Tom: So welcome back to another episode of DrDoctor Will See You Now, the podcast where we explore the human side of creating technological change in the NHS. And I'm absolutely delighted to say that we have Professor Ian Abbs, former chief exec of Guy's St. Thomas and champion and advocate of digital health for as long as I can remember, joining us here in the studio to talk a little bit about his life, his career, the state of the NHS today, and how we move forward in the digital ecosystem going forward. So Ian, welcome.
Ian: First of all, thanks very much for having me at DrDoctor Will See You Now. Fantastic to be here. Yeah, there's a lot to talk about.
Tom: There is a huge amount to talk about. And I suspect through your career, you've seen all sorts, you've probably seen a few cycles repeat. For those people who are listening who don't know you, can you tell us, in your own words, a little bit about your journey right from the beginning from medical school? How did you get interested in medicine? How did things start?
Ian: Yeah, well, first of all, to my guests, you know, that was quite a long time ago. But thinking back, I was always interested in sciences, and started to think about sort of medicine as I was coming up to my A levels. One of the reasons I think I thought medicine would be quite interesting was that I'd read and seen quite a number of the films and that sort of thing called Doctor in the House. It was a series that ran in the sort of sixties and seventies. And that was my kind of idea, really, of what medicine would be like. I didn't come from a medical family. And so I had a rather probably what you might describe as a sort of rose tinted view of what medicine was like. But I started at medical school, and had a fantastic group of friends who've stayed with me until today. And then sort of post medical school went into clinical practice, mainly in hospitals, started to become interested in particularly how organs when transplanted, either accepted by patients or rejected by patients, and therefore went into renal medicine with a particular focus on transplantation. And then over time went through sort of training, and then became a consultant at Guy's Hospital in the mid 1990s. Actually, the great experience I did have - given the one of the main kind of drivers into medicine was believing in the Doctor in the House book - is that I did have a great friend, a trainee, in fact, at the Whittington, who invited me to her birthday party, which I went to. And there was a pretty sort of happy man wandering around pouring out glasses of wine for people. And I recognized in his kitchen, there were a whole number of Doctor in the House posters. And I rather sort of naively said to him, goodness me, you know, you like Doctor in the House even more than I do. And he kind of smiled and laughed and said, yes. And then I wouldn't drop it really. I said, I really think, you know, because it was the period when Dirk Bogart was playing the main kind, you must really like Dirk Bogart, because you seem to have so many pictures of him. And he went, yes. And I kept going in the same vein, really, and then realized that he was the author of the Doctor in the House book, a guy called Richard Gordon. But then I had the great advantage of saying to him, do you know what? It's nothing like. So to a certain extent, you know, I was able to say to him that some of the things that I'd expected out of medicine, were not quite the same as he portrayed them in those books from the sort of 1960s. But it has been for me, a fantastic journey. I've absolutely loved my career in clinical medicine, mainly for the patients I've looked after, for the colleagues I've worked with, and I absolutely loved clinical practice. But there came a time, I suppose, after I suppose I've been a consultant for six, seven years, when I started to think about the way that services were organized. And that's when I started to think about career alongside that of clinical practice.
Tom: Yeah, that's really interesting. So to train in London, Guy's Hospital in the 1990s. And I'm sure there's some sort of link between kind of your interest in transplantations and whether or not they get accepted and change management. And, you know, the realities of putting digital systems into hospitals. I suspect there's something in...
Ian: Yeah, I think that's a good point, Tom. I mean, there's something about my first degree was in immunology. So about how complex biological systems work. And then I started to think about the way that organisations work in the same way that perhaps the human body works. Again, it's systems, biology. And then how do you change the way that systems work? I've often thought about my later time in management and ultimately in leadership. And looking after organizations in the same way that you look after patients. In the same way that a human has a particular type of physiology, anatomy, and sadly, sometimes a pathophysiology that leads to disease. I think organisations in many ways work the same. Organisations have an anatomy. They have a physiology, they have a system of the way that the organisation works. And unfortunately, sometimes they have a pathophysiology, they don't work well. And then very often trying to understand how what is going on in an organisation requires you to do the same diagnostic process, as I would have thought I did look at caring for patients. And sometimes you can examine, think about an organisation, examine it critically, and then come to a diagnosis, because if you can come to a diagnosis in organisations, as you can come to a diagnosis in people, then that gives you a chance of changing things to mend it, to actually cure one of the problems. And so I think there is something similar between the way that you manage organisations and the way that you manage people. I've always been very interested in digital.
