From Shed to Scale: Why Great NHS Ideas End Up Abroad

Tom: I just want to talk a little bit about screening, because I find screening fascinating. I don't know if you saw that one of the AI companies in San Francisco, Midjourney, who are famous for making AI images, announced last week that they're becoming a medical imaging company. They've invented something that looks like a spa. You walk in, it uses sonar underwater to ping your body, and it creates what looks like an MRI. I have no idea if it's any good, or if it's high fidelity enough. But what a fascinating outcome from an AI business that was about making pictures, turning that technology around into a whole new sort of diagnostic.

Tim: Sounds fascinating. Do you have to wear your trunks, though, to go into the sonar? That's my immediate thought, I can't help it. But it sounds fascinating. There is so much we don't yet know.

And it's really important, and I come back to the cultural thing again, that we keep our eyes open, our ears open, and stay open to conversations and suggestions. Because not that many years ago, I know clinicians who would have immediately closed that down. I would have. I'd have said, "That's not grade 1 evidence. I haven't read that in the New England Journal of Medicine or The Lancet, so I'm going to dismiss it out of hand." And I would say that to patients. Patients would come with a cutting from some spurious magazine article and say, "Look, can I try this?" And I'd say, "No, there's no evidence for that at all. Don't waste your time, don't waste your money. Take these tablets instead."

That's wrong. We need to be open, because some of those things actually do work. We used to call them alternative therapies, or complementary therapies. But you do find a strand of scientific research which shows that they can offer an advantage, or cut down the progression of a disease, or modify a disease. We've got to be open to this. So any technology, however Tomorrow's World it sounds, we need to look at it, take it seriously, and encourage people to take part in research.

Because underpinning all of this is the research culture of this country, which is very strong, but we are not exploiting it to its full advantage. We have the research world, we have innovation driven by businesses, and we have innovators inside organisations. The three are often very disconnected.

So I recently hosted an innovators' breakfast. Bristol is a great enterprising city for many reasons, so we got local innovators in who'd each worked on something healthcare-related. We got some patients in, some clinicians, some digital people, and I just sat down and listened to the conversation. Twelve innovators came in with products at various stages of design. All of them fantastic. I couldn't fault any of them. Such was my enthusiasm, I'd have signed them all off immediately.

But what I heard from them was the frustration they had trying to get integrated into the NHS.

Tom: Yeah, it's so hard.

Tim: There's something about our procurement that makes it incredibly difficult. You have to be well financed, well advised and fairly tenacious to get through NHS procurement with an early-stage product. It's really difficult to get into good quality research, to get through ethics committee approval, to access patients legally and ethically. It's really difficult to share information. I come back to information governance being a problem that we need to face up to. I don't know what the answer looks like, but we need to face into it and ask lots of questions.

And then of course there's the difficulty they find in scaling. I've seen so many people with fantastic things they've built on a bench. It almost looks like they've made it in their shed. It works, and they cannot scale it. And I think, yes, it's big, it's clunky, it's not going to last a week on the bedside or on a patient's arm. But this is all solvable. You need some funding, some resourcing, some scoping. And people find it very hard to access that. So there's something about the investment model we need to get right as well.

We're definitely a country of innovators and inventors. That's deep-rooted in the culture of the United Kingdom. But we aren't always good at scaling things. I don't think that's just the NHS, actually.

Tom: To the tenacity point, DrDoctor is 14 years old. It's taken us 14 years to get some scale. The mission is still the same: solve the supply and demand challenges. The route up the mountain looks different to how we thought it would. But to any innovators listening, I feel like now is the moment. If you're ever going to create change in the NHS, go and talk to people, network and have the conversations, because the NHS needs it. And I think it's more open than it's ever been.

Tim: I think so. Whether or not you'd call yourselves trailblazers, you have been there. You've stayed the course, to the point where your brand and your products are now recognised. You've gone through that trust cycle.

Tom: Yes.

Tim: And that quality cycle, and the proving benefits cycle. I'm sure it's felt like a very hard road.

Tom: And 14 years has flown by.

Tim: It has flown by. I remember first seeing your product. So well done. But you're right, encouraging others onto that journey is quite difficult. We work with universities and try to encourage the commercial input, the spinouts and so on. And so many fail.

Tom: Yeah.

