Magpie - Issue 2 - Healthcare

ISSUE

Healthcare

Spring 2018

TRENDS AND SIGNALS FROM CULTURE

We are a transformation business

Magpie is published by BrandPie. We are a global transformation business that uses the power of purpose to help clients transform their brands, cultures, strategies and business models.

Transformation breeds new kinds of organizations. We combine the smarts of a strategic consultancy with the impact of a world-class creative agency.

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Signals from culture Issue 2 — Spring 2018

hello@brandpie.com brandpie.com

E D I TO R

Rishi Dastidar C R E AT I V E D I R ECTO R

Sophie Lutman

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Where humanity meets technology meets medicine

D

ateline: a night towards the end of November 2017, somewhere in the Accident and Emergency department (ER) of St Thomas’ Hospital, on the south bank of the River Thames in central London.

Your correspondent is being wheeled into an magnetic resonance imaging (MRI) machine to have some sort of scan. Just before the procedure begins, the nurse in charge gives a final instruction: “don’t forget to smile in there.”

A RT D I R ECT I O N / D E S I G N

Pablo Funcia Scott Snashfold

C O N T R I B U TO RS

Richard Burton Sally Bye Pablo Funcia Chris Holmes Dustin Lawrence Eliza Lorimer Lucy Maber Terry Moore Federica Pisano Nick Ranger Scott Snashfold Sally Tindall Chris Walmsley PUBLISHER

Kim Nguyen

LDN

6 Regent’s Wharf All Saints Street London, N1 9RL, UK +44 20 7831 4834 N YC

33 Irving Place, 3rd Floor New York, NY, 10003, USA +1 917 887 3202

It’s this spirit, moments where humanity meets technology meets medicine, which you’ll find running through issue 2 of Magpie.

Taking a sideways view of health, we want to show you different angles and unexpected views on some of the key trends, topics and talking points in an industry that is only going to continue to grow in economic importance.

So while you’ll discover stories and analysis from the frontline of how healthcare is being transformed by digital and genomic technology, we’ve also tried to consider some of the policy and societal implications of challenges such as ageing populations, the impact on children’s health from the rapid proliferation of screens, and even what end of life care might be like where you live.

If that sounds bleak, rest assured it isn’t. In putting this issue together we’ve found that, more than anything, the passion – the purpose – that people have to care for others is intact, no matter how dramatic the change buffeting the sector is.

Do let us know what you think of the issue, and indeed any prescriptions for improvement you might have, via hello@brandpie.com. — RD

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@BrandPie I N STAG R A M

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© BrandPie 2018. All rights reserved. Registered in England No. 6614246. BrandPie Limited, registered office as above. Neither this publication nor any part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of BrandPie Limited. Published by BrandPie Limited, 6 Regent’s Wharf, All Saints Street, London, N1 9RL, UK, telephone +44 20 7831 4834; email hello@brandpie.com; www.brandpie.com. Where opinion is expressed it is that of the author and does not necessarily coincide with the editorial views of the publisher or BrandPie. All information in this magazine is verified to the best of the author’s and the publisher’s ability. However, BrandPie Limited does not accept responsibility for any loss arising from reliance on it.

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M AG P I E 0 2

C O N T E N TS

Tell us HAL

Speak like a doctor

Take the test

One shot against cancer New therapies arriving

FEATURES

TAKE OFF

6 14 7 8 19 10 24 12 13 How artificial will AI in healthcare be?

Happy birthday, NHS? On the wish list, a new purpose

Disrupting healthcare

An interview with Echo

Paging Dr Google

On digital hypochondria

The fat in different lands Obesity in full

The danger of default young

Don’t forget the elderly

Before the screen becomes routine

Telemedicine’s growing pains

What’s on the other side of the looking glass?

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The danger of looking at screens

All watched over by social networks of loving grace

34 40 Can tech solve the social care crisis?

A visual essay on hospitals

48 50

TAILPIECE

Making medical factories fabulous

To the end

On palliative care

A doctor of the past, a doctor of the future

Lessons from 1967 for 21st century healthcare

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Photography © Tyler Lastovich

TAKE OFF

How artificial will AI in healthcare be?

AI will fundamentally change patients’ relationships with their healthcare, say Richard Burton and Sally Bye If we mention ‘technology’ and ‘healthcare’ what things come to mind? A big magnetic resonance imaging (MRI) scanner? An ambulance maybe. A heart monitoring machine, by the side of a bed.

Technological progress in healthcare has until now (broadly speaking) mostly been about giving medical professionals tools to make us, the patients, better. While in the main it’s been good for all of us, it hasn’t changed the fundamental nature of power in the doctor-patient relationship.

But it is the potential – the rapidly-arriving reality – of what AI will bring to the patient experience that is really interesting. No doubt we’ve all read the headlines about IBM’s Watson being able to diagnose cancer, and Alphabet’s DeepMind using machine learning to spot injuries to kidneys.

The combination – it’s actually truer to say ‘combinations’ – of mobile technology, the internet, big data and artificial intelligence (AI) are poised to change that. We’ll soon be entering a landscape where patients are empowered to take control.

And when AI and mobile technology come together, we expect to see a slew of apps that will really help patients with different conditions directly. Take, for example, Woebot (woebot.io), a cute animated robot that asks you questions about how you are feeling and what your energy levels are like. In reality it’s a chatbot using AI to deploy cognitive-behavioural therapy techniques to help people deal with depression and anxiety.

Many of us have already got used to using Google and other online sources of information to try and find out what’s wrong with us, or get consultations at a time of our choosing. Meanwhile, our smartphones allow us to scan barcodes so we can make healthier eating choices, provide us with support if we’re trying to stop smoking (got a craving? Press a button for distraction!) – even diagnose everything from skin cancer to Parkinson’s disease.

Similarly, Ada (ada.com) is an app that uses AI and real-life medical cases to train itself so it can help people self-diagnose. After users describe their condition, Ada asks a series of questions about their possible symptoms, cross-referencing answers against self-provided medical information.

People get a summary of likely conditions, with the option to chat online with a physician for extra peace of mind.

As patients stream medical data from smartphones and wearables, this positive feedback loop will only grow – and so healthcare AIs will learn to do more and more. Future apps and programmes could, for one, provide automatic diagnosis from a description of symptoms and use Instagram to spot behavioural traits that suggest you are depressed.

The underlying idea behind these advances is clear; hopefully you as a patient ‘feel good’ (or at least better) by playing an active role in managing your health; and by agreeing to share your data, you are also ‘doing good’ by helping to train medical algorithms for the future.

Is there a limit to the empowerment of patients that AI can provide? We may get diagnostic facts, but will we get empathy, understanding and maybe even humour?

There’s an inherent human element to healthcare that however much technology moves forward will always be needed.

Artificial intelligence is fine; but artificial compassion will never catch on.

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Communication isn’t just a vital part of the doctorpatient relationship, it underpins it – so much so that medical students are trained in it as much as making a diagnosis. So could you speak like a doctor? Take our light-hearted test to find out

Speak like a doctor

Exam set by

Terry Moore

Q1

Q2

What are the three basic components of communication that doctors should know about?

When starting an appointment with a patient, should a doctor:

A

Repetition, repetition, repetition

A

Wait for the patient to speak?

B

Verbal, non-verbal, paraverbal

B

Speak first?

C

Salutation, prescription, invoice

C

Greet them through the medium of interpretive dance?

Q3

Q4

On average how long does a patient speak before a doctor interrupts them during an appointment?

What should a doctor never do while in a corridor?

A

12 seconds

A

Run

B

21 seconds

B

Do a knee slide in tribute to AC/DC

C

Let me stop you there

C

Have a discussion with a patient

Q5 Is ‘mindfulness’: A

The name given to the feeling you get when you’ve been revising for an exam, and can’t cram any more information into your brain?

B

The secret codename given to the file that proves the existence of the Loch Ness Monster?

C

A meditation technique that doctors can use to help improve their communication with patients?

ANSWERS

Q1 — B Patients only remember about 50% of what’s said during a consultation, and 50% of that is forgotten once they leave the room. So things like eye contact, affirmative nods and a gentle tone of voice, as well as the words used, help to put people at their ease.

Q2 — B Some patients can interpret reticence as indifference. So doctors should shake hands where they can, and introduce themselves first.

With help from: https://greatergood.berkeley.edu/article/item/how_doctors_can_communicate_better_with_patients and https://www.ncbi.nlm.nih.gov/pubmed/25954636

Q3 — A And in that short a time, it’s more than likely that the patient hasn’t finished explaining what they think might be wrong with them.

Q4 — C While the walk and talk might be beloved of US dramas, it is less good in clinical settings as it implies that doctors aren’t listening to a patient, well, patiently.

Q5 — C Research suggests that by using the four skills of mindfulness – attention, curiosity, cultivating a ‘beginner’s mind’, and presence – doctors can improve the quality of their interactions and communications with patients.

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TA K E O F F

18 / 04 — 18

SIGN

ONE SHOT AGAINST CANCER EXPIRATION DATE: NEVER CAR-T REFX#: 00018

QTY: POTENTIALLY INFINITE

Personalised cancer treatment is here, but bringing it to a mass market won’t be cheap, writes Eliza Lorimer

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A revolution in cancer treatment is just around the corner. Rather than blasting bodies suffering the disease with drugs and radiation, white blood cells can be ‘reprogrammed’ to tackle the cancer themselves. This approach has the potential to transform cancer care, prolonging the lives of patients in a way that current techniques cannot. There is a catch however: the cost – and the prospect that scaling production up might not easily bring the price of the treatment down.

A LIVING DRUG

This groundbreaking approach is called ‘CAR-T’ cell therapy. CAR stands for chimeric antigen receptor, and T cells are a type of white blood cell that play an important part in our immune system. The therapy involves genetically engineering T cells so they can spot abnormal cancer cells and then destroy them – the patient’s cells are taken out, modified and then infused back into the bloodstream, ready to multiply and attack the cancer (see diagram).

Nicknamed a ‘living drug’, this is a personalised form of treatment which has already shown remarkable testing results in severe blood cancers, with some scientists predicting it could even replace chemotherapy in ten years.

Novartis’ Kymriah was the first CAR-T cell therapy to be approved by the US Food and Drug Administration (FDA) in August 2017.

