Unmet need in NHS primary care – How can industry best support PCN leaders?

Dr Farzana Hussain (GP Principal, The Project Surgery) and Prof. Phil Richardson (Chair and Chief Innovation Officer, Mtech Access) explore the unmet needs of Primary Care Networks (PCNs) and how industry can best support primary care leaders and GPs as we head into winter, 2024 and beyond.

Former ‘GP of the year’ and strategic influencer over primary care policy, Dr Farzana Hussain, discusses the unmet needs in primary care, how primary care leaders are responding to these challenges, and where industry can best offer support.

Phil and Farzana discuss:

•  How unmet needs are identified in primary care, the processes followed, and datasets used to inform decision making
•  The specific challenges facing primary care as we head into winter
•  The role of PCN leaders and their impact on national policy
•  How industry can best support and collaborate with PCNs
•  Ongoing lessons from the pandemic and the vaccine roll-out

Learn more about this webinar at: https://mtechaccess.co.uk/unmet-need-nhs-primary-care/

Discover or NHS Insight and UK market access services: https://mtechaccess.co.uk/uk-nhs-insights/

This episode was first broadcast as a live webinar in October 2023. 

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Transcript

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- [Host] Welcome to this Mtech Access webinar. At Mtech Access, we provide health economics, and outcomes research, and market access services, from strategy through to implementation. Our unique NHS relationships guide and validate everything we do in the UK. We work with over 80 NHS Associates to bring our pharmaceutical and medtech clients authentic insights into the NHS. We can help you answer key questions related to the NHS, from how to communicate with integrated care systems, places, and primary care networks, to how to capture pathways of care. Get in touch today to discuss your market access goals. First though, I hope you enjoy the webinar.- Hello, and welcome to this NHS Whispers session. I'm Phil Richardson, and I'm delighted to be hosting this webinar today on unmet needs in primary care, and how can industry best support primary care network leaders. I'd particularly like to welcome our NHS Associates who play a key role in the work we do. And for those that don't know us well, Mtech Access is a specialist health economics, outcomes, and market access consultancy with a track record in evidence-based delivery. We specialise in supporting both pharmaceutical and medtech clients, and we work both nationally and internationally. And we also work as a collaborative partner with NHS colleagues. So today we're focusing on unmet needs in primary care, and I'm delighted to welcome our guest, Dr. Farzana Hussain, who's a GP in East London and a national champion for population health and equality. So welcome, Farzana. Welcome to NHS Whispers.- Thank you. Thanks for having me, Phil.- No, you're very welcome. I'm delighted that you're here today. Maybe you could take a moment just to introduce yourself and give a little bit about your background.- Sure, I'd love to, thank you. So, yeah, I'm Farzana, so I'm a GP in Newham in East London, and I've been a GP for, it's my 22nd year now. I've been a doctor for 26. So I hadn't actually intended to work in Newham. I actually did my undergraduate training to become a doctor in Wales, actually in Cardiff, but then got married to somebody in London, so moved over. And when I first came to Newham I thought,"Oh, it's really ugly here. It's got lots of concrete, not much green. I don't think I'll stay for more than six months." Six months became 27 years. I actually live as well just a little away from the Olympic Village actually, where they had the Olympics in Stratford. But Newham's kind of known for sadly some of the, you know, all the wrong reasons. We had the highest COVID death rate in the first wave of COVID, sadly. Despite the Olympics of 2012, we still have a lot of poverty. We're 74% BME. So I run a practise of 5,000 patients. Newham's quite a young population, and within Newham, my practice, The Project Surgery's quite young. So out of my 5,000, I've only got 200, only 200 over 65s. But despite that, lots of long-term conditions. So people are getting sicker at a younger age. So lots of under 40s with things like diabetes. So apart from being a GP partner, I like to try to keep out of mischief, do a few other things. So I love being a GP, and it's been really nice over the 22 years to be able to do different things. So when my children were younger, they're 19 and 20 now, but when they were younger, it was nice to do more medical education roles along with my GP partner. So I became a GP appraiser. I was a GP trainer, and the GP appraiser was quite flexible as well. I've always been quite interested in sort of quality and regulation. So when the GP contract in 2004 had the Quality and Outcomes Framework, what many GPs called QOF now, it's part of our national contract to look at long-term conditions and improve the management. I was a QOF assessor, so I had the privilege of going to sort of visit practices and seeing what they're doing. And after that sort of then CQC came along, the Care Quality Commission. So from 2014, I was a specialist professional advisor for them, again, doing visits, similar things. Then tottering along with my patients. And Phil, I was getting this frustration sort of quite early on actually, even within the first 10 years of how much I liked being in the consulting room, but how limited the help I could give my patients in the consulting room was, because a lot of system constraints and society as a whole. And I think, you know, we are seeing that a lot now. When the kids got to teenage years, 14 and 15, I had to do far less for them. I used to just give them a bit of money, feed them and cope with the banging of the closed doors and them not speaking to me. But it did actually enable me to do a bit more. So I got quite interested in work outside of the consulting room. And so for example, if I have a young patient with asthma, and actually we know that that child also has asthma because they live in damp conditions, and how housing can influence health. And actually mum's a smoker, which we know bothers the asthma, but actually that's all mum has as her go to, you know. So all those wider determinants of health. And then back in about, this was about 2017, and I've got quite interested in the work of the NAPC, the National Association of Primary Care. And they were talking about these things called primary care homes, which were sort of looking after a population of about 30 to 50,000, and general practice working together with the hospitals, with the community trust, mental health trust, voluntary sector, and particularly our communities. And then interestingly in 2019, that became part of national NHS England policy, and the primary care networks developed. And so I became a clinical director for one of our nine primary care networks in Newham, the largest one. So up to three years, I was the clinical director. So we were looking after like 67,000 residents. One thing led to another, Phil, and I was quite really passionate about this module of community care and the NHS Confederation at the time were building up their primary care arm, because they have their other networks, the hospitals, ambulances. I got the chance to be co-chair of the national PCN network, the first co-chair. And that was quite nice for me, because I've never done a role like that before. I've never had the chance to like be, well, it was online because of COVID, be in a virtual room with sort of junior ministers. So it helped my learning, but also helped me see what a complicated system it is. Maybe sometimes I can controversially say we make it more complicated, we make it more difficult. So yeah, so that's me really. So I'm still enjoying being a GP, and yeah, just liking to learn and try to keep myself out of mischief.