Tom: Welcome to DrDoctor Will See You Now, the podcast where we cover the latest tech innovations across the NHS and the health service. And I'm really excited to say that I've got Professor Tim Whittlestone, who is the new Chief Medical and Innovation Officer at Bristol NHS Trust. Newly formed. Welcome, Tim.
Tim: Thank you.
Tom: You're a consultant urologist with 25 years' history and an increasingly exciting career in innovation. Please introduce yourself.
Tim: Yeah, well, you said most of it. 25 years as a consultant urologist in Bristol, largely, but trained in Oxford, Cambridge, and the south-west of England. And my urology career was very varied. I still practise, actually, and still practise clinically and surgically. But my surgical career was very varied, ranging from initially female urology, particularly becoming an expertise in female incontinence, but then moving into minimally invasive surgery and introducing quite a lot of robotic surgery.
Tom: Cool.
Tim: And then finally, really, really hyper-specialising in testicular cancer, which I still have an interest in. Gosh, I can't remember, but many, many years ago now, I brought the first robotically assisted retroperitoneal lymph node dissection to the UK, which at the time seemed like a very big surgical technology leap, but is now fairly established as normal practice.
Tom: Wow. Exciting. So you've seen some real pathway innovations there.
Tim: Yeah.
Tom: Talk to me a little bit about how you brought those first ones in. Was there pushback? Was there resistance to robotics in surgery? Because it feels like now everyone's embracing that, but it must have been different.
Tim: Yeah, there was lots and lots of resistance. And I had nervousness, to be honest. Not nervousness in the technology and the safety, but in the very fact that there is a steep learning curve. And that learning curve was translated into very prolonged operative times, literally to the point where it would take twice as long to use a laparoscopic and subsequently a robotic technique. But those learning times collapsed down very, very quickly. And we were able to prove significant patient outcome benefit, not least small scars, not least a reduced length of stay, and ultimately a financial benefit for the NHS. I remember, in a really short space of time, patients who were having really quite complex major retroperitoneal surgery, who I would routinely keep in hospital for 14 days. That was my standard. You're going to be here for 14 days, possibly longer, maybe a day or two shorter. It became a 24-hour stay in hospital.
Tom: Really? Wow. So better for the patients, much better financial outcomes, I assume, from that as well, as well as the kind of experiential.
Tim: Indeed. And much more agility, because every bed and day you stay in hospital reduces your agility to do more surgery, change the date of surgery, bring the surgery forward, plan the surgery. As soon as you can bring an operation down to a relatively short inpatient stay, day case ideally, 24-hour possibly, then you become a much more agile service. You can bring that date, you can move the date around, you can do more cases. You can do those cases outside of a traditional bed base, into a dedicated elective unit, for example. And that unlocks so many benefits for the patient and for the hospital.
Tom: Yeah, that's incredible. I love the idea of the robotic surgery intervention, which I think of as a sort of quite clinical thing, enabling actually system change there.
Tim: Indeed. And we always see the same when there are individuals or organisations who manage to enact change. It's that trio of patient experience, better outcomes, and financials.
Tom: And it's really interesting to see you reference those straight away at the beginning.
Tim: You're absolutely right. So I think one of the things that twigged to me very early on in my career was that patient experience is undervalued, especially in the NHS, but in healthcare all around the world. I see systems, hospitals, clinics, teams, which are designed sometimes more for the benefit of the system, the hospital, and the team than they are for the patient. And it doesn't take much for you to see medicine from the other side, perhaps become a patient yourself, have a family member or a friend who's a patient, or just listen to patients and just listen to their experience, to see that we're not a very customer-friendly service. And that, I think, is still lacking in a lot of healthcare design. It's still lacking in the NHS, more by necessity than design. But I think it's our real opportunity to enhance not only the experience, but also the outcomes. And it's really important. I've been to some places internationally, and I've seen where just simple things like the physical environment that we care for patients in, if that's done with a view to enhancing the patient experience, the customer experience, it actually translates to a better medical outcome. I remember recently looking at some hospitals in the Middle East, for example, where they'd greened the interior. They'd put in internal gardens. It was an absolutely beautiful space, and I thought, this is amazing. And then they were able to demonstrate that their length of stay was reduced, their patient feedback was improved, and their hard outcomes were better. I can't explain that.
