Ahead of the Curves: Getting better? Where next in the great health debate?
This discussion took place in December 2021 as part of the Ahead of the Curves series, in partnership with Stifel Europe. This phase of the programme focuses on a new sunrise for the Professional Services, Health Tech. and Competition & Regulation.
You can also listen to the podcast interviews which provoked this discussion here.
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It’s in some ways odd that COVID has dominated the health conversation over the last two years. In the years pre-pandemic very little headline-grabbing medical research related to infectious diseases or vaccines. Six hundred and fifty thousand people die each year from malaria but not in the developed world. “First World” public health was a worthy backwater concerned with keeping MMR rates up among inner-city children and rooting out TB among the homeless. Reality TV health spots stick with flies on the wall in A&E or drama-filled observation of brain surgeons probing within millimeters of neural disaster.
For the latest in Jericho’s Ahead of the Curves investigations in association with Stifel we chose health. Inevitably, as this conversation took place largely between individuals based in the UK, the role of the NHS was discussed widely. The state plays a huge role in healthcare in Britain - not only in a socialised medical service free at the point of delivery but also as the sponsor of medical research that takes place in its universities.
Opening the conversation, Eithne O’Leary President of Stifel in Europe outlined a number of challenges. Medical technology will have a major impact on how, where, by whom and how often care will be provided in the future. But how do we ensure the nexus of tech, common sense and the promotion of wellbeing come together to target today's challenges of an ageing population, chronic illness, mental health, loneliness and isolation? How do we spend health money better and more intelligently? And how does an organisation like mine at Stifel get involved? How do we pick impactful winners?”
It’s certainly true that when it comes to increasingly complex diagnostics one needs to consider what's the best way to the most positive outcomes? Is there a widening gulf between the cutting edge of medical innovation and what is actually practised on the primary care coalface? What about getting less ill in the first place?
“I’m still convinced that the NHS has great staff but they’re badly used.”
Professor Karol Sikora, the chief medical officer and founder board member of Rutherford Health which makes proton beam therapies for cancer treatment has never been muted in his criticisms of the NHS for which he worked as an oncologist for many years before striking out into the private sector:
“We have to admit that there is an unlimited medical need out there and those with resources get by the problems by paying for services privately,” he said, reminding us that most European countries expect patients to pay at least something for consultation and have insurance schemes. “I’m still convinced that the NHS has great staff but they’re badly used.”
“The predominant users are elderly people who pay very little tax and have nothing else to do in some cases. We have to look at a different way of funding chronic elderly care. We’ve done this with the care system, the state may help those who are indigent. We have to look at health care and social care in the same way. The NHS is not resilient and part of the problem is getting people out of hospital.”
But what did Professor Sikora see in terms of benefits from the private sector when it comes to scientific discovery? “The private sector mutates and competes, better, faster, cheaper services. In the NHS the professional staff don’t know who the leaders are and the managers aren’t medical professionals. The tragedy of the NHS is that everybody loves it so much but you hear so many terrible stories of people not being able to access it.”
“It may be a rationed service with GPs as gatekeepers but that gate-keeping role could be done by a computer and not a highly trained individual. NHS 111 is a great example. At the moment there is no incentive to make the NHS more efficient.”
“The great irony is that I’ve ended up helping more patients through financing and working in a bank than most doctors do in their entire career.”
Dr Nick Moore, Managing Director, Healthcare Investment Banking at Stifel explained that he worked within the NHS between 2000-2006 “My generation inherited a significant decrease in training hours,” he noted. “So, medical knowledge was going up exponentially but training was going down so there was pressure to sub-specialise. I wanted to continue learning and being at the forefront of medical advances. The great irony is that I’ve almost certainly ended up helping more patients through financing lifesciences companies working in a bank than I would have done if I had stayed in clinical practice.”
Was his job bringing together capital and research like having to pick winners? Almost like trying to choose a Hollywood blockbuster from an array of promising scripts? “You can’t take a scattergun approach to investment but you have to go in with a grounded sense that not everything is going to work. You have to have enough different shots on goal.”
“I think we’re learning a lot from our American cousins that failure is part of success. You can’t expect everything to work perfectly. Our education system sets us up with the wrong goals and you get into the real world and learn you have to make some mistakes to generate those ultimate successes.”
Dr Moore then told the group about the story of Renalytix, a diagnostics company with which he’s been closely involved. “The science came out of Mount Sinai healthcare system in New York and it’s backed by a number of high-quality UK and US institutional investors. Stifel have raised over $100MM for the company in the past couple of years, both on the London Stock Exchange and also on Nasdaq in the US. What they’re doing is dramatically improving health care outcomes for patients with kidney disease and taking a significant amount of cost out of the health care system. Improving care and decreasing cost is a very attractive avenue for investment and great for patients.
