AI in publishing, the Darzi report, and population levels

Jessamy, Gavin, and Richard come together for another bonus episode of The Lancet Voice. A freeform chat covers xenotransplantation, the use of AI in scientific research, the Darzi report into the UK's National Health Service, and falling population levels over the next few decades.

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Gavin: Hello and welcome to The Lancet Voice. I'm Gavin Cleaver, and I'm here with my co host Jessamy Bagginel, and editor in chief of The Lancet, Richard Horton. There's another bit of a bonus episode for you today, as we enjoyed making the last one so much. We sat down for an informal chat in the lads offices in central London, and ended up covering xenotransplantation, AI in publishing, the Darzi report on the UK's national health system, and falling population levels over the next few decades.

We hope you enjoy listening in, and please do send me any thoughts or feedback you have, or anything you'd like to hear us talk about, to podcasts at lancet. com.

Right, well, everybody's brought a lot more notes with them this time, so you would hope that the podcast is going to be A little bit more organized than the last one, I guess. Richard, you wanted to kick us off by talking about a meeting you attended recently in Paris on xenotransplantation. 

Richard: The meeting was held in the absolutely magnificent, typically French National Academy of Medicine, the hall where Louis Pasteur and Marie Curie gave lectures, so immediately you feel that you're, uh, in Paris.

Incredible company sitting at desks that remind me of when I was a pupil at school, uh, wooden desks with the old name on in the 1800s when I was at school. Exactly. Thank you for that, Gavin. And it was, uh, and I wasn't actually expecting the meeting to be quite as transformative as it was, uh, to be honest, um, whenever you're invited to a meeting in Paris, you just accept because it is the most beautiful city in the world.

incredible because I had not appreciated that the science of xenotransplantation over the last three years, only the last three years has undergone a step change such that we are now very, very, very close to being able to transplant. I won't say unlimited, but trials plot successfully. Uh, modified, genetically modified pig organs, genetically modified pig hearts, pig livers, whatever 

Gavin: you care to think of.

So I would consider myself relatively up on the news, but I've literally not heard anything about that. Is this, it's been churning along in the background, just constant incremental improvements or? 

Richard: No, it's well, yes and no. Um, so about 30 years ago, there was a burst of interest in xenotransplantation.

And People like Tom Stiles, who was a pioneer, pioneer in liver transplants. Um, he started transplanting baboon livers into people. Uh, but we didn't understand anything about the immunology, the reasons for rejection, anything at all. And so they all failed. So people thought xenotransplantation was a dead end.

So nothing happened for 30 years. Um, and then one or two stunning discoveries were made, uh, in relation to pig organs to understand why rejection took place. And once people understood that, and then you could genetically modify pigs so you could produce knockout pigs, in other words, where you've knocked out a particular gene, three genes in fact.

And then you start putting other genes into the pig and they're up to about 12 genes into these pigs. Then the organs now don't get rejected, they're tolerated, and they work. They're not perfect, yet, but this is all in the last three or four years, and it's completely changed the field. 

Gavin: That is some full on Blade Runner stuff, isn't it?

That is 

Richard: It really is. I mean, it's, it's, it really reminded me of, um, You know the Keio Shiguru novel with the idea where you we're going to have animal farms we're, we're going to have farms where we breed animals. We breed pigs with the single intention of harvesting their organs. So as much as it's a medical breakthrough, which will completely change the field of transplantation and all the people who are on waiting lists and unfortunately, who do not survive being on waiting lists, we're going to meet a massive global need.

But it's going to change our relationship with animals. It's going to raise new moral questions about how we use animals. At the moment, if I give an organ to you, it's an act of altruism. You know, it's me giving you a gift, and I don't expect you to give me anything in return. But as soon as we have farms of animals with genetically modified hearts and livers, well, then we're going to get into the fact that, well, I can buy that heart, I can buy that liver, so we're going to have a market in organs.

And it's not going to be just a domestic market, it's going to be an international market. So you can see that suddenly this rather lovely gift relationship that we have at the moment is going to disappear. And we're going to have a very, very capitalistic market in, uh, in, in organ transplantation. So there's this immense opportunity.

But there's a rather fearful, um, concern about what might happen as a result. Unless, of course, it's well controlled. Unless it's well controlled. But my worry is that the science has moved so fast, as you say, you didn't know about it, I certainly didn't understand that it was moving this fast. Um, the science and the practice could outpace the regulation.

Because we have not had any discussion about this in society at all. I mean, I've not read any newspaper articles, I've not seen any. any discussion in the media about the fact that we're going to very soon have pig farms with hearts available on demand. 

Gavin: I wonder if scientific research more commonly outpaces regulation these days.

Richard: Well, it's interesting, isn't it? I mean, sometimes people say there's an ethics industry and they bemoan ethics because we overregulate research. And I've certainly heard clinical trialists very upset by the regulatory environment, which actually stops them doing research rather than encourages them doing research.

There used to be when we were in the European Union, various clinical trials directives, which were very burdensome. And I can remember people like Richard Peto and Rory Collins going over to the EU to lobby to try and reduce those regulatory burdens. So but here, we don't have anything at all. So it's yes, I think there are some parts of medicine where We over regulate and then other parts where there's just nothing, you know, there's another area is biosafety level laboratories.

There's no international regular regulatory system for biosafety level laboratories, BSL 4, BSL 3 labs. People are doing all kinds of stuff and we don't know and that's one reason why everybody is so anxious about what happened in Is this a brexit bonus? No, I don't think it's a brexit bonus. Um Because we've been looking for them for a while We've been searching for them, but I don't think so because we've still got massive regulatory overload in in research But I think in this area it sure sure sure is in need of some attention.

Let's put it like that 

Jessamy: I think essentially, if it's a, if it's a medicine, and we conventionally think of it as a therapeutic, then there's a fair amount of regulation. But essentially now, with exponential growth in Biotechnology, in digital health, in organ transplantation, all of these other areas that don't really fit into a kind of, here's a pill, you can take it, devices, then there's almost, there's a, there's an exponential gap between the growth of what we know and how, and what we can do and, and policy and regulation to try and think about how we should be controlling and implementing.