Tom: Yes.
Tim: But there is something there. There is a magic there that we need to enhance.
Tom: I agree. Do you know what's so interesting about that? It's one of the things that we often talk about at DrDoctor - if you can get rid of the reliance on bringing people into a physical outpatients department, it enables you to sort of split place and care.
Tim: Absolutely. And I've always imagined that rather than having hospitals in the middle of cities, you should have clinics and diagnostic centres there. And then if you need an elective stay, go out into the countryside, have space around you, recover in an environment that's designed for recovery, rather than one that's squashed into a city centre.
Tom: This is music to my ears.
Tim: Nothing frustrates me more than looking out of my window in my office in a hospital and seeing a full multi-storey car park, with patients and their carers driving around looking for a parking space. I've seen physical fights in the car park.
Tom: Really?
Tim: And I can understand why.
Tom: Yeah. You've got an appointment. It's probably a very stressful event for you.
Tim: Yeah, totally. You've had a day off work or a day off your normal activities. You've got your family with you. You're anticipating potentially very difficult, troublesome information. And you can't find a parking space. What is the return on investment in bringing you to a hospital supercentre for that? Yes, I can understand it if there are additional things that need to happen, if there's a very specialist investigation that needs to happen on the same day, in the same environment. I could understand it if you were immediately going to enter a treatment pathway. But otherwise, why do that? I remember doing quite a lot of work during Covid, and by necessity we had to move a lot of care to remote access. At the time, there was a great deal of anxiety and some pushback that we were devaluing the patient experience by not being in the same physical space as the patient. We've done quite a lot of research on that, and it's not true. It's a different encounter with the patient if I have it out of hospital, maybe in a community setting, or even ultimately digitally. There's a different experience for both the giver and the receiver of care, and as long as we understand that, we can tailor the experience differently. If I try to do a video link to a patient and say, I'm terribly sorry, the investigations demonstrate you've got a very significant and serious cancer, and I try to do that as I would face-to-face, but digitally, it would not work. I have to tailor that experience for the patient. We have to do some pre-information, some checking about the patient's understanding of the environment they're going to receive the information in. And we also have to do some very careful, timely follow-up to make sure they've understood and computed the information. But if we make that leap, we can do it a whole lot better than dragging people to hospital, having a day off work, having a fight in the car park, getting frustrated and anxious, with cortisol levels through the roof before they even walk into the room.
Tom: Yeah, I completely agree that the ability to personalise that communication and knowledge transfer journey is really critical. It often feels like we design services around the system, or around the needs of the hospital, or even the consultant, rather than thinking about what it looks like to be a patient. And I think the other interesting thing is, when you design a system like the one you've just described, where the people who really need face-to-face time because there's a difficult diagnosis to discuss can be prioritised using data, you can actually make the clinical experience much better.
Tim: You can. Because you allow people to operate at the top of their practice. Indeed. Certainly in Bristol and Weston, we have very ambitious plans to really disrupt our outpatient model. It goes without saying, and I could probably pick any hospital trust anywhere in the country, that there are, give or take, 30% of outpatient appointments which are absolutely no return on investment for either the clinical team or the patient. They just do not need to exist. I've looked back carefully through thousands of records to understand why that happens, and it's pretty obvious. It's because we don't have a robust administrative layer in the middle to give me confidence that the patient will ever be seen again. As soon as you introduce that concept, I know I'm dealing with a risky environment. Here is a patient who I'm not anticipating anything happening to within 6 months, but I absolutely do need to know what happens to them over a longer period, because I know something can go awry. If I have no confidence in my ability to do that, my natural instinct, for safety reasons, for risk reasons, and for my own protection, is to say, come back and see me in 6 months' time. 30% of appointments are due to that. There's probably another 30% on top of that where there's very little return on investment and certainly no added benefit to seeing the patient face-to-face in a hospital building. We're looking critically at whether those patients can be seen out of hospital - as you said, in a country field, which sounds glorious - but perhaps in community hubs, repurposed general practice facilities, newly designed place-based campuses, or indeed via a digital interface that intercepts the need to physically see a patient, whether that's on the telephone, via video, or via an app. And finally, the real power here is putting control of care back to the patient. So rather than me prescribing a 6-month appointment where I'll bring you in and maybe do a blood test because it seems like the right thing to do, without being quite sure what it's for, why don't I say, look, here's your condition, here are the red flags, the warning signs that we should intervene, check your medication, think about a further investigation. It's not rocket science. You don't need a medical degree to monitor your own condition, especially with some simple technology. And when things aren't quite as good as they've been, or even when an algorithm can say your symptom scores have shown a drift over time that you weren't aware of, an alarm bell rings, and that triggers an intervention. That's where we can do the most benefit.