“Their approach is combining analysis of three biomarkers in a blood sample and an AI algorithm that can sift through the patient’s electronic medical records and distill it down to a simple score out of a hundred in terms of a diabetics patient’s risk of developing advanced kidney disease. We really have no way of diagnosing renal impairment until it too late – we don’t have the smoke detector, we only know we have a problem when the fire is well underway. Renalytix are providing that smoke detector for diabetic patients so doctors can intervene before the problem is very advanced. Right now the vast majority of diabetic patients that develop renal failure end up in critical renal failure unexpectedly in the Emergency Room, and in the US that is extremely expensive, so if you can predict that and get the right patients in for careful monitoring then it’s a great way of taking cost out of the system as well as dramatically improving care and quality of life for patients.”
“There are opportunities to save a lot of money in the NHS and one of the best ways is to have interconnected services and to improve the technology, so that the left hand knows what the right hand is doing.”
Denise Kingsmill said this was timely because she’d just been in the chamber of the House of Lords where they were discussing the health and social care bill. “It’s pretty apparent that the government is a mess, frankly” she said. “There are opportunities to save a lot of money in the NHS and one of the best ways is to have interconnected services and to improve the technology, so that the left hand knows what the right hand is doing. I also want to stand up for test and trace. It’s fashionable to say they’ve failed but it’s actually a pretty damn good system. It is the constant changing of political ambition which has caused a huge problem for NHS Test and Trace. One of the most fundamental things to approach is the delivery of care – we deeply underpay those people who are expected to perform miracles and deliver the care. Brexit hasn’t helped with the shortage of staff.”
Patience Wheatcroft disagreed. “There is still a real fear of failure in the NHS as legal action can wreck careers. I think test and trace has been the most atrocious waste of money. We didn’t have to do it alone, we could have bought an existing system, ours is incredibly inefficient. For instance, if someone in the household is pinged, test and trace rely on that person to inform the rest of their household and they count them as having been pinged. How many people actually have the app on their phones? The NHS is appallingly inefficient and always has been.”
She doubted whether the NHS will ever be able to deliver what it needs to in its current form.
During the week before this conversation Kate Bingham, a biotech venture capitalist, who led the UK government’s COVID Task Force was very critical of civil service “groupthink and risk aversion that stifles initiative and encourages foot-dragging.” In an outspoken attack on Whitehall and therefore the Department of Health, Dame Kate said that the country would have faced months of delay in getting vaccines if it had been up to the normal machinery of government. She complained of a “devastating lack of skills and experience in science, industry and manufacturing” in government as she accused civil servants of treating business with “hostility and suspicion”.
A number of participants thought this very unfair. “ The government and its civil servants are not in the position to take that sort of risk-heavy approach for reasons that are more philosophical. Whilst there is informational value in failing, it’s not a pleasant experience.”
“If you can properly analyse the problems in their context, understand the drivers, instead of just throwing money at it you can have real impact.”
Wendy Jephson encouraged thinking from a behavioural science perspective, “In big organisations there is an inherent challenge for leadership who have to deliver regular and predictable returns. Combining that with the high risk of researching, designing and implementing technologies that can deliver impactful change is something few are achieving. This is completely understandable. To try and have the people running ‘business as usual’ make dramatic and sometimes terminal changes to work they are significantly invested in is incredibly difficult. It also requires specialised skillsets that are typically not part of a BAU team. If you can properly analyse the problems in their contexts, understand the drivers, instead of just throwing money at it you can have real impact. It requires looking at the system you have and into which you are going to insert a new intervention before you begin designing interventions. That way you have a much better chance of both adoption and spotting potential unintended consequences. Mindful and scientific approaches are what leads to improvements in efficiencies and effectiveness of the people in these complex organisational systems.”
“To try and take the politics out of the NHS is impossible. So we need to build upon capability within the public sector.”
Chi Onwurah, the MP for Newcastle Upon Tyne Central and a shadow minister for Digital, Science and Technology said: “I’m concerned that we are not taking the right message from COVID. This downgrading or undermining of the capability of the skills in the public sector doesn’t reflect the asset that the NHS is to us. To try and take the politics out of the NHS is impossible. So we need to build upon capability within the public sector. I’m deeply concerned about the existing inequalities in the health sector and the ongoing issue of the NHS and innovation: it’s slow to bring in new and take on board new technology. Putting practitioners at the centre of new technologies is critical. We must make sure that NHS is a public, not private asset.”
For her part, Vicky Pryce, an economist, wondered why health economics has always been “the least attractive for anyone to be working in. The NHS needed more resources and they were not forthcoming. Now, of course, we need many more – do we have enough? We shouldn’t be attacking the civil servant, they are under pressure not to make mistakes. When they are made it tends to be the civil service or agencies who get the blame.”
“In the NHS the problem is we don’t know what metrics were trying to measure up against. So we lurch from anecdote to anecdote.”