- Yeah, well, I'm sure the first is true. The second I'm not so sure, but I think there is definitely, there's definitely a lot of interesting things you've just talked about. I think being able to join the dots by being in those different settings, I think becomes massively important. And I completely see what must have felt in isolated way as a GP in general practice, and then suddenly having access to the different conversations which happen at all the different levels. And our audience are trying to unpick how the structure works and what that complexity is and the moving parts. And I think even with being in the system, and certainly my experience in the system was similar. It's a pretty dynamic situation with things ebbing and flowing. But I'm really interested in the primary care network bit. I was going to ask you, if you would've started again, if you'd still would've been a GP? I'd be quite interested in that. And then the primary care network, having had access to all the different things, either the Confed and the way it works, or CQC, or some of the other advisory work that you've done, as well as practice in what is quite an unusual demographic compared to lots of other demographics. How does that help empower the PCN? And does it empower it? And do you have an integrated neighbourhood teams as well sitting on underneath that? So anyway, would you have been a GP if you had to start again? Would you still go back and be a GP?- Absolutely, absolutely, I would. I think I didn't know much about it to be honest, Phil. I mean, my dad's still up, I grew up in Lancashire in the North West in Preston, and my dad's a retired anaesthetist. He's still up there. So, I didn't know much about general practice. I always remember like dad going on his own calls, and, you know, more about hospitals. But I just thought I would like it. And I remember the day when I really wanted to do it. I was the third year medical student, and we had just been let loose on the ward to actually see patients. And my consultant, I was doing a breast surgical form, he said, "Do you want to take the history for this lady who had breast cancer?" And it was all me, just on my own, on my own, just me. And he was a great consultant. He just let me, and I loved talking to her. I didn't know any of the medicine, but I loved talking to her and I loved that bond with her. And I thought, I really want to do this. Gosh, about nearly 30 years later, I'm so happy that I'm doing it. I'm interested in people. I'm naturally nosy and I think if you're naturally nosy, it's a really good quality to have as a GP. I've also been lucky that I've been at the same practice for 20 years, and I think that continuity with the small list size. They're not family, but they are an important part of my life. And that human relational connection I think has helped me get a lot of joy in my work.- Yeah, I think that is really interesting. That ability to have a sense of the population and where it's at, rather than what might be, you know, a clinically analysed piece of data on a spreadsheet showing what the numbers are. I think that, I mean, that must make a massive difference, you having the insight of experience it, and understanding who the people are much better.- I think it helps the work, definitely. So we've got some data recently about, the Public Health gave us some data, so talking about integrated neighbourhood teams. We're still very much in our infancy in Newham about that, as I think many areas are. But it's nice to actually think, oh, there are teams called Public Health, and they are really good at giving you data, and not data for judgment. Because the data that the average GP is used to like me is you haven't hit your targets for this, you haven't, you know, it's very much data for judgment, which doesn't always, you know, it's not always positive, and psychologically doesn't always make us want to do more. And they gave us this data on the number of children that were on free school meals, and it was absolutely correlating with the number of children that I thought were at high risk of knife crime. So really interesting to use data in a way to think about, so we were doing a PCNY project actually on health inequalities about trying to reduce knife crime. And interestingly, when we saw those young people, 11 to 18, it was all the things, the medical bits you would expect, like mental health and, you know, substance misuse. But at the moment, we've got a gap in those wider determinants, and it's fantastic to be on here, to be honest, to see how, where the NHS is missing parts, maybe what we could, you know, work in partnership with our industry colleagues together about, because the NHS is missing parts. We're still, I think, very much sadly in the medical model. I mean, I know we are the National Health Service, but we are still very rooted in the medical model, which I think is not going to work for 21st century medicine.- Yeah, and I think that's a really helpful reflection. There has been quite a lot of discussion about the wider determinants of health, but then when the pressure comes on, the medical model comes back out, and it's a treatment of a body part or a mental part or something, and it's very often not holistic. And I think primary care and certainly GPs, championing the causes the way you do is really the essence of the whole basis of an integrated care system. And I think the bit around how you bring it together in a way which says medicine is a part, and I think some people are quoting that it's perhaps only 5% of the solution, but we're giving it 100% of the attention, and perhaps there's a different way of thinking about it. And that seems to reflect what you're experiencing. The knife crime though is quite interesting because that, I heard you talk at UCL about the the knife crime story, which is absolutely fascinating. And while it's incredibly troubling as a subject, the insights that you were getting from it, and the either causal or at least correlation between some of the other things, that was quite an interesting point of view to take. And I wonder if we think about our audience coming from industry who are passionate about helping patients, passionate about care overall, coming similarly from a medical model actually, and then trying to work in the wider space. If you had access, if you had volunteers of help or access to resource or something, and you were looking at either the knife crime and extending that out or against some other things, what would be the things front of mind that perhaps we could work with people afterwards, if they're interested in having a look at some sort of key themes or key topics?