Richard: Yeah, I think the on devices, that's exactly right. I mean, with devices, you just have to be able to show that your device is kind of approximately similar to the device that exists already. And you don't have to prove its efficacy as you in the same way as you do with a medicine in a placebo controlled randomized trial.

And that's why we got into all the trouble with breast implants in France several years ago. Because breast implants were being produced from all kinds of manufacturers. And there was absolutely no quality control. There was absolutely no proof of efficacy. And so, who suffered? The women who received the breast implants.

Jessamy: And I think also when you've got technology now which can be used within devices. Then actually the, it's very difficult to regulate anyway because it's a, it's a changing scale because it might be that you have software updates or, you know, the actual, the actual very fundamental basis of what that technology is doing can change from month to month because of the way that it's being developed and improved.

And that's incredibly difficult to regulate. 

Gavin: Especially in a kind of situation where security updates can often malfunction. Yeah. You know what I mean? Like it's kind of incremental progress. As we saw a couple of months ago when about a sixth of the world's laptops shut down is uh, it's quite often not only difficult to regulate, as you say, but it's quite often difficult to manage for the actual companies that are putting out the monthly updates as well.

It's a bit of a minefield. 

Jessamy: Yeah. 

Gavin: True. So what have you been up to the last month, Jess? 

Jessamy: I have not been anywhere as glamorous in 10 being anywhere. Um, but I've been thinking and talking and writing a bit about generative AI and our policies here, uh, and what other journals are doing, uh, which has been very interesting.

Richard: You're our local expert on generative AI, so 

Jessamy: I don't know whether I say that, but I've been very, I've been very much thinking about it. 

Gavin: Uh, recently. Where are you right now on generative AI? 

Jessamy: I think it's a very good efficiency tool, uh, and there's huge opportunities to make researchers lives easier, to make publishing better, uh, but there's, I was on a panel recently and this isn't my own, uh, idea, but I'm going to steal it from someone else.

Essentially, you know, our mission is the best science for the best of lives, right? Or, you know, so, but every single thing that we do in that value chain has to do with text. Okay. So now we have this innovation that can generate text. There's no part of what we do that will not be disrupted or transformed by this technology.

And that's incredibly exciting. It's also challenging. And so it will transform the way that we work and the way scientific publishing works. How 

Richard: much do you think our authors are using AI tools at the moment? 

Jessamy: Well, we've implemented this little checkbox. And at the moment, it looks like 6 percent are declaring it.

When I use it, 

Richard: Is that in research articles? 

Jessamy: It's more in green content. So that's our clinical education reviews. But we do also, there is a feeling across our journals that more and more people are using it but not declaring it. And that often results particularly in the editorials or correspondence in lots of sort of generalized flowery language that is, you can see it's sort of probability linked words put together, but it actually has very little meaning or insight or novelty.

And so it's not really adding to the scientific literature. And so I think I'm thinking more and more of it as efficiency tools, and I'm sure that there's much more that you can do with it, but for things where there's human interpretation, where there's context, where there's a sort of necessity to really understand the landscape and to look forward, I have not found it to be helpful or useful.

Richard: There's 6%. Do you think it's mostly him? And I can see that it would be helpful here. Because if I was trying to, let's say, write for a Japanese journal, I wouldn't. quite nowhere to start. Um, so do you think is for non English language? I think that because, 

Jessamy: but also the English language speakers who might be neurodivergent, who might be dyslexic, you know, there are lots of clinicians who and healthcare professionals who are dyslexic or have other neurodivergent, um, Issues and, and I think that, so them being able to put something through a large language model that will formulate it in a way that's sort of socially acceptable, then that's a, an incredible tool, you know, and, and will help with inclusion and divest here.

Gavin: I think it's a really good blank page destroyer as well. That's what I often use it for. If I just can't think of how to start a particular thing, I'll go to a large language model and say something like, how would you start this? Or, you know, like 

Jessamy: brainstorming, 

Gavin: brainstorm, like write the first paragraph of this.

If you were me, you know what I mean? And then rather than copy and paste that, which is very lazy, you can actually finally look at the thing. And it's almost like you've started writing the article. And often I find the starting is the issue. And then once I've got the yeah, the rest comes on. So I often use it as kind of like a prompt machine more than anything.

Richard: Yeah, no, I mean, it's interesting, um, the way into a subject when you're writing is so important. Yeah. And you don't want your first paragraph to be like a cough. Um, that is just a sort of boring, you know, rendition of a summary of on 8th August, 2016. So, so you want to try and find, um, Kingsley Amis always used to say that he, he, he should begin a novel by something like a shot rang out.

In other words, you should have something that immediately catches the reader's attention. And that's just as true in scientific writing as it is in novelistic writing, I think. So. And I don't know whether a large language model can do that. 

Jessamy: I think it's very good at doing that. Particularly if you can give it examples and prime it before.

And say this is the style that I want you to make a big impact. 

All: But I 

Jessamy: think Gavin's point is You know, that's the ideal, where, where human creativity is enhanced, but the oversight and the intelligence and the, the kind of, um, and the authority, I suppose, remains human. 

Gavin: It's like I often say to my multimedia colleagues these days, we have to be on top of the machines by this point, otherwise the machines are going to do everything for us.

Hmm. The other thing that I think is really interesting is that it's having an effect the whole way down, not just scientific research, but how people earn qualifications as well is having a major effect. Anecdotally, uh, my partner is a course director at a local university and it's got so bad there that they have switched to entirely in person assessment.

So they replaced all of their essay writing for one course this year. With, um, an in person science day where students, undergraduates had to come and present a particular scientific paper as if it was a poster at a scientific conference and then talk lecturers through that, which ended up being fantastic because also they got local school children in to see these presentations and then they could see people that looked like them presenting scientific research and things like that.

So very wonderful. But, um, it's striking how quickly it's kind of infected assessment at a university level 

Richard: because everybody was using it to rather. 

Gavin: Yeah, that's pretty scary. 

Jessamy: I think there's so much to talk about on this topic, you know, because there is a huge element of de skilling, you know, whether that's researchers, whether that's a higher education, whether that's in medicine.

You know, what, what happens when we rely on things to such an extent that actually we don't. 

Richard: You could get people to actually write their essays in an exam situation. We did this at A level going back a few centuries. Um, where you'd actually have the essay topic and you wrote it by hand. You know, you have to write for an hour 

Gavin: and a half.