Tim: Which is also okay. It's fine. It's good, because it means there's a check and challenge culture. But an equal number suddenly pop up in another country.

Tom: Yes.

Tim: And that's really sad, isn't it? Not only do we lose the economic benefit, we lose a bit of the control and personalisation for our population. Then those products come back and get sold to us, but they're not necessarily focused on the human peculiarities of the UK market.

Tom: I'm still really passionate about the NHS, about changing it and creating an incredible patient experience. I'm also really passionate about the UK creating impactful international businesses, because we have the skills, we have the desire, we have everything. But as you say, it's so sad that people end up in the US, Europe or the Middle East, because that's usually where the money is.

Tim: Yeah. And again, that's the human condition. People will go to where the money is. But it's not just the technology. I'm not saying this because it's my employer, but I do think the NHS is world-class.

Tom: It is.

Tim: And I think we need to be willing to export that as well. That unique funding model, the organisational structure, which is clunky at times but getting more streamlined, and that patient service element, as opposed to a more commercial one. I think it's really phenomenal. It's not just technology we should be exporting. It's our healthcare design, our system design. And I understand that's a buoyant market.

Tom: I think the world needs it.

Tim: The world needs it.

Tom: I think the pound per outcome we achieve in the NHS is phenomenal. The patient experience, once you're in the system, is really good. It's not as good between the moments of care, but once you're in, it's phenomenal. And I'm going to go back to Penny's quote: there are 8 billion people who need affordable healthcare. If we could lead that next revolution in care globally, what a fantastic place for the UK to sit in the world economy.

So let's talk about what that looks like. You're currently writing the strategy.

Tim: For Bristol.

Tom: So 2027 to 2037. What does healthcare look like in 2037?

Tim: It's less about shiny buildings and more about population health. I've enjoyed the last 14 years of my professional career sat in a very shiny building. Southmead Hospital in Bristol is beautiful.

Tom: It is.

Tim: Beautifully designed. You've got that nice environment where you feel safe and you feel well as you walk through the building. But it's less about those shiny buildings and more about dispersing healthcare across our population. So we're looking at models of care that take anything out of the hospital that doesn't add value to the patient journey. I know return on investment is an overused and very broad phrase. But let's take it as close to the patient as possible.

That doesn't necessarily mean the patient's home. Our quite detailed questioning and surveys of patients tell us they don't necessarily want you knocking on the door. There's something there that says, "This is my home. I don't want a doctor or a nurse or a healthcare professional knocking on my door." But equally, "I don't want to travel a long distance to a shiny building." So we're looking at options for that intermediate care.

Tom: You talked about an intermediate environment. I'm really interested in the high street for this, because the high street feels so underutilised. What an opportunity.

Tim: I don't know whether you've visited one of the very big diagnostic centres we partner with. It's in a shopping centre, Cribbs Causeway regional shopping centre. What was a value warehouse selling toilet rolls is now a seven-day-a-week diagnostic centre offering everything from plain X-ray through to endoscopy.

Tom: Amazing.

Tim: Very efficient, well liked by patients, well connected, easy to get to, and really good patient feedback. We're now moving the majority of our non-inpatient diagnostics out of hospital. But that's just the start. That's pulling everybody into a big facility, a converted warehouse. Let's democratise it even further. Let's go down to high street diagnostics.

One of my daughters said to me the other day, "I had to have an afternoon off school to go to hospital for a blood test. I sat there for two hours until someone took my blood, nobody said much to me, and then I left. Couldn't I have had that done in a chemist's?" And I said, "I don't know whether you can, but maybe you should be able to have it done in a high street chemist."

Tom: Or in your sweat, like you said.

Tim: Or in your sweat. Because that's so much easier. And that result could be available for a clinician to review, or for an algorithm to review, at any point, 24 hours a day. Democratising health.

So in terms of our strategy, it's definitely a dispersed model. Because I'm an enthusiast, I think we should embrace the big clinical paradigm shifts: genomics, metabolic health and the advances there, and artificial intelligence as a diagnostic, education and screening tool.

Tom: Totally.

Tim: It's also about embracing different models of care. Some of them are top-down: left shift, digital and prevention. Essentially the same ideas, clustered differently. We definitely need to embrace those.

