impactful decision making that has worldly consequences, albeit being a part of that. Did your work in policy give you a framework for starting a business in the right way? You mentioned that the first thing you did was a couple of key partnerships. You've mentioned leavers quite a lot. The reason I ask the question is because one of the things that I did straight after leaving medicine or initially putting one foot in, one foot out was to work in policy.

20:42Dr James Somauroo:And I worked at NHS England, I worked at Health Education England, and it gave me an understanding of, oh, hold on a minute. you can change a rule here and all of a sudden you enable so much innovation downstream because all of a sudden these companies have to adhere to this rule and technology is the answer and it just it was this light bulb moment of the importance of policy actually and the importance of setting the rules in the right way to then again it's a phrase but you know make the ground more fertile like it literally causes there is cause and effect to changing the rules so that people then then go in i wonder if and i'm i guess that's my question did sight of that change the way that you built ampersand or do you think you built it with all of those things in mind and how and your feelings on lobbying and all that sort of stuff like yeah talk to me about that yeah i mean i think the first thing to say is at the beginning of one's career being very junior working in a large institution like that you're not really change making but you're right you're getting a really interesting perspective on how difficult it is to make change because you're balancing and this i think i'm not sure if this is you'll have a much better perspective and maybe i can ask you the question back about health care but i know that in foreign policy my big takeaway was this is so complex and there are so many competing objectives and imperatives that you end up risking

22:15really minimal returns for your effort, because at every turn in the road, you see that somebody else wants you to go in a certain way. And I guess I haven't really thought about this for 20 something years, but if I just think back, so when I was doing this, it was right after the Iraq war and we were thinking how do we contribute to civil society development in in a country where you know our actions had in some fashion both created an opportunity for civil society to develop after an extended period of difficulty but also where we had kind of thrown the status quo into disarray and had a responsibility to do something about it and And, you know, we organized, for example, a conference in which we brought together civil society stakeholders from the region, 40 or 50 people from about 20 or 30 different organizations.

23:21We worked really hard. We had really senior support to make it a success. while it was an important foundation stone the big takeaway and part of what motivated me to think are there other ways to make more difference is that the return on all of the effort invested by all of the attendees all of the policy makers all of the organizers you really couldn't say there's the big difference that we made if you see wow yeah i do and so in a way the learning for me I think it was kind of different from what you experienced in healthcare and maybe that reflects the naughtiness of civil society maybe it reflects the naughtiness of you know an unpopular war and um the kind of political fallout from that but I mean I don't know how do you see it in how did you see it in NHS England you know did you what were some examples of where you saw kind of change being led from from those kind of instrumental decisions yeah it was when I was

24:24Dr James Somauroo:at health education england actually i i remember there was a rule change around how gp practices had to do triage and it was it was a policy change that went through and overnight the requirement for the ability to triage 24-7 went from zero to one. And was it 24-hour triage or was it telephone triage? It was something along those lines. And it was just such a light bulb for me that I'd never seen anything like it, that overnight then the phones just start ringing of all the people that I know in the space doing something similar of, hey we need to meet this target we need to and it was interesting because the people that then get in touch were the ones that you know the the the teachers pets at school that want to score top marks immediately they're the ones to pick up the phone first and so and and obviously the ones with budget and all the rest of it they're the ones to pick up the phone first and and you sort of map out like i can see the practices that i'd want to go to if i vote for the people that rang first but ultimately then it starts to trickle through it like over time there are more and more people and it was just it was so it was just so interesting to observe the other thing i'd say about working in policy as well was you're quite right about how you describe the the delicate balance that has to occur both between policy organizations and the causes that they represent and how they're holding quite a balance it's an overused term but ecosystem it really does operate like that together now from a foreign foreign policy angle i imagine the consequences were way worse when you get this wrong but i can remember hee uh i'm sure i can say these things now that the the organization doesn't really exist anymore but um a report would be written about something uh call it i don't know one i was part of uh there was an issue with gp being seen as lesser And they were trying to tackle that at the medical school age group, basically, or seniority that go right down and tackle it at source at medical school.