- Well, I think the first thing to say is, it would be great to have interest because like a lot of NHS projects, we got a little bit of seed funding to start this project, but then the funding stopped. So again, you know, unless it's some very measurable disease focused outcomes, sadly, often contractually in the NHS, we don't want to know. So unless it's your diabetes control, or the number of days spent in hospital beds, you know, because knife crime is such a huge holistic topic, and because young people generally don't take up bed space, young people are not as potent. So I guess if I had a magic wand, Phil, I mean there'd be a couple of things. We did, we know young people use a lot of social media, so we did actually have, so as part of the project, we did commission a social media, not a platform, like they're a company, I think they've got, can't remember what the name. But that they just did a page for us where any young person could look at it and say, when they were on their social media. I don't know how the tech works, but it just like came up as sort of an advert type thing for them."Are you affected by knife crime?" Phil, we had people who are not involved in this project or anything, we had 200 responses and we had over 1000 views. So they gave us the stats for the views. Not many young people wanted to leave their names, but I understand they wouldn't want that. But it was fascinating insight that young people, 15 year old boys and maybe a few more girls, but 15 old boys don't come and see 50 year old GPs like me, unless they're dragged in by their mother for acne, and then their faces are down. But you know, asking them to engage with us in the consulting room, it's not very useful. And then asking them,"Are you worried about being involved in a gang?" It's just not the right environment. But it was striking to me that to get 1000 hits from a cold page where you'd think young people wouldn't be interested. So I guess my first thing would be to get help in how we actually engage with our young people, and it's not face-to-face. It's not face-to-face. I don't think the NHS is particularly good at embracing the tech. I know we've got the NHS app, but again, that's not going to meet the needs of our young people. And then I think some things that I feel don't actually cost that much. So having not necessarily, you know, a highly skilled clinician, but having more sort of youth workers, and that's what we've used. And that doesn't need to be a person, you know, that might be done again over technology, over an app, and if there was any more concern, then they could see the person. But so that they would have support of a human being, but they could do a lot of their communication. I mean, I noticed in my own 19 and 20 year old, or I mean, I actually asked them,"If you had the choice of going to see your GP face,"'cause they're fit and well luckily, so they don't have any health problems. But would you email them? You know, would you go online? Would you telephone? They both wanted to do it online. That's how they communicate. They were Snapchatting their friends. They can't bear to see people in the room. It's just like, what a waste of time. But that's how they communicate. So it's almost like learning the language. So I guess those would be my two, or something about more engagement with social media, and also something that has a human, so that they're not in a faceless world,'cause I think teenagers also go from suddenly needing a bit more and not being able to express it. But I think that would, and I haven't found in my experience in the NHS that we have any sort of like, what I've said sounds really radical even though in the non-medical world, that's happening all the time. But if I asked for that in the NHS, like, well, we don't do that. You know, that's not going to happen.- No, okay, well, that's fantastic. There's a couple of really good clues actually, and then we can follow up if anybody's interested in taking it forward. But there are definitely some organisations we're working with who are working above brand, is the phrase, to move away from therapy areas and much more holistically into care itself. And I was having a conversation yesterday with somebody who was looking at social media surveillance to help identify trends and conversations that could help and inform the type of engagement that you've just been talking about. So there's probably quite a few things in the mix there. So, that's really helpful. And I think if we sort of broaden out into broader therapeutic areas, you and I just were talking earlier about cardiovascular disease. One of the challenges I think probably for patients and maybe clinicians, and certainly for industry is the, well, who's in charge? If you look at it from a integrated care system, primary care network, specialist groups, alliances, the national directives with some clinical director nationally owning it. How do we, well, how do you sense make in that space to make sure, you know, it's all been the best we can, collectively what the best service is? And then how could others start to think about it?'Cause it's massively frustrating I think for everybody. We're just interested in, you know, you might have some interesting perspectives on, if we just take cardiovascular diseases. I mean we could have used diabetes or any other thing. But if we just take CVD and then, how does it all add up?- I'm glad you've asked me the question who's in charge, because I thought I was the only one who didn't know, but it's clearly not just me who doesn't know. And I do think that this is actually a very important question, if not the most important question, because at the moment, you know, we've had PCNs, primary care networks for four years, but now integrated neighbourhood teams are coming. And you know, you know, I just read in the "Health Service Journal" yesterday that all 42 ICSs are have blown, are on target to blow their budget. Like, none of them have managed. And actually where I am in North East London and Greater Manchester, we are the two biggest culprits. And you know, a thought sprang to mind that if you've set a budget and the whole country has not managed it, perhaps your budgeting was wrong. I mean, if you sit an exam and everybody's failed it, you do need to wonder if the exam question was correct. But I think we've got, I know funding is important, but I think we have got two major distractions in the funding. And then the power of an integrated care system should be integrating care, but of course, because we've got disparate provider organisations, we often sadly still see in reality that the larger ones, often the acute trust are the ones who are still holding the power. So it's very difficult then to shift resources out into the community and primary care, because actually, and that's how it's always happened. And when people are under stress, they tend to carry on doing what they've always done. I guess my challenge to myself is so, you know, that's the problem, what's the solution? Is I think maybe we should all be in charge. So, you