Tom: I'm smiling inside hearing you say this, because it's exactly the world we've been trying to build for a long time. We call it between appointment care.
Tim: Yeah.
Tom: It's the bits that happen when you're not in the hospital.
Tim: Yeah.
Tom: And I'm sort of interested that the NHS gets it, but I feel like it's tried to do PIFU, tried to do advice and guidance, tried all these point interventions, which do work, but they're just point interventions. What I love about what you've just described is that if you put all of those things together - place, communication preference, risk acuity - and design it as a system, it fundamentally changes what it means to be a patient, for the better.
Tim: Absolutely. We could talk for hours about this. PIFU, advice and guidance - they have a place. They were absolutely the right interventions at the time, and they've got advantages and disadvantages. What you've described is moments in time, but of course this is a continuous journey. We're all continually alive until we die, and our illness or symptoms are changing minute by minute, second by second. That's too much information for me as a consultant urologist to compute for however many patients we have on our books, which is where technology comes in. If there's technology that can reliably inform the patient and the clinical team that there are early signs of a change - which could ultimately lead to a hospital admission or the need for a significant change in medication - let's exploit that now, because it's key. It's never about criticising the patient, but I think healthcare has been designed to make patients feel they have no control over their life or their illness. Everything has to be done with a clinician, a healthcare provider, a medical facility. That's an overreliance. Ultimately, we're all responsible for our own health, our own lifestyle choices, our own compliance with medication or treatment. We have choices, and that's the beauty of the human condition. But equally, we have to take responsibility for that, and some of that responsibility is self-management. Giving patients the power and the tools to self-manage is really important. We can't cope otherwise. We're on a one-track road to ruin if we continue to say that anything that changes, anything new that happens, come and see us.
Tom: Yes. Come through the door, give us a call. It doesn't make sense, does it?
Tim: It makes no sense. The supply and demand equation has been broken for a long time.
Tom: Absolutely. And it's getting worse and worse.
Tim: Indeed. You're absolutely right. I think we all, myself included, walk through the front door of a hospital or a GP surgery and become a patient.
Tom: You do. You sort of put this persona on. Giving patients a bit more agency to care for themselves is exactly the right thing, and I'm super interested in how technology can do that. There's this expression some of the Americans have coined, which I quite like - abundance. If you could give everybody a guide and assistant in their pocket, everybody could get the help they need to self-manage, and it could be escalated to a professional when they need a professional.
Tim: That's the one. That feels absolutely right. And we're getting there.
Tom: And I love how aligned we are on this. Penny Dash, who's the chair of NHS England, said last week that we're a decade away from affordable healthcare for 8 billion people, everybody in the world. She believes that to do that, we're going to have to have pathways with no human intervention at all, including surgical. Do you think we're going to get there?
Tim: We will. Of course we'll get there. Penny's put an ambitious timeline on it, and I think that's great, for us to be ambitious. But yes, we will get there. There's something we remain quite suspicious about with technology.
Tom: Yes.
