What Does Good Healthcare Consulting Look Like?

[00:00:00] Dear listeners, welcome to Faces of Digital Health, a podcast about digital health and how healthcare systems around the world adopt technology with me, Tjasa Zajc.

[00:00:14] Today, we're going to talk about consulting in healthcare.

[00:00:18] Consultants are present more often than we might realize.

[00:00:22] They work with healthcare providers to improve clinical efficiency, manage costs, implement new technologies or streamline administrative processes.

[00:00:31] They can help with regulatory compliance, help insurance companies design new products, governments hire them to help with policy development, program evaluation and much, much more.

[00:00:44] I spoke with Mehdi Khaled, internal medicine doctor and Fortune 50 health tech executive with over 25 years of international experience.

[00:00:54] He has helped shaping many large-scale transformative digital health projects across four continents and within 40 health systems.

[00:01:03] As a managing partner at CEHA, he specializes in developing and executing cutting-edge health and digital health strategies with a strong emphasis on the meaningful use of data to drive health system improvements.

[00:01:19] Before we begin, I'd like to thank one of our listeners, David, who sent me a message and asked if there's anything that we can do in order to improve the audio quality of the recordings,

[00:01:31] because he noticed that they are quite quiet.

[00:01:35] So we added a few steps in the post-production to help with that, and that's going to be the practice for all the future episodes.

[00:01:43] And I would just like to emphasize that the quality of the content and the audio quality of the recordings is very important to me personally.

[00:01:52] So if you ever have any additional suggestions or comments in order for us to improve,

[00:01:58] please send me a message or write a rating or a review wherever you listen to your podcasts.

[00:02:05] It does make a difference.

[00:02:08] Now let's dive in today's discussion.

[00:02:25] Mehdi, hi, and thank you so much for joining this discussion for Faces of Digital Health,

[00:02:32] where we're going to talk about consultancy and consultants in healthcare, their importance, their contribution,

[00:02:41] also some of the challenges that we see in consulting, because consultants are present more often than we might realize.

[00:02:49] They provide advice or strategy to improve clinical efficiency, manage costs, implement new technologies.

[00:02:57] They can advise governments for new strategies such as decreasing a specific disease burden or digitalization practices.

[00:03:07] So they can be highly respected, but at the same time, also a lot of people are annoyed when they hear the word consultant

[00:03:15] because there's a lot of, I guess, frameworks that they use and it can seem like it's just copy-pasting.

[00:03:23] And most importantly, once the job is done, once, say, a strategy is written, the consultants leave and there's no accountability.

[00:03:33] So that's kind of the challenges we're going to outline today.

[00:03:36] I want to start with your observation and your description.

[00:03:41] How would you describe how consultancies can do good and where they do poorly?

[00:03:46] You've been in the space for over 25 years.

[00:03:49] You're a clinician, you're an entrepreneur, you worked with government.

[00:03:52] So 25 years of experience on four continents.

[00:03:56] We have so much to dig into.

[00:04:00] Indeed.

[00:04:01] Thank you, Jasper, for having me and thanks for listening.

[00:04:04] I think it's a bigger question that begs a lot of reflection.

[00:04:08] Context is very important.

[00:04:09] In general, yes, I agree with you that some of the consulting companies, the big ones, tend to have some negative stories.

[00:04:18] But let's say these are still exceptions.

[00:04:20] They make a big noise because of the impact they trigger.

[00:04:24] But then in general, these are still exceptions.

[00:04:27] In a Bain study that has been done until 23, I think this is very important to mention here at this point,

[00:04:34] because this Bain study has been conducted over 10 years with 300 clients, Bain and non-Bain clients.

[00:04:42] And they noticed that in the study, only 12%, over 10 years, still 12% of the big transformation projects meet or exceed their goals and targets.

[00:04:53] But still, we have a big proportion of projects, big transformation projects either fail to achieve the targets or still settle for mediocre results.

[00:05:05] And the proportion in 10 years of companies settling for mediocre results increased from 50% to 75%.

[00:05:14] So still accepting a mediocre result is still a big issue here.

[00:05:20] And I think that begs a lot of reflection.

[00:05:22] Now, in terms of consulting, I think accountability is a big word here.

[00:05:27] And because we're in healthcare, accountability is still a very rare ingredient in healthcare.

[00:05:34] The reason for that is very complex.

[00:05:37] But then, let's say that accountability should start with the healthcare provider.

[00:05:42] And just as the healthcare system or ecosystem has more than the healthcare provider, you have the pharma companies, you have the insurance companies, the payers.

[00:05:51] The two latter are, to me at least, are necessary evils in the equation.

[00:05:56] You need the pharma companies because you need the drugs.

[00:05:58] You need the insurances because you need the coverage.

[00:06:01] And to me, pharma companies and insurance companies, payers, are banks in golden wheelchips.

[00:06:09] So basically, it's just there.

[00:06:11] It's part of the system.

[00:06:12] They deliver some value, but it's a self-centered value.

[00:06:15] They're there for the business, for the money.

[00:06:17] Now, to flip back and focus on the healthcare provider side of the equation, I think accountability has to be written big there.

[00:06:26] Because you can't blame the failure of big projects only and solely on consulting companies if the client, who is a healthcare provider, hospital, or government system, is not accountable by design.