Simon McDougall who has recently stepped down from the Information Commissioner’s Office said: “It was shocking how much a good crisis can shake things up. We knew beforehand there were issues around culture and tech. The NHS is still the largest purchaser of fax machines in the UK. As someone who has worked in most sectors, I found it by far the most dysfunctional sector I have worked in. A lot of the barriers that have been there for many years have been broken down elsewhere and there is opportunity now to change things. So much of it boils down to a single patient view. There has been lots of work done on this but it's slow progress. If I were granted one NHS-related wish it would be giving the health service a single customer view. In the NHS the problem is we don’t know what metrics were trying to measure up against. So we lurch from anecdote to anecdote.”
Sanjay Patnaik from the Brookings Institution in Washington, D.C. didn’t think looking to the US health models for inspiration was an especially good idea. “The US system suffers from the same inefficiencies,” he said. “And, believe me, they still use fax machines here as well. In the US, the system is very fragmented. For those who are wealthy or get comprehensive employer-based insurance, insurance can be very good, but for many others it is not – especially for the elderly. The human costs of the US system are high and COVID has shown its serious weaknesses: people who are sick frequently went to work because they needed to, for example. Just consider the fact that average costs for the birth of a child in Washington, D.C., are more than $20,000 to the insurance company.”
Patience Wheatcroft explained - “One of the downsides of ‘we love the NHS’ campaign during COVID was that it should have said ‘we love the NHS workers.’ If ever there have been plans to improve what the NHS does, the local MP joins the people in fighting to protect the local hospital come what may, regardless of potential better clinical outcomes.
“Until we can get the politicians out of the way and restructure into something more workable – we won’t’ get the reform we really need.”
“I’d put the NHS into a royal commission of some sort and out of the political arena. In recent memory there have been 20 reorgnisations of the NHS, perhaps half have improved things a little but the other half have clearly made things worse. Until we can get the politicians out of the way and restructure into something more workable – we won’t’ get the reform we really need.”
Eithne O’Leary made the point that the potential valuable contribution the private sector can make to health wasn’t helped by the scandals over NHS PPi procurement when the pandemic was at its height - “The assumption on the part of the voting public is that privatisation is in the interest of those that are doing the privatising. Sadly, the government and prime minister have destroyed what trust the public had in this area.”
Denise Kingsmill agreed: “The answer is independent and strong regulators to make certain that that doesn’t happen. The most heinous thing ever delt to us was compulsory competitive tendering which meant that you were forced to take the cheapest option. What happened was, people were dismissed and reemployed at lower wages – a rotten system that could be improved.”
“Brilliant clinical care can’t operate optimally in a system that is so chaotic”
Lesley Smith wasn’t convinced that “picking goodies and baddies” is anything other than a politician’s game. “You might have brilliant clinical care in the NHS but appalling administration and administrative technology. But brilliant clinical care can’t operate optimally in a system that is so chaotic. It’s not that it’s intrinsically badly managed but that new systems have been added on in a piecemeal way and no systems talk to each other. The reason stand-alone app-based finances or healthcare management work is because they aren’t stuck over layers of legacy systems. But re-gearing the technology of the NHS is a different ball-game.”
Patience Wheatcroft summed up her thoughts: “there is intense hypocrisy over privatization of healthcare. Opticians, dentists and the rest have been private services for ages. Many hospitals have private wings. Private and NHS work hand in hand and we need a degree of honesty about it.”
Finally, Eithne O’Leary addressed the issue of why those who deliver healthcare are traditionally paid relatively low wages for what they do. It’s assumed that their higher sense of purpose compensated. “One of the elements of why doctors and nurses end up getting paid less is because there is an element of vocation in what they do. Perhaps it should be framed that improving efficiencies would allow better remuneration for those working within it and exploring that narrative. The public has demonstrated the capacity to understand and make complicated decisions – we all know there is a trade-off that is going on.”
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The discussion was attended by:
Matthew Gwyther, Partner, Jericho Chambers
Wendy Jephson, Former Head of Research, Ideation & Behavioural Sciences, Market Technology, Nasdaq; Founder, LetsThink
Denise Kingsmill, Former Chair, Monzo
Simon McDougall, former Deputy Commissioner - Regulatory Innovation and Technology, ICO
Nicholas Moore, Managing Director, Healthcare Investment Banking, Stifel
Eithne O'Leary, President, Stifel Europe
Chi Onwurah MP, Shadow Minister for Science, Research & Digital
Sanjay Patnaik, Director, Center on Regulation and Markets (CRM)
Vicky Pryce, Economist and Business Consultant, Board Member, Cebr
Karol Sikora, Chief Medical Officer and Founder, Rutherford Health
Lesley Smith, Vice President of Corporate Communications & Public Affairs, Revolut
Baroness Wheatcroft, Member House of Lords