Tim: All of us do, to a degree. I used a mapping app to get here today from the tube station, and I double-checked it twice because I thought it was taking me the wrong way. I'm still curious, not cynical, but I don't always trust the technology. And of course it was taking me the most direct way - when I decided it was wrong and took a left, I added 5 minutes to my journey and went down a very dark alley. So we have to get over that trust barrier. We have to be able to share data, and I think this is one of our current bottlenecks - our understanding of data sharing, wrapped up with consent and information governance, is really confusing to navigate. That's a barrier we have to work through. Certainly in Bristol, we're progressing hard on a shared data environment, anonymisation of data, and digital twinning, so we're able to manipulate data without any patient identifiable information. We're doing that at scale, in detail, on a 1 million population, and in general on a 5 million population, so we can understand how the technology can run in the background.
Tom: I think your challenge was, would I develop and have the diagnosis of prostate cancer and a robotic prostatectomy without ever meeting a urologist?
Tim: Yeah. It's possible. I am very trusting now of the technology to diagnose my prostate cancer, very trusting of it to help guide me through the complexities of treatment, and very trusting of being hooked up to a robot to do the operation. Where I would still value a face-to-face conversation is in the decision-making process for my treatment options. And that's part of a wider conversation about the role of large language models and artificial intelligence.
Tom: It's part of that debate.
Tim: I'm a believer that artificial intelligence can be more efficient, quicker, and perhaps more accurate than human intelligence. I understand that. But where artificial intelligence lets us down is that it doesn't mirror human behaviour.
Tom: No.
Tim: And that's where there's something fantastic about human behaviour, which never ceases to make me smile. I can say to a patient, Mr Smith, your PSA is X, your Gleason score is Y, your MRI scan demonstrates this - it is absolutely the best possible treatment for you to have a robotic radical prostatectomy. That will give you the best cancer-free outcome, the best long-term survival, and the least symptoms from treatment. And that's perhaps irrefutable. And the patient thinks about it and says, actually, no, I don't want to do that - I'd rather go and have some therapy with crystals a long way from here, because I've heard that's really good. And I absolutely celebrate that. I never criticise a patient. I double-check that they understand the ramifications and the outcome, but there's something beautiful about the idiosyncrasies of human behaviour, and that's where a 100% technology pathway will struggle. It won't allow for the variance of the human condition, and we should celebrate that variance.
Tom: Absolutely should. Otherwise, we give in to becoming machines.
Tim: People do have really valid reasons for making those decisions. I've had patients who couldn't have an operation because there was no one to look after the dog.
Tom: Yeah, I'll have the dog for you. If it's a nice dog, I'll look after the dog for you.
Tim: But they're so wedded to their pet that they can't bear to be without it. And actually, what's wrong with that?
Tom: Yes. Well, that's why we're alive, right? For our passions and the things that matter to us.
Tim: Indeed. I am also very convinced of the value of AI and LLMs in the way we operate as humans.
Tom: I think we've embraced them internally at DrDoctor, and it's transforming the way we work, freeing people up to do the stuff they're really good at - allowing our delivery and forward deploy teams to spend much more time having these conversations. I'll talk to Claude about our product strategy, but it's really only when I sit with my senior team and my co-founders to test that, that we get the moments of creativity.
Tim: The creativity - that's the joy of it. You can go into a business conversation, a strategy conversation, or a clinical conversation with everybody really well prepped, and then you can have those sparks.
Tom: You can.
Tim: And the richness, the people in the room - you can see those sparks fly around and actually become a thing. Now, we might get there. We might have such capability to replicate the creativity and the nuances and foibles of the human. Who knows? The imperfect machines that we are, we might be able to have imperfect artificial intelligence. But I do think in healthcare, because these are life and death decisions, and certainly life-changing decisions that people are facing, they are the ultimate decisions we have to help people make. We have to respect that it's not algorithmic. It's often the biggest conversation you'll have in your life.
Tom: Indeed. The other thing that really excites me about AI is that it's allowing us all to raise our aspirations. Back to Penny's quote about providing affordable healthcare to everyone globally - the NHS has such an opportunity to lead on that. And 2 years ago, we would have had a product strategy and a set of things we thought we could change. These days, that product strategy is 10 times more expansive, because we can go so much faster and do so much more. And that's what really excites me, particularly about where you're sat right now - the chance to design such an exciting future state and actually get there, deliver it faster, with higher quality.
