As part of our podcast series, we spoke to Dr Sam Shah, who is on the panel at the 2020 conference. Sam grew up in West London. He moved into clinical practice and was drawn into public health after working in many different organisations, including as a GP where he was introduced to health technology.
Sam is most proud of having launched and introduced NHS 111 online. He also considers his work on Healthy Places, Healthy Lives one of his greater achievements, which focuses on areas in the U.K. to reduce the health inequalities, including specific areas such as domestic violence, teenage pregnancy, and alcohol consumption.
As an NHS clinician, Sam is very aware that health inequalities affect every part of society and the world, generating differential health outcomes, varying access to health services, and disparate experiences using health services. In our interview he talks about tackling these health inequalities by considering the wider social determinants, and shares his belief that people should always be at the heart of digital development.
HEALTH ISSUES ARE COMPLEX, THERE’S NO ONE SOLUTION
Ten years ago, following Sir Michael Marmot’s review of Health Equity, one of the programs that came out from government was Healthy Places, Healthy Lives. The team I worked on was focusing on some of those requirements in terms of working with local authorities, councils, Health Service Providers, including the NHS, of how to resolve of some of those issues by bringing together different agencies, working with communities to tackle some of those issues.
A good example was working on teenage pregnancy. The factors and drivers behind teenage pregnancy was far broader than health care. It was unemployment, income, and housing. So by focusing on those problems, and trying to solve some of those things, we reduced teenage pregnancy as an inequality in society. A public health approach is probably in something that stuck with me.
In health care we often start off and think the problem is in health. But actually, most of the things that affect health are far beyond and wider than health care. They relate to the way people live, their families, culture, ethics, law, economics.
In health care we often start off and think the problem is in health. But actually, most of the things that affect health are far beyond and wider than health care. They relate to the way people live, their families, culture, ethics, law, economics. And one of the challenges, of course, is trying to convince people that we don’t always need more clinicians, rather we need a better way of tackling those wider social determinants.
When you talk about social determinants, who are the people you would bring in to talk about those sorts of things?
I think it’s a complete mixture of people from everyone from social scientists, psychologists, economists, lawyers, ethicists, people responsible for the environment such as environmental scientists. It’s a complete mix of different people far beyond health care because whilst public health has health in the title, it’s far more interesting to work out what the causes are which go beyond health care.
TECHNOLOGY IN HEALTHCARE
You were previously Director of the Digital Development for NHS X. What does technology bring to healthcare? Why are you so passionate about it?
Well, of course it’s not all about technology. But I think what technology represents is a cultural shift in society. And over time technology has meant different things. These days we often analogise technology with digital technology. But of course technology is much broader than that, and so for me technology is advancement, creating something often relating to the machine that is for the betterment of society.
I guess what technology represents is a reduction in inequity, it’s a way that we’ve democratised access to different things from banking, shopping, and even health care.
Today, the internet has been one of the biggest advances of technology, certainly throughout my career over the last 30 years, it’s played a big part of everything I’ve seen. And then in healthcare we’ve seen technology become useful for tele-health and people connecting to their clinician. I guess what technology represents is a reduction in inequity, it’s a way that we’ve democratised access to different things from banking, shopping, and even health care.
You’re passionate about the fact that people should always be at the heart of digital development.
So often we get hung up on the technology itself and those people who can access the technology. But for every person that can access technology, there are many more that can’t and we do need to think about what works for people. And what might work for one person in one community at a point in time might be very different for somebody else from another community or even a similar community. So we do have to go back to basics. It’s about people and what their needs are – and that’s not just in healthcare, but that’s probably in every single sector – really understanding the behaviour of people.
Why does somebody have a need, and why do they draw on that need that results in them demanding a service? We’ve really got to understand people, how they interact with one another, what drives them to behave in a certain way. What is that health-seeking behaviour? What’s their preventative behaviour?
It is definitely about people and what their needs are: their clinical needs, their emotional needs, their practical needs. And then based on that need, how do we design services around those individuals? Which might in some cases involve technology, but it might not.
And for me that’s key because it’s important in the way that people live their lives, but it’s also important in the way in which they interact with health services. And so that people dimension is more important than technology, and often there will be the cultural barrier. Why would somebody want to use technology? Why wouldn’t someone want use technology? What need makes them more likely to access health care at a particular moment?
I’ll give you a classic example. I might have many patients who are in pain, but there are only certain things that cause them to seek health care to deal with that pain. Quite a lot of people want to manage that pain for themselves. Now that may not be the right thing. But what is it that makes that determining point between them actually seeking healthcare and not seeking healthcare? So it is definitely about people and what their needs are: their clinical needs, their emotional needs, their practical needs. And then based on that need, how do we design services around those individuals? Which might in some cases involve technology, but it might not.