know, I've reached 50 and I'm very unedited in what I say, so I don't really mind who I upset now, because I think who is in charge of the 5,000 patients I look after? Actually I am in charge, I am their advocate. They cannot speak up at meetings. How much impact has it made, Phil? I mean, you could challenge me and say, so in the last, since 2017, you've been a GP Federation Board Director. So we have a Pan Federation, like at place level, looking after, you know, all 46 practices and the 400,000 people in Newham. So I've been a GP Federation Board Director. I have had, you know, a Confed national role. I was on the NAPC's national board. Has it made the impact and change to my patients in the consulting room? Which is why I wanted to get out of the consulting room. I'm not sure. I don't know. I cannot say to you hand on heart that I have made the impact that I had bushy tailed, bright-eyed, gone out there and thought I'm going to do this. I've got the opportunity to speak to, you know, ministers. I actually do think I've failed. I don't think I've made the impact. I don't think if you looked in East London's cardiovascular disease prevalence, it's any better. In fact, we know that there's a financial cost to it, that cardiovascular disease is not only still one of the biggest killers in the country, it costs the NHS one of the morbidity with the, you know, amputations and everything else, and the heart attack treatment. So that bit, I'm still trying to fathom. I've not got there, like why I can't connect that policy because we all want to improve health for the nation, but why that isn't happening. What I would say to like anybody on this call is like, well, what I've started doing is I'll talk to anyone and everyone, like you, and I was so lucky to meet you. That's how we met. We were just both at the talk at, and thanks to you, we kept in touch. And I think sometimes I think if you like say your story, sometimes it does affect somebody. Somebody might say, "I can try and help" or "What can we do to help?" So in that sense, I think it's probably, I think we're all in charge because I'm not getting a sense of who is in charge, and everybody feels that where there's money concerned, they are in charge, so they want the money. But when there's outcomes and holistic care, nobody wants to be in charge. It's like somebody else's fault.- Yeah, I think that's really interesting. I did an interview with the BMJ back in 2015, I think it was, and I was suggesting that GPs become the chief exec of the community. And as a way to try and normalise the chief exec of a hospital equivalency where funding typically flows, or decisions are typically made. And there were a few people who thought it was a good idea, and then there's quite a big outcry how dreadful that was. But I think the bit which is, you are the advocate for your patient group. I couldn't think of anybody better than you to do that, because it has to be impossible for patients to put together the various pieces of the various pathways. I was in a hospital, a teaching hospital recently in pathology. There was a person in there and they were ranting generally, they were in a wheelchair and they were ranting generally to anybody who might listen. And they said, "This is the fifth time this week I've been in here because five different specialists have asked for the same set of bloods to be done." And you think, well, who's speaking up for that person? And of course, nobody. So the phlebotomist was saying, "Well, you know, we can't do anything about it. We just have to process the requirement." There was no direct connection back to what effectively is the multiple consulting team dealing with each of the individual pathways. And that's likely a person who would end up at your front door saying,"This is happening to me and I don't know what's going on, and can you help?" So, I think there is, I think I love the bit about you standing up and saying, you know, it's your responsibility, and there's quite a few GPs who are in that same space. And I think it's the wisdom of the crowd, or the collective movement or something that will make it work. And people do want to help, but they don't know how to, because they've been siloed either professionally, or clinically, or pathway, or organisationally, or something, and feel disempowered. And I suppose my worry is, it'd be interesting to get your thoughts on the patient. There is a lot about patient empowerment, which feels a bit of an abdication of responsibility in lots of cases. You mentioned about the app earlier. Well, you can now manage your healthcare on the app. Well, you can't really, because you don't have access to a 10th of the information that anybody else would have access to, understand it either.- Exactly that. Yeah, I mean, your example of the bloods is a really good one, isn't it? Because, I mean, I'm lucky that in East London we do now have the East London patient health records, so at least I can see hospital blood results. So that's been really sort of like, but they can't see ours yet. So the hospital can't see ours but at least we can see theirs. But again, who has got, you know, overall responsibility for that? And I do know that now obviously GPs from last October have given, we are sort of contracted to give full access. But again, not everybody has access to the app and not everyone can understand it. So that again is somewhere where I think, you know, I wonder, some of these are quite simple things like just, it would be a short term thing to help patients where people just understand the main bits about the app. I know when wanted to change our consultings to not just face-to-face but to online at the practice, my admin team did quite a lot of, for about three months, quite intense training of, we'll help you fill in the form, you don't have to do it by yourself. And this is an area where English is not the first language for the majority. But what was interesting is after they'd done it with the reception sort of holding their hand the first time, then second time just on the phone talking, they got it 'cause it was confidence as well. So sometimes these short term things, so that again, you know, might be something where some help will be useful, because people are generally not stupid. They are very motivated to want to know about their own health. We're not all motivated to look after our own health. I certainly am not doing enough exercise. I hate exercise. But you know, but I'm still interested in my health. We are interested in our health as human beings. So I think that would be good, and it would certainly help this duplication, which of course wastes resources as well, doesn't it?- Yeah, well, yeah, it absolutely does. And then the solutions are obviously just done at a single point in time. So symptomatically responding, rather than more holistically responding. So not doing a whole person response but responding to a rash, or anaemia, or some other thing. Whereas actually probably a lifestyle change might be more appropriate. Talking about exercise though, I was involved quite a lot of hospital reconfiguration work, and I suggested at one meeting that perhaps the hospital car parks should be about 400 metres further away from the hospital rather than right outside the front door, just to get step count up. Anyway, that was dismissed as a bad idea too. But I think you have to keep trying, don't you?