Designed to treat children and young adults with acute lymphoblastic leukemia, a rare blood cancer, it has surpassed expectations, with 83% of patients in remission within three months. Some of those patients were told they only had a few months or weeks left to live before having the treatment.

A similar level of success has been achieved

by Yescarta, the second CAR-T therapy to come to market in October 2017. Made

by Kite Pharma, it treats adults with an aggressive form of non-Hodgkin’s lymphoma, a disease that historically has had a poor survival rate. With Yescarta, 58% of patients were in complete remission after a year.

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A doctor removes white bloodcells from cancer patient

The cells are taken to a manufacturing facility

Source: Novartis

CAR-T BEFORE WORSE: HOW PERSONALISED CANCER THERAPY WORKS

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3

The cells are administered to the patient

The reprogrammed cells are sent back

The cells are re-engineered to recognise cancer cells and wipe them out

WHAT PRICE A CURE?

With over 240 CAR-T clinical trials underway globally, CAR-T therapies are now attracting significant investment from big pharma. Just a few weeks before Yescarta’s FDA approval, Gilead Sciences acquired Kite Pharma for $11.9bn. Not bad for a small biotech firm only established in 2012.

Other notable purchases include biotech giant Celgene spending $9bn on Juno Therapeutics, a company with a host of CAR-T cell therapies in the pipeline, including one to treat lymphoma which is likely to be approved later this year. Celgene is also partnering with Bluebird Bio to develop a treatment for multiple myeloma that should come to market in 2019.

Of course, another reason why big pharma is interested is that these life-saving treatments are not cheap. Kymriah costs $450,000 per dose, while Yescarta comes in at a more modest $375,000 – some of the most expensive cancer treatments to ever come to market. Novartis estimates that it has spent $1bn throughout the development, trials and initial manufacturing of Kymriah.

The eye-watering price points are explained by the fact that the manufacturing process for editing genes at an individual level is currently complex. Figuring out how to deliver these highly personalised therapies at scale is the next big challenge.

There is also the trade off between short-term expense and long-term savings to consider.

At the moment it takes 22 days in the lab to engineer Kymriah and its one-off infusion.

But that means the end to lots of hospital trips over years of treatment.

The good news is that the history of drug development suggests that cost of CAR-T therapies will fall as more companies enter the field, especially as big pharma pumps money into to the field to scale up manufacturing. Which could, in time, have the happy result of making, for many people, cancer treatment a once-in-alifetime experience.

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TA K E O F F

Paging Dr Google It’s Thursday 3am. I’m awake. I can’t lift my right foot. I do the obvious thing.

I google. “Why can’t I lift my foot?”

20,300,000 results. My consultation continues: Google: Did you hit your leg?

Me: No Google: Crush your foot?

Me: No Google: Severe head trauma?

Me: Nope Google: Neurodegenerative disorders that cause foot drop

Me: ...Oh god

Google Search

I’m Feeling Hysterical

Memento mori.

The Latin for ‘remember you have to die’.

How can I forget? To be reminded of the immanent is an everyday thing with me.

I’m not a philosopher. I’m a hypochondriac.

Like many of my hysterical brethren, I often think of my own death and the events leading up to it – something that part of me believes is happening right now. And no matter what you or anyone else tells me, I won’t believe otherwise.

Which is why I turn to the only thing I trust to give me the truth. Dr Google.

So often has a twinge equalled cancer or a cut the beginning of Necrotizing Fasciitis.

I’ve diagnosed myself with afflictions I can’t even pronounce, focusing on the worst possible condition from the exotic to the obscure, because there is always ‘that slight chance’. Google ‘NHS misdiagnosis’ and you’ll see what I mean.

And of course technology maybe, just maybe, is making this worse. Add the world wide web to hypochondria and you get ‘cyberchondria’, a term coined by the UK’s The Independent newspaper to describe “the excessive use of internet health sites to fuel health anxiety.”

The easy availability of medical information online doesn’t always put minds at rest. Dustin Lawrence reports from the bleeding edge of ‘cyberchondria’

I understand digital self-diagnosis is far from perfect, but why would that stay my hand? A simple search can produce a smorgasbord of conditions to fret about.

As an example, WebMD’s symptom checker app (on every hypochondriac’s smartphone, trust me) generates more than 50 results for ‘cough’, from the common cold to oesophageal cancer. Something similar happens when you search ‘foot drop’.

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ll of this places a strain on my A relationship with my GP (physician).

Below, a brief account of our last meeting:

My name is Dustin, and I’m a Google Patient

GP: So what’s the problem?

Me: I think I have MS GP: How do you know?

Me: I have foot drop – look GP: OK, let me have a look at you

Me: It’s not my leg, I wasn’t in an accident, so it must be MS GP: Or it could be a trapped nerve in your lower back

Me: But from what I’ve read on the internet and according to my DNA test, I have an above average chance of having MS GP: (sigh) Well let’s take a look at your back first and then I’ll refer you to a physio

Me: But I NEED to see a neurologist!

GP: What you NEED is a therapist!

Rather than being called a ‘cyberchondriac’, I prefer the label ‘Google Patient’, a more helpful way to describe my special kind of millennial hypochondria. Those of us in the group display certain special qualities:

You’ll be unsurprised to hear I haven’t seen him since. He’s been avoiding my calls or is always “with another patient”.

I’ve been handed over to the doctors who provide part-time cover, which means I hardly see the same person twice. Which is probably best for all of us.

Typically I’ll want to see someone about one condition, then end up talking about three more. I once made an appointment for a discomfort in my lower intestine (colon cancer, obviously) and ended up examining a questionable mole (melanoma), a suspicious rash (Lyme disease) and my badly behaved knee (Ehlers-Danlos Syndrome).

– being obsessive about information – knowing our own health records (and for some of us, also our DNA sequencing) – asking lots of questions.

And according to recent research in the Harvard Business Review*, the prescription to meet our needs is relatively straightforward: provide clarity and order; give us detailed information during the consultation, and in brochures and on websites; and be transparent about medical outcomes and risks.

There’s a pressing need for this, not least because cyberchondria costs. In September 2017 researchers at Imperial College London estimated that trips to hospital clinics for internetinduced health anxieties cost Britain’s National Health Service (NHS) £420 million a year in outpatient appointments alone.

Right now, the medical establishment is conflicted about how to respond. In UK the Royal College of General Practitioners (the GP regulator) recently recommended that people consult Dr Google before visiting a GP as part of their new ‘Three before GP’ policy, to ease pressure on surgeries.

And yet the body continues to complain about patients having used Google prior to consultations in 80% of cases.

The dilemma is real: do you empower patients in the hope this helps to alleviate pressure on health systems, or does directing them to search medical information online lead to panic and anxiety?

Solutions like cognitive behavioural therapy, which the NHS does recommend in certain cases of medical anxiety, seem excessive as large-scale responses. In reality the vision for the medical profession should be one where digital diagnosis truly empowers both patients and healthcare professionals, through establishing a stronger connection between both.

Technology should become a platform to facilitate the conversations that reduce fear and ease anxiety long before a gammy foot causes far more worry (and cost) than it is worth.

As the internet de-mystifies medicine for patients – as Dr Google potentially becomes sentient – doctors will have to become more human.

Oh, and my foot drop? Turns out it was an inflamed tendon.

* https://hbr.org/2017/11/howdesign-thinking-is-improvingpatient-caregiver-conversations

TA K E O F F

C O M P I L E D BY

Chris Holmes Chris Walmsley Sally Tindall

The fat in different lands You may scoff but obesity is now a major public health issue – the ‘new smoking’ as some experts call it – in both the developed and developing world. Surprised by the latter? It might appear to be a paradox that countries can have cases of both obesity and malnutrition, but as The Economist reports, poor parents will try to feed their families on the cheapest food they can; and often these

convenience foods contain fewer nutrients relative to their calories. Hence, the greater risk of obesity.

Of course, there is still a strong correlation between the wealth of a country, and the likelihood that members of that population will become obese. Put bluntly – the wealthier the place in which you live, the fatter you are likely to be. Here are some more fast facts about fat:

7% of children aged between 5-19 in the developing world are now considered obese1, up from 0.3% in 1975 Nearly 28m young Chinese people are overweight; in 1975 it was less than 500,000

Also in 2015, 9,929 hospital admissions were directly attributable to obesity; it was a factor in a whopping 525,000 admissions the same year

People are bad at recognising how significant the problem is; in the USA, 2/3s of adults are overweight – but thought the figure was only 50%

According to the WHO, on current trends obese children will outnumber undernourished kids by 2022

In the UK, in 2015 58% of women and 68% of men were overweight or obese. Obesity prevalence increased from 15% in 1993 to 27% in 2015

Obesity is one of the leading contributory factors in people developing diabetes.

Unsurprisingly, incidences of this disease are going up globally also

Worldwide, adults with diabetes now number 366 million. That is projected to rise to 552 million by 2030 – 9.9% of the globe’s population

Photography credit: Peter Tarasiuk

d environment Foo

And in case you were wondering, over-eating is actually only one of the factors that leads to obesity, and not even a major one. According to the Nuffield Trust, a whole range of influences are involved (illustrated right). This means that the hard fact is that solving the obesity crisis won’t just involve eating less, but a whole host of other societal, cultural and environmental changes.

Definitely something to chew on.

Individual psychology Food consum- OBESITY ption

Biology

Physical activity

ivity environment Act

CAU S E S O F O B E S I T Y

ietal influences Soc

https://www.economist.com/blogs/graphicdetail/2016/01/daily-chart-3?zid=318&ah=ac379c09c1c3fb67e0e8fd1964d5247f https://www.economist.com/blogs/graphicdetail/2017/10/daily-chart-10?zid=318&ah=ac379c09c1c3fb67e0e8fd1964d5247f https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/613532/obes-phys-acti-diet-eng-2017-rep.pdf https://www.nuffieldtrust.org.uk/news-item/can-the-nhs-help-tackle-the-uk-s-obesity-epidemic https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3198075/#B1

M AG P I E 0 2

1— The World Health Organization (WHO) defines a person as obese as when their body mass index (BMI) is two standard deviations above average for their age and gender.

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Current digital design practices are at risk of excluding the elderly, says Scott Snashfold

The danger of default young

have got used to new digital behaviours quickly – seemingly born tech-ready. But is this true of older generations?