[00:06:40] So it's difficult to push the accountability on the consulting companies if nobody owns anything anywhere, anytime.

[00:06:50] In your opinion, or in your observations, how do you think that this could be improved?

[00:06:56] I absolutely agree with you.

[00:06:58] Even governments change.

[00:07:00] A first minister is going to present a new strategy for whatever for the next five years.

[00:07:05] And then the second minister comes in, and not rarely.

[00:07:08] They just want to do everything differently.

[00:07:10] And also, I think strategies are like ideas for startups.

[00:07:16] You can have one, but that's not what's going to impress the investors.

[00:07:20] Investors are going to be impressed if you have the distribution model and if you can demonstrate it, you can actually execute that idea.

[00:07:27] So ideas are extremely important, but the implementation and the strategy behind how you're going to get that into the real world is even more important.

[00:07:37] What are maybe some of the good practices or successful projects that you saw in your career that you might highlight as a good example?

[00:07:46] Or at the same time, then we can move to the most common mistakes that are made and how they could be avoided.

[00:07:54] Yeah, that's a really great question.

[00:07:56] Now, in terms of, so we talked about accountability, but then because we're in healthcare, to me, there are two big principles in healthcare that should apply no matter the context or no matter the continent or geography.

[00:08:09] Number one set of principles is we have to define our true north here and your north star.

[00:08:16] Because you're healthcare, you're not a bank.

[00:08:18] You're healthcare.

[00:08:19] You should care about your patients and your citizens equally.

[00:08:22] And so principle number one is founded on four pillars.

[00:08:28] Pillar number one is access to healthcare services.

[00:08:32] Number two is the cost of those healthcare services.

[00:08:35] Number three is the outcomes that you provide outside of that cost equation.

[00:08:40] And number four, last but not least, actually should be number one, is prevention.

[00:08:44] We have very few systems and governments that are truly focusing on prevention.

[00:08:50] And I'll give you some examples later.

[00:08:52] They're really actioned at properly and efficiently with numbers that follow.

[00:08:58] The principle number two is based on governance, leadership, and accountability, obviously, right?

[00:09:05] I'll start with this one because it's easier and we see it everywhere.

[00:09:08] And I go back to the principle of prevention.

[00:09:10] I'll give you some examples there.

[00:09:12] Principle number two is based on governance and leadership.

[00:09:15] And in most countries, the way decisions are made are top down.

[00:09:23] So when you try to trace back in, let's say, 10 years from now and say, okay, why did we make that decision?

[00:09:29] The answer is almost always because that boss that time said so.

[00:09:34] So you almost have no traceability on the decision-making process.

[00:09:39] And so you end up in a catch-22 where, for example, Australia, they made a decision in 2011 with my PHR, my personal health records, which was the first shared electronic health records for patients.

[00:09:53] They made it an opt-in.

[00:09:56] So basically, you opt in if you want to opt in.

[00:09:59] And that was a decision by the government then.

[00:10:02] So the adoption, obviously, was very low because it was very poorly marketed and people were scared about sharing their health records and cloud and everything was a thing.

[00:10:12] So they cut that short.

[00:10:13] The next government came and they made it opt-out.

[00:10:16] So all of a sudden, you had 20 million citizens having records all of a sudden.

[00:10:19] So decision-making is very important.

[00:10:21] So I'll go back to principle number one, which is based on those four pillars.

[00:10:25] And I've talked a little bit about prevention.

[00:10:26] So prevention is very important because governments who have understood the value of that see results immediately.

[00:10:35] Singapore is not part of the OECD countries, but they've done a benchmark study to see how they fare in terms of diabetes management against OECD countries.

[00:10:49] And they came second before last.

[00:10:51] Last, obviously, being the United States, which has the biggest government spend on healthcare and the worst outcomes.

[00:10:57] That country tells you everything what not to do in healthcare.

[00:11:00] But then Singapore did the study and said, we're second to the U.S. in leg amputation.

[00:11:04] And when you're a diabetic and you reach the stage of leg amputation, it's pretty much the end of the row.

[00:11:12] And so they did something and something very genuine.

[00:11:15] They said, we're going to create an office that is called the War on Diabetes.

[00:11:19] They created a whole campaign called the War on Diabetes within the Health Promotion Board, which is part of the healthcare system that is focused on, as its name says, prevention, health promotion.

[00:11:33] And guess what?

[00:11:34] That was 2011.

[00:11:36] They started 2010.

[00:11:38] And now the trends are reversed.

[00:11:40] You have less diabetic patients, less pre-diabetic patients, less obese patients.

[00:11:45] Singapore is the only country on the planet that has the highest healthy life years.

[00:11:52] Basically, life expectancy is around 86, 87 years.

[00:11:58] And in those 87 years, only 9 or 10 years are lived with diseases, which is in Austria, for example, we have the same life expectancy.

[00:12:07] But the disease life years is 26.

[00:12:10] You have 26 years of your life expectancy years are burdened with diseases.

[00:12:17] In Singapore, they have around 9 or 10.

[00:12:19] So these are very important principles to stick to.