26:47Dr James Somauroo:You know, the denigration of GP as a specialty and wrote this report on why it was happening and how it was happening and what they thought root causes were and how they thought things would change or how they could change. And that goes into a report that's written and it has recommendations. And those recommendations point out the varying organizations. and it's funny when you go through something like that that you know the relationships involved you know you're going to soft sound in inverted commas those recommendations with those organizations but not in a way that we're putting this all on for show actually it had formal utility than that for me you were actually asking what breaks if i suggest you guys do this and actually it was a lot more nuanced i think than than perhaps you would give credit for you know oh this is all a fix this is all they all knew what was coming i did it i suppose yes to some extent but actually i don't think you can reduce the intention of those individuals i think their intention was still very much in good faith in doing that i actually think though you're more likely to see a positive result when those recommendations are received in a way and perhaps rewritten slightly in a way that they can be acted upon without any more consequences down the line now i can appreciate though that when you extrapolate that you then everything regresses to the mean and actually everything regresses into what's the least work and there's no truly disruptive recommendations or activity which to be fair some will argue that is a perfect reflection of those party organizations and how they work yeah yeah i would though say that from what i saw there was real innovation genuinely there was there were people that really wanted to get things done and would go over and above to make sure that you know the odd recommendation did get through that would ruffle feathers and that kind of thing and so look i i've i've i've seen it from all those angles but um i i just i just came out of it if i'm being completely honest i came out of it with far more respect for policy than i had going in and and that is a fault of my own that i didn't i i perhaps went in blinded by or biased by a sort of general eye roll and deep sigh on oh policy it's boring it doesn't do anything blah blah actually from what i saw it was it was genuinely the opposite that's so interesting and actually you know there's a there's an adjacent topic that i think is so relevant and current as well which is when you look at the amount of political change that we see in society today it's really difficult to see consistent policy design and implementation because every x months you have a new person sitting at the top of the org who's got their own vision for what they want to do and who you know kind of encourages um particular change and i mean you know it's very difficult i think to be an innovator or to be a change maker in a in an environment that doesn't have kind of consistent policy objectives and so on and so forth.

30:19And, you know, I mean, I think we're seeing that now, right?

30:26Dr James Somauroo:With, you know, how many health secretaries in the last eight weeks? How many health secretaries? Exactly. And so actually, I agree with you. I have massive, massive admiration for people who work in that kind of environment and who continue to kind of pursue change, even though it is, you know, even though they're kind of being buffeted by pressures from all different directions. I do wonder, you know, the extent to which we actually pay the price for that as well, though, you know, I don't think, you know, working in a company who, at least in earlier iterations worked very closely with the nhs i really feel that um we could do with more longer term planning and a more stable political environment um in which to kind of deliver health care public sector health care in the uk and i mean you look at countries that do it well none of them is doing it with seven different people's vision in 10 years you know um they're all doing it outside of the political cycle and they're doing it with 10 and 25 and 50 year views and that's really what gives um people at our end of the of the spectrum the confidence to actually invest and to say, you know what, this work that I'm doing today fits a 10-year need that society has, makes a change that in 25 years' time will be relevant, so on and so forth.

32:07And, you know, I'm not saying that necessarily a Scandinavian health system, I don't know, actually, I don't have the information. You probably know better than I do. And I'd ask you the question, actually, does that kind of health system foster better innovation or does it foster more efficient innovation or is it actually none of the above

32:28Dr James Somauroo:I don't I don't know truly because I've not worked in it but what I will say is you know you and I met when I was at the digitalhealth.london accelerator and it was our job to accelerate innovation into the UK health system our job was to select the 30 companies per year that were most likely to have success in the NHS and then use our contacts our relationships our knowledge in order to fire them at the NHS and give thoughtful introductions and facilitate things as much as possible. And that was our job. I think when you were talking then, the thing that came to mind for me was the phrase, the risk of innovation.

33:05Dr James Somauroo:There is enough risk to starting a startup and doing everything you can to make it succeed. without then introducing risk on those adopting it that are now fearful of their jobs if it goes wrong and that's what you talked about that that lack of that lack of sort of solid consistent feeling that you you can try something that's likely to succeed and has passed all of the safety and information governance requirements and all those things, I can now try this knowing it's not going to contribute to me losing my job or worse. That's so interesting. We haven't done that. It's so interesting. You will have the same, if not a better purview on this than me.

33:56There are so many different groups in the NHS and adjacent organizations, for example, trying to figure out what safe and well-delivered medtech looks like. I can think of, you know, organizations and groups within, you know, NICE, the MHRA, NHS England, you know, the trust themselves, et cetera, et cetera, private sector organizations, all of them doing work that on its own is really important. But if as an innovator, you don't know which of the four, five, six different initiatives turns into the policy framework, you can't really prepare ahead. So actually, you're right to point that out. It's not just that consistency of policy is important.

34:48It's that when you're innovating ahead of the curve, as so many of the companies that you'll have seen at Digital Health London or that I see around as well are doing, you actually need to know the kind of input stream as well. It's not just when the policy gets announced, everybody starts running for it. It's that you hear about all of these other things that are going on and you think to yourself, well, if I follow the innovator passport model, this is what I need to do. If I follow the DTAC model, this is what I need to do. You know, if it's the NHS digital playbooks, that's what I have to do.