“There’s an app for that.” That catchy little slogan, almost 10 years old now, was our introduction to what more the iPhone could do over and above calling, listening to music and surfing the web. Part of why the slogan worked is that it implied that there was a digital alternative you could dabble with, for work, play and everything else.

My contention here is that for older people, using and navigating ‘digital’ experiences doesn’t come as second nature. They are, in the main, designed for and by relative youngsters. We design apps and websites based on what we think is super clear and simple, and it is then judged by those who think likewise.

However, today it feels like that choice is gone – when it comes to many aspects of customer service across a wide range of industries, an app appears to be our only option.

But what about those who aren’t even close to being digital natives, who haven’t grown up with daily digital experiences?

Superficially, that’s great. Because pretty much everything we need to run our lives has moved to a digital platform, it in theory means that things will keep getting faster, and better. And the small device in our pockets, through which we access these services most of the time, is so intuitive to use that it doesn’t even come with an instruction manual – we all know how to use one.

Is that really the case? For a younger demographic, probably yes. They will have been there at the start of the app revolution,

All the persona development and user experience research and testing in the world, doesn’t mean that there aren’t people who don’t find it a struggle to transfer money with their banking app, or to book a doctor’s appointment through their GP’s website. There are still many people for whom sending or opening an email isn’t common or easy.

Intuition vs memorisation Of course, I find using my iPhone an intuitive and easy way to control many aspects of my daily life, and this will be true for many people too. But I have also witnessed older people (my grandparents for two) who don’t find the iPhone intuitive, and instead have to follow a regimented process they have memorised to access a select number of apps; the rest of the device remains uncharted territory.

Why is this? It could be that younger people are just naturally more comfortable with new technology, and so have taken to this world with aplomb.

VIEWPOINT

Or is it because digital experiences are designed exclusively by a younger generation, and without serious regard for the needs of older generations? And if this is the case, can we really afford to do this when we know the elderly population is going to skyrocket in number?

Of course there are specific apps and websites targeted at certain age groups. But my concern is with those apps that are, in theory, meant to be universal – ones in the banking or healthcare sectors for example.

Can a digital innovation really be classed as such if it does not work for – or blatantly disregards – a certain demographic?

How important an issue is this? We could just shrug our shoulders and claim it’s not worth worrying about. We could argue that this current cohort of elderly people are not actually going to use digital healthcare services, but as younger generations will this frees up resources that can be redirected towards older people.

But we also know that digital innovation can often also be code for reducing employment in industries, and trying to make digital interactions default.

So there are scenarios in which, for example, telehealth apps actually have the effect of reducing the number of ‘real world’ interactions with GPs that are possible – something that in my view could be catastrophic for older people’s healthcare.

I can certainly imagine a future where high street banks are few and far between due to the success of online banking. And what then if you are older and need to use a bank?

Designing to be inclusive All of this, to my mind, suggests we have to take a much more inclusive approach to digital design. We need to work a lot harder at involving and considering elderly demographics in our research phases, establishing practices and principles that take their current and future needs into account, and not assume that just because something is intuitive for a 30-year old does it will be for someone double that age.

We will all get old at some point. None of us will want to find ourselves isolated from the technology we will need to rely on to live normal life. Right now, too many of the governing assumptions behind digital are skewed towards the young.

We need to change this, or risk leaving the elderly behind.

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FEATURES

HAPPY BIRTHDAY, NHS?

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ON THE EVE OF ITS 70TH ANNIVERSARY, LUCY MABER ASKS WHETHER THE NHS NEEDS TO REDEFINE ITS PURPOSE

T

he National Health Service (NHS) is no stranger to intense scrutiny and criticism. Lauded as one of the world’s greatest healthcare systems by some, decried as a catastrophic failure by others, it has occupied a central position in British political life since its foundation, with countless commentaries and solutions put forward to try and change it, improve it, ‘fix’ it.

And while not wanting to add to the in-tray of Simon Stevens, chief executive of NHS England1, it is possible to go beyond this sterile debate, and begin to reframe how we think about the NHS. By using the tools of purpose and employee engagement, we can move away from scratching the surface of operational solutions. The suggestion here is that the NHS needs an emotional heart transplant – and then that greater change, on an operational level, will cascade from there.

Take purpose first: the NHS was founded 70 years ago with a clear mission to provide healthcare to everyone regardless of location or income. But is this still even possible in light of the demands and expectations of patients today?

And secondly, engagement: it is fair to say that everyone who works in the NHS is compelled on a personal level by their own innate sense of purpose yet disenfranchised with the very system that ought to be bringing it to life. How do you begin to engage a workforce stuck in a totally unique bind?

1— …rather than all of the UK; thanks to devolution, NHS services in Scotland, Wales and Northern Ireland are organised and provided separately by the relevant devolved governments.

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M AG P I E 0 2

HAPPY BIRTHDAY, NHS?

THE ESSENCE OF BEING BRITISH The NHS was born on 5th July 1948, and for the first time hospitals, doctors, nurses, pharmacists, opticians and dentists were brought under one organisational umbrella to provide services that were free for all at the point of delivery. It was revolutionary – a system financed entirely through taxation so that people could access healthcare without financial worry.

Since its inception the service has been guided by the same three principles: to meet the needs of everyone; to be free at the point of delivery; and to be based on clinical need, not the ability to pay.

The NHS fundamentally changed the UK’s healthcare infrastructure. But in a far deeper, visceral way, what the NHS stands for has become something that people are fiercely proud and protective of. In 2014 a survey asked the British public, “What is the essence of being British?”

The most common response – having access to the NHS. This strength of sentiment makes it impossible to tackle the problems the NHS faces with merely functional, organisational or structural changes. Anything that threatens the integrity of providing universal healthcare goes against the very grain of what it is to be British.

But the UK has changed beyond recognition since the early days of the NHS. A population that is both aging rapidly and more ethnically diverse, is now posing very real problems in providing healthcare. Combined with rapid technological development, and its accompanying expectations, and you can see why the NHS is not just a perennial political hot potato, but also struggling to fulfil its purpose.

And whereas most organisations would have adapted, the NHS has stuck to its founding principles. That in itself isn’t a bad thing – but it poses an interesting challenge.

If we looked at the NHS’ purpose as we might do for a private company, what might we learn? In short, does the purpose of the NHS need to be redefined?

IN A FAR DEEPER, VISCERAL WAY, WHAT THE NHS STANDS FOR HAS BECOME SOMETHING THAT PEOPLE ARE FIERCELY PROUD AND PROTECTIVE OF

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LIMITLESS, WITHOUT DIRECTION A good business purpose is a north star – it frames a sense of direction; guides decision making; gives a framework for reporting and measuring success, and helps an organisation navigate transformation. Take Unilever as an example. Its purpose states that to succeed requires “the highest standards of corporate behaviour towards everyone we work with, the communities we touch, and the environment on which we have an impact.”

2— For simplicity’s sake, NHS trusts are the main organisations through which specific healthcare services are delivered at a local level. The UK government has an aim of making all trusts attain ‘foundation’ status in due course.

This is a clear example of a purpose that: – Qualifies what success looks like. Although it is still broad, it is quantifiable and can easily be supported by targets or proof points.

That flexibility is important to capture so that the purpose can be relevant for all parts of what is a huge, complex, diverse, global business – Has boundaries. The people that they work with, the communities that they touch and the environment. It does not pertain to every person in every circumstance. Although broad, it has a sense of being finite and quantifiable.

Now think about the NHS. It was created to be, effectively, a ‘boundary-less’ institution – its very nature is to be indiscriminate in who it provides for. A private business knows who it serves – there’s a clear line in the sand. But the NHS is meant to be limitless by its very nature, conception and heritage.

Which then poses a real problem as to how it can gain any sense of direction. If the purpose of the institution effectively limitless, how can anyone derive a realistic set of guiding principles for decision making or how to invest resources?

We know that patients are invested in the NHS – both emotionally and as taxpayers. As an institution, it is directly accountable to us; we are the ‘shareholders’. But this doesn’t necessarily take into account that our expectations around what should be available and invested in are defined around what we, as individuals, need. And of course, my needs as a health-conscious 27-year-old living in Central London will be different from an octogenarian living in the North East – and yet we will both expect that the NHS will serve us both, comprehensively.

A GOOD BUSINESS PURPOSE IS A NORTH STAR – IT GUIDES DECISION MAKING AND HELPS AN ORGANISATION NAVIGATE TRANSFORMATION

PURPOSE AS A FOUNDATION But if you look closely amongst the complexity that is NHS England, you can start to see organisations experimenting with and using purpose as a tool.

Take the Royal Marsden as an example.

A NHS Foundation Trust2, it’s one of the world’s leading hospital dedicated to cancer diagnosis, treatment, research and education. It’s a specialist institution with a separately defined purpose: to “continue to make a national and global contribution to cancer research and treatment, so that more people are cured and quality of life is improved for those living with cancer.”

Though NHS foundation trusts operate under the NHS umbrella and are governed by the same principles (free care based on need, not ability to pay), they are not subject to centralised direction. Rather they are run at a local level and are accountable to local patients and communities. This instantly lessens their scope of responsibility. Some parameters have been drawn and suddenly their purpose is ring-fenced.

In the example of the Royal Marsden, focusing only on cancer patients is, arguably, critical to its success. The organisation knows who to serve and who not. Patient expectations are managed. A sense of purpose is clear. Its reputation for excellence is not solely down to having this, of course, but certainly goes a long way to establishing it.

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HAPPY BIRTHDAY, NHS?

For International Women’s Day, it presented on its website stories from employees across their corporate business and its products.

Stories not separated by function or business but instead brought together to tell a coherent and compelling story about Diageo. And it really should be possible to start doing something similar for the NHS. These staff stories and successes exist – they’ve just not been joined together, across the system’s disparate entities.

MOTIVATING THE MOTIVATED

Re-engaging a disenfranchised workforce is a complex and long process and storytelling is by no means a quick-fix to improve staff morale. Yet telling the compelling stories from throughout the organisation is a simple and effective starting point. Celebrating successes, homing in on the stories that support a clear purpose and owning areas of excellence could do wonders in establishing pride and morale amongst employees and goodwill with us, the patients.

Photography © Luis Melendez

Of course, excellence cannot be delivered without a workforce. Medicine is an industry where those who choose to work in it are often motivated by something higher – the individual pursuit of a greater purpose.