Tim: I used to think that. We used to talk about these things for years and years, and I was accused of being disruptive. I don't think that's always a good sign. In the seats on the stage, there's disruptive, which is often seen as very exciting - let's gravitate towards the disruptive. But the seats next to the disruptive are the crazy people, so we have to be careful that disruptive doesn't appear crazy. I don't think this is disruptive any more. I think this is about facilitating it, operationalising it. What we're talking about here is not disruptive. It's just limited by culture.
Tom: Culture, dare I say.
Tim: I'm not even sure it's limited by funds. The potential pivoting of funds from the inefficient healthcare system we currently operate to a much more efficient one - I think the books will balance. There may be some double accounting for a period, which is hard, but ultimately the books will balance. So I think it's culture.
Tom: Yeah, I do think you're right. I think the money's there.
Tim: It is.
Tom: The cultural point's so interesting. You've gone from an individual innovator with those early robotic interventions to now being a system leader. How different is it trying to innovate as a system leader, as opposed to an individual? And what's the role of culture in that?
Tim: I always say you only need one person of influence to completely scupper your plans. I've seen this in clinical teams - maybe one individual, who I've respected, maybe even been a friend, who's worked really hard in the opposite direction to a transformation piece. That individual can cancel, or significantly slow down, a project or piece of transformation. So you constantly have to check in - not just on a stage, where everybody's agreeing, of course they are, you can pull people with you like that - but go around and individually check that you've addressed the personalised concerns and fears of the key decision makers, the key transactional people in the room. Often they're frontline clinicians, and the motivation behind that can be very broad. There can be genuine concern about the direction of travel, or personal motivational reasons - simple human things. Will my status as a consultant be diminished by this technology? Will I have a job?
Tom: Yes. And it's interesting that the theme I'm getting from this whole conversation is the psychology of humans and their resistance to change, or how they embrace it. It comes down to simple things for all of us.
Tim: Indeed. And trying to understand that.
Tom: Certainly it's true that one of the things we observe about the NHS is that it's really hard to say yes, but really easy to say no. And that ability for one person to veto will often stop a whole project from moving.
Tim: It does. I also observe that - and perhaps this is changing - but historically, the risk-reward ratios have been quite out of kilter. The reward for taking a bit of a risk is very limited in the health service, generally speaking, so it's much easier to say, let's not do that. I do think that's changed, partly because of the financial situation, and partly because people have realised that if they don't, there's a much worse outcome over here.
Tom: You've got a lot to do in Bristol now. It seems so exciting. How will you bring the system on that journey? And how do we help all of those individuals see that we could end up in a world where patients can be seen in a beautiful clinic somewhere in a grassy field?
Tim: I think data is really important, and backing things up with data. Giving nice talks about things is one thing, but you're dealing with a significant number of people who've got experience and a scientific background - they'll want evidence that what you're saying can be substantiated. So data is important, and pointing out simple things - demographic change, patient experience, the general direction of the customer service agenda - is really important too. I'm currently looking at our clinical strategy for 2027 to 2037, and we're starting with all the usual building blocks. What's the demographic change of Bristol and Weston? It's quite interesting how that population grows - there's a new town being built just outside the city centre, and Weston-super-Mare, a seaside town, is taking off in terms of building and population increase. The demographic profile is changing. Then you start to lay on hard facts - what will be the influence of metabolic medicine, of genomics, of preventative shifts? How will that change our demand and capacity? And you very quickly get to the first headline, which is: do nothing is not an option. Once you've sold that - and it's not a difficult sell - the question becomes, so what do we do? Do we go down the traditional route? Employ more people, train more specialists, buy more kit, have 6 more scanners, put in more inpatient beds, build new outpatient facilities?
Tom: You know where I'm going with this.
Tim: So then you cost that, and we're looking at -
Tom: A significant amount of money.