[00:12:23] So going back to consulting practices that act within these contexts, if you're not surrounding yourself with these principles,

[00:12:31] with this northern star that it's about healthcare, we need to move indicators, we need to do more prevention, we need to inspire our clients to do more of what's right and not do what the client asks, then you're in trouble.

[00:12:45] Because most of the time, what we notice is when we get into bigger engagements and bigger government projects, the problem is ill-defined.

[00:12:53] So when you start with an ill-defined problem, you only come to have solutions.

[00:12:59] So what we do typically is we try to redefine the problem and dig deeper to better understand what the problem is in order to come up with a solution that is more sustained.

[00:13:08] Here's a practical, maybe a bit of a tricky or difficult question.

[00:13:13] So you mentioned that the decisions are often made top-down.

[00:13:18] And I was thinking if that's a good thing or if that's a bad thing, because obviously you want to include the end users.

[00:13:25] And especially when it comes to workflows in the healthcare system, the digitalization projects need to support those workflows and not hinder them.

[00:13:34] However, if we look at the DIGA system in Germany, when it was set up, the medical community was strongly against it because it was something new, something different.

[00:13:48] So when the government decided to implement that framework, they were thinking that this is probably something that's good for the end users.

[00:13:58] We actually didn't know that yet at the time when they decided to do that because there was no large-scale example of the distribution of digital therapeutics until that time.

[00:14:08] So it was a leap of faith from the German government and minister Jens Spahn and also a very necessary top-down decision that many in Europe are now following.

[00:14:19] So how do you, as a consultant, see the challenge of working and listening to the people that are in the end going to have to use new technologies, new solutions, and having the potential different reality and better future in mind?

[00:14:37] Because we are always used to how things are currently done.

[00:14:41] So a lot of times new ideas seem impossible to see ever, even if they then become reality.

[00:14:49] You really have the gift to ask important questions and very clever questions.

[00:14:53] Thank you for that.

[00:14:53] So it's a very important aspect here.

[00:14:57] So let me say it in one sentence.

[00:14:59] We're delivering modern medicine in a system that has been designed in the 60s.

[00:15:04] That's the answer.

[00:15:05] Short one.

[00:15:06] Legal frameworks and policies typically follow the implementation and adoption of technologies and never the other way.

[00:15:13] You see what happened just lately with the AR Act and everything else.

[00:15:17] So technology evolved, was implemented, adopted, and then governments start hedging their bets on, okay, how can we make sure that this technology doesn't do any harm because it's healthcare?

[00:15:27] Now, there are two aspects or two ways to look at it.

[00:15:30] Number one is always the gap that we have in the medical clinicians community between them understanding digital health and the gap that the technical community and the vendors have in understanding healthcare.

[00:15:47] That gap is always there.

[00:15:48] The gap of the medical community understanding technology is getting bigger because technology is evolving a lot faster than medicine is evolving.

[00:15:58] And so there is a study that has been done by the Australian Healthcare Agency, Digital Health Agency.

[00:16:04] I think that showed that around 60% of doctors have a willingness to understand more digital health concepts and things and technology, but only less than 20% of them have the knowledge to get there.

[00:16:20] So there is a gap in understanding and we need to bridge that gap.

[00:16:25] The problem of DIGA specifically is it has been, it is still a very visionary thing to do.

[00:16:34] And I think the adoption was slow because of many portals related to communication.

[00:16:39] It's a new technology.

[00:16:41] And also the difficulty to get things approved and done because it's seen as a drug, as a prescription, right?

[00:16:48] So you prescribe DIGA, you prescribe the applications.

[00:16:51] And when you see it in a country like Germany, where the digitization index of hospitals was at 18 on a scale of 100, you understand why the adoption was slow.

[00:17:02] Because the access to technologies by those prescribing physicians was not there.

[00:17:09] And communication about the benefits to do so was lagging behind.

[00:17:14] So there was a focus on getting things off the ground at the technology level, but the effort has been lacking in terms of poking up the advantages and making sure the technology is available for people to prescribe.

[00:17:28] But also for patients to adopt.

[00:17:31] I know a few patients in Germany who are COPD patients and they have to renew every three months.

[00:17:36] They have to renew something so the application still works on their phones.

[00:17:40] So it's a little bit burdensome for the patient that they have to still do something for the COPD application.

[00:17:48] I don't know if I answered that or your question there.

[00:17:50] Yeah, maybe just from the consultancy perspective, how important is the context that you work in when you're advising?

[00:18:00] So, for example, in Germany, as I said, this was a really top-down decision.

[00:18:05] Jens Schwann took it regardless of the consequences.

[00:18:08] Luckily, it's now a success story depending on which angle you take.

[00:18:13] But it's still there.

[00:18:14] It's not something that the next minister would just kick out.

[00:18:17] And then there's smaller countries like Slovenia.

[00:18:21] And I remember one time one policymaker said that the reason why people are afraid to do change anything here is because we are not accustomed to failure.

[00:18:34] So if you are the minister or the head of the digital sector at the Ministry of Health and you're going to push for something and that's going to turn out to be unsuccessful,

[00:18:44] that failure is going to follow you wherever you go because it's a small country.

[00:18:52] The decision-makers or those in power are very risk-averse.

[00:18:56] So how do you, as a consultant, go after that?