This is a, this is a sign of two people that didn't do a humanities degree. Yeah. That's how we did all the essays. , . 

All: All, 

Gavin: all of my exams were turn up and pick two essay topics and you've got four hours. 

Richard: Exactly. So that would be, and, and if you have to write them by hand, then you can't use Ative AI for that.

No. 

Jessamy: But then it's so funny, isn't it? Because there's this, there's, there's a divergence there because on the one hand, we've got, you know, this, but as generative, I basically being able to write university level essays. And on the other hand, I've got my kids who are at a state primary school. And learning exactly the same thing that I did in exactly the same way as I did, you know, 30 years ago, which seems which also doesn't seem quite right.

Richard: Good progress. 

Gavin: If there's something that works, then why change it? Well, it's interesting though, isn't it? Because when they grow up and reach the workforce, they're never not going to have access to these tools. And so sometimes you can look at like, for example, a school smartphone ban and say, well, actually, you know, they're always going to have this to hand.

Yeah. They're never not going to be able to just pull something out of their pocket that's got a calculator on it, for example. 

Richard: Can I just add on? I haven't done this. I ought to try it. Um, but if I wrote in to GPT, please generate me a data set for a randomized trial in 5, 000. It would do it. Yeah, 

Jessamy: I'd do it.

Richard: It would do it. Yeah. 

Jessamy: There's a great, um, study in, I think, Nature that did this. They had a false hypothesis, uh, something to do with ophthalmology. And said, please generate a manuscript with a data set that shows that the hypothesis is correct. And it did it perfectly. 

Gavin: The models have even taken in so much of, for example, the Lancet, that you could tell it to output this piece of scientific writing in a Lancer House style.

Jessamy: Or Richard Horton style. 

Gavin: Yeah, it can do that. 

Richard: Incredible. So how do we, what checks? So we have, at the moment we have authenticate for, um, checking for plagiarism, there are various image manipulation tools. Are there any tools out there to check to see if the date if a paper so you said the self declaration of 6 percent do we are there any tools that 

Jessamy: we don't have any reliable technology that will pick up when generative AI has been used.

I think there are, there's different claims on the market that tools are more successful. But my understanding is that that tends to be That they get high percentages of pickup because they're using a very small data set to train it on and to validate it on and then when they actually put it out into the world, it doesn't, you know, picks up 50 percent or something like that.

So there's nothing that we can reliably use. But I think that's a, you know, that's obviously a huge advantage. Um, area of activity for someone like us. 

Gavin: That's also become one of the problems again, at university level is they have lots of checkers that they run students essays through, comes back and says this essay was 90 percent AI generated.

And the student goes, well, no, it wasn't. And you know, you can't go into that history and uh, look at, yeah, you can't prove anything. So, yeah. 

Jessamy: So what we're going to be asking for is the prompt that you use, the large language model version that you use and, and sort of, and how, how you asked it. To change your manuscript or to help you develop your manuscript.

Richard: And I think we as editors then, we're going to have to ask the question in the manuscript meeting, when the paper comes up, you know, could, whether AI has been self declared or not, could AI have been used in a malign way in this paper? 

Jessamy: And I guess we have to think about what malign means, because actually using it to enhance a formatted, structured article that hasn't changed in centuries, is that so bad to make it more readable to, as long as there's been human oversight, as long as it hasn't done the data interpretation, as long as everything's accurate.

Richard: But then that's, so, data interpretation, that would be, wouldn't it? 

Jessamy: I think it would be, and our policy is that it shouldn't do data interpretation, but you know, again, to what degree? So if you say, if you've got a huge data set and you say to a generative AI, can you help sort this out? Can you clean it?

Can you divide it into samples, which will make it more easy for human methodologists to interpret? You know, there's 

Richard: a, or if you put a scale there, if you feed that data set and say, draw me five conclusions from this, that would, 

Jessamy: that would, we would feel that would be, that 

Gavin: It's, it's sort of the case where you ask it to do things beyond cleaning and sorting data is that's when it can start hallucinating and that's when, especially in large data sets, you could get just random numbers introduced because it's all it is really is a predictive text model so it puts the numbers there where it thinks those sort of numbers should go but at that point if you've got a large data set and you're the person Doing the research you don't know which numbers are hallucinated or not.

So that's when the danger comes in I'm feeling more anxious 

Richard: as this conversation proceeds. 

Jessamy: I think we should be 

Richard: it you do Okay, then we have to think what do we do about this? Well, we can do for now spend more time on papers I mean think about them more than we probably do I mean we think about them a lot, but we need to think about them more because 

Jessamy: I think we like we're lucky to have a huge Assistant editor team who will read every line of things and we're also lucky to have the time to be able to focus on articles.

So for a lot of our editorials, commentaries, correspondence, we have highly experienced editors who will read them. And for the most part, even if AI hasn't been declared, they'll be able to make it. judgment as to whether this is novel or whether this is actually adding anything to that debate. 

Richard: But I just wonder, you talked about the self declaration, maybe we need to ask the direct question.

Have you used AI? 

Jessamy: That's what we ask. 

Richard: Oh, so they They 

Jessamy: ask that. So when they submit 

Richard: So when they say no When 

Jessamy: they submit, they have to, they have to say, has this been used in any part of your work? And then if they click yes, they have to describe how So 

Richard: if they said no, we hope they're not lying. That's essentially as far as we can go at the moment.

But we think that some are. 

Jessamy: Across the journals, editors feel that they particularly are in correspondent and commentary because they have seen an increase in content, particularly from some authors who might not have any expertise in that area, who are sending in a correspondence or a commentary on a topic.

Richard: Actually, I've noticed that in the letters, because Monique. She looks after all of our letters on the weekly, but all the letters that she shortlists, she shares with me. And I see letters from some places where they're commenting on something, and you see the authors and where they're from, and they've got absolutely no particular reason to be commenting or expertise on that particular subject.

Exactly. And you 

Gavin: do think that's weird. I don't know particularly what the phrases are as well, but I get the impression that there are some phrases in AI generated work. That are hallmarks of AI generated work that aren't often used by people, but for some reason are in the AI data sets. And so apparently that's another way that you can spot it is these particular phrases.