And yet the NHS’ workforce is disenchanted with the system. Last year there were 17,707 registered complaints regarding the values and behaviour of the staff, whilst in 2015 the number of staff who experienced harassment, bullying or abuse from patients, relatives or the public was staggering (47% of ambulance workers, for example).

The question then is whether the organisation’s purpose is enough to transcend an individual staff member’s experience? Or is the system too reliant on the individual’s sense of purpose to stop them from moving to the private sector, or even leaving healthcare altogether?

There are countless case studies that show how an engaged workforce can turn a business’ success around. Engaged employees are motivated to do their best work, productivity shoots up and you retain the best talent. People want to come to work, they understand their job and critically, they know how their work contributes to the overall success of the organisation.

One of the most compelling ways to engage a disenfranchised workforce is to bring them back into a central narrative that’s founded on real-life success stories. Take Diageo as an example, an organisation with a strong if recessive masterbrand, and dominant product brands.

SUCCESS, THATTAWAYS

So on the one hand individual employees are likely motivated by their own sense of purpose; and the ideology behind the NHS chimes with that. But at the same time it’s a difficult place to work and these people are on the frontline when it comes to abuse and dealing with the strain on the system.

Changing the course of the NHS is like trying to make an oil tanker do a u-turn. You can make as many functional decisions as you want, but ultimately you need to decide where you want to go and start steering.

Navigating towards a successful NHS is not easy. But should Simon Stevens come to us for some advice, our top-level thoughts would be: 1.

Redefine the NHS’ purpose. And try, where possible, to define boundaries.

2. Re-engage your workforce. They might already have their own sense of purpose that brings them into work every day – but try to bring them on the journey to championing yours too.

Simple, no?

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‘Disrupting’ in the healthcare sector is a tricky word…

Healthcare is different and needs to be treated with a lot of respect

Just how hard is it to bring about transformation in healthcare?

Magpie met with one of the UK’s leading start-ups in the sector to find out. Interview by Rishi Dastidar

Images courtesy of ECHO

Echo co-founders Stephen Bourke (L) and Sai Lakshmi

S

tephen Bourke is a man in a hurry.

What start-up founder isn’t, you might ask, but since he and co-founder Sai Lakshmi started Echo in 2016, the business has been moving at a rapid clip, to become the leading light of a cluster of healthcare focused startups based in London. Echo’s initial focus is on helping National Health Service (NHS) patients get their repeat prescriptions more easily through a mobile phone app. And while making repeat prescriptions work better might not sound sexy it’s important, as 40% of medication isn’t taken as directed, costing the UK’s healthcare system wasted billions every year.

It’s a task that Echo is succeeding at, so much so that it has attracted investment from leading venture capital firms such as White Star and Rocket Internet. The business was named Best British Mobile Start-up at this year’s Mobile World Congress.

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agpie met Stephen at Echo’s modish offices in West M London for a long conversation about the impulse behind the business, the role of customer experience in building the Echo brand, and how transforming a sector like healthcare is not always glamorous work.

(Questions and Stephen’s answers have been lightly edited for clarity.) We began with the obvious: If you remove the barriers to people getting their meds, they’re more likely to take them

MAGPIE Why did you start Echo?

SB To solve a very personal problem. Both Sai and I take repeat prescriptions and

we have done our entire lives, and we felt that there was no solution for us on the market. Every month, it was a hassle to get my repeat prescription – the request to the GP, going to the pharmacy, them having the meds in stock. It was taking up too much head space.

Also, I’m pretty disengaged with my condition, and if you have someone who’s disengaged and it’s a hassle to get your meds, then guess what? They end up going in for emergency appointments to get a repeat prescription. That is certainly something I experienced – booking a last minute GP appointment, begging the pharmacist for an emergency script and even, in my case, going into A&E once to get a repeat prescription.

When we started we were very much about, ‘How do we make life as convenient as possible for us, as consumers?’ It was only later we realised that Echo’s impact, or potential impact on medication adherence. If you remove the barriers to people getting their meds, they’re more likely to take them. If you nudge people towards taking their meds, they’re more likely to take them. If you provide people with information explaining what the meds do, they’re more likely to take them.

We’re really trying to solve a problem that we understand, intimately. When we ask ourselves what we should do and what we should prioritise, we start with first principles: what do we, as professionals working full-time, need, and what do we value? We then focus on delivering that.

MAGPIE This wasn’t necessarily about using the latest ‘hot’ or ‘sexy’ technology.

SB Initially, we were a bit tempted by some of the more out there ideas, ranging from blockchain, to AI, but then we said, ‘No, let’s go back to first principles and build something that solves an immediate problem today.’ We’re using today’s technology, and that works. Mobile phone technologies, and also some backend technology developed by the NHS: those are the two factors that make Echo possible.

MAGPIE And yet as Echo grows it’s become clear that this is a service being used by people who aren’t busy professionals.

SB Yes, for Sai and me it was about convenience first and foremost, but actually a

lot of our users value that we deliver to their homes, because they have mobility challenges, they can’t get to the pharmacy; they benefit from that and that’s not something we thought about or planned for.

We have customers with more complex cases and conditions than we’d expected. Sai and me, we take one, two items each day, but we have some patients who are on 30-plus items each day. Thinking about them makes us think harder about their experiences with the app: things like how the alerts appear, if you’ve got 30 items versus one, how do you build it? We’re learning all the time. The typical Echo user, if there is such a thing, is a 38-year-old working mum, which obviously I’m not, and hence why UX testing and user research has become such a huge thing for us.

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AGPIE You’re rare in being a start-up founder whose title is ‘Chief M Experience Officer’. How much has Echo’s customer experience informed the brand – or is it the other way round?

SB One of the challenges I had using other services that existed before us was

fragmentation, and a lack of communication, which just keeps you at this kind of low-simmering edge of anxiety – that’s what we want to eliminate, because really I need to know that my meds are going to arrive on time. If I need to see my GP, I want to know as early as possible. I need to know that there’s going to be sufficient stock; and I want someone to be accountable for that end-to-end experience. We don’t solve one thing: it’s a 100 little break points that all come into the patient experience.

Then in terms of the brand everything we do, from the look and feel of the app, simple things like how the icons animate, right through to how we talk to patients, how we interact with the surgeries, to the packaging in which we send out the meds: all of that needs to be robust. It needs to feel solid.

MAGPIE Are there any particular brands that inspire this approach to the way you deliver experience?

SB We take a lot of inspiration from Apple, but more recently I’m taking cues from

In terms of the brand everything we do, from the look and feel of the app through to how we talk to patients, needs to be robust

Fisher Price. I know that I can hand any Fisher Price toy to my daughter, and she won’t choke on it. There’s a clear kind of signal there. They might not have all the flashy features of some other toys, but there is a solidity to the product. You know what it stands for and there’s an accountability to the product, and that comes through every little touch point you have.

MAGPIE Yours is a brand that’s being built experience first.

SB For us, brand and experience are one and the same thing. The brand is what we do, day-in day-out. It’s everything from investing in our security to our backend infrastructure. It’s the work we do with the NHS. It’s not often anything to do with the logo or the colour scheme; it’s how we work; it’s how we operate; it’s who we recruit: that is the brand, and the brand is the experience, both for our users and the GPs, but also for our employees.

MAGPIE How do you know what a good employee fit looks like?

SB Well you never really know until you start working with someone. One of the

things we do, in our recruitment process, is that you will meet lots and lots of Echo-ites, five or six people. In a very informal way, we’ll get someone in for a few hours and we’ll get staff to drop in. We take a temperature gauge, based on how people feel and whether or not they’re going to be a fit.

It’s a lot of hard work building a start-up. It’s a lot of dedication and you do need to believe in the mission and the goal, so I think it’s important that people see what we’re building. That doesn’t mean they have to have come from a healthcare background, it means they must see why it’s so important that we do the right thing.

MAGPIE I’ve noticed in what you’ve said and the way that you’ve said it so far that you’re not using rhetoric around transforming the industry, transforming the sector, transforming the world. Is that deliberate?

SB I think we have a big mission here and we have goals that extend far beyond

pharmacy services. However, we do feel that we only get the right to unlock those next opportunities and have those conversations when we feel confident that we’ve solved the first thing that we’re working on.

‘Transforming’ is a good word, but ‘disrupting’ in the healthcare sector is a tricky word. We’re providing an essential healthcare service, and disruption, by its nature, doesn’t necessarily fit with providing a continuous care pathway.

Healthcare is different and needs to be treated with a lot of respect. Doing an alpha release and seeing what happens is really tough in healthcare, because everything from data security to how things are handled, communication, all of that needs to be robust.

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AGPIE How have you gone about getting the M trust to do what you do in, what from an outside perspective appears a risk-averse sector?

SB Making sure that we deliver the best possible patient

experience and we let our patients and users do the talking for us. When I meet people in the NHS, and in government, quite often they’ll have already spoken to an Echo user about our service. And when that happens, it opens a lot of doors, because people can see that we strive to do our best and to provide utmost care and attention and respect, for our users.

The NHS does recognise the need for innovation and is working extremely hard to make innovation happen.

Because, frankly, we’ve got an ageing population.

We have to find some sort of new way of doing things, and technology is one of the tangible answers. The only way we’ll be able to provide universal healthcare, free at the point of care, is through technology: there is no other way.

MAGPIE Are there parts of the NHS which are more open and receptive to innovation?

SB Someone gave me a great analogy the other day: the

NHS isn’t a massive whale but a shoal of fish. And within that shoal, there will be people keen on innovation and those concerned about something new coming along, disrupting the very, very tough job that they have to do.

If you imagine that you’re already working every hour in the day, you’re under huge amount of stress and then this new technology comes in. You feel the people behind it haven’t answered some of the key questions you’ve got and it’s just a rehashing of something you saw 18 months ago that didn’t work out… you’re going to get jaded. The onus is on the innovators and their supporters to make the case – and to ensure that there’s a continuity of care and systems.

If you think about something like a platform migration, that can be hugely disruptive. Even if the new platform offers long-term savings, who’s going to deal with the day-to-day impact? Who’s going to pay for it? Whose weekend is ruined by this? And so one of the principles we have at Echo is to minimise disruption.

Use existing pathways, existing workflows, however that GP surgery works right now. And that involves understanding these systems, and adapting to them.