Tom: Yeah. So before we go on to digital, so you're six or seven years in, you decide, okay, maybe there's another track for you here. Are you unusual amongst your peers? Are other people thinking that too?
Ian: I think it is unusual to go into sort of organisational management as a doctor, as a clinician, really. In fact, there were probably more nurses and allied health professionals in management roles than there are doctors. It is unusual, but unusual in the UK, because if you go to other countries around the world, US or Australia or continental Europe, you'll often see more doctors in management roles. And in fact, in the large academic centres in the US, it will be unusual for that to be run by somebody who wasn't clinically and probably medically qualified. So there is something different between the ways that different countries have developed. I was very interested in looking after patients. One of the metaphors I've sometimes used, which certainly helps me think about it, there are lots of clinicians who are very, very good at improving what they do on a daily basis within a relatively narrow field. Yeah. So certainly in hospital practice, I'd almost make that analogy to perfection in the sort of ploughing of a single field. So each row becomes increasingly a better ploughed road. So people are always searching for excellence in the thing that they do, and they have a laser focus on that. And I hope I had a pretty good focus on that when I was in clinical practice. But I started to get interested in, okay, so we're ploughing this field this way. What if you look into the next field? You know, are they ploughing that field better? Or in fact, is what they're doing worse than what we do? And what are the reasons behind that? So I started to get interested in comparison, really, between both different services within an organization and the same services between organizations. And how do you learn from the best to improve what you're doing yourselves? And then started, and actually, there are a number of clinicians who do that. So you'll get people, for example, looking at clinical director roles, who are running reasonably sized parts of organizations who will look over the wall and particularly do the comparison between organizations for improvement. And then there's a smaller number who think, well, operations - even ploughing in a farm context, or running a service in a healthcare context - it only works in the context of the total organization. So you can have a very good field, you could be ploughing a very good field and doing good things for patients. But ultimately, it's unlikely, if the organization around you is barren, it's unlikely that that field, good though it is by itself will be sustainable. So all service operations happen within the context of the greater organization. And so a few people, including me, are and have been interested in how whole organizations run. So eventually, I moved to running larger parts of the organization in the early 2000s. It was interesting at that stage, and we may come on to talk about this, but that was in the first wave of what are known as foundation trusts, which in the early years of the Blair government after 1997, had more autonomy for decision making, more autonomy for the boards of those organizations, including decisions on investment, on financial management, and on the tension of surpluses. And that was a strong incentive, particularly for the organizations I was working in them, particularly Guy and St. Thomas', which was a first wave foundation trust to continuously improve its services. I went into running a larger part of the organization, particularly around specialized services by the mid 2000s, and then went through a number of roles ultimately, to start as the medical director and then chief medical officer at Guy and St. Thomas' in 2011. And then I became the chief executive of Guy and St. Thomas' in 2019, and stepped away just recently.
Tom: Yeah, and I'm really interested to explore that kind of late 2000, that sort of, yeah, that point from CMO to CEO and that step. I think we first met in about 2015. So you were CMO then, and I remember having my eyes wide as I met you Ian. Going back to the 2000s, so Guy's and St. Thomas' merger had happened before the FT status, just a little bit of history for those people that weren't around.