- I did really like your point that, you know, ahead of your time, Phil, that you made in 2015 about, you know, general practise COs, because that's interesting because the GP Federation started about 2016, didn't they? And I was on it on, yeah, started 2016. And sort of one of the visions of the GP Federations would be that at place level, so instead of 46 different practises all trying to get their voice in, and no one knows which GP need to talk to, that they would be the overarching. Again, it hasn't really been lived out as such. And I think one of the issues, and this is a controversial statement, but I can say this'cause I am a GP partner, I think because the GP partnership model of course is designed to be competitive, not collaborative, I get more brownies if I register more patients and can get them off my mates. So, it is designed to be competitive, and I think that's one of the issues we're seeing in integrated care systems, because of course it makes sense to all integrate care, but when we all want our pennies and everybody's overspent and the hospital's overspent, it's hard to see how in reality people will collaborate,'cause organisations will of course fight for their own organisation.- Yeah, and it becomes a multiplier when you start bringing in local authorities and the responsibilities in the wider social care space. And then you need to bring in a very large number of private providers who provide actually most of the social care in the care space. And then you've got all of the charities and voluntary sectors and all sorts of others, and unpaid carers who play a massive role in all of this. And there is tension, isn't there, between that competitive position, which is I need to demonstrate my performance, versus actually I need to get everybody to the best health they can be, based on what they're prepared to do and we can collectively do to help them. So I think that is quite a challenge. But some people do need to break ground and say actually that we should stop messing about, and we're all in the same space. So, what can we do collectively together? And when teams come together that way, and I've seen it with care navigators and people looking at flow from a patient point of view, as opposed to a performance point of view, then magic can happen at an individual level.- And I think the economic, ultimately, you know, I've changed my position as I've got a lot older. When I started work, well, I mean, I'm a huge believer in this, but when I started work, it was almost like I was taught, I'd say it was almost an indoctrination, I feel like. I was taught that like anything private, like it's a really dirty word. Like all those private providers, like if they're non NHS, well, they're just grabbing money. It's terrible. And then as the years went by, I thought, I'm a GP contract holder, like I run a business. It's an NHS business, but I need to have money to pay my staff, to pay my bills. I mean, I'm running a business, it's just it's an NHS business. And sometimes I think, as I've gotten older, it's a personal viewpoint, but it's just sometimes I think the word private is almost used as a dirty word. And it does, I think, sometimes inhibit innovation. So I was on a meeting today, and somebody was telling me that, well, it's not somebody, I mean, that CQC have got their State of Care Report coming out launching on the 20th of October. And that they found, I mean, this probably isn't news to you, but in social care, for every one pound spent, seven pounds is actually, you know, got back, as it were, because of the savings you are making on, you know, the carers who are not working because they're caring, but like seven pounds, that seemed like financially... And I think Confed did a report quite recently looking at the wider economic thing, not just in health, but again, we know that we're in a time at the moment in this country where a lot of working people, I think we've got more people out of work than before, and surprise, surprise, young people on waiting lists for their needs for their hits. The number of sick certificates I'm writing because they can't go back to their job, but they're waiting on a waiting list. So, investing does then have better financial outcomes, even if we take the humane aspect out of it.- I think, I was involved in the work, it was the end of December. It was December 9th actually last year that the Confed report came out.- Oh, you were part of that, oh, yeah.- Support of that. And this was addressing the ICS's fourth objective, which seemed a bit vague at the time, which is, you know, improve economic and social contributions. And I think that expressing health as a, how can health be a positive contributor to society, both communities and families, and economic and social prosperity seems a much better way of framing the discussion than, how can we systematically, through productivity, increase symptom resolution? Or whatever the equivalency is.- It sounds robotic, doesn't it? Your first, yeah, one was so much more humane.- It doesn't sound, and you know, people in the main want to do, they want to contribute to society, want to contribute in the economic sense. And I think we're letting perhaps some old fashioned ways of thinking getting in the way of what now is quite a dynamic fluid economy, with people making very different choices,'cause they're much better informed, and have access to information in a much different way. So I think there's definitely something in that space. But I was struck by some of the work you did during the pandemic in driving up immunisation rates, and particularly the kind of, the demographic you have in the main nationally was more disengaged from government policy, if that's the way of framing it, than other demographic groups. So, what was the secret sauce then? What was it you did that managed to make that difference?- So, this was one of my highlights, Phil, and this is why I've loved being a GP, and actually for the last 10 years, I was single handed because suddenly, I used to have a partner, but suddenly he passed away 10 years ago. One of the nicest things about being lead of just a 5,000 list is I can have an idea in the morning, and by 12 o'clock it's implemented, because we have only 10 people in our team. So what actually happened, Phil, is in the area I am, I mean, immunisation rates for our kiddies, it's always hard to get them up. It's never easy. And London had already had a bit of a measles outbreak, and it was at the time, when at that point we still didn't have a COVID vaccine, we were in that first lockdown, those early days. And I could see that obviously the message was, you know, GP surgeries, you know, are closed. It's all on the telephone. But of course, nursing appointment was still available, and the immunisation rate just dropped because, you know, I had a mum say to me,"I don't want to bring." People care about their tiny babies. You know, "Don't want to bring my two month into what might be a COVID ridden waiting room." And I actually thought to myself, we've got an infectious disease in the world that we don't have a cure for, but now we are going to have all the Victorian diseases come back in our kids. We've already had a measles outbreak, you know, diphtheria's going to come back, polio's going to come back. So it was just a wacky idea. I thought what would happen, because we are having, you know, people started having walking meetings outside. I thought, what would happen if we started immunising our kids just outside, sort of just in the front garden? And we're lucky that we're a house that actually geographically lends itself, or we're a corner house with a big front garden. So it started off being called the drive-through clinic, where parents could drive in, and we would literally, the nurse would go with her helper with the anaphylaxis kit and jab the baby. And then we realised that 50% of Newham, and they don't have cars.