You’ve said there are three constant needs in health care, which will always remain the same: clinical, emotional, practical.
Between a patient and clinician there’s the clinical need: there’s something wrong with that individual that I can clinically diagnose and for which there be a management treatment plan. But there will also be emotional drivers: they’ll have concerns, about their family, about their friends, about accessing health care. There will be practical concerns such as if they’ve got children, who’s going to look after them. They might be working on zero hours contract making it impractical to seek health care, or they might have to take time off work. Or they’re looking after other people such as a family member or a parent. All of these things are realities.
In healthcare for a long time, we focused very much on the clinical need but less, if at all, about the emotional and the practical needs.
In healthcare for a long time, we focused very much on the clinical need but less, if at all, about the emotional and the practical needs. A good example might be a parent with a child who is unwell. The clinical team assesses the child and decides that there’s a clinical need, but it’s not very high, and the child should be seen in 3 or 4 days. Emotionally that parent may not feel reassured, they may still be very worried, so they might decide to go to the next point in the system where the doors are open, the emergency department, but that’s not necessarily the best place for them. But they’re there, they’ve paid for parking, or they’ve taken a long time to get there, they’ve got on public transport.
So they feel emotionally connected to that space now, and practically they’ve taken time off now; tomorrow they may have to go to work. So when you take those factors together, that person doesn’t have an inappropriate attendance. For them it’s appropriate. They’ve got a problem they’re trying to deal with. For the system it may not be clinically convenient, but the emotional and practical needs mean that it’s right that a person has done something. Often that balance is between these three things. The issue that we have in healthcare is trying to balance those needs and often we focus on the clinical but the other two are often overlooked, and that’s where technology can play a part in helping solve some of those things.
THE FAST ADOPTION OF TELEMEDICINE
One of the changes brought about by the pandemic is the fast adoption of telemedicine. It was happening very slowly pre-pandemic. What in your opinion the risks, opportunities, and challenges are around tele-health?
I think the risk is, especially when we look at the adoption, has that adoption been uniform in the population or has that been within a certain group? I suspect that adoption has been high amongst those people that have access to the internet, a computer, a safe space. There’ll be many other people who probably haven’t adopted tele-health and I’d be really interested in understanding those individuals.
On the clinical side, there’ll be clinicians who are comfortable using that technology as well as clinicians who aren’t. So where there’s a match between the two – patients who have access to a smartphone and clinicians who are comfortable with technology – adoption is probably high. Where there isn’t a match between the two, adoption is probably considerably lower. So right now, during the pandemic, we’re seeing adoption at a very high rate in one group in the population.
There is an opportunity here, which is to better serve those people who can’t access these services and the technology, and can’t access tele-health. This also leaves more time potentially to support those people who physically need to go into a service and with that in mind, I guess we’ve got one way of trying to make the service and the system potentially more efficient.
If you look at the number of interactions, there’s approximately 1.4 million interactions every 24 hours in the NHS in England alone. That’s probably more than any other health system in the world or publicly funded health system in the world.
The NHS in England is one of the most efficient Health Services in the world. If you look at the number of interactions, there’s approximately 1.4 million interactions every 24 hours in England alone. That’s probably more than any other health system in the world or publicly funded health system in the world. So it’s already very efficient in terms of number of people having an interaction for the amount of money.
In terms of tele-health there is a risk we might omit people who have an impairment, who can’t access these services, who don’t have access to the right technology or skills. There’s an opportunity that we could end up driving a different type of efficiency in the system, but we could end up also driving a new inequality of which we need to be mindful and address.
But longer term we need to do more to democratise access to technology. We need to identify those people in society who don’t have that access and work out how we make it better for them.
In the very same way that the training datasets used for AI could be biased — we can end up driving datasets that themselves are biased, so the solutions might become biased.
There’s also a new and emerging risk which is that the risk of the data — in the very same way that the training datasets used for AI could be biased — we can end up driving datasets that themselves are biased, so the solutions might become biased. So that’s another thing you have to address. But overall, I do think there’s an opportunity from technology, we have to be mindful when we use that technology and adopt it in healthcare that they will be those people that are omitted because of it.
DIVERSITY IN THE HEALTH SERVICE
In 2019, the Financial Times named you as the fourth most influential BAME tech leader in the UK. Healthcare is for everyone, and yet that diversity is not reflected in the people who work in healthcare, particularly at the board and clinician level. Can you speak to that?
One of the things we’ve all seen globally during the pandemic has been the impact of COVID-19 on certain communities. The reason those communities are most affected isn’t just about race or ethnicity, although that’s one of the factors. If we look across users in the health service, the people who have the greatest need often come from the most deprived background and, in some cases, those communities will also happen to be ethnic minority communities.