Tim: Significant. Billions, really, if you want the truth of what the traditional route would take us to. And you say, well, actually, that money doesn't exist, because we're perhaps at maximum funding envelope for healthcare. So we have to find an alternative, and the alternatives are technological, digital, and cultural - changing patients' and the population's expectations, asking them to take responsibility, asking populations to invest much more in education, prevention, and screening. If we get those 3 elements right - and it's all 3 of them, we talk about the prevention agenda, the left shift agenda - but for me, it starts with education. We can't expect people to stop smoking if they don't really understand the dangers of it. But that's just one example. We have to do the educational piece, put the prevention tools in, and exploit every possibility to screen for early disease, because the evidence is overwhelming that picking up any disease at its preclinical stage gives us an opportunity to modify that patient's disease profile and their life. That takes us into a very different looking healthcare system, one which absolutely will have digital technologies underpinning it, constantly looking for those opportunities. One of my great interests is in the power of the genome. How many years have we talked about genomics and its potential? It's felt like the potential's been there so long that we started to think, maybe this was hype. It's not hype. We're starting to see genetic diagnostics and genetic interventions which are halting and curing diseases.
Tom: Amazing. So we know that the technology works.
Tim: Yeah. Are we starting to understand what the genetic code can tell us about your or my susceptibility to disease, even with our different lifestyles?
Tom: Yeah.
Tim: And therefore there's a huge opportunity to understand how 64 codons, as I always say, can write your future journey, and how technology, healthcare, and life sciences can steer that journey to a much healthier life.
Tom: And I think that is our next adventure, and that's really exciting, isn't it? Genomics does feel like it has the potential to unlock so much. And it's less than £100 to sequence a genome now.
Tim: And falling all the time.
Tom: We should be doing that for everybody. I'm also fascinated by the fact that there are sensors everywhere now - it's normal to have a wearable or a sensor.
Tim: Absolutely. They seem to be getting better and better every day.
Tom: Absolutely.
Tim: Wearable technology is one of my favourite subjects. One of my interests is working with one of our university partners to exploit as much information as we can from wearable technology, and we're at the tip of an iceberg here. Your watch is monitoring your basics, if you like - we're starting to sample the sweat that sits under your watch, and the power of that informatics is incredible. I think we'll look back in a relatively short space of time and be horrified by the sights of people sticking and needling you and sucking out blood. We're in the dark ages.
Tom: Yeah, it does feel slightly like that's gone, because we're not measuring exactly the same things, but we can measure thousands of different things in sweat, for example, which tell us the same as a traditional blood test.
Tim: Yeah. So why aren't we doing that? The technology is amazing, and it gives you the power to look at it if that's what you want to do, and to take appropriate action. One of the things we're working on at the minute is hydration - being able to monitor really quite complex biochemistry in sweat to tell you when you should really hydrate, because otherwise you're going to have a significant impact. And this isn't for elite sports people - it's for people like you and me on a hot day like this in London. So the sky's the limit in wearable technology. And then you look at the revolution happening in diabetes.
Tom: Yes.
Tim: I remember, as a medical student, teaching patients to prick their skin and test regularly, because they didn't like coming into hospital to do it. Diabetic control was all over the place, and ultimately you'd see eye disease, amputations. This was normal - the bread and butter of the healthcare I was educated in. That's changing so rapidly, to the point where wearable technology, closed-loop systems, and an algorithm in the background to look for and predict patterns would help me manage diabetes better, or perhaps even reverse it. It will be a game changer in our capacity and demand modelling, and it's happening now. In our clinical strategy for 2027 onwards, that's a factor we'll take into account - we'll start to make decisions based on a reduction in endpoint complications from type 2 diabetes, a reduction in endpoint diagnoses, and a general improvement in the metabolic health of our population. Wearable technology has got so, so much further to go.
Tom: It really does, doesn't it? I find diabetes fascinating. My wife is an endocrinologist, and she's right at the edge of this - they're running pump clinics now, prescribing GLP-1s, bringing it all together. But she says her main job is education.
Tim: Education. Absolutely. I'm pleased you've commented on that. It's the 3 pillars again - education, prevention, and screening. But it starts with education.