But it’s difficult and the shoal of fish isn’t always swimming in the same direction. And there’s some big questions, politically, about what’s the future of the NHS? Do you charge people for not attending GP surgeries? There’s lots of philosophical debates that we stay out of, but they’re happening, and they can dictate and determine what’s going to happen with innovation at large.

You just have to keep turning up every day – tenacity has to be your watchword. And when I look at our peers in healthcare start-ups, the average age of an employee seems to be almost 10 years older than most tech startups, 35 versus 25. There’s a few different things going on there: it’s about, having the experience, know-how – and we have a huge responsibility, which is tough.

MAGPIE This reinforces the idea that transformation is not about revolution, but is fundamentally a gritty, slow process.

SB Going in with a transformation programme that is

‘revolutionary’ in healthcare is tough. We need to make sure that a GP on the other side of the country who’s never heard of Echo, doesn’t feel alienated, feels like we’re bringing them along on the journey. The onus is on us to do that, and that’s about turning up every day and taking the time to explain.

AGPIE How closely do you work with other start-ups in your M sector? Are they competitors or something else?

SB I look at some of the relationships that we’ve built

with ostensibly competitors, and see that we have enough common challenges to pull together. There are companies that, where we overlap with, we work very closely together, and we help each out and we share information. We chat to each other almost every day.

Again, that’s because we’re both working towards a bigger picture, and at some point in the future maybe we’ll be head-to-head competitors, but for now that we’ve got common goals.

Partnerships are really, really important. If you think about care pathways, it might be that, in the future Echo naturally will hand over to another partner, depending on the patient’s condition and life stage. I prefer being able to say to a patient ‘Here’s continuity of care’ and hand it to someone’s who’s ostensibly a competitor than leave that patient stranded.

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AGPIE Right now it sounds like you’re not particularly worried that an M Amazon or an Apple can come in and do what you do on a larger, more efficient scale?

SB Anyone coming into this market has to realise that, no matter how big they are,

One of the principles we have at Echo is to minimise disruption, use existing pathways, existing workflows

£17bn

UK yearly spend on medication, half of which isn’t taken as directed

or how much money they have, they’re still only going to be part of an ecosystem.

They can’t compel a GP to issue a prescription on behalf of the patient. Every prescription that is dispensed by us, has to be authorised by the GP. And the GP may well have a good reason to refuse what the customer wants. So for one thing customer satisfaction is not in your control in the same way. If they come into this market the big e-commerce players will need to work with stakeholders and commissioners, which kind of goes against their operating models at the moment.

MAGPIE What do you consider the biggest potential risk to Echo’s brand?

SB Losing sight of why we started the company. I think we can weather an awful lot, as long as we remain true to our mission. We’re almost 40 people now, so we need to make sure that we hire people who share our values and who are on board with the mission, so that as we scale we continue to focus on the things that are important to us.

MAGPIE And on the flip side, what’s the thing that people love about Echo?

SB That it just works. A lot of the people I talk to are surprised when we tell them that you can get this service, and it’s free, and it works with your own NHS GP. At the start they can be quite sceptical. And then when it works they’re like ‘What!?’.

The simplicity is what surprises and delights people, first and foremost.

And then the second thing is accountability. Because we’re working in a complex multi-faceted, many stakeholder market, things can go wrong and do go wrong and you know it’s easy to pass the buck in those situations. It’s much harder to say, ‘We’re going to try and get this sorted’ and to let people know exactly what to do and to be there. Frankly – giving a shit.

From clinicians’ perspective, I think they like that it reinforces a GP’s directions. We spend in the UK £17 billion a year on medication, and half of that isn’t taken as directed. It’s a huge issue. So, anything that nudges people towards better compliance, gives them the tools to understand why they’re taking meds, reduces barriers to compliance, helps keep people better for longer, and reduces strains on healthcare.

AGPIE It’s invidious to ask of a business that’s growing as fast as Echo M but – what’s next?

SB Unfortunately I’m going to be boring and saying ‘more of the same’. We have

many, many, many things we need to fix and improve. We’re still trying to nail our core product. We think it’s the best on the market, but we instinctively know how many other things we need to do in order to make it the most frictionless app that it can be: and that remains our core focus as a team.

Because making hard things look simple is tough, and that remains our mission, to make it just work. That doesn’t just mean from a patient’s perspective, it means from a clinician’s perspective, and it means from our team’s perspective.

And then, obviously, scaling that.

AGPIE This is a good story to tell; transformation is not this romantic M thing. It’s the business of doing the same every day.

SB 100%. There’s any number of different things that we could do in the app, and

it’s Sai and my job to say, ‘No. It’s just going to do that.’ I mean – ‘map my genome, sure, but if I can’t get my pills I don’t care.’

For more information about Echo, visit echo.co.uk

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BEFORE

THE SCREEN Telemedicine is poised to help national healthcare providers improve efficiency, but there are still challenges to overcome

BECOMES writes Federica Pisano

ROUTINE

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T

elemedicine – using telecommunication and information technology to diagnose and treat patients remotely – seemed to me like something out of science fiction only two years ago. And now, after my first online medical appointment, I’ve been asking myself: is this what the future looks like?

Having grown up in a family of doctors, I would have expected to say no way. Being examined by someone in the same physical space as you, the use of complex devices when needed, a human interaction providing a sense of security and comfort… all to be replaced by a screen, just like so many other aspects of our lives already?

Of course, I am idealising the traditional face-to-face, doctor-patient experience. We all know the difficulties of getting an appointment with a general practitioner (GP)1, let alone a referral to a specialist, something that can potentially take months – and then when the appointment finally occurs, it can be nothing more than a cursory exam that takes less time than the journey to the clinic.

83 BPM

GP is the term commonly used in the UK to refer to a physician.

1

World Health Organization, ‘Density of Physicians’; last retrieved: March 2018

2

Aliya Ram, ‘The doctor will see you now — on your smartphone’, Financial Times, 22 March 2018

3

4 Maike Telgheder, ‘Online-Ärzte drängen mit Macht nach Deutschland’, Handelsblatt, 28 March 2018

Aliya Ram, ‘Babylon signs Tencent deal to deploy health technology on WeChat’, Financial Times, 5 April 2018

5

6 …rather than all of the UK; thanks to devolution, NHS services in Scotland, Wales and Northern Ireland are organised and provided separately by the relevant devolved governments.

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5K It is unarguable that, around the world, healthcare systems are struggling to cope with the growing demands placed upon them, a situation that is only going to get worse. Challenges such as ageing populations and unhealthy lifestyles are here – but the resources to tackle them aren’t. Over 45% of member states in the World Health Organization (WHO) are reported to have less than 1 physician per 1,000 patients2. And the current global trend of reduced real terms investment in national healthcare systems suggests the situation isn’t going to get any better any time soon. We face two daunting challenges: ensuring a sufficient level of patient treatment and care on one hand, whilst guaranteeing its quality on the other.

Simply put, telemedicine will be key in solving those challenges.

And around the world, national healthcare systems are starting to embrace the potential of these technologies.

For example, in 2017 the Swedish healthcare system, for the first time, allocated public funds to pay for video consultations for patients, run by the start-up Kry (kry.se/en). The company now serves 2% of all primary healthcare patients in Sweden, as well as people in Norway and Spain.3 You can tell that telemedicine is being taken seriously when even countries with a strong precautionary approach to healthcare are actively debating whether to license its wider use. Take Germany, where the country’s medical association was due to decide in May whether to remove the its current ban on the tech. This hasn’t stopped pilot projects taking place and businesses preparing to enter such an attractive market – estimates suggest about one third of appointments with physicians there would take place online if made available.4

HAND, NOT IN GLOVE As befits a country where state provision of healthcare has been dominant since 1948, the situation in the UK is more nuanced.

Telemedicine start-ups have been quick to offer their services to paying patients – but it is unclear at the moment to what extent the National Health Service (NHS) wishes to support such innovation by private companies.

But Babylon’s attempts to try and provide a similar service for NHS patients have so far not been as successful. Working with the NHS, it developed a free mobile app called GP At Hand. However, NHS England, the main organisation responsible for healthcare in the country6, has prevented the app from being launched due to concerns over data protection, and the fact that up to 43% of the providers Babylon was working with did not meet the Care Quality Commission’s standards on providing safe care.7 More fundamentally, it appears that there are question marks over the potential service GP At Hand could offer. As it stands the app cannot provide help to patients with “complex mental health problems or complex physical, psychological or social needs” as well as pregnant women, people affected by dementia or safeguarding issues.

This is in stark contrast to one of the NHS’ key principles – meeting the healthcare needs of everyone.

And perhaps worse, GP At Hand’s business model could, in theory, threaten the longer term financial viability of the NHS. Registering to use the app implies that a patient must then deregister from their current GP practice – which means that practice would lose the centrally allocated funding for that patient.8

Launched in 2015, Babylon Health (https://www.babylonhealth. com/) provides video consultations to patients via a subscription model. It promises appointments with GPs available 24/7, easily arranged from your smartphone, while the app also offers a symptom checker, a health tracker which monitors test results and your activity level, even mental health consultations. Plus prescriptions can be sent to your home address – potentially a seamless healthcare experience. And you can add your relations to your account, so they benefit from your subscription – like a shared Netflix account but for your family’s health.

The model has so far proved robust enough that Babylon has been able to expand to Ireland and Rwanda, while signing agreements to begin operating in Saudi Arabia, and China in partnership with Tencent, where the service will be available on WeChat.5

7 Hannah Crouch, ‘CQC findings show online primary care providers still need to improve’, Digital Health, 23 March 2018 8 Naureen Bhatti, ‘Seeing a GP on a smartphone sounds wonderful – but it’s not’, The Guardian, 16 November 2017

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Where telemedicine is likely to be adopted quickest is in countries like China, where most patients have to pay for their own care.

Over 180 million users are registered to use Good Doctor, a local telemedicine platform which provides online consultations and free diagnoses. And as one commentator notes, Good Doctor offering 15 minute appointments is a positive advantage; most face-to-face meetings with physicians in China last 5 minutes.9

15 MINS

TELE IT LIKE IT IS While the potential of telemedicine to address and meet the everincreasing demand for healthcare is clear, there are still urgent challenges to be addressed to ensure its effectiveness, especially in taxpayer-funded healthcare systems where there is an expectation of care for all:

1

2

3

4

Should services be prevented from cherry-picking patients?