And our new strategy is a lot about patient experience. It's less about promoting our outcomes. Of course outcomes are important. You wouldn't sign up to a healthcare contract if I told you I wasn't very good at curing you.

Tom: No.

Tim: But increasingly you'd also be asking, "Will my relatives be able to visit me 24 hours a day if needed? Will I get access to good quality rehabilitation?" That's how the picture is looking for us.

We have a lot of physical estate in our trust. At last count, and it changes every day, I think there were 17 buildings delivering healthcare. Many of them are old. Some are 100 years old, and some are older. That physical environment needs refreshing. What was appropriate as a shiny city centre facility at one point may no longer be fit for the future.

Tom: And for all of that to work, there are some bold decisions to be made. We talked earlier about culture. How willing are these organisations to take bold steps? Of the four or five things you mentioned, which are getting the most traction, and which are getting the most pushback?

Tim: Different audiences give me different degrees of enthusiasm and pushback. Yesterday I was talking to a group of clinicians who were very cynical, perhaps even confrontational. They said, "We do not believe your ambition for outpatient transformation. We can't see a way to reduce outpatient follow-ups by 30%, let alone 60%. This isn't going to work, Tim."

When you unpick that a bit more, it's because there's a lack of understanding of what's available and what the alternatives are. And a lack of understanding of how willing patients are to embrace different models of care. So you start to explain that, you start to demonstrate it, and people do soften. They increasingly understand the need for that transformation.

It doesn't get over the natural question of, "What about me as the provider? What's in it for me? Does that mean you won't need me to work five days a week, or seven? Will you ask me to work from home? Will I have to have a computer in my spare bedroom? Will you make me travel somewhere other than the place I've turned up to every day for 10 years?"

Tom: People's routines matter to them.

Tim: Routines are vitally important. So you talk it through and look at the options. Yes, maybe one day a week you turn left instead of right and go somewhere different, into a very different environment. But look at the advantages. Look at the potential change to your work pattern and the positives that come with it. That's just one example.

In terms of the big clinico-scientific paradigm shifts, I think there's a lot of pushback about metabolic health.

Tom: There's a lot of hype, understandably.

Tim: There is. And it's an area I'm absolutely fascinated by, and I'm really chasing the scientific data. I was recently in a meeting with metabolic health experts looking at GLP-1s. Even I walk into those meetings with a cloak of cynicism, looking for the hard evidence. I'm reverting to type: show me the evidence. There's value in that.

And I'm starting to see the evidence. Particularly if you look at North America, where the model is very different, so the data collection is very different. The insurer or revenue provider has every piece of data about claims, consultations, symptoms, diagnoses and scans for the population they insure. So there's very reliable data. And they're starting to show that within a relatively short time, people whose metabolic health has been improved through medication are having less addiction, fewer mental health crises, less ovarian cancer.

Tom: Amazing.

Tim: Reduced progression of prostate cancer. And the list goes on. Literally every day I can add something to it. I can't explain it. I'm not clever enough to tell you why a drug that slows down the emptying of your stomach, or however a GLP-1 works, and I'm sure it's more complicated than that, protects you from X or Y. Perhaps it's explainable biochemically, through metabolism, obesity or glucose. Or maybe through things we don't yet fully understand, like inflammatory markers caused by imperfect metabolism. But these are real endpoints and rapid changes in the populations they serve, and it's replicated in other parts of the world.

Now, we haven't got the funding for GLP-1s. And it's an imperfect system. If you have the income, it's relatively easy to buy. I'm sure you can buy it within 100 yards of this building.

Tom: Absolutely.

Tim: And if I don't have the income, it's quite a struggle to get it. I have to be extreme. I have to prove my BMI, prove my ill health. It's almost as if I have to be reverse means-tested to get hold of it.

Tom: Yeah, absolutely. It's very medicalised.

Tim: That's not good. That's inequity, and we need to solve it. Maybe oral drugs, off-patent drugs or different preparations will help. Loosening the guidelines will help. And we should do that really rapidly. I think we will.

So we move to oral medications quite quickly, we reduce some of the cost, and we start to prove the financial benefits. Again, balancing the books, double accounting, but ultimately balanced books and a lower run rate in the future. We're building that into the strategy. Let's look at endpoints for type 2 diabetes, for obesity, for some cancers, for addiction, for mental health. And let's build a changing profile of demand into our strategy, assuming these reduce.