- Cars, yeah.- So then we said, well, your buggy could be a vehicle, so the baby would come in the push chair. But it really took off, Phil, it's probably one of the best things I've ever done, because there was no bureaucracy. The only thing I needed to do, this will make some people laugh, I needed to let Care Quality Commission, our regulators know that I was doing this in the front garden. We had to register our front garden as a branch surgery. (laughs)- No. Really? Wow.- So that we were so that we were regulated. But they were fine. We can do this for you, but my front garden at the surgery is actually a branch surgery of The Project Surgery, so that we could do it legally. Parents were brilliant 'cause, you know, there were some days in April it was still cold and I said, I don't really, I just want to. They were like,"We can see you're trying your best, Doctor." And we kept our rates up. I was so happy.- That's fantastic.- Since then, things have been bad in London when we've had to have a polio catch up campaign. There's been a polio outbreak in Newham. So I'm glad I did what I did, because things have, you know, we are seeing a bit of resurgence. That's a really good example of something where there was, because everything was new, there was very little bureaucracy, and it was that trusting, if Farzana or someone like Farzana's got a madcap idea, but the intention is improve, just let her do it. I don't know if I could do that now. I think the bureaucracy's come back again.- Yeah. Well, it does eventually catch up, doesn't it? To take the innovation out. That's my experience. I mean, I remember being involved in the very first conversations about the first vaccine and the need to have it at minus 80 degrees. And I was told nationally that GPs couldn't possibly do this. They couldn't possibly, so it has to be a hospital delivered service. And then there was obviously quite a lot of pushback from primary care who said,"Well, don't be a nonsense, you know, you'll never be able to do it in a hospital." But your solution's a fantastic one. One of the things I was going to ask,'cause I've got some experience of working with GPs who work in communities which are pretty much NHS averse, just generally averse, whether people might have been happier to come to your branch surgery to get treatment even going forward, whether it's immunisations or not, than they would to actually go into what is a clinical building. And I don't know if that is-- That's a fantastic point you raise, Phil, because when we had all these sad deaths during the first wave of COVID, I became very passionate about promoting COVID vaccination, because I could see that it was mainly my BAME patients. In fact, it was so stark, out of my, I've only got 200 over 65s, After the first few weeks of COVID vaccine, 100 of them had had their vaccines. The 100 that hadn't had them were all non-white except two Eastern Europeans. So all my British Caucasian patients had had them, and I was fascinated by this. So because the numbers were small, I actually rang them to ask why, not to make them have it. And the media got hold of it, Phil, and I got, like, I became a literal celebrity. I was on the news and everything. And it got bigger and bigger, as stories do. Like, "Oh, Dr. Hussain rang all her patients. Dr. Hussain rang all of Newham. Dr. Hussain rang everybody in London." I never rang everybody in London. I didn't ring 8 million people. But the story went that I single handedly rang 8 million people. It was hilarious. But when I called them, this is why I think you are, very important point you raised about people being of averse to NHS. It was stories of, you know, some of my Afro-Caribbean patients were saying,"But I know," 'cause they're still old, they still remember their grandparents' generation. They're in their 80s and they remember their grandparents being slaves. They remember their grandparents being tested upon. So it was quite a deep thing that they needed to vocalise. One of them, I just said, I've known her very well and she actually, my mum died when she was 57, but my patient was actually the same age as my mum would've been. And I just said to her, I said,"My mum would've been your age. I've lost my mum, but if I could have had my mum have this, I would've asked her to have it." And as it's not my mum, but she went and had it. She went and had it, and her son, he said, "I don't know what you did, but I was trying convince my mum." And that's the power of a relationship-- Yeah, it is, yeah.- Because I could never have got away with saying that to her if I didn't know her. Didn't work for everybody. But I think you raised a really important point there, Phil, about where we do healthcare and who does healthcare. So I had a bit of pushback when people saw me on TV. Somebody said, "You're working for Mr. Boris Johnson, aren't you? He's told you to talk about COVID vaccine, hasn't he? And I don't believe in it." And I said, "I don't get paid from Mr. Boris. I am independent in the work I do. I don't get paid by him directly. I can say what I believe in." And when they understood that like I wasn't being controlled, because I think there was a lot of upset, and there still is in many, many communities that they tie in immigration rules with, oh, so they can't be thinking about our health. And that's where I think we need the local community sort of doctor voices more than ever to be truthful.- Yes, and I think it's interesting, there's something work we did brought in faith leaders and community leaders and others, and we discovered during the vaccination programme a Nepalese community that weren't registered with anybody. And they had managed it themselves. They had their own way of dealing with healthcare. And it was only when they came forward, some of them came forward for vaccines that we suddenly appreciated there was a community based. And they were the extended families of one of the local army Gurkha regiments. And that was quite interesting. And it seems that there are, you know, the language at the time was hard to reach groups, and I think more recently everybody's realised it's hard to reach services. And I think that's becoming more relevant. But the settings of care, I think, that feels like that's really important in how we go forward.- Definitely.