Richard: We've seen that in some peer reviews, haven't we? We've seen some peer reviews which have clearly been generated through some sort of chat GPT model where it, and the way it's written, it's, it's almost like written this person's, this ethereal character. Yep. The, the, should consider It 

Jessamy: sounds very nice, quite hyperbolic, very flowery language.

But 

Richard: you'd never write that. But you'd 

Jessamy: never write 

Richard: You know, we would never write, the author should consider getting a statistician to look at these data. I mean, you'd never write that, but that's, I've seen You'd just write stats in caps. Yeah, 

All: well, it's 

Richard: just, you'd just write that this is clearly mistaken and, uh, frightening new world.

It is. 

Gavin: Talking of frightening new worlds, Richard, the Darzee report came out in between podcasts. What did you make of it? 

Richard: Well, I know Arrow Darzee quite well, um, because, uh, I've followed his career over many decades from, uh, stunningly successful surgeon to becoming a labor minister in the Tony Blair government, um, or Gordon Brown government.

Um, and he was put into the house of Lords when he became a minister. Um, and he really championed the idea of two things in particular, one quality and second, which got general practitioners up in arms, poly clinics. Um, and then when labor went out of government, he's kind of went quiet for a while. Um, and then came back, as you say, with this report on the NHS, he said that the, um, NHS is in a critical condition, but the vital signs are looking okay.

Um, And if you read his report, uh, I would say the emphasis is more on the critical condition than the vital signs being okay. Uh, what's particularly interesting about his report is not the report itself, but the annex, which is 330 pages of tables and graphs, which just shows how decimated in almost every department of, uh, the NHS.

care has become. Um, and he lays it out completely dispassionately. There's no text written in the annex. It's literally just tables and graphs. But as you read through them, you just see how over, really it's been over the last decade in particular, um, how the NHS has become so critically eroded. And he places particular blame for that on Andrew Lansley's Health and Social Care Act 2012, because that was the reorganization, which he, he, he has some very choice words to say about it.

He calls it calamity. That really was the starting pistol, um, because once that happened, it was a disorganization, not a reorganization of the NHS. And it never recovered from that. And then after the decade of five prime ministers, under conservative, different conservative governments, the NHS has indeed reached this critical position.

And it's not clear at the moment, what is going to happen, because Keir Starmer said at the launch of Aridaz's report, Reform or Die, which is a great phrase, what reform? 

Gavin: I mean, it used to be the case in UK politics that we would talk about, there's no magic money tree. People would, uh, you know, say, well, we've got this, and in fact that happened a lot during the election campaign, everyone was just talking about how they would make efficiency cuts to fund all of their particular pledges.

But I think the new kind of watchwords or the new kind of catchphrase in British politics these days is, the reform fairy. Which is just the idea that we can wave a magic wand and do this magic thing called reform, and then everything will be all right. Whereas actually it's the capital investment that's required.

Richard: So, Arab Darzi emphasized the importance of capital investment into infrastructure. Um, At the end of his report, there's a very brief section on what should be done. To be fair to him, he wasn't asked to write a report on what should be done. He was asked to do a diagnostic audit of the NHS. But, what worries me is talking about the idea that technology is going to solve the problems of the NHS.

Greater patient and staff engagement is going to solve the problems in the NHS. Um, having a moving money closer to where the patient needs to be cared for, creating a neighborhood NHS. These are very fine phrases, but what does it really mean? Because at the moment you, you have hospitals delivering care.

Are you really going to start closing hospitals and moving money into community care and primary care? Maybe reinvent polyclinic? It's not that easy, and it's certainly, he's talking about a ten year, um, period of NHS reform. I, I, I can't see clearly what that, the shape of that reform, he makes, he does say very, very definitely, uh, in his report, there should be no Lansley like top down reorganization again.

I think we can all agree with that. And the integrated care system model that we have at the moment is, it's not perfect, but it's a lot better than what we had before. And the idea of integrating care is absolutely the right idea. Um, in terms of the reforms that need to be implemented now, um, we really have no clue.

Uh, and so there's a, we've got the diagnosis and then there's a whopping vacuum, um, when it comes to what do we do next? Go on then, you're Wes Streeting, what do you do next? Uh, well, what Wes Streeting has done, um, is he's created another group, um, that's meant to come up with the answers. Is that what you would have done?

No. And I said this to Ara, um, directly face to face. I said, well, you've produced the, you've produced the diagnosis. And now you're going to walk away and leave it to somebody else to come up with the answer. That seems completely crazy to me. You should, you know, now better than anybody where the problems lie.

So. You should be involved somehow in working out what the solution is, but that's not what Wes Streeting has done. Um, he's handed that over to a different group, and I think that's a, that's a mistake. Um, because the people he's handed it over to are not working full time in the NHS. Ara Darzi is working full time in the NHS.

Um, so he has a stake in the solution. Uh, so I am, I am concerned. Well, I think what I, I, you can't do everything all at once. So there's got to be A few objectives and probably the biggest concern at the moment is, and this comes out in the 330 page annex, is the really catastrophic, um, length of waiting times that are facing every, everybody from cradle to grave.

I mean, if you look, I looked at the data for children. You know, tens of thousands of children waiting, um, over a year for an appointment is just unacceptable in a health system like the U. K. 's. So, uh, I think that, um, I think my focus would be on how do you get the waiting times down so it's access to care.

And at the moment, I think the evidence is pretty clear that there are so many barriers to access to care that that's the problem. Because my reading of his report. The vital signs being good. What he's saying there is we do have fantastic NHS staff. Um, And we do have more staff than we did in the very recent past as well.

And that's one of the fascinating, um, facts that comes out of his report. We've had a 17 percent increase in NHS, NHS staff between 2019 and 2023. But productivity hasn't gone up. Why hasn't productivity gone up? Because there hasn't been the infrastructure investment and, and so on. Addressing infrastructure, but that takes a longer time.

I think it's getting the care pathways. Worked out so you can get people in to see a primary care doctor into Community care or into a hospital and if you can address that as the number one priority Then let's then think about what the other phases are But the most important thing has got to be surely in a national health service That when a patient needs care, they have access to care and for literally tens of thousands of people If not hundreds of thousands of people, they're not getting access to care 

Gavin: and it feeds You Doesn't it interview the other problem that the UK seems to be having, which is a lack of productivity caused by so many people unable to work.