[00:19:00] There is a very thin line to walk there.

[00:19:02] The very thin line takes a lot of what I call cultural intelligence.

[00:19:07] You need to be aware of the culture you're navigating.

[00:19:09] Decision-making in Germany, unlike the Minister of Health who took that decision, typically decision-making in Germany is very long as opposed to the Americans.

[00:19:19] So people decide.

[00:19:20] And this is important to understand in the context of consulting.

[00:19:24] Because you come into a context, you have to understand how decisions are made.

[00:19:27] Because that process can last nine months or two days, depending on where you are.

[00:19:33] And so decision-making is very important.

[00:19:34] In Germany, they take a long time to decide about something.

[00:19:39] And then when the decision is done, they go straight into implementation.

[00:19:43] In the US, the culture is such that decisionism is made very quickly.

[00:19:47] But when the decision is made, it means let's start to work with the option to change our minds down the road.

[00:19:56] So that's why the American-German M&As quite never work.

[00:20:01] Because the decision-making process is completely different.

[00:20:04] For the Germans, if the decision is made, that's it.

[00:20:07] We're not going to review it.

[00:20:08] We implement it.

[00:20:09] We review it eventually, but not during the implementation.

[00:20:11] And then we talk about another thing related to decision-making, which is doing the right things for the wrong reasons.

[00:20:19] So in a lot of instances, we see countries doing things and good initiatives.

[00:20:24] But when you dig deeper, when you really look under the hood, that they're doing it because a neighboring country has been doing that.

[00:20:30] You're buying 40 million worth of AI technology.

[00:20:33] I'll buy 50 million worth of AI technology.

[00:20:36] You hear it's great.

[00:20:38] They're investing.

[00:20:38] But they're investing for other reasons that healthcare principles dictate.

[00:20:45] It's a thin line to walk.

[00:20:47] Our role as consultants is really to, number one, inspire people to move to the next level.

[00:20:54] I always try, in our practice at least, I always try to get ministries to start really thinking about prevention.

[00:21:01] To really stop building hospitals and hospital beds and buying hospital beds.

[00:21:06] Build it of their come, right?

[00:21:08] So it's think about healthcare as highways.

[00:21:12] The more roads you build, the more cars you have.

[00:21:14] It's the opposite thinking.

[00:21:16] It's counterintuitive.

[00:21:17] So we need to think about how can we leverage new technologies to keep patients and citizens where they are, meaning at home, and manage them from there.

[00:21:25] That's a future Pro-Healthcare system.

[00:21:28] That's a modern healthcare system.

[00:21:29] Now, what we do is we try to inspire by providing evidence that what we're saying would work.

[00:21:38] Contextual evidence that if you don't have capacity to execute on this particular idea, keep patients at home and use telemedicine or telehealth or technologies that will enable you to do this.

[00:21:50] We will help you build capacity.

[00:21:52] And the example of Singapore is amazing to me because, and to cite Singapore as well, Spain, specifically Catalonia, is the Singapore of Europe right now.

[00:22:03] Because Catalonia is 20 years ahead of the rest of Europe in terms of technology adoption, etc.

[00:22:08] So not because of another person, it's because its facts are there to show that.

[00:22:13] Because the way they're thinking about the healthcare system is very close to the way Singapore thinks about the healthcare system.

[00:22:20] When Singapore created Ministry of Health Holdings, which is a private limited company that is managing the public hospitals in Singapore that are 13 or Pac-11 13, 2008,

[00:22:32] 2008, they didn't have capacity, they didn't have the workforce and the skills to manage such a big project and ambition because they were going full digitalization.

[00:22:43] Full everything is going to be digitized.

[00:22:45] They didn't have that.

[00:22:47] So what they did is they hired high-level executives.

[00:22:51] We're talking minister minus two.

[00:22:52] No country does that.

[00:22:54] No country does that.

[00:22:54] Hired people from all across the planet, the four corners of the planet.

[00:22:58] They brought people from Canada, people from the UK, people from Australia, New Zealand, the best of the best, and put them together in a team to manage the whole digital healthcare, new healthcare ecosystem.

[00:23:09] And they flanked those people with locals so that, and everybody knew this, it was not a secret, it was not a stab in the back, it was a known thing.

[00:23:18] So all these people came from outside Singapore, had limited contracts in time, and they knew that they had to transfer knowledge and know-how and experience and expertise to the locals.

[00:23:28] Now you look at Singapore, the whole healthcare system and digital health system, 99% are locals.

[00:23:36] And that's something that consulting companies still do not do.

[00:23:42] So the practice is still anchored in, we provide you with expertise, but we do not want to transfer the expertise to you.

[00:23:52] So that's one side of the coin.

[00:23:54] The other side of the coin is the willingness of the client to build capacity.

[00:23:58] And we know that, again, to cite Catalonia, Jordi, whom you had in one of your podcasts lately, is the head of digital health strategy in Catalonia.

[00:24:09] Jordi himself, in a country like Saudi Arabia, for example, is replaced by a fully outsourced department called SMO, Strategy Management Office,

[00:24:20] that is populated by a consulting company doing the job of what Jordi is doing in Spain.