And if we look at the make-up of the health service, the people at the lower grades, those people doing a lot more of the day-to-day work, who happen to themselves also be ethnic minorities, ee’ve seen a lot of those people be disproportionately affected. And that’s not just people who are black or Asian, but there’s also other people, people from Jewish communities and other communities too, but ethnic minorities by and large. Unfortunately as you go further up the system and not just by race, that diversity doesn’t exist in the leadership roles in the NHS.
We need to do something more to try and improve our inclusivity of those individuals in decision-making roles, in those leadership roles.
The decision-makers don’t reflect that, and even I don’t reflect that. I’ve come from what I would classify as being a fairly privileged background and I am not reflective of those people who are the day-to-day users of the health service. But there are good people in the health service who do reflect those users and we need to do something more to try and improve our inclusivity of those individuals in decision-making roles, in those leadership roles.
If those at the top are all privileged people, that’s not going to help serve the needs of the population. Because one thing, of which we’re all aware, is if we can be more inclusive in our decision-making, we will get better outcomes for society from what is one of the world’s biggest publicly-funded health systems serving a very broad population, and trying to reduce that inequity. And so it’s really important that we do something to change this.
Over the years I really struggled with whether or not we should have quotas, and I know there’s been a lot of debate in other sectors about this but perhaps in our very expensive but well-intended publicly-funded system like the NHS, maybe it’s time to at least have some measures and targets.
We need to change the diversity at the top so that those people making decisions reflect wider society: the single parent families, ethnic minorities, the people from very deprived backgrounds, the people who might’ve had really difficult upbringings.
Perhaps we need to have them to change the diversity at the top of the system so that those people making decisions reflect wider society: the single parent families, ethnic minorities, the people from very deprived backgrounds, the people who might’ve had really difficult upbringings and ended up in very difficult circumstances in their earlier lives. And at the moment I would say the top of the NHS doesn’t reflect those communities. We need to do more to change that because I think by doing that we might better serve the needs of people in society, the NHS might be more relatable to those people, and we hopefully will get better outcomes. Right now, I think we’re a long way from that.
Two clinicians from the Shuri Network are talking at the conference. Are organisations like the Shuri Network one solution? Do you think there are others? You talked about quotas but what other solutions do you think there are?
The Shuri Network is fantastic. It’s a really good way of supporting people, of highlighting the issues, and really trying to lobby for change, and around development and training.
If we can change the incentive system in the entire public sector, especially the NHS, I think there’s some opportunity to bring real change.
I have a really strong view on this. For a long time, we focused on training and education, and we can only go so far with that, but I think we need to change the incentive model in the system. If we can change the incentive system in the entire public sector, especially the NHS, I think there’s some opportunity to bring that change. And one part of that, of course, will be helping provide opportunities and not necessarily formal university opportunities, but those things that bring about social mobility, that will give people chances, apprenticeships and other training opportunities, that will drive a difference in the workforce.
But we need to have a less rigid way of recruiting as well. Our recruitment at the moment is very much designed around the paternalistic society, one that has been driven by a formal type of education from universities, but there’ll be people in society that didn’t have those opportunities, there will be people, for example in technology roles, who won’t have a computer science background because they couldn’t go into that type of role, including women, who weren’t encouraged to go into those type of roles.
I’m sure the sociologists and the anthropologists would be able to tell us the reasons why we’ve ended up with this make-up of society. We need to take those factors and re-design leadership roles so they encourage those people to come into roles who wouldn’t have done, make them more inclusive but quotas is one thing, incentives is the other thing.
Measuring boards on what they’ve actually achieved, not what they’re going to do, but what they have done. Making it a requirement of people in very senior public sector roles that this becomes part of what they have to do, and not just seen to be listening: what action have they taken? And measure them based on the action and that outcomes. That might make a difference.
Make it a requirement of senior public leaders to buddy up and pair up with people from outside the system.
And also shadowing opportunities. Make it a requirement of senior public leaders to buddy up and pair up with people from outside the system, to bring them in, to give them that chance and maybe workplace apprenticeships, and maybe other schemes. It’s incumbent on all of us in senior roles in the public sector to open up those opportunities. Not just listen to people, not just talk to them, but actively do something that changes someone’s life.
One of the things that I tried to encourage when I was still in NHS England and NHSX was providing opportunities to those people who are school-leavers, people in their early part of university, from places who wouldn’t normally come to us, to do placements. And we had some of those placements, certainly last summer, and one sixteen-year-old man from a Black background from a very deprived community. His Church asked us if we give him a placement and I was really encouraged by this, and he wrote a lovely blog at the end of his placement. It was nice for him to see the opportunities but also for us to work out how we can open up those opportunities, and I’d really like to see public sector do more of those things.