These people are waiting on waiting lists. They're not participating in the workforce anymore. Growth across the country is sluggish. I think we have a record number of people currently, um, out of work and not seeking work. 

Richard: And there it does. He makes the point that NHS. should be fixed because it is an engine of prosperity for addressing exactly that point, Gavin.

And what's interesting about what we're streeting is done in terms of prioritizing the parts of the country where you can't do everything all at once. So where do you begin and he's arguing you begin where you have most people who are not in work because of sickness. Um, so that's a very interesting way of prioritizing your, um, NHS resources.

Um, so they're making a very explicit link between health and the economy. And for a government that's put the priority on growth, you can understand why they might have done that. You 

Jessamy: know, at the end of our last podcast, I was slightly sceptical about Darzee's report, um, because I felt, you know, we have heard with, he's been involved in UK health for a long time, surely we needed some fresh voices, but actually the report is absolutely critical and it's a fascinating and brilliant report that we haven't had this level of transparency on where the NHS is for 15 years and, and we need it.

Um, and I think that for me, what came across. is this capital aspect. The productivity, I hate the word productivity. For the conservative government, it always felt like asking NHS staff to do much more for less. But actually, when you look at the hard data, you know, there are 7 percent fewer daily outpatient appointments for each consultant.

There are 12 percent less surgical activities for each surgeon and 18 percent less activity for each clinician working in an emergency medicine department. That is an extraordinary decrease in productivity. I mean, You know, it really fathoms the brain how that can happen when we've had such technological advances, where we have incredible staff dedicated to working, committed to working.

And when I look at that annex, the capital issue does seem to be such an important one because that 37 billion of being able to do have more hospitals. When you look at the investment that happened under the labor government in like those first 10 years, you know, it doubled, it was extraordinary. That's how you're able to do so much more.

And I don't think that we can get away from that. So although, you know, last week Wes Streeting at the labor conference, it was a great speech. He said all of the right things, but actually, and I'm delighted that he's negotiated a salary increase for resident doctors. Brilliant that, you know, we're going to say that care workers need to be paid more.

This is all fantastic. But there was nothing about increased capital, there was nothing about an actual social care system that we were going to pay for, and without that, it's very hard to see how these three, you know, tilting to technology from sickness to prevention, how are we going to do that? 

Richard: Yeah, I agree, I agree, I agree.

Take one specific example then. Um, Because you come from the world of surgery. So, so the, the point about we've got more surgeons and we've got less units of surgical output as you the figure you just quoted. So what, well What's the reason for that? Is it that we're, we're not, we don't have enough operating theatres?

Or is it that we're not using our operating theatres efficiently? Are some of them not being used during the day? Or do we not have enough nurses? Should we be using them at weekends? What's, what's the sort of reason? 

Jessamy: I think there's a whole mixture of things. I think when you look at this report, you do see the huge impact that social care is having of stalling up beds, so you actually don't have beds to move people into.

We don't have the right infrastructure in terms of surgical pathways of people coming in and being efficiently, you know, uh, operated on. And we've seen that now with these new vanguard areas where surgical teams are doing high productivity and they are decreasing the surgical list, you know, very impressively.

And then they're, you know, doing very low, um, sort of not, not difficult operations, but lots of them and having a high output. So there are a lot. I think there's a lot of room to be able to turn that around. We haven't focused on that 

Richard: because I know, you know, when I was, um, as we now call them a resident doctor, you would literally I mean, the idea of day case surgery hadn't even been introduced.

And so patients would come in, and they come in on a Sunday night, and then you clock them and they'd have their operation on the Monday. Um, and then they'd be in all week, and then you'd hope that you could kick them out at the end of the week. But, um, and mostly you did. Now, of course, everything's day case, and it's laparoscopic.

Um, so, possibility of increasing the productivity, this word, I, I agree with you, it's not a pleasant word to use in health. But in terms of the units of output per person, should be enormous. But we're not, for some reason, we're not, I see the point about social care. Is it? I mean, that's one part of the population, but it's not everybody.

Jessamy: It's not. But I also think it's crisis. And for a, for, for, you know, we have a health system, but the boundaries of each health system changes. You know, there's a hospital, there's a hospital trust, there's the outpatient. So when a hospital trust and every single one in the country has been in crisis for about 10 years.

Richard: You mean financially? Financially. 

Jessamy: Financially, but also from a, from a 

Richard: capacity 

Jessamy: point of view. How do you ever have the headspace as you have the, the resources and the capacity to change things around to make things more productive. You don't, you're just on black alert the whole time. You're just trying to survive.

And, and that's where I feel I was at an event a couple of weeks ago on, on waiting lists. And I was having this conversation with, you know, other NHS leaders and It's really hard when you, I mean, these are such complex organizations that are incognito. How would you actually then take a step back, divert resources to say, Okay, we're going to do the whole of our surgical department differently.

It's incredibly difficult. 

Richard: And then maybe that does need to be a complete change in the way we think, that we actually, we have operating theatres open 24 7. 

Jessamy: Yeah. Maybe. 

Richard: Weekends. 

Jessamy: Maybe. 

Richard: I mean, then you would expand your capacity. You would. Considerably. 

Jessamy: You'd sweat the assets for sure. You would, you would, 

Gavin: you would, you would.

But, but. For a long time, like Jess and me say, there's still no beds to discharge people into. You know, that capacity is not there. 

Richard: And that, I remember when we did a series, uh, with one of our colleagues to be a client on the German health system. This was obviously pre COVID. And one of the great strengths of the gym, although they saw it as a negative, um, at the time, although as it turned out with COVID, it turned out to be a great positive.

They had a huge amount of spare bed capacity in their hospital system, which they didn't use at all. And so they didn't think they were very efficient. 

Gavin: Right. So I've been reading some articles about this this week, and that was the major complaint about the NHS in the late seventies, early eighties. It wasn't that there were too many spare beds.

And so from 1987 to 2019, beds per capita in the UK decreased by 53 percent to try and meet the kind of, that, the word, say 

Richard: that figure again. 