Ian: Yeah, so Guy's and St. Thomas' based in London, Guy's on the south bank of the Thames near the southern tip of London Bridge near to the Shard, St. Thomas' on the south bank, one end of Westminster Bridge, opposite Parliament. Interestingly, going back in history, they'd always been strongly linked, both geographically and through history, by being next to each other in North Southwark. Guy's Hospital actually having been built on St. Thomas' Street, St. Thomas' being on the other side of the road, St. Thomas' moved from its site in Southwark to the site opposite Parliament in the 1860s, when the hospital was built partly through subscription when Florence Nightingale came back from the Crimea. And although they had been strongly linked in history, there's quite a strong rivalry that developed between Guy's and St. Thomas' through the early parts of the 20th century, such that by the time the 1990s, they were actually quite strong and competitive rivals. And the decision that ultimately came from things like the Tomlinson report on the future of teaching hospitals in London, led ultimately to a decision for Guy's and St. Thomas' to merge. And they were feeling strongly held around what that would look like. And the decision to merge was taken in the early 1990s. And although those opinions strongly held prevailed for a little bit of time, actually, I think once through the merger itself, over time, I think the different constituencies of Guy's and of St. Thomas' came to realize that, in fact, the organization was stronger together. This must be about 1997. Under the Blair government, the foundation to trust models began in the early 2000s. And by that stage, Guy's and St. Thomas' had some pretty visionary leadership, a very strong chief executive and a guy called Jonathan Michael, and a very strong board led by Patricia Mobley, I think at the time, and went for early recognition as a foundation trust. And you needed to demonstrate a certain quality of operational quality and financial performance. And at the time, people worked hard for that recognition. And from that recognition came this sense of autonomy and that we were accountable for our own future. One of the things that had characterized Guy's, and a bit later, St. Thomas' was clinical leadership, was the formation of something called the clinical director model, which is where you have a clinician, usually a doctor in the Guy's, Thomas' model, who was fully accountable and remains, in fact, that model still works today, is fully accountable for the quality operational performance and financial performance of the services that they run. And that clinical leadership combined with a strong organizational leadership, I think was one of the reasons that Guy's and St. Thomas' was successful. Plus the coming together during the merger, because that gave us a degree of scale.
Tom: Yes. And a tricky thing to have managed by whoever the leadership was at that point.
Ian: Yeah, because there certainly was a sense of rivalry and uncertainty about what the outcomes - partly to do with what was suggested at the time to be hospital closure. But certainly the organization in that sort of mid to later 2000s period grew quite rapidly. And it was one of the periods when not only did the services grow, but the physical estate grew as well. And so we built a number of buildings, including a new children's hospital, amongst others. And so there was a sense of momentum.
Tom: And in that period, so we're in the middle 2000s now, you know, pre Blair, long wait lists in the NHS. I, you know, I remember the newspaper headlines. And then the NHS did a phenomenal job of cutting through those, but was relatively flush with cash.
Ian: Yeah, yeah, absolutely correct. I mean, the sort of performance improvements were significant during that period between about 2002 to 2008. And that was the period when often patients were waiting two years for heart bypass graft, a long time, for example, for routine hips or knee replacements. But two things happened at that stage. One was, you absolutely rightly say, Tom, was a significant injection. So relative terms, the resource envelope grew by about 6% per annum per year, right over about a six year period. Okay, so that was an unprecedented moment of financial and other resource growth within the NHS. And that was coupled with tight performance management of targets. And I have no, I think targets do produce certain types of behaviours. And you can coupling resources with a particular type of target, you can incentivise and induce change. And I think we certainly saw that during that period. And you saw waiting lists fall quite significantly. Now, it is possible, and we also saw some downsides of particular types of incentive models in that period, particularly around incentivisation of particular types of financial performance, which might have edged out and we certainly without going into details now, it certainly in some organisations edged out the quality conversation. And that focus on financial turnaround may have contributed to some of the very, very sad outcomes that we saw for some people during that period. But I think in general, and certainly for the organisation I was working at the time, that combination of autonomy and freedoms of decision making, the ability to grow services, particularly those that were enabled by an increase in resources, and then the ability to reinvest, retain surpluses into future services became a virtuous - in my view, a virtuous circle. And it did at the time have the patient at the centre, because that was a moment really, of almost trying to bring into what had been a great, a service organised, I would say more around organisations than around patients, a real change in the conversation about patients at the centre, and really trying to focus on the patient experience and the patient outcome as a core part of the foundation trust movement.
Tom: Yeah, which makes perfect sense. You know, you give an organisation agency, you incentivise it well, and hopefully the patient and consumer experience kind of follows as part of that. So we manage the waiting list, it's now the mid 2010s, you're CMO, where does this interest in digital health come from?