It was inspiring for us, but it also taught us a lot about why we needed to change and make the system more inclusive because there were ideas and things that came about from that, which helped us, and having someone who could relate to the people we were trying to help, who was part of our Sprint team, who came to our stand-ups and influenced us. It was so powerful.
INCLUSIVITY IN DECISION-MAKING
What did you learn from that sixteen year-old who was from a deprived community?
The first thing is that we definitely don’t know everything as policymakers. We might have lots of clever people around but we are so far removed from the people we’re trying to affect, we need to be more inclusive when we come to decision-making. The second thing is we need to improve the opportunities for everyone in society through public sector because by doing that we’ll hopefully reduce inequalities, not just in health, but across the system. And the final thing is have no assumptions, literally have no assumptions, because we don’t know what people are going through, we don’t know about their backgrounds, and we certainly don’t know what their potential is, and the only way we’re going to change that is by giving people a chance and talking to them. There’s a lot more we can all do to be more inclusive.
Don’t think about someone’s past and their background, but really think about what they offer now and what they can offer in the future. People change.
Also, there are people who have had difficult starts in life who will have come from very different backgrounds who might get into trouble early in their lives. So don’t think about someone’s past and their background, but really think about what they offer now and what they can offer in the future. People change. For that reason we need to encourage people, especially in public sector which is one of the biggest employers in England, to also be more available and more accessible to those people because they will really help us change. They will change our approach to delivering services to people who may not have thought of. I think that’s something I’d like people to think carefully about when they’re designing and developing services. Not just in the UK, but globally.
INTERDISCIPLINARITY IN PUBLIC HEALTH
The Anthropology + Technology Conference champions the value that social scientists bring to technology and healthcare. From your perspective as a clinician, how you see the social sciences contributing to this space?
I’ve been so lucky that in my public health career I’ve got to work with so many social scientists. They add tremendous value in the design of public health programmes and often make them more relatable and realistic for the people that we’re trying to affect, everything from understanding behaviour change through to what some of those incentive models might be, and understanding the psychology of individuals.
If we all going to have a more digitally-enabled health service, which no doubt we will, which is so rapidly moving and changing, I think there’s a massive role here for social scientists to help us as part of a multidisciplinary approach to designing services.
As a clinician I might know lots about clinical diagnosis. I might know about managing and treating people, but there will be so much I don’t know about, where the help of a group of social scientists could really benefit me, and help me the number of ways: understanding the past and where people come from, understanding how people have got to where they are now, and thinking about the design of services to take people to where I want them to get to. And so the past, present, and future is certainly something where I can see social scientists will really help us. And if we all going to have a more digitally-enabled health service, which no doubt we will, which is so rapidly moving and changing, I think there’s a massive role here for social scientists to help us as part of a multidisciplinary approach to designing services.
It’s very much about us. And it’s also much bigger than us because people are part of the economic benefit of society and if we can keep people economically active, we can keep them contributing to the workplace, to society, to culture, then we’re more likely to have a more prosperous society around the world —this applies everywhere around the world — and if we can design around those people, and help those people and rather than them being done to but making them part of our conversation, part of the discussion, part of the design, I think we will have a better outcome for everyone.
Being part of the design is absolutely crucial, isn’t it? And how often does that happen?
Working with researchers helped us really understand the needs of a broad base of people to understand what made them use a service, or not use a service, so that we could influence the future design of those services.
It doesn’t happen often enough. When I was working with some social scientists, they really helped with different designs as opposed to us assuming we knew the answer. Working with researchers helped us really understand the needs of a broad base of people to understand what made them use a service, or not use a service, so that we could influence the future design of those services. We did an exercise with a group of scientists that helped us understand why people use urgent and emergency care services, which gave NHS England some rich insights that wouldn’t otherwise have come about, which I hope will influence the future design of those services. Equally the way in which 111 online as an urgent care service has been designed or the NHS’s own app has been, using that approach to users.
When I was recommissioning some services a few years ago, meeting both the deaf and the hard of hearing community really pushed us to think about the design of those services to meet their needs. And I think if we hadn’t met with them and really understood those nuances, I don’t think we would have designed things that were at least better than they were before. They’re far from perfect but this highlights why we need to have that blend of social scientists, people from health care, and citizens. People in healthcare don’t have the answer. Yes, we can design policy, commissioning models, and technology, but we don’t always know is what’s happening to people.
What I really like about working with anthropologists is that the historical context is key. Take a place like London: there’s a reason historically that Tower Hamlets one of the most deprived places. It gives you much better understanding of how to design the future, based on knowing what happened in the past.
You can listen to the full interview with Sam on our podcast here.