[00:24:29] That is outsourced and the contracts are perpetuated over time to manage the projects and manage the strategy, etc.

[00:24:37] Now, what we're missing here is what I call the corporate memory.

[00:24:43] And so when you do that, the practice perpetuates the fact that you're depleting your own memory as an institution, as an organization,

[00:24:51] from building know-how and practice in managing your own practice.

[00:24:56] And you'll be forever depending on consultants coming do your job, and they will do it always more poorly than you do it yourself,

[00:25:04] because they don't put the skin in the game, they don't put the heart in it.

[00:25:08] They're not from there, they come and go, and people change.

[00:25:11] And so what we advocate for is this transfer of what we call the golden quadrant,

[00:25:17] is when the client is willing to build capacity, and when the consultant is willing to transfer that knowledge.

[00:25:23] So what we create all of a sudden on a project, we create what we call rainbow teams.

[00:25:29] The rainbow teams are teams from our side, and teams from the customer's side,

[00:25:34] and they work together, we don't make a difference who belongs to who.

[00:25:37] And so we work together, and we make sure that during those 6, 9 months, 12 months, 24 months period of the project,

[00:25:45] transfer of knowledge happens, and we help the client build capacity.

[00:25:50] It's very rare. We'd like to see it a lot more than we see it now.

[00:25:54] I don't know to which extent you can talk about the projects that you were involved with,

[00:26:00] but if you can, even if it's just mentioning the continent or the region, not a specific country,

[00:26:07] what can you share in terms of your experiences in a good example and a bad example of collaboration,

[00:26:16] or how you help define the strategy.

[00:26:20] And maybe we can go through the whole process.

[00:26:23] When you come to a new client, let's say a new government,

[00:26:26] how does that look like?

[00:26:29] Who decides how long you're going to be there?

[00:26:31] How much time do you take to get acquainted with the local context?

[00:26:36] And where do you go from there?

[00:26:38] When do you know that or can be sure that you understand enough to be able to create a framework

[00:26:45] and a strategy for this specific environment?

[00:26:52] So the best case scenario is when you're brought in to be part of defining the problem.

[00:27:00] The worst case scenario or the suboptimal, not worst case, but suboptimal scenario is when you get an RFP

[00:27:06] and you respond to a, the client wants to do that.

[00:27:11] We want to do a strategy for the national health, whatever.

[00:27:14] And then you're almost framed.

[00:27:17] When you respond to an RFP, you're framed.

[00:27:19] Now, depending on your relationship with that particular client, namely governments,

[00:27:25] you can still help refine the problem.

[00:27:28] So we're currently responding to an RFP in one of the Middle Eastern countries where you can see when you read it,

[00:27:35] you can see the problem has not been properly defined.

[00:27:37] So data everywhere, we need to do this, we need to do this.

[00:27:40] And the main key word that is missing is data strategy.

[00:27:46] And they're not defining, they're not saying we need a data strategy,

[00:27:49] but you can tell that they don't have one, but they need one.

[00:27:53] So how to position that in an RFP and tell them what we suggest to do that if the budget doesn't allow you to do that?

[00:28:01] And so that is, it's very tricky.

[00:28:03] So you can, so if you get the, if you get the contract, you can start changing things by, as I said before,

[00:28:10] can show the evidence that something is missing and you can show the value of what you offer it,

[00:28:15] that it will sustain your business a little bit more when you do things, when you define the problem from the ground up.

[00:28:22] And so that's one example.

[00:28:24] The second example is, you talked at the beginning about copy and paste.

[00:28:28] And I'll give you a very good example from Hong Kong and Australia at the same time.

[00:28:33] Shane Solomon used to be the head of Victoria Health in Australia,

[00:28:37] and then Hong Kong Health Authority hired him to become the CEO, I think back in 2008 or something, even before.

[00:28:45] What Shane did in Victoria Health was they created the program,

[00:28:50] and this is also partly related to consultancy efforts, not that we've done,

[00:28:54] but we've been involved with the Hong Kong government later on in doing the same program,

[00:28:59] is they took what they call the hospital admission reduction program.

[00:29:03] It's called HARP.

[00:29:04] They tried to, the frequent flyers, people who are readmitted in the hospital very frequently,

[00:29:10] those chronic disease patients, and tried to put up a program with a predictive algorithm,

[00:29:16] we call it AI today, but it's still algorithms and analytics, advanced analytics,

[00:29:20] to predict the risk of a patient being readmitted into a hospital.

[00:29:26] It worked in Victoria at a rate of 23% reduction of hospital readmissions,

[00:29:31] which is hospital readmission is, for the listeners who don't know it,

[00:29:34] is readmitting a patient with a readmission that could have been avoided within 28 days of discharge.

[00:29:40] That's readmission.

[00:29:42] And most cases these could be, can be avoided.

[00:29:45] The problem is, the program has been stopped because the cost of running the program

[00:29:50] were higher than the costs achieved by reducing 23% of the hospitalization rates.

[00:29:57] In Hong Kong, it was the opposite.

[00:29:58] They reached the exact same number, 23%, and the cost was lower.

[00:30:03] And they achieved even better results because they've been able to actually employ nurses

[00:30:10] who were on maternity leave and who could work half-time, but they had to come to work.