Right now it seems that companies like Babylon Health can only take on patients under certain narrow conditions. What happens as these services scale?

How is funding allocated in the future? In the UK at least, GP At Hand’s current approach could ultimately make the NHS unsustainable, as funding for non-telemedical GP practices dwindles.

Can medical data ever be made secure enough? Strong regulation and monitoring in theory can do this, but recent furores about Facebook’s data protection might see the beginning of a backlash, as patients object to their health information being shared between a variety of private healthcare providers.

How will we know telemedicine works? Pilot projects and peer monitoring must be put in place to rigorously evaluate the quality of telemedicine services, and to check that they are relieving pressure on healthcare systems.

Having a consultation with your doctor via a screen is no longer science fiction. Telemedicine has huge potential: not only to bring greater efficiency to healthcare but to also give patients a better experience. Collaboration between private companies and the bodies that allocate public funding or reimbursement will need to become more creative, aiming to deliver new services to people while protecting their rights as patients. And we can hope that private firms in this space will be motivated by a higher purpose and not just the desire to make a profit.

Benjamin Shobert, ‘Why China Will Capitalize On Groundbreaking Healthcare Solutions Before The West’, Forbes, 2 February 2018

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Photography Š Brandon Wong

Our dependence on smartphones and devices with screens might be having a negative impact on health – especially of children.

Terry Moore investigates

O M AG P I E 0 2

W H AT’S O N T H E OT H E R S I D E O F T H E LO O K I N G G L ASS?

lder Magpie readers – anyone over 30 – might remember the Nokia 3310, a now iconic mobile phone. Along with other early mobiles, it effectively had only three functions; you could use it make a call, send a text message or play ‘Snake’. And of those, sending a text was far from easy to accomplish. A tiny screen, crudely digitised characters, predictive text functionality that was more annoying than useful, and an awkward keypad that required you to press a key multiple times to select specific characters.

Despite all of that, texting was rapidly adopted, especially by younger people as their preferred means of communicating with each other. A whole new abbreviated lexicon emerged and kids mastered it at lightning speed, clunky keys or not. And, ironically, hardly anyone actually ever used a mobile to make a call – except maybe to phone mum.

What is quite astonishing about this is that the rise of texting was never anticipated – the dominant use of messaging instead of voice calls by a younger demographic was never foreseen. Which got me thinking: new technologies are developed, researched, refined, launched, commoditised, and yet it seems that we have no way of really knowing what people will actually do with that technology – and more importantly, what the potential downsides might be.

Never out of reach A mere 11 years since the first iPhone arrived on the market just about everyone you know has one, or AN Other smartphone, and the latest model is a must-have for any self-respecting 10 year old. And just like no one predicted the take-off of text messaging, no one (well, apart from Steve Jobs) could imagine the effect on human behaviour and our everyday lives that smartphones, and other devices with screens, would have.

Photography © Charles Deluvio

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Who would have dared to imagine modern society’s total dependence on them, as they have invaded every aspect of modern life – work, leisure, relationships, friendships, shopping, travel, everything? Who foresaw that a whole generation would document their lives on Facebook?

Who could have imagined crowds of people walking along city streets staring at their phone screen?

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Photography © Andrew Guan

Our smartphones are never out of reach; we check them last thing at night and they’re the first thing we turn to when we wake. A study in 2015 concluded that young adults used their phones an average of five solid hours a day and Apple says that, on average, iPhone users unlock them 80 times a day. Of Generation Z, the cohort that grew up with this technology, 40% self identify as digital device ‘addicts’ and cannot imagine going without their devices.

It is the nature of technological change that it influences, and hopefully improves, the way we live our lives.

But while the impact of the smartphone clearly has been seismic, it is a moot point whether this advance has been entirely positive.

Some of the world’s biggest businesses, like Facebook, are predicated on a need we didn’t know we had, to use our smartphones to post information about ourselves and express our opinion to the world every few minutes.

Whole industries have sprung up, bent on finding the next ‘Angry Birds’ or ‘Candy Crush’ to keep us eyes down and glued to these small screens. And when Apple’s engineers put a camera in the iPhone did they have an inkling the entire world would become selfie obsessed? On a visit to China last year it felt like the whole population of the Peoples’ Republic were taking pictures of themselves.

I saw a very young girl, I guess no more than five years old, posing and taking selfies, most likely copying her older sister.

This could all be classified as harmless fun, perhaps. But in any other context we would call this type of behaviour an addiction, an obsessive-compulsive disorder. Everyone with a smartphone is afflicted to a greater or lesser degree. And these mass obsessions are not passing fads – these are the defaults of the way we live now.

Should we be worried? I think we should.

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Photography © Ludovic Toinel

Broken bonding By 2019 over 36% of the entire world’s population, 2.5 billion people, will have a smartphone. That is the same number of people in the world that do not have access to proper toilets. And while the health implications of poor sanitation are well understood we are only beginning to consider the potential long-term health effects of the smartphone on humans.

As the generation that lives life on social media become young parents they’ll most likely continue checking their phones 80 or more times a day. How often do you see a young mother or father wheeling a pushchair or sitting next to their child on a bus checking messages on their phone? Or mother taking selfies with baby as prop?

Or the fractious infant pacified by playing with mum’s iPhone? Not a problem, right?

Psychological Society, when very small children get hooked on tablets and smartphones, this can cause permanent damage to their still-developing brains. Human evolution over centuries has determined that, to develop normally, a child brain’s neural networks need specific stimuli from the outside environment. Unsurprisingly, these stimuli are not found on today’s tablet screens.

Except psychologists are coming to realise that this common, everyday behaviour in today’s young parents is compromising the development of their young children.

These habitual phone behaviours reduce the level of parent-baby and parent-child interaction and so compromise the ‘bonding process’ – forged by facial expression, eye contact, and talking to the child or new-born – that is so critical in those early months, laying the foundations of healthy development.

A recent article in Psychology Today highlights a number of troubling studies connecting delayed cognitive development in kids with extended exposure to electronic media. Well-meaning parents who give their toddlers iPads with videos and interactive stories to keep them amused may be doing more harm than good. A baby will often try to ‘swipe’ a real photograph or pinch their fingers on a book as if it were a touchscreen, and young children arrive at nursery often struggling to pick up basic fine-motor skills such as holding pencils, pens and crayons.

It’s generally been accepted that prolonged exposure to screens is not good for kids – to the point that some countries by law impose limits on ‘screen time’ for children. The proliferation of tablets and smartphones has introduced a whole new complexity to this issue.

The US Department of Health and Human Services estimates that American children now spend a whopping seven hours a day in front of electronic media, and that kids as young as two regularly play iPad games and have playroom toys that involve touch screens. According to Dr Aric Sigman, an associate fellow of the British

iPads also have the potential to make young children ‘cognitively lazy’ – a tablet spoon-feeds images, words, and pictures all at once to a young mind; it bypasses the need to take the time to process a mother’s voice into words, visualize complete pictures and exert mental effort to follow a story line. Kids become lazy because the device does the thinking for them, and as a result, their own ‘cognitive muscles’ remain weak.

Sources: https://www.psychology today.com/us/blog/behindonline-behavior/201604/ what-screen-time-can-reallydo-kids-brains?page=1 https://www.psychology today.com/us/blog/mentalwealth/201402/gray-matterstoo-much-screen-timedamages-the-brain https://www.fastcompany. com/3061913/whathappened-when-i-gave-upmy-smartphone-for-a-week

When a child gets too used to an immediate smartphone-style interaction – that is, an immediate response and gratification – they will learn to prefer smartphone-style interaction over real-world connection. Too much screen time impedes the development of a child’s ability to focus, to concentrate, to lend attention, to sense other people’s attitudes and communicate with them, to build a large vocabulary—all those abilities are potentially harmed and normal development becomes stunted.

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In any other context we would call this behaviour an addiction.

Everyone with a smartphone is afflicted to a greater or lesser degree – these are the default of the way we live now.

Et in smartphone ego

Photography © Hugh Han

It’s not just children we should be concerned about either. Research has shown smartphone use and technology dependence in adults can impair attention, productivity and memory, dampen creative thinking, increase stress levels, reduce sleep quality and lead to ‘cognitive errors’ like forgetting meetings and walking into people.

The research also suggests that the constant availability of the smartphone limits the analytical and intuitiveness of people’s thinking and reasoning – because everything can be googled.

Of course, smartphones in themselves are not a bad thing – it’s obvious they bring huge benefits and pleasure their users. But there should be no doubt that heavy use of them can all too easily bring about trends, behaviours and traits that can impair quality of life.

We marvel at the bright, the shiny and the new in technology, and we rush to embrace it all in the belief that it can only make our lives better. For the most part it does just that, but with the lightning speed of technological development and stuff of science fiction becoming a reality daily, we must be ever more alert to not just the benefits but also the unintended consequences of technologies on our wellbeing.

Shortly before his death, Stephen Hawking suggested that most of the threats facing humanity come from progress made in science and technology. “We are not going to stop making progress, or reverse it,” he said, “so we have to recognize the dangers and control them.”

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oving grace

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In the developed world, how we look after aging populations is rapidly becoming the most important policy issue governments face. Can technology help cure the social care crisis? Nick Ranger reports

My great aunt Bella is often on my mind. She’s in her mid 80s and lives in northern Scotland. She is deaf, doesn’t have a phone and wouldn’t be able to use it anyway. Her chronic mobility problems make her housebound. In and out of hospital regularly, she relies on her son-in-law Nigel, who lives in the next town, to do things like her shopping and taking her to appointments. She is a stubborn woman who values her independence, but needs the help of a small group of people to get through the day. And being based in London, there’s little I can do on a day-to-day basis to provide support.

In the UK there are millions of people in a similar situation to Bella and Nigel – about 7 million are family caregivers. In the USA that number is 40 million. Those people provide help and care to loved ones 24/7: administering medication, dressing, bathing, cooking, cleaning, providing transportation, talking and listening.

They are silent heroes. And while they are all doing something amazing every day, their situation isn’t sustainable, either for the caregivers personally or for society as a whole. As Gail Gibson Hunt, president and CEO of the USA’s National Alliance for Caregiving, says: “Not enough is being done to support family caregivers in the public or private sector. There’s a double-edged sword when we fail to support caregivers, because we put both the caregiver and the care recipient at risk.”