Ian: Yeah, that's a really interesting question. So I have to take you back quite a long way, because my father was an engineer, right. And he came out of the war, he was in the electrical and mechanical engineers, and he came into what was the developing UK computer industry. Okay, so his first roles there were for a company that eventually became International Computers Limited, ICL. Yes, which was, and certainly through many decades, the preeminent UK computer industry. It was an industrial leader. And so this is where computers were, you know, you plug stuff in and you had punch cards, and they were mechanical as much as electronic. So he came out of having been in the desert, mending tanks into building computers from the components that you mentioned, Tom, so they were, you know, they were effectively hand built. And these are developments on the sort of Turing bomb and things like that. So he was building computers for ICL from scratch. And I remember going with him once to one of the sites that had a very state of the art mainframe, which was about the size in my memory, and I was about five or six at the time, in my memory, it was the size of a house. And it was enormous. And I remember my father saying, Would you like to get inside? So I said, Yes. So he opened a little hatch in the side door. Yeah. And I walked into - probably crawled in actually, crawled into the center of the computer, and sat with the computer running. Wow. And in those days, this will date me a bit. But in those days, one of the variable resistance models were achieved in mainframes, by the presence of valves, which were effectively light bulbs that had a effectively a filament and with different resistances. And so as current flowed through this massive computer, the size of a house, the light bulbs went on and off with varying intensity. And so to my infant mind, I was in the center of a star cluster. Amazing. So I was hooked. Yeah. Yeah. So I was hooked on technology really from - from an iPad, can you? It's difficult to. So I don't know how many other people, I expect there are some but how many people could say I've been inside a computer? Yeah, not many. So that was quite an important early experience for me. So I've always been interested in technology, but technology for a purpose. And I had sort of an early understanding or an early belief that technology was going to change the way that we did things in many places. Actually, another interesting experience when my father went to work on the development of clinical computing at King's College Hospital in the 1970s. Wow. Okay. And it's actually interesting as a, if you are a sort of historian of medical technology. So they built a mainframe at King's that had many of the capabilities that we see in current hospital computer systems. Well, I mean, when was Epic founded? 79? Yeah, so late 70s. So mid 70s, a mainframe computer but with terminals on umbilical cords. Wow. Okay. Effectively. So computers on wheels are, you know, so pretty modern compared to this sort of... Yeah, so you but you could theoretically have - they had an experimental sort of ward set up with a mainframe, computers on carts, but connected to the mainframe, but you could enter the history and details of the patient. You could enter lab results, and then you could call them up. So it was the early form of an electronic medical record, but on a mainframe. It was interesting at the time, cause that project came to an end more to do with culture than it did to do with technology. And that sounds a lot like today. And it's interesting to reflect, as I'm sure we will, on what is different today to what we experienced, what was experienced then. Because culture killed the program, not the inadequacies of the technology. Because they were starting to do things like rudimentary drug interaction alerts and things like that. Yeah. And one of the things was the clinicians at the time, the doctors particularly, said, well, we're not here to enter. We're not here to type. Yeah. I don't want to log into another system. You know, it was counter cultural to the way that clinicians, particularly doctors, particularly consultant doctors worked. And so that program came to an end. But I was always struck by those two experiences that sort of either end of my sort of developmental period, really, cause I remember getting to see my father when I was in my later teens at KCH in Denmark Hill. There, that early experience of sort of getting into a computer and saying, you know, this is incredible technology. But then at the end of my teens, seeing actually that some of the limitations on technology are human cultural, not technical. And that I'm sure we'll come back to, cause that has been an interest of mine over time, but I certainly saw in my early life. And of course, as well as those technologies, you know, I started while I was in clinical training, to start seeing that the elucidation of the sort of gene sequencing, that now is seen as being relatively standard technology, but again, was an amazing, transformational piece of science. What's interesting now is that we stand on the threshold of a new period in science, technology, and medicine, which is this convergence of the revolution in biology around the elucidation of the gene, and gene sequencing and the data and AI revolution, and particularly that what you might describe as digital biology. Now that convergence of these two areas, which are many years, were completely separate. I think it's a new era.
Tom: One of the things I was most struck by, on a recent trip to America was how AI is changing drug discovery and it, you know, it speeds up that process. It changes the way that the pharma companies are thinking. They're all building labs in Silicon Valley, which are all simulation labs. But it's that ability to go and build personalized molecules around an individual's needs, which as you say, is going to completely change the way that we live. And hopefully we'll deal with some of the systemic challenges like antibiotic resistance and all these things that we worry about.
Ian: Spot on. I think that's spot on, Tom.