[00:30:17] They couldn't access medical records of the patients from home, obviously.

[00:30:21] And so talking about copy and paste sometimes is important because contextual implementation

[00:30:29] is also important.

[00:30:30] What I miss in consulting is the innovation.

[00:30:33] So when was the last time you've heard of any big consulting?

[00:30:37] Nothing against them, but when have you heard that a big consulting company in healthcare

[00:30:41] came up with a big innovation?

[00:30:44] It's almost as rare as seeing the blue moon we saw yesterday.

[00:30:49] The problem is, the copy and pasting is great when it comes to running workshops.

[00:30:55] We have the same structure, etc.

[00:30:57] But it's not great when it comes to implementing processes.

[00:31:03] A process that works somewhere might not work somewhere.

[00:31:07] Actually, it rarely works somewhere else.

[00:31:09] You have to change it.

[00:31:10] You have to understand the environment.

[00:31:11] So what we typically do is we trigger workshops and we push people to think out of the box.

[00:31:17] And we have, so the workshops that we do, we tell everybody from minute number one, we have

[00:31:24] no hierarchy in this room.

[00:31:25] Every voice counts the same.

[00:31:27] Even if stakeholders come from conflicting agendas and different backgrounds and points

[00:31:32] of view, etc., that's fine.

[00:31:34] We encourage everyone to say what they think.

[00:31:37] How would they solve the problem?

[00:31:39] How would they define the problem?

[00:31:41] And we get to a point where people get creative, really, because they feel they're not hindered

[00:31:45] by the presence of a boss here or a boss there.

[00:31:48] They're free to talk.

[00:31:50] And I think these kind of workshops where you push people to think, to be part of the solution

[00:31:55] and not part of the problem, is a practice that we'd like to see more in the consulting

[00:32:01] practice to that.

[00:32:02] Yeah, it means a lot if you feel included and heard.

[00:32:06] And then it's also easier in the next steps when changes are about to be implemented to

[00:32:11] go after them because you were a part of designing how the next steps should look like.

[00:32:18] However, again, a practical example.

[00:32:21] You said that the worst thing is if you come to a situation where the framework is already

[00:32:25] designed.

[00:32:26] How do you deal with situations where the budget is designed and then you have to find a solution

[00:32:34] for everything else?

[00:32:35] And a budget for a specific digitalization might be, say, very limited.

[00:32:41] And you can already see from the beginning that it's going to be difficult to do something

[00:32:47] good because there's not enough funding reserved for that specific thing.

[00:32:51] What do you do then?

[00:32:53] Because I guess the most frustrating thing to observe is when the decision makers then

[00:33:01] decide to implement a poor solution just because it's cheaper and that's what the budget allows

[00:33:08] them.

[00:33:08] And we know how difficult it is to replace legacy systems in healthcare.

[00:33:12] When you put something in, it's there.

[00:33:14] It's not going to be changed very easily.

[00:33:19] Yeah, good question.

[00:33:20] That issue is seen more often than we think that it occurs quite frequently, that budgets

[00:33:28] are limited and projects are not really ambitious.

[00:33:31] Think of it this way.

[00:33:33] In democratic countries where you have elections, the solution that you provide will have to fit

[00:33:40] within one electoral cycle.

[00:33:42] Okay?

[00:33:43] Very clearly.

[00:33:44] For obvious reasons.

[00:33:46] In countries where we don't have elections and that where ministers can be there for a

[00:33:53] longer period of time than one electoral cycle in, say, a country like in Europe, decisions

[00:33:57] are made top-down based on the maturity level of the leader.

[00:34:02] And so the governance process in identifying what's best and decision-making process, again,

[00:34:08] is top-down.

[00:34:09] Now, when we are restricted by those contexts of having to deal with limited budget, limited

[00:34:16] time, etc., immediately what we do is to flag the risks.

[00:34:21] So, for example, say we've been in a situation to be told, I need to have 150 patients in that

[00:34:31] particular region, in the country in the Middle East, to be part of a telemedicine pilot project.

[00:34:40] In number one, there was no telemedicine policy.

[00:34:45] Number two, technology was not ready.

[00:34:48] Number three, communication was not ready.

[00:34:50] Number four, use cases were not ready.

[00:34:52] There was no way to do that.

[00:34:54] No way.

[00:34:54] But because the minister said so, it has to happen.

[00:34:59] It eventually happened.

[00:35:00] But then we have to flag the risks of doing so.

[00:35:03] And we have to make sure that there are mechanisms to mitigate those risks.

[00:35:08] So, for example, in telemedicine, it's very tricky because telemedicine is a very good example

[00:35:12] here.

[00:35:13] We hear about telemedicine boom during COVID for obvious reasons.

[00:35:18] But then I haven't seen a single study, and maybe because of my ignorance here, but I haven't

[00:35:23] seen a single study that compares the outcomes of a telemedicine practice versus an in-presential

[00:35:29] clinical practice.

[00:35:31] What is the outcome of...

[00:35:33] There is no mechanism to catch near misses in telemedicine practices.

[00:35:38] Very few mechanisms.

[00:35:40] What happens if the patient reacts to certain drug ingredients?

[00:35:44] What happens if...