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Beanpoles can’t shoulder the burden

As the baby boomer generation begins to retire, we are also witnessing a dramatic increase in both neurodegenerative disease and mental health issues, meaning that more and more older people will need some form of active caregiving, over and above the support we all might wish to have as we age. On current projections three in five of us will become carers at some point in our lives and in the UK, by 2030, the number of carers will increase by 3.4 million. In the US the ratio is expected to be four-to-one; by 2050, there will be fewer than three potential caregivers for every older American.

Meanwhile the shape of the family unit is changing. While the closeknit extended family is still prevalent in southern Europe and many developing nations, in northern Europe and North America, the more traditional family models we’re used to, the nuclear family and the micro family, are gradually being replaced by what sociologists call the ‘beanpole’ – families that remain close knit emotionally and communicate regularly, but are distant geographically, with younger generations often moving for work, even living in different countries, and so not close by enough to provide care.

There has also been, arguably, a change in what we give to and expect from the communities we live in. We know fewer people, and have less in common with our immediate neighbours. Combine this with a shift to the virtual communities we spend so much of our time in now, and effectively we aren’t in touch with the people who live around us like we used to be. Those who are lucky enough to have family members in their care network may get the help they need if they have their own Nigel living locally – but that network is shrinking.

Then consider those who need looking after. They often feel that they are self-sufficient and not inclined to ask for help – even when they may suffer loneliness and hardship – as they don’t wish to become a burden to someone else. So they suffer in silence.

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Where we all labour

In the USA, the typical family caregiver is a 49-year-old woman caring for an older relative – but nearly a quarter of caregivers are now millennials and are equally likely to be male or female. Men, often stereotyped as failing to take on this particular responsibility, represent 40% of the caregiver population. About one-third of caregivers have a full-time job, and 25% work part-time.

If a caregiver is aged 75 or older, they are typically the sole support for their loved one, providing care without paid help or support from friends or relatives. A third provide more than 21 hours of care per week, have been caring for 5½ years and expect to continue for another five. Nearly half suffer high emotional stress and financial strain.

Source: AARP and the National Alliance for Caregiving; http://www.aarp.org/caregivingintheus/

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The caregiving cliff

There is also a knock on impact on the workplace. The responsibility of caring for a loved one can become the equivalent of a second full-time job, and the burden of care has serious consequences for caregivers.

Increased anxiety, stress, depression and lack of sleep affect caregivers at a higher than average rate. This means they too could become a burden on the healthcare system, other family members or are, at least, less productive at work. In the UK, the economic contribution of caregivers is £132bn annually. In the US, it tops $470bn (see page 38).

Which is where the state comes in. In the UK, social care is a legal responsibility of local government. And while funding of social care has been relatively protected in recent years, money for other services has been cut. There has been a 32% real-terms reduction in local authority spending on non-social care services between 2010-17.

Libraries, youth services, sports facilities, parks, road maintenance, recycling and waste collection and many other ‘non-essential’ services have suffered, while social care costs continue to grow.

It is clear that the status quo is unsustainable in the long term. The AARP says that the US is “facing a caregiving cliff”. But radical changes in technology could mean that we are on the cusp of a solution.

Holistic helping

If we think about the social care problem as linear, there seems little opportunity to solve the crisis. But a number of businesses, apps and initiatives are taking a more holistic view, looking to use the power of online social networks to reconnect communities with people who need help the most.

Probably the first solution to try and tap into the power of the social network was Lotsa Helping Hands (lotsahelpinghands.com). Launched in 2005, it supports the creation of online caregiving communities through a simple calendar app, which allows caregivers and volunteers to provide assistance by providing logistical support.

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Some newer apps are more narrowly focused, offering ways to organise your own tasks and those of your family. Carely (care.ly), for example, uses instant messenger functionality to co-ordinate family visits to a relative in a care home. CareZone (carezone.com/ home) helps caregivers organise files, contacts, medications, and provides a journal where this information can be shared with other caregivers. And the athenaWell app (previously Patient IO) allows patients to send secure messages to their carer teams, and track their health data.

As the baby boomer generation retires, more and more older people will need some form of active caregiving.

But that doesn’t remove the need for a platform to pull everything together into one solution. So something like CircleOf (CircleOf.io) is a step forward. Launching this year, it’s a mobile app and care collaboration platform that will connect those in need to those who can help. Its functionality allows family, friends and co-workers to create a community of care. It will also have a marketplace that will integrate with Amazon, Lyft and other brands, so that groceries, hot meals and prescription medicines can be delivered, providing a rounded care solution.

CircleOf is attempting to make it easy to get help. The idea is that by using the power of a social network to arrange care, families can share the burden among a wider network. And by integrating a marketplace, it should become easier for carers to arrange for everyday events to happen automatically, further reducing pressure on primary caregivers.

Unpaid, unlamented

40m

70%

$470bn 126m

Number of people who are the primary caregiver for family members

Percentage of working caregivers who have difficulty managing their job and caregiving responsibilities

Value of unpaid care provided by family members

Work days missed by family caregivers per year

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We should all be Nigel

While it’s possible to integrate several technologies around a collaborative social network to provide tools care givers need, the bigger challenge will be getting more people involved in actually providing care.

Social networks are great for bringing together like-minded people who share an interest. What remains to be seen is whether people outside a primary care network, family and immediate friends, will volunteer, or indeed whether the people most responsible will be comfortable opening up the care of their loved one to a wider network.

At one level they will have to, given the cliff edge care services face.

And, if these tools get widely adopted, there are other questions that will need to be answered. Will the intimate details and data of individuals be protected? Will we need to vet volunteers joining care communities to ensure they are genuine?

It feels like integrated social collaboration apps are a good starting point, bringing together local people and services to connect and support those most in need, ultimately putting them back at the centre of a community.

$25.2 Lost productivity

But can our familiarity with social networks and the ease with which we can engage online, encourage us to volunteer and take responsibility in our offline communities? Can we transfer the power of social networks to create real community spirit around those in need?

All figures for the USA. Sources: FCA Caregiver Statistics 2015: Work and Caregiving https://www.caregiver.org/ caregiver-statistics-work-and-caregiving; GALLUP

If we can, then maybe social networks can transform social care. And perhaps the majority of us will be encouraged to do a little bit more to help carers and the people they love – people like Nigel and Bella.

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P ROJ ECT BY —

Alvar Aalto

COMPLETED —

1933

The Paimio Sanatorium for Tuberculosis is considered one of the most revolutionary healthcare designs of the 20th century.

Paimio Sanatorium by Alvar Aalto. Photography © Moritz Bernoully

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Hospitals don’t have to be unfriendly and unwelcoming, as our survey of innovative designs over the years shows. Selected and introduced

by Pablo Funcia

Making medical factories fabulous

N

obody likes going to hospital. The prospect of even a routine visit makes most of us feel uncomfortable at least, as we begin to think of sterile clinical rooms, unfriendly spaces, harshly lit corridors, let alone that there might be something wrong with us.

Traditionally hospitals have been designed to be functional and efficient – ‘medical factories’ as the UK healthcare think tank The Kings Fund put it in 2008. In reality this means that they are intimidating spaces, rather than welcoming ones that could aid recovery.

Nature Trail by Jason Bruges Studio. Photography © Jason Bruges Studio

Research shows that good design and art can contribute to the improved wellbeing of not only patients, but hospital staff and visitors as well.* And in recent years, designers and artists have become increasingly involved in the transformation of healthcare centres.

From intuitive wayfinding to comfortable furniture, colourful environmental graphics and interactive installations, the following pages showcase a selection of projects, past and present, that demonstrate that hospitals need not be factories but welcoming spaces.

* https://www.guysandstthomas.nhs.uk/our-services/ cancer/about/cancer-centre/cancer-centre-art.aspx

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Maggie’s Manchester P ROJ ECT BY —

Foster + Partners COMPLETED —

2016

MANCHESTER, UK

Photography © Nigel Young — Foster + Partners

* https://www.fosterandpartners.com/ projects/maggie-s-manchester

Maggie’s Centres provide free practical and emotional support to people suffering from cancer.

They’re also places where sufferers can meet other people or simply relax. They serve as great examples of how the active involvement of skilled architects and designers can make a significant positive impact on our collective perception of health and care centres, what they – could – look and feel like.

The example below, by Foster + Partners, harnesses natural light and warm materials to seamlessly integrate indoor and outdoor spaces, with a focus on greenery*, to provide an open and spacious environment, a ‘welcoming home’.

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CHICAGO, USA

Photography © David Schalliol

Prentice Women’s Hospital

P ROJ ECT BY —

Bertrand Goldberg & Associates COMPLETED —

1975

Demolished in 2014, Prentice Women’s Hospital remains a pioneering example of brutalist architecture and innovative hospital design1.

The iconic structure of the tower was defined by the desire to split each floor into four ‘communities’, to strengthen the relationships and social ties between patients and nurses.2 It was a cutting-edge project at the time, but from today’s perspective a brutalist building is less likely to be thought of as human, welcoming or inviting.

1— https://www.dezeen.com/2014/10/02/ prentice-womens-hospital-chicago-bybertrand-goldberg-associates-brutalism/ 2— https://www.archdaily.com/432976/ ad-classics-prentice-women-s-hospitalbertrand-goldberg Photography © David Schalliol

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Guy’s Cancer Centre

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A RC H I T ECT U R E —

Rogers Stirk Harbour + Partners A RTS P RO G R A M M E —

Guy’s and St Thomas’ NHS Foundation Trust in partnership with Futurecity (‘Mountain’ project depicted is by Karel Martens, Harry Pearce, Pentagram) COMPLETED —

2016

LONDON, UK

This recently opened centre is the result of a collaboration between architects, designers, artists, hospital staff and patients to create a new space that integrates both cancer research facilities and treatment services. According to Guy’s Hospital, the architectural project puts patients “at the heart of what we do”1 by giving the environment a human scale, and fully integrating responsive works from the hospital’s art programme.2

Photography © Pentagram

This ambitious project is a reminder of the importance of careful planning, active involvement from end users and seamlessly integrating many creative disciplines involved, in order to achieve maximum positive impact.