- If we maybe jump forward in a technological sense, as opposed to a time-based sense, and have a look at how you, or maybe, or your colleagues have started to use technology in primary care. I'd just be quite interested in what sort of things have you embraced? And there's probably a question, which is, how did you get funding?'Cause you know, the GP contract's not aimed to fund things in that way. And the commissioning system has now been disassembled and reassembled in a slightly different structure, which is for some people still not completely clear how all that works. But have you got any examples? And I've tried to avoid brand names, but if we could talk sort of therapeutic areas and types of technology.- I'd say overall, I don't think, I don't just think we're bad at using technology, I think we're very bad at using technology. So I think overall, we're not good. I mean, you know, for us to, there are many practices who still haven't managed to embrace online consultations, which is, you know, quite, if we take ourselves out of health, we think actually most people do communicate on email these days. You know, it is, but actually somehow for some practices, online consultations are still very difficult. Texting patients is still very difficult. So I think our baseline is very low. The other thing to say in probably our defence is we are not very approached. So, I've been recommending a few like sleep apps to my patients, but that's actually because I was approached by some people who were involved in that app. I wouldn't have known about it otherwise. It didn't happen through the practise or the PCN. One of the reasons I was very interested in this is because as a GP, I'm very limited and very rubbish at treating insomnia. You know, all the medications are addictive. We don't want to give sleep tablets. And actually, not everybody is clinically depressed, but there's a lot of distress with cost of living and isolation, COVID trauma. A lot of people are suffering from mental distress at the moment, which isn't clinical depression. So insomnia is big. So that was really helpful in my work. But I wouldn't have known about it unless it was, you know, it was like a chance meeting, like you and me. So I guess a question for myself is, how do we talk to suppliers in, you know, industry more? And how do we do that without, I guess, how do we do that? This is probably not so much for the younger GPs,'cause they've been probably brought up differently. But certainly 22 years ago when I trained, Phil, like you didn't talk to anybody in pharma because somehow you would get, you know, with a bad thing to do, and they'd give you too many pens, and you weren't allowed to have the pens. There was a real sort of, almost a moral thing about it. You don't have, like we never had drug reps in our practice. And as time has gone on, I mean, I recently did some, I did a health inequality webinar with, I can't remember who, but one of the big. I can't remember if it was Pfizer. I can't remember who it was. But it was nothing to do with brand. It was just that they wanted my, you know, we did a webinar with some other experts on health inequality, but there was no branding in it at all. And I thought this is such a great thing because we're giving information. So I think there's a cultural thing to overcome for both sort of GPs my age and pharma. And then the whole practical of actually how PCNs are probably better placed, but how do you go to, you know, even 46 practices in one small area? But a PCN is a big unit, so it might be easier to approach a PCN.- Yeah, I think that's really interesting. It's been a standing issue for all time. How do you stay current? And particularly with technology, how do you stay current with the dynamics of the technology space? And I think there are definitely, there's definitely a need for, there's an education piece. There's also a relevancy piece. And one of the bit, the other bit I was going to ask you about is data, and how data is used, or how data isn't used really, to look at maybe case finding or unmet needs in its broader sense. And then that'd be quite interesting just to maybe think how we could tie those two things together. How can we have intelligent decision making? How can we then have schemes for identifying things that we've triaged or prioritised? And then how can we get solutions that are not point solutions, but are integrated patient centred solutions? Or some something, anyway. So starting with maybe the data.- So the data, so I think that, I don't think we're using our data very well, because we don't always know what the purpose of the data is. So if I think back to my basic quality improvement sort of study that I did a little bit of, so they talk about the Plan, Do, Study, Act cycle and the PDSA. So, we kind of want to study the study bit, like the data, we want to do it with a purpose, so that we can act on it. I know that most GPs are also a bit afraid with, because we get data for judgement ."So, Farzana, you've got a red on your" whatever, you know."You haven't done enough health checks this month." So then the next month you don't even want to look because you immediately feel judged. So there's that data for judgement. But I also think that some of the data we have, we don't join it up. So there was some work done in the North West in Chorley, I remember a clinical director said, and this will seem so obvious to you, Phil, but wasn't to us as doctors. They wanted to identify their frail elderly, and to help with, you know, hospital, a bit of preventive care. And they'd realised that if they got the council data from who needs an assisted bin collection, that actually it was all the same people. And then there was another lot that correlated with the people who kept calling the fire brigade out actually were having symptoms of dementia, because they kept calling the fire brigade. So that data was there but health weren't having,'cause health weren't asking for it, because there wasn't a joined up purpose. Once they'd got it together, they thought actually we don't need to create any more data because the answer's like staring us in the face. If somebody got an assisted bin collection, they're probably not very mobile. And if somebody keeps calling the fire brigade, they might have some confusion that's going on. So I think my one challenge to myself, and to ICS did these, we need to first of all have a really good purpose of what are we going to do with the data, and then have we got this information or data somewhere, or do we need to collect more?- Start to collect it, yes. It's quite interesting. So, I mean, my view on this is that we should start looking at relatable data rather than relational data. And the judgement data, the performance data you've talked about, there's a huge amount of that and there's a lot of people very excited, business intelligent view of that data and what it's telling us historically typically rather than forward facing. But it's mainly activity based. It is based how many, how heavy, how long, how wide, what else with. And some of the things that I've looked at, we looked at in Bournemouth, we were looking infrared photography of houses. And the houses that were dark either had nobody was in there, or the roof was very well insulated, or there were people sitting in there without any heating on.- Right.