Gavin: From 1987 to 2019, beds per person in the UK decreased by 53%. My god, that's, that's, that's quite a figure. France currently has three times the capacity per person and Germany currently has four times the UK does, which are astonishing figures.

And, 

Richard: you know, maybe from the hospital point of view, maybe that's the route of one of the routes at all. 

Jessamy: I mean, also, when you walk around our hospitals, you know, it would be so much easier to just build a new hospital when you're, you know, talking about Norfolk Park, we're talking about high waken hospitals, these are dilapidated buildings, which have been built on over time where there's bits of flooding coming through.

How do we make these into places that are meant to deliver care? 

Richard: So you would recommend then, I mean from a hospital point of view, so two, two, a recommendation, but then a question, um, you would recommend a massive hospital building program, massive investment. Well, 

Gavin: it's not even building at this point, is it?

It's just rebuilding what we currently have because it's all falling down. Well, okay. Actually, I've got a, I've got a good figure for this as well. At the end of 2023, guess what the urgent backlog of maintenance costs was in the NHS? The backlog of maintenance things that needed to be just maintained right now.

This is a money figure Yeah, a billion ten billion. Oh, it's enormous. 

Jessamy: It's in such a so I think you're right when you say The vital signs are so strong because we have such an incredible, it's the 

Richard: people 

Jessamy: star. It's the people. You know, people. That's the end of 

Richard: is the people, 

Jessamy: but our actual reason, 

Richard: the problem, the problem with that argument is that that.

While I, having worked in a hospital, I'd love hospitals, I, their palaces to modern medicine. 

Jessamy: They can't, they can't be the place. But that's not, that's not the future. I agree, I agree, I agree. 

Richard: Everything, every report that's written, whether it's for DARS or EIPP or whoever, it's all about prevention, it's all about primary care, it's all about But 

Jessamy: that's where the reimagination and a reform of how we're viewing health starts, doesn't it?

And they, but they both have to come together because The reimagination of bringing health closer to communities of having neighborhood centers, you know, all the rest of it in the IPPR report. Fantastic, but that's going to take time. And meanwhile, we also have to have places where we're delivering care, just as you say.

Because primary care 

Richard: is falling apart even more. 

Jessamy: Also falling apart. Also falling apart. 

Gavin: Well, we were talking about staff rising, weren't we? But actually the number of GPs has fallen, which has a big knock on effect. 

Richard: And if you, what's fascinating is the encroaching of the private sector into that.

Cooper's, um, one private sector organization has introduced this system where you can pay, it's like a Netflix subscription every month. And for that, or pay by the gp, right? Yeah. You can get access to a GP by phone and if you pay a little bit more, you can get face-to-face access to a gp. I mean, if we're all buying on Netflix and Amazon Prime subscriptions, um, 25 quid a month isn't, you know, for a certain proportion of the population.

is going to be affordable. And then you end up with a two tier system that you're going to have people who can afford to pay the 25 quid a month and get see their GP whenever they want. And everybody else has to use the NHS, which 

Gavin: It's got, it's been, but it's also not like we're magic, it's not like these private companies are magicing these stuff out of thin air.

Jessamy: Same pool. 

Gavin: Yeah, exactly. Exactly. 

Jessamy: Can I take us on to another intractable problem that I was looking at when we 

Gavin: You mean, you mean we haven't solved the last one? We're not going to solve 

Jessamy: the other extracts today, but you know, maybe tomorrow. But um, but in that, in that appendix, and, and, and, People often will say, you know, we're a sicker, thicker, poorer nation.

These poverty and deep poverty rates in children, we've, these are flat, we've flatlined since 2001. There are so many figures in that appendix where we're just flatlining. We haven't done anything for 20 years on some of these massive issues. And yes, things have got worse. But we've also had a political system, which has totally 

Gavin: Hmm, if this was a video podcast, I would see Redwood and Jasmine wading through pages and pages of very serious looking graphs.

Yeah, 

Richard: yeah. Yeah, that this is a country that's making no progress. 

Jessamy: This is not me. It's we've made no progress in 2001. 

Richard: Yeah, no, absolutely. This is a country that's making no progress at all. And, uh, and it's interesting because West Street was quite heavily criticized for saying that the NHS is broken. Um, and that that's just too much doom and gloom.

But when you actually look at the data, let's not say the NHS then, but you know, our health system, um, is broken. It's not delivering for people because either waiting times are getting worse, we're getting sicker, Access to care is, is reduced, quality of care is mixed, productivity has gone down. I mean, there are very few signals, apart from the science.

And this is where I will, this is where I will, I, I, this is where I think, um, we do need to be optimistic. Because science is delivering for, um, patients. It's, you know, the transformation in care across ages. almost all domains of medicine in the last decade or so. It's incredible the contribution that scientific advance, um, has made, whether it's in medicines, uh, whether it's in diagnostics, uh, surgical treatments, it's, this is the cutting edge.

And I think, uh, You know, one issue that's often not talked about is, how can we make sure that we rapidly translate scientific discovery into clinical care? And I don't feel that we talk about that enough. And in America, they do that, not everywhere, but they do it very well. If you go to the Cleveland Clinic, literally, I mean, perhaps not every single patient, but it feels like every single patient is entered into a randomized trial.

mixed together and it's in the signs all over the Cleveland Clinic. Care, education, research, there's a sort of holy trinity. Um, so this is a, this is an institution that's all about serving the patient. It's an institution, it's a learning institution, and it's an institution that's generating discovery science.

So, and, and, and those values. At the heart of an institution, you really feel that it's, it's like working full speed. It, it's really sharp as an institution. And the hospitals I go into in the NHS, you do not feel that. What you feel is this is an institution full of way too many people just struggling, as you say, to keep its head above water, but you don't feel that it's, uh, it's about serving the patient.

It's a learning institution, and it's all about cutting edge science. And if we could institute those, you know, one of the areas where the UK could be proudest of any country in the world is the quality of its science. And it's quality of its life sciences and clinical sciences. in particular, but they seem to be utterly divorced from the NHS.

And I do not understand that I do not understand how somehow we've got a management structure for the NHS, which is utterly separate from this amazing science research ecosystem that we've created. And somehow we have to bring the two together. And I do think that the values that drive Discovery Science and make us literally the leader in the world per per headcount of scientists.