Now, it's not all perfect, because there's a flip side: what's the increased demand? Of course, it's that we'll have more frailty.

Tom: Yeah.

Tim: We'll have to talk about more end-of-life care, and more novel end-of-life care. So we're building those into our strategy as well. I don't think we're gambling or going down a risky clinical path. I think we're pivoting our clinical strategy to be future-proof. Increasing our end-of-life and frailty provision, maybe reducing our diabetic, bariatric and some metabolic provision. These are low-risk moves, and they'll reward us in the future as we pivot more and more.

Tom: I have to say, I absolutely love the systems thinking around that, because that's what we need. Full systems thinking. You can't just think about the endpoints. You mentioned screening, and I want to touch on that. Within the Bristol strategy, do you get to own screening?

Tim: I'd say we're very fortunate. The organisations that have come together to form Bristol Foundation NHS Trust have essentially had screening contracts. We've run screening businesses, if I dare say it: cervical, breast, and increasingly Healthy Lungs, the lung cancer screening programme. And I'd point to the lung cancer screening programme as a game changer, in my view.

It felt radical at the time. Let's go out and ask people of a certain age who've smoked to come and have a scan, and we'll see if they've got cancer. It doesn't sound like a great sell. We know there's a heck of a lot of psychology around tobacco dependence, and a heck of a lot of psychology that says, "I never want to know if I've got lung cancer."

Tom: It's fascinating.

Tim: Absolutely fascinating. So to go out with a scanner in the back of a van and say, "Come on, line up." First you've got to admit you've been very naughty because you're a smoker, that you're a certain age, and then you've got to submit to a test that might say you've got cancer. I wasn't sure about the take-up rate or whether we were selling it right. It's been a fantastic success.

Tom: Has it?

Tim: Fantastic. People have come forward in abundance. And we're starting to see a complete reversal of the inequality in lung cancer outcomes. Ten years ago, if I was from a wealthy part of Bristol and I was diagnosed with lung cancer, my outcome would be roughly twice as good...

Tom: Wow.

Tim: ...as if I was from an area of Bristol or Weston where income was very low. We've levelled it. And bizarrely, we've tipped it the other way.

Tom: Really?

Tim: This needs further explanation. But we're now seeing slightly better outcomes for the people on the lowest incomes in our population. Maybe that's because we purposely targeted those populations first in our screening programmes, because we knew they had the greatest need. So now we almost need to level up the other way. We need to make sure the levels keep going up and up.

Tom: That's absolutely fascinating.

Tim: So screening, for me, is really important. Again, there's the stigma of finding a disease. But this isn't stigma, it's an opportunity. An absolute opportunity to change your future life course if we can find that illness early. We know there's a funnel of options, which starts very wide for malignancies or other conditions we can screen for, but narrows very quickly the more advanced the disease. So we explain that and educate patients about it, and suddenly you see uptake of screening rise.

Combine that with your genes, your genetic sequence. And we're only scratching the top of the iceberg at the moment. Hopefully technology and AI will come in and rapidly show us the patterns we need to spot. There are billions of patterns to look for. Something that says, "If you've got this code, and this code, and that mutation, that variant there, and that bit of your gene missing, you're potentially going to develop disease X or Y in 10 years' time."

Tom: Yeah.

Tim: Now, is that a death sentence? Is that like saying, "I'm really sorry, you're going to get this disease, and we thought we'd tell you 10 years early so you could really worry about it"? That's a concern. But take the other side of genomics, which is targeted therapy. Those codons translate to proteins, and that's what life is: proteins. If we look at why those proteins aren't working for you, why they're making you susceptible to this disease, we can tweak them. Look at what's happening in proteomics and in AI's understanding of the shape and pattern of proteins. We tweak those proteins, and you don't get the disease.

Tom: Yeah, I mean...

Tim: Or the disease you get is a shadow of its former self.

Tom: This is amazing. It feels like science fiction, but it's available to us right now.

Tim: It's happening now. It's not science fiction, because it's proven. There are diseases we can screen for, and diseases where we can change the protein or manipulate the genome so you do not get that disease, full stop. They're rare diseases, because that's where most of the genetic research has been. And as a country, we're absolutely phenomenal at rare diseases and the genomics of rare disease. Take that into common diseases, into cancer and chronic disease, and you can see where we go.