- And then if you overlay that with the frailty data and identify, oh, okay, so there's a couple in their 80s live there, and they're not currently resided in any of our organisations. So they're not, you know, they're not being hosted by the NHS for some form or another. So the likelihood is they're in home in an unheated home. So, let's use the first responder, which is the local person in the neighbourhood who's happy to pop in with a cup of tea or do something and say, here is something. And that could create a massively avoidable set of circumstances that subsequently follow. But it's that related data or the other things we'd started to talk about is quality data, and you can overlay employment data, and you can overlay people who aren't on a transport route. You can start to do all sorts of things like that, but it needs to be intelligently done. And at the moment, we've got a very big cupboard full of data which shows how many interventions have happened, and other bits of data which are broken apart, and nobody, the thinking isn't being done. There's not time to think about it. But those type of things I think would start to make a big difference if we started to have that and then look forward with predictability rather than historical analysis and said, what is the likelihood that this community in this particular subset of people might have a propensity for these sort of things that we could do wellbeing intervention, before we need to do a clinical intervention? Something like that.- Yeah. Yeah. Sounds really sensible. I love that infrared actually picking up people that you just wouldn't know were there otherwise, yeah.- Anyway, so it was just one of the things we were exploring. But you can see with new drone technology and other things, you could do that as a normal piece. We're running out of time. I knew this was going to happen. And you did too, didn't you? You said, we did, we weren't going to allow enough time. I just wanted to maybe bring it back. You've talked about some really fascinating, we've talked about the knife crime, we've talked about working with communities, how changing settings of care. You've talked about working across the different parts of the health network. I think you undersold yourself about impact. So I think maybe for another day we could revisit that,'cause I think you're making a fantastic impact. And influence and nudging people along the right pathway is as important as just fixing one thing. And so I think being famous for helping nudge things along is probably much better than, you know, being famous for having done one thing once. So I think you're a serial achiever rather than, you know, a one-shot wonder. So I mean, that's very impressive things you've done. But if we then bring it back to the audience, and there was lots of things that you talked about today which were opportunities to get involved and make a difference, if people could come with a mindset which is about, you know, how do we address the whole care question, rather than how do we just address a tiny part of it. So, what's your call to arms? What's your rallying cry, would you say, to perhaps, let's get something done?- I suppose for me it's a very basic, and it's, I guess, my personality. I love people, Phil. I'm glad that, you know, we're in touch. So, I have very little knowledge of our industry partners, and I think many GPs are in my position, we have very little knowledge of it. So I think my one thing would be like, I should probably be more curious, and I'm sure industry partners do try and keep getting that knock back. But, you know, keep trying because I don't think there's ever been a time where I've noticed either I'm growing and seeing more gaps, but I believe there are more gaps now. I think there are more. So, 10 years ago I wouldn't have said, actually, I think we really need to make something for people who've got musculoskeletal problems, who we know are not going to get their elective knee hip operation for over two years. They need some care. That doesn't need to be going to hospital seeing a physio all the time, but they need some just to chivvy them along. So we've got more gaps in healthcare in a way we need to provide, which we just didn't have that gap before, and the NHS can't fix that at the moment. Is there something we can do with industry for that? And a lot of it doesn't have to be really medical. I mean, just the idea of somebody acknowledging that it's really hard being on a waiting list for two years and not going to work, and not getting the same pay, and looking after your family. Just having someone even to cheerlead for you is psychologically and physically, it reduces physical pain. So, you know, just things like that where I feel there's so many opportunities because the NHS is so struggling at the moment. But how do we make that connection? I guess it's talking to, and I know every GP says,"I'm too busy to talk to you," but again, some ideas on where are there some gaps and, you know, it would actually help the GP, it would help the care of their patients, which I think most GPs want to achieve that.- Yeah. Fantastic. Well, I think that's very clear. There's an open door, although not quite sure which door it is or how to come through it. But I think there is a bit, and certainly, we're obviously a very willing to help, you know, coordinate some of this, or help aggregate some of this into sensible chunks of things. But I think that was a great place to finish, which is the chief execs of the community are open for business in a way they collectively never been open before for all sorts of different reasons. But the healthcare is a team sport, isn't it, going forward, and I think we need to work in that way.- Yeah. Brilliantly put. Yeah. Well, thank you for having me. Lots of food for thought. I hope that, yeah, there'll be some, you know. I'm sure there will be some, it's got me thinking about, you know, new ideas, new pathways.- Good. Well, thanks, Farzana, you've been brilliant, as I knew you would be. I really enjoyed talking to you this afternoon. It's been an absolute delight. Thank you very much for sharing with us your insights and your experience. I think you've really ignited a conversation, and let's just see where it goes. So thank you, thank you for today.- Thank you very much.- What I'd like to do is just now finish off by thanking our audience for joining us. Thank you for the questions that you submitted beforehand. Hopefully I managed to get most of those included in one form or another. If there are any questions that we didn't answer, then we'll just follow up after the session, and we'll share those. If it's prompted anybody to think about what they might want to help, even though they might not be sure what that help is yet, or they're already working on ideas, then just please get in touch and then we'll help facilitate that conversation. So thanks very much everyone. Thanks for joining the NHS Whisper session today, and thanks again Farzana for your brilliant contribution. Thanks everyone and goodbye.- Bye everybody. Bye.- Bye.- [Host] Thank you for watching. If you'd like to find out more about our work with the NHS or how we could support your market access goals, please email info@mtechaccess.co.uk, or visit our website at mtechaccess.co.uk.