35:22And then you go and talk to the customer and you're like, well, actually, I'm DTAC compliant. And they're like, that doesn't mean anything to me. I was going to say it needs to mean something.

35:30Dr James Somauroo:Yeah, exactly. Exactly. And so I think, you know, we're all working in, you know, maybe that's maybe that's what all innovation is like. And I just don't know better. But it seems to me like in UK health care in particular, we are actually trying to do so many things at the kind of policy and pre-policy level that at the kind of post-policy level, uncertainty is just so manifest. and you know I've got to say that's that's probably a lot of the reason why you know companies coming from other markets with pre-packed products are shaping policy is because they're coming in and saying hey what we've got works you should do it like this and suddenly all of that policy work is kind of collapsing under well here's something that works from the outside i'm sure we all know what we're talking about here um so you know i do think that that's yeah it's a very it's a very dynamic environment you know and and that's great fun but is it the most efficient way to deliver benefits for the end user whether that's the health service or the patients that depend on it i'm not sure about that no i mean either And I think if I could change one thing, it would be to somehow reduce the requirement for innovative people on the adoption side, on the hospital side, on the healthcare side, to reduce the demand for those people to exist and to somehow just put an innovative framework in place.

37:10Dr James Somauroo:You know, I had Shafi on here a few weeks ago and I got him to tell me the story in detail of like his innovation, what he what he did and what was so innovative about what he did. It turns out, to cut a long story short, and this is in no way intended to be reductive, but he built such incredible relationships in the hospital that he worked that he'd go to the board of the hospital and say, hey, I want to stick a VR headset on and just 24-7 live stream a whole surgery patient experience. like is that okay and there were people in that room that because he'd built those relationships and proved it and all the rest of it said we'll find a way to get this done and that was somewhat reductive that story but you can hear the full story on the episode but the point is the most the most important thing he did was get innovative people build a relationship of trust and do it that way i'd love to just find a way that we can reduce the need for that and actually just have a framework that did it rather than those people that are willing to take risk because the reason they could take the risk is because they've got just so much you know equity and inverted commas in the system that they're the ones that can make those decisions they have the power and and frankly can't be sacked if but they also have the knowledge that they can do it in the safe way they know those information governance requirements all the rest of it and i don't know this this this there's something there for me but you obviously with ampersand have pivoted away from the nhs and i say pivoted away i mean you've that's that's again that's also quite reductive like you spent a lot of time like doing a lot of things in the nhs you have nhs practicing co-founders and well and you've made a lot of impact in the nhs what's what what's been that journey for you and and yeah let's talk about that a little bit yeah well look i mean you know i think i mentioned um at the beginning the kind of framing for us was we needed to understand what was happening in patients' lives between appointments so that we could make more informed decisions about how to deliver treatment.

39:19And obviously throughout that process, we've kind of been, you know, almost accidentally creating a pretty deep data set that reflects what's going on in people's day-to-day lives. And so it wasn't a massive step for us to think, what are the other use cases? who else is interested in understanding the real story? Who else is interested in watching the movie instead of seeing a few stills? And that's really what, you know, so much of, so much of substantive decision-making in healthcare, whether it's pharma companies, whether it's payers, whether it's hospitals, managers, so on and so forth, they're making decisions on the basis of these snapshots that they capture at moments in time where the patient has an interaction with a pharmacy, with an insurance company, with a healthcare provider, so on and so forth.

40:17I suppose the way that we've seen it is that pharmaceutical companies, scientific researchers also benefit from watching the movie rather than looking at the stills, if that makes sense. And in particular, when you see what a person with a condition like Crohn's or like arthritis, like psoriasis and eczema goes through and you see the complexity in their individual experiences and just, I guess, for people that aren't necessarily too knowledgeable because they are quite sort of niche conditions. Yeah. immune-mediated and inflammatory conditions basically have this, as I say, this cadence of relapse and remission.

41:08The triggers for periods of relapse are generally speaking quite poorly understood and quite personal to the individual. Now, depending on who you ask, some people would say my trigger is a particular food type. Others would say my trigger is, you know, a period of stress. Some would say I just can't keep up with my medications and so on and so forth. And generally, if you ask doctors, they'll say, well, there's not really that much evidence for that. And so you have this disconnect between what patients themselves or what people living with the conditions themselves believe to be true and experience in an N equals one context versus what clinicians and maybe the wider kind of research-based scientific community conclude by doing clinical trials and studies and seeing patients at scale in short appointments.