I do not understand why we cannot transfer those values into the NHS. And if we could, I think that would be transformation. And Ara doesn't talk about that in his report, actually. But maybe that would be that would be my 

Gavin: prescription. 

All: Very good. 

Gavin: I've got a good link here. Richard, you mentioned headcount just 

All: one 

Gavin: thing you wanted to talk about before we wrap up today was Hungary.

Why don't you tell us a little bit about that? 

Richard: Well, one of the great mysteries of, uh, this coming century is going to be the demographic time bomb that is, is going to explode as the century proceeds. And we've known about this, uh, demographic time bomb for some years now. I remember studying it at school.

Exactly. So, you know, it's not a surprise. It's not a surprise, but we published a paper a few years ago from our friends at the University of Washington, IHME. which looked at the projections of population at 2100. And it's a paper that I just, one of the most important papers I think we've published. Not, not in terms of medical science and the impact on patients, but in terms of just the way the planet is going to evolve.

Because so many countries are going to see their populations collapse. By the end of the century, Countries like China, Japan, um, South Korea, Countries in Europe like Poland, many of the former Eastern Bloc countries, Spain, Portugal, Italy, You're going to see their populations half, literally half. And what that means is you're going to have an elderly population with dramatically reduced working age population.

And the social contract that we have at the moment, whereby the working age population generates the tax revenue that creates the welfare state and keeps everybody, in particular older age populations, safe and secure, that social contract is going to break down. It's not going to work because you're not going to have a working age population that's going to be able to create the tax revenue that supports the welfare state, that supports the rest of the population who's not working.

So, the countries that we currently, currently think of. as really critical to our future. Countries in Europe, countries like Japan and China, that isn't going to be the case by the end of the century. So the point is that we have this problem, we're not producing enough children. Now, this is a very, very difficult area to talk about, because where you want to start off with is a position where you're talking about sexual reproductive health and rights.

It's not about coercing families or women in particular, assuming we have more children. It's about protecting the rights of individuals, but recognizing that we have this challenge. So, um, just in the last, in the last few days, Vladimir Putin has talked about, um, the catastrophe that as he calls it in Russia, because Russia is going to be one of those countries that's going to see a dramatic fall.

in its, in its population over the course of this century to essentially unsustainable levels. Now the response in the response in Russia has been exactly the wrong response. Um, it's basically a response, which is highly coercive. Um, it's going to, it's attacking feminism. It's attacking sexual reproductive rights.

It's talking about how you can restrict abortion. Um, very, very aggressive, um, withdrawal of rights from the population. Interestingly, in Hungary, which is not what you would expect, uh, Viktor Orbán isn't exactly the, uh, progressive, no, he's not progressive, he's not the poster child for a kind of, uh, democratic politician.

Um, but interestingly, he has introduced a set of what he calls carefare measures, where There are grants given to families. Um, there are tax breaks. There are, um, you can, uh, there are benefits on mortgages. There are low interest loans and grants all given to families who have more children. So he's tried to create a set of pronatalist policies.

Because Hungary is one of those countries that's going to see a catastrophic collapse in its population. And if they don't do anything about it, they will be an unsustainable country. So it's very interesting what you're seeing at the moment. This, you know, China's plan was to go from a one child, um, country, then it went to two children, and I think it's gone to three.

Um, but it hasn't worked. Uh, you're still seeing a very rapid decline in fertility. But also in Hungary, it's done subtle. Right, that's 

Gavin: my 

Richard: point. In 

Gavin: Hungary. It 

Richard: worked. 

Gavin: In Hungary. Well, it worked. It worked for a short term. In the short term it worked in the short term, and now it's gone back to roughly where it was 

Jessamy: gt.

They're spending 5% of gdp, which is a lot, which is a lot of money. Protein policies. 

Richard: It's a lot of money. It's a lot of money. It's true that it's fallen back a little, but it did advance a little as well. So they went from 1.2 births per woman to 1.59 births per woman. Um. Now, what do we do about this? Um, there are two solutions to a catastrophic population collapsed, as we're going to see in many countries.

One is what Victor Orban was doing to try and have pro natalist policies, basically strengthening the welfare state to encourage families to have more children. And the second is another hot topic, immigration, and The solution surely has got to be a mix of the the two. You strengthen the welfare state so that families are safe and secure to have to have children and you attack this vicious, racist, anti immigration movement, which is swept across the world.

Um, because unless China is willing to accept more migrants, unless Japan is, unless much of Europe is, then It's not going to be sustainable. So it's a very I find this whole, you know, demography is not destiny, but it's sure is a big part of destiny. And it's going to affect our future in in ways that We, again, we don't talk about, it's not in the, in the public debate.

Gavin: Well, the other issue affecting countries like Hungary, of course, is that often skilled workers emigrate to, using freedom of movement across the EU to, uh, to countries where they can expect to earn a better wage and have better, um, working protections. 

Jessamy: The brain drain. Yes. We need an ethical framework to be able to sort of shape immigration to around the world.

To, to balance out these populations. But I went back to our DVD, obviously, our Bible, about these pronatal policies. And I, because I just think it's such a fascinating area and some of these policies are so interesting. So in general, okay, there, there, there's very little data on whether they work or not.

But IHME say that such policies have led to strong, like very few have ever led to strong sustained rebounds. Um, and most empirical evidence suggests that there's an effect size of no more than 0. 2 additional live births per female for any pronatal policy. So when they change their projections to 2100, where, you know, the replacement rate is 2.

1 total fertility rate, and if we have no pronatal policies, then we'll be at 1. 59 average globally in 2100. If we do pronatal policies That will only take us up to 1. 68. So 

All: we have to 

Jessamy: have immigration. 

Richard: We have to have immigration. But I would say we also have to make sure that we're creating a welfare state, which protects women and families so that they can say safely have.

Um, children, and look, this is a hot political issue. Very, you know, in the last two days we've seen a contender for the Conservative party, Kemi Bock. 

All: Yep. 

Richard: Talk about the fact that maternity 

All: go 

Richard: Yeah. Basically the, the, the, it's too generous. Maternity pay is, is too burdensome for 

Gavin: companies. So one of the most incredible correlations I've ever heard a politician make, uh, which was Kemi Badnock when she said that we didn't used to have maternity pay and women had lots of children.