[00:35:45] So, the what-ifs are not caught, are not dealt with.

[00:35:48] The outputs and outcomes are not dealt with, to the point where in Saudi Arabia, when they

[00:35:52] did the...

[00:35:53] Saudi Arabia again, because they're very advanced in terms of digitization, they had their first

[00:35:58] platform running in telemedicine a long, long time ago.

[00:36:02] But then when they did the survey of the population about what do you think about the telemedicine

[00:36:08] solution, the answers were great because of the access.

[00:36:12] You immediately get an appointment.

[00:36:14] But it wasn't that good for the quality of care delivered.

[00:36:17] So, you almost make the service available, but that service is what I call a digital extension

[00:36:25] of mediocrity.

[00:36:27] So, you don't want that.

[00:36:28] You want to work on your processes and you want your processes to be solid and waterproof

[00:36:34] and tight before you start digitizing.

[00:36:37] So, when we're limited by what you said before in your question, limited budget, limited time,

[00:36:43] etc., we flag those things.

[00:36:45] So, it's not good to have a telemedicine solution implemented if you first haven't done your

[00:36:52] homework on defining policies, credit the policy providers and certify the solutions for patient

[00:36:59] safety.

[00:37:00] So, we flag those risks.

[00:37:02] People will take their accountabilities when it comes to that.

[00:37:06] Can you think of the most difficult case that you worked on?

[00:37:12] What was it about?

[00:37:13] How long it lasted?

[00:37:14] Why was it difficult?

[00:37:15] What made it difficult?

[00:37:17] I remember when it's difficult to answer this question without offending anybody.

[00:37:23] Don't mention names.

[00:37:25] No, I won't mention names.

[00:37:26] But the way we think about it is this.

[00:37:29] Every project is challenging in its own way.

[00:37:31] And for every challenge, we try to extract the lessons learned.

[00:37:38] So, we learn, we grow, and we learn how to avoid making those mistakes again.

[00:37:43] We make mistakes in consulting.

[00:37:45] Those mistakes are mostly related to judgment.

[00:37:50] Make judgment mistakes.

[00:37:52] That's very often the case in consulting because you're in a different environment.

[00:37:56] You don't know people.

[00:37:57] You don't know the relationships between stakeholders.

[00:37:59] And you have a very limited time to deliver.

[00:38:02] And then you would not like shortcuts.

[00:38:05] But sometimes you have to take shortcuts.

[00:38:08] Let's put it this way.

[00:38:10] The most challenging cases or projects are the ones where giving feedback is challenging.

[00:38:19] So, giving feedback is a cultural dimension that really can trigger a lot of people.

[00:38:26] But giving feedback, for example, to a customer in the Netherlands is great because it's like a straight arrow.

[00:38:33] This is not good.

[00:38:34] We need to change it.

[00:38:35] Okay.

[00:38:36] You say that in the Middle East and everything is taken personally.

[00:38:39] It's as if you're attacking the people in their own way of being, not even way of doing.

[00:38:46] And so, it's very crucial to understand how feedback is taken.

[00:38:51] Sometimes people do not like feedback.

[00:38:54] Sometimes we have to walk around the subject to get to the point with some people.

[00:39:00] And then the context within which you give feedback is important.

[00:39:03] Sometimes it's better to do it one-on-one, like physically, around the table, not via Zoom or via call.

[00:39:10] But never give feedback in a bigger round of, in a workshop.

[00:39:15] Giving feedback in a workshop that affects a whole country or a whole ecosystem is something not to be done in any country because it can trigger the sensitivities between people.

[00:39:26] Start finger pointing, yeah, I told you, et cetera.

[00:39:28] So, those are the very difficult projects is giving feedback.

[00:39:31] And you know that a lot of outcomes of these big projects relies on that feedback.

[00:39:35] That's why we're there.

[00:39:37] If you go to a doctor and the doctor fails to tell you that you have this and that disease, then why are you going to a doctor anyway?

[00:39:44] So, it's very tricky.

[00:39:45] And I think the most difficult, because one-site instances or regions people would know, people have been in the industry for a long time, know which regions accept feedback better than others,

[00:39:56] is when we fail to deliver the message of the feed for people to grow.

[00:40:02] That's a problem.

[00:40:04] What would be your advice to individuals, companies, countries that are looking for advisors?

[00:40:15] How can they find a suitable advisor for them?

[00:40:20] Because on the one hand, if you've got a lot of experience from abroad, some people might say, yeah, but we're different.

[00:40:26] That's not going to work with us.

[00:40:28] Then again, you are also just a person.

[00:40:30] So, as you mentioned, you have your own judgment, which can be, yeah, you can misjudge in some occasion.

[00:40:37] So, what's your advice on choosing a good advisor?

[00:40:43] What are the key things to think about?

[00:40:46] It's a tricky question because I don't claim to be an authority in the subject matter, but then we've seen a lot of things and I can maybe talk from the little angle.

[00:40:55] I see things in terms of what good consultancy looks like, but then again, it's a mirror question.

[00:41:03] So, it always goes back to the client what they want and the level of maturity the client has.

[00:41:08] Some clients look for consultants to just do what they tell them to do.

[00:41:12] So, you have a vending machine and you tell the consultant, put me cherry coat here and lemonade and they do it.