1— https://www.guysandstthomas.nhs.uk/ our-services/cancer/about/cancer-centre/ building-design.aspx 2— https://www.guysandstthomas.nhs.uk/ourservices/cancer/about/cancer-centre/cancercentre-art.aspx 3— Is a success/results reference needed to back this?

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Photography © Jason Bruges Studio

LONDON, UK

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Nature Trail at Mittal Children’s Medical Centre, Great Ormond Street Hospital

This interactive installation combines the use of wall graphics, movement sensors and LED panels to reveal forest creatures – a moment of distraction for children as they move past.

P ROJ ECT BY —

Jason Bruges Studio COMPLETED —

*http://www.jasonbruges.com/art/#/nature-trail/

2012

While the visual quality and impact are undoubted, the underlying strategy behind the project deserves praise too.

By focusing attention and resources on one specific space in the hospital*, it maximises impact and active engagement from children, at the moment it is perhaps most needed.

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Sheffield Children’s Hospital rooms P ROJ ECT BY —

Morag Myerscough COMPLETED —

2016

S H E F F I E L D, U K

1&2— https://www.dezeen.com/2017/02/05/ morag-myerscough-bright-colourwards-sheffield-childrens-hospitalinteriors-uk/ 3— https://www.designweek.co.uk/ issues/30-january-5-february-2017/ morag-myerscough-transformsrooms-sheffield-childrens-hospital/

Photography © Jill Tate

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Brightening up children’s hospitals is perhaps the toughest of hospital improvement briefs. Even more so when you consider that even relatively simple projects face strict clinical regulations when it comes to implementation.

In her work at Sheffield Children’s Hospital, part of the Children’s Hospital Charity’s

arts programme, Myerscough used her signature colourful geometric patterns to develop bedrooms “that you felt good to be in”1 for children of various ages and their families. However, the need for sterile and easy clean finishes compromised the palette of materials she could work with, as well as the installation process.2 The restrictions have been worth it, however, with transformative impact achieved solely by the use of environmental graphics and carefully considered, strippedback interior design – and overwhelmingly positive feedback from patients.3

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Around the world palliative care is coming out of the shadows. A brief survey, compiled and introduced

by Sally Tindall

I

t’s commonly assumed that in modern society we don’t talk about death, much preferring to hide it away. And if this is right, then it follows that we talk and think about palliative care even less.

Many people who have not had any involvement with it assume it’s about helping people to die a good death. In fact the opposite is true. Palliative care is defined by the World Health Organization as, “an approach [to care] that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”

The focus is on improving the quality of life for people, enabling them to live what remains of their time as fully as possible.

As you might expect, the availability and quality of palliative care globally varies enormously. This is not just a case of developed nations having more money and resources available to offer better care. In 2015, the Economist Intelligence Unit issued a ‘Quality of Death Index’, which ranked palliative care in 80 countries. Some emerging nations, perhaps surprisingly, ranked higher than more affluent countries (see map).

USA (9/80) To qualify for hospice home care, two doctors need to say the patient is likely to die within 6 months; in most cases a very difficult prediction to make. In return, the patient has to relinquish insurance coverage for disease treatment, something many are reluctant to do until they’ve explored all possible treatments. The net result is diminished quality of care.

As in so many things, the USA has been in the forefront of changing trends in palliative care. In the 1950s most people died at home, largely because they saw no benefit in going to the hospital. However by the end of the 1990s 83% of people died in an institution, thanks in part to a greater ability to treat people with new drugs and procedures until the very end of their lives. Many doctors saw – and maybe still see – their role as not giving up until they have to.

But is this what people actually want? Increasingly the answer is no – they want to improve the quality of their remaining days, not the quantity. A recent randomised study conducted at Massachusetts General Hospital offered people with stage 4 lung cancer the choice of receiving either the usual oncology care, or that plus a palliative care specialist who discussed what would be important to the patient as they approached death.

People who had that discussion ended up stopping chemotherapy sooner, opting for hospice care (either in a specialist care centre or at home) earlier. They had less suffering at the end of life. And the fascinating thing is they lived 25% longer.

Panama (31/80) Panama’s size means that it can only afford a primary care approach when thinking about end of life treatment. Health staff are trained in hospice and home care services for patients with diseases in an advanced stage. But increasing care quality is a challenge, due to tight regulation of opioids; the law has not changed since 1954.

Sources: Economist Intelligence Unit, ‘The 2015 Quality of Death Index’, http://www.eiuperspectives.economist.com/ healthcare/2015-quality-death-index Compassion in Dying, ‘What happened to the Liverpool Care Pathway?’, https://www.compassionindying.org.uk/ wp-content/uploads/2015/02/IN05-What-happened-to-theLiverpool-Care-Pathway.pdf BMC Medicine Dr Katherine Sleeman, King’s College London, ‘Why the world needs to get ready for more people dying’, http:// www.bbc.co.uk/news/health-43159823 Atul Gawande, Being Mortal: Medicine and What Matters in the End (Profile Books, London; 2015)

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Spain (23/80) A national strategy for palliative care was launched in 2007. Laws give every citizen the right to receive palliative care at home or in hospital, but only 3 regions have detailed legislation to cover this.

However a unified approach across 17 regional health systems has increased access to services, and the ‘la Caixa’ banking foundation has supported the integration of 29 psychological and spiritual care teams into Spain’s palliative care network.

Mongolia (28/80) Before 2000, Mongolia used just 1kg of morphine a year for patients nearing end of life; there were no hospices or a government policy on palliative care. But a single person, Dr Odontuya Davaasuren, campaigned to change this. Ulaan Baatar now has 10 palliative care centres, and provincial hospitals can accommodate palliative care patients too. Since 2006, affordable morphine has been available, and in 2013 non-cancer palliative care programs began.

China (71/80) Filial duty means most think outsourcing care of relatives is wrong; but the one-child policy implies that some people will have 2 parents and 4 grandparents to care for, which will lead to increased demand for state or private help. Patients and doctors focus on curative treatments, not palliative care options; awareness of the latter is increasing, but is unsupported through the national healthcare system.

South Africa (34/80)

TAILPIECE

A strong palliative care tradition is shown by the country having largest number of functional hospices on the continent; the first masters degree in the subject was offered by the University of Cape Town. The prevalence of HIV/AIDS in the country has led to development of non-profit initiatives innovating new approaches to end of life care, while the government is prominent in raising the profile of palliative care globally.

To the end

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TA I L P I EC E

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echnology in healthcare – it’s always a positive, right? You would be forgiven for thinking so, when looking at the broad thrust of commentary around how artificial intelligence (AI), big data and other digital-powered advances are going to transform the way that medicine will be delivered.

And yet, of all the sciences medicine is the one that needs to remember the human element the most – let me put into your mind for a moment the image of a robot nurse taking blood from you. In time this might feel normal. But for now I’m sure a few of you recoiled at the prospect.

Perhaps there is a danger that in the rush to adopt the benefits of cutting edge technology, something might be lost, an essential part of practising medicine and giving care – an empathetic understanding based on common concern and feeling; something that as of yet even the biggest of super computers cannot deliver.

For pointers as to what we might what we need to preserve in this new future for healthcare, it’s worth turning to something first published in 1967. The late art critic John Berger, most famous for his pioneering book Ways of Seeing, and documentary photographer Jean Mohr, collaborated to follow and record the work of Berger’s doctor, general practitioner (GP) John Sassall. (In the UK a GP is roughly equivalent to a physician in the USA.) Berger and Mohr lived with Sassall and his family, in rural Gloucestershire in the south west of the UK, for six weeks and with the permission of his patients, they joined him on emergency visits as well as accompanying him in his clinic.

The resulting book, A Fortunate Man, is a hymn to the many things a doctor must be: scientist, surgeon, listener, confidante, first responder, and perhaps unexpectedly “a clerk of the community’s records”, in Berger’s elegant formulation – a figure who helps the community know itself, remember the important things about itself.

Being a country doctor meant Sassall had to cover a wide range or illness and complaints –the usual bumps, grazes and colds for sure, but he also had to be first on the scene

There are lessons in a 1967 book for how 21st century healthcare should be practiced, writes Rishi Dastidar to emergencies (the book opens with him attending a man crushed by a falling tree), minor surgery, even basic psychotherapy.

Perhaps because of this breadth, he was able to develop long, lasting relationships with his patients, sensing changes in their conditions over time, not necessarily based on clinical diagnosis but rather an informed instinct. While AI certainly promises the ability to know a patient’s records inside out, it might not be able to replicate the empathy that allowed Sassall to tell something was wrong even if he had no immediate proof.

And while the prospect of telemedicine has many promising advantages to it, you struggle to imagine that care delivered via an app can ever fully remove the need, especially in moments of extremis, for the actual physical presence of a doctor. How else is a patient going to get the level of thoughtfulness on display as when, in a small moment of humanity, Sassall treats a man scared of injections by gently tapping on his arm, to distract him from the needle going in?

Berger was drawn to writing about Sassall because he felt that the GP demonstrated that practising medicine was a service – and more than that, a calling. So the question arises – can we, do we, should we try and to programme in this notion to medical machines when we can? If we accept, as Berger does, that a doctor is “an honorary member of the family,” will we extend that offer to a doctor that is software?

It is clear that the medicine in the 21st century will be powered by data – collecting more of it than ever dreamt of, analysing it, using its predictive power to a depth previously unthought of. But as the book tells us, at the heart of Sassall’s

way of practising medicine is the idea of fraternity, recognising a patient as a person with a condition. “It may be,” Berger writes, “that computers will soon diagnose better than humans. But the facts fed to computers will still have to be the result of intimate, individual recognition of the patient.”

A human recognition.

Sassall’s way of working came at a cost.

As Berger put it, “He has to face, far more nakedly than many doctors, the suffering of his patients and the frequent inadequacy of his ability to help them.” Sassall suffered frequent bouts of depression and ultimately took his own life. And while it might be glib to say doctors powered by AI won’t get depressed, it is worth recognising that the potential of all these wondrous new technologies in medicine won’t be fully realised without recognising and aiding the humanity medicine demands of its practitioners.

“I sometimes wonder how much of me is the last of the old traditional country doctor and how much of me is a doctor of the future.” Sassall says towards the end of the book, adding, “Can you be both?” That is the challenge healthcare in the 21st century ultimately faces.

A Fortunate Man: The Story of a Country Doctor by John Berger & Jean Mohr is published in the UK by Canongate