Yeah, I know, I know, I know. 

Richard: So, so, so if you imagine that you're a woman in her 20s, in a cost of living crisis, and you're thinking about having a family, and you've got Kerry Badenoff saying that she's going to withdraw and you're working, but and your company provides certain maternity benefits, but she's saying we want to withdraw those, uh, see the reduce.

Is that going to encourage you to have a child? No, it's not. Of course, it's not. So the stronger the social protections are, the more that supporting the rights of women to choose. That's what we're trying to do is trying to strengthen the rights for women to make the choices they want to make. And at the moment, We're not doing it.

Jessamy: I agree. I agree. Except, I do also think, because this came, like, there, so there was the Budapest Demographic Summit, right, where all these right wing leaders go across and talk about how they need to have normal babies. Yes, 

Gavin: I have some choice quotes from that. 

Jessamy: Oh, yeah, yeah. Go on. Go on. 

Gavin: One of the featured speakers was, uh, Jordan Peterson, which is always a sign of a good event.

Yes. And he said, The proper encapsulating structure around the infant are united and combined parents, man and woman. 

All: Yeah. 

Gavin: All alternatives to that are worse. Single people, divorced people, gay people all deviate from that. 

Jessamy: Okay, so this is my point, is that there, this is our approach to it, which is policy based, which is evidence based, but there is actually a whole Group of people who come at this from a completely different perspective and, and many of them are women as well.

They're not, they're not just men that are saying this. There are many women who, uh, uh, think that, that wokeism is bad, that we should all go back to being married, that we should stay in that. I don't understand how that's the conclusion that you come to, but it is a conclusion and it is an approach. For a really large proportion of most high income countries, 

Richard: but I want to argue rights based approach to strengthen social protections as a as a means.

Jessamy: I want to argue with you, Richard, I agree with you. 

Richard: But there are too many Jordan Peet's, yeah, no, it's, it's, uh, but if we if we don't do something, we're already 2024, um, the world's population is going to peak, I think it should be sort of, um, you know, 2060 something. Yeah. Um, so we really have to start bending these curves the other way for many of these countries.

Uh, otherwise we're really going to be in trouble. 

Gavin: But to go back to the beginning of what is now an extraordinarily long podcast, this is where we get, this is where we get the robots to help out, right? How are the robots going to help? They'll automate productivity in some way. The robots will earn the money and we can all sit around at the seaside.

Jessamy: 2160 is when it's going to peak. But before that, you're going to have these dramatic changes in high income countries who are also playing with the idea of populism. And so how, how do you both tackle, because it's a, it's a, it's a sort of downward spiral, because you've got demographic changes, put pressure on the economy.

There's less money that's going around. We've already talked about how basically as in the UK, we've made no progress on child poverty. We've made no progress on people living in poverty. So, so for this group of people over the last 20 years, nothing has worked for them in this centrist approach to politics.

Now we've got this very changing demographic climate change. All of that's going to make it worse. And the only place for them to go to, for the most part, is a, is a populist approach, because they. centrist or even a progressive approach, which is policy based probably doesn't sound as enticing as we think it should do.

Gavin: It's also, I think, the case is that a lot of politicians just spend their whole time kicking that particular generation, let's call them Gen Z, for want of a better phrase, and then wonder why they aren't doing the things that they say. Um, having a child is far less affordable than it used to be. Raising a family on only one income is almost impossible in a lot of high income countries.

And then, politicians, a lot of whom contributed towards the conditions of unaffordability, of the constant need for, for growth, are like, well, Why is no one having kids anymore while they look at, you know, two people together who are both working full time careers and in order to afford even the basics?

Richard: Well, it's very interesting you raise that because I had a very interesting conversation with somebody here and I haven't thought of it this way. We were discussing, um, why has there been, because we're about to publish a commission on self harm in a few weeks. And, uh, we were discussing why have the rates of self harm among the kids.

women, young women, um, adolescents increase so dramatically. And of course there has been this discussion about the role of social media. Uh, and interestingly, what she said to me, um, was she didn't buy the story that it's social media. Um, and she's younger, she's in her, um, I think early mid born baby, mid thirties.

Um, and her argument was, she said hers was the first generation. Which, you know, every generation before hers expected earn more, succeed more than their parents. And hers was the first generation where she had to look at her future and realize that it may not be as secure or as prosperous as her parents.

Um, and that, she said to me, that people like me had to understand the psychological shock. Of that realization that that understanding that your future may not be as secure as your parents future is a hell of a realization to have to confront. Um, and of course, in that case, then the idea of families, children, and all this sort of thing is completely off the table because it is, you know, you just don't have a, you don't have that.

Again, it's about choices. Your choices are contracting. You've got fewer choices to do than you did to begin with. 20 years ago, and that's how so that's a policy question then how does a government? Expand choices for people and part of that is about social protection of which the health system is is is a part 

Gavin: Yeah, I agree.

I'd like 

Jessamy: a hundred percent real 

Gavin: any functioning capitalist society has to have an extremely strong role for the welfare state That's just how it works There's winners and losers in a capitalist society and the losers need to be supported But 

Richard: that's where this demographic issue then becomes so vital because the social contract that underpins that welfare state those social protections is under threat And, and I don't understand why we're not talking about that more.

Luckily, well we are, but the wrong people are talking about it. Exactly, exactly, exactly. Fortunately, um, the UK's population is pretty stable at 2100. Germany's population is predicted to go down by about 20 million. France's is pretty stable. America, which is still, despite all the political argument, a country of immigration, is stable.

Um, so there are points. For, um, a stability for the future, there's a hell of a lot of change coming. 

Gavin: Well, it seems an upbeat 

Jessamy: place to leave it, 

Gavin: to leave it. Uh, just me, Richard. Thank you as ever. And, uh, thanks to you for listening if you're still here after an hour.

Thanks so much for listening to this episode of The Lancet Voice. If you'd like to find out more about any of the podcasts that The Lancet puts out, you can find them all now on thelancet. com slash multimedia. Remember, you can subscribe to The Lancet Voice wherever you usually get your podcasts, and we'll see you again next time.