Ten years ago I'd have said, "This will never happen in my lifetime. This is 100 years away." Then you accelerate it with a machine that can take 100 years and bring it down to six months, and you start to see the power. So what we're now lacking in that space is just the creativity.

Tom: Yes, it is, isn't it?

Tim: It's knowing what to ask the machine to go and look for.

Tom: Yeah.

Tim: Let's get creative.

Tom: What a brilliant note to end on. I'm so excited by the future you've described. It feels tangible, it feels real, and I'm motivated by everything you've said. I'm going to finish with a few quickfire questions.

Tim: Oh, exciting.

Tom: Robot or surgeon: who do you trust?

Tim: I'd go back to my previous answer. I'd trust the robot to do the operation, but the surgeon to help me make the right decision.

Tom: Amazing. One NHS policy you'd abolish tomorrow?

Tim: I've got to be careful here. But on the macro scale, the internal market. Splitting the commissioning and provision of medicine doesn't seem quite right. It's one pot of money, one bank account, one population, one workforce, one set of scanners. Can we just have a think about what the point of splitting commissioning and provision is?

Tom: Brilliant. Bring it back together. The most overused word in health tech right now?

Tim: Strategy. Despite being the person who's writing strategies. Strategy means everything. I talk to people who'd have a strategy for what to eat for breakfast. No, you don't need one. And strategy isn't the endpoint. It's just the roadmap, almost invisible, behind the scenes. We should be talking about the transformation we want to see. The strategy is just the stepping stones to get there. But everybody I meet is talking about their strategy, and I think it's become devalued.

Tom: I agree. It's about execution and culture.

Tim: Culture beats strategy every single time.

Tom: The book or paper that changed how you think about healthcare?

Tim: There are lots of books. But the one I come back to time and time again is pretty odd. I don't know if it's even in print, and I'll probably get the title wrong. If Disney Ran Your Hospital.

Tom: I really haven't read it.

Tim: It's from years ago. I won't name the author in case I get it wrong. It's Fred somebody. Have a look and try to find it. It's not a scientific piece of writing, but it's a really good coffee table read. And it made me think, yes, if Disney ran the hospital, it would be a great experience.

Tom: I just find that title fascinating.

Tim: I wouldn't mind standing in a queue for three hours if people were giving me a free badge, bringing me drinks, checking on me, making me happy. It's about making this customer service, not just delivering some operations and some drugs. It should be about customer service first.

Tom: I think you've answered this, but GLP-1s: game changer or overhyped?

Tim: They're a game changer. We should really be considering how we can afford them at population scale.

Tom: If you had £10 million to spend on one innovation, what would it be? You obviously have several billion to spend.

Tim: I wish I had billions to spend. I don't know where that money is. But £10 million is about the right amount to do something that personally interests me. I'd spend it in care homes and nursing homes, on digital technology that lets residents or their carers interact with healthcare in real time, whether that's diagnosis, education, screening or treatment. We haven't quite got that right. So often these people don't have a smartphone, or they've lost it, or it's been taken off them, which I found quite incredible. Those environments are really tricky for digital integration. I'd put £10 million in there. We'd get a fantastic return on investment, we'd keep those patients somewhere they feel safe and secure, in their own environment, and we'd make sure we don't drive a digital inequality gap.

Tom: Amazing. What do you wish patients understood better about the NHS?

Tim: There's lots to say here. The piece I keep coming back to is encouraging patients to take more responsibility for their own healthcare. It's not a given that we can rescue everything and everybody. There's a lot of personal responsibility. I'd also say that a medical or nursing degree, from any institution anywhere in the world, is really high calibre.

Tom: And finally: excited about the future of healthcare, or terrified?

Tim: I'm very excited about the future of healthcare. I'm beginning to think I don't want to see the end. I want to keep going. I want to keep driving this and keep understanding it. And I regret that I possibly won't be here in 50 years' time to see where it's taken us.

Tom: Professor Tim Whittlestone, thank you so much. Polymath, systems thinker, surgeon. I've enjoyed this conversation so much.

Tim: So have I. We could have talked for hours.

Tom: We really could. I can't wait to see what you do in Bristol, and I hope we're going to be part of that journey with you.

Tim: Thank you.

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