[00:41:19] They don't challenge you.

[00:41:20] They don't tell you why cherry coat has a lot of sugar, your healthcare institution and blah, blah, blah, blah, blah.

[00:41:25] They talk you out of the idea.

[00:41:27] So, there is one category of consultancy that does whatever the client wants to do without asking questions.

[00:41:36] And that's typically seen 80% of the time.

[00:41:39] So, basically, just deliver what needs to be delivered.

[00:41:43] You have a bill of quantities, you deliver on that, project done, in time and budget, great.

[00:41:48] And you have another type of consultancy that actually are tethered to the four pillars of healthcare, access, costs, outcomes and prevention.

[00:41:59] Plus, surround themselves with good practices of governance and how decisions are made, etc.

[00:42:03] And try to move in within that framework and pull the client within that framework of evidence-based practice.

[00:42:13] That's rare.

[00:42:13] So, I think, depending on the maturity of the client and what the client wants and the level of accountability of the client,

[00:42:21] if, say, we're moving into the realm of Spain, very mature, they're no other one, they have already paved the way and they're leading the way,

[00:42:32] the category number two of consultants would be an adequate choice.

[00:42:38] They would want somebody to come and challenge them on what decisions or how the decisions have been made, try to inspire them and move forward.

[00:42:47] In other cases, like countries in the Middle East particularly, there are countries within the Middle East and instances within the Middle East that really want to move forward and be leaders

[00:43:02] and look for the second category of consultancy to come and challenge them and help them move forward.

[00:43:09] But there are still other countries who still look for, just give me that and that's fine.

[00:43:14] So, we need to know what the client wants.

[00:43:17] That will define what category of consultancy you'll get, basically.

[00:43:23] I mentioned in the beginning that you worked across four continents, over 40 healthcare systems.

[00:43:29] And what caught my attention was when you mentioned that one of the clients had an idea about the technology that they want to have,

[00:43:37] but they didn't have the data strategy.

[00:43:39] So, you know, based on your rich experience in a digital health project,

[00:43:45] where do you see that, yeah, healthcare systems struggle most or do most mistakes?

[00:43:54] I think very clearly in the sequence of doing things,

[00:44:01] in most cases we still see technology-led projects as opposed to clinically-led projects.

[00:44:08] Again, because we're in healthcare, we have to really stick to the Northern Star.

[00:44:13] What do we want to achieve here?

[00:44:16] We see a lot of hype about AI.

[00:44:18] We still see the hype of AI in healthcare.

[00:44:20] And we know that new technologies are always overestimate the potential of new technologies in the short term,

[00:44:31] but we completely underestimate the impact in the long term.

[00:44:34] Look at Facebook, right?

[00:44:36] This is not healthcare, but look at social media.

[00:44:39] Completely underestimate the effects on people in the long term,

[00:44:42] but then we hype the effects on the short term.

[00:44:45] And I think that's the problem.

[00:44:47] The problem is new technologies are coming up to the market at a very high pace.

[00:44:52] The level of understanding of those technologies from the decision makers is still very low.

[00:44:58] The understanding of the impact is almost never assessed,

[00:45:01] but we still see a lot of technology-led projects.

[00:45:06] And we see that technology-led projects, in our experience, most of the time fail

[00:45:10] because they've never been tethered to what you want to achieve in healthcare.

[00:45:15] Why do you want to implement AI?

[00:45:16] So we still think about technologies as,

[00:45:19] okay, if we buy the technology that can make up for the mistakes that we've done.

[00:45:23] And this term has, this behavior has a term.

[00:45:29] We build what we call management debt.

[00:45:32] So you make decisions to cut corners,

[00:45:34] but you end up with a lot of technology that is really useless

[00:45:39] or not meaningfully used to move your healthcare indicators as a country.

[00:45:44] And we see that as a problem today.

[00:45:46] So most of the time you have technology projects or digital health projects

[00:45:51] that are led by technology vendors,

[00:45:55] they come with a solution, but they don't really understand the problem.

[00:45:59] So what is the problem that you're trying to solve here?

[00:46:01] I always think less is more.

[00:46:03] So do less technologies, more of your homework

[00:46:06] and defining what your data strategy is.

[00:46:08] What do you want to do with your data altogether?

[00:46:10] Spain does a really good job with that.

[00:46:12] If you go to the, there is an open data website in Spain,

[00:46:18] data.gov.es or something like that,

[00:46:20] where they put the data at the disposal of startups

[00:46:23] and startups can use that healthcare data to come up with solutions.

[00:46:27] And there are quite a few apps and things that emerged from that particular initiative.

[00:46:34] And that's great because there was a strategy to reuse healthcare data anonymized

[00:46:39] for the benefit of the patients and the general citizens.

[00:46:42] And that's great.

[00:46:43] So you foster innovation,

[00:46:44] but you don't lock yourself into buying technologies

[00:46:47] that you don't know why you're using them because everybody else is using AI.

[00:46:50] Let me buy an AI system.

[00:46:52] So that's a problem.

[00:46:54] The problem number two is really deeper than,

[00:46:57] is the way we know that in most cases,

[00:47:01] data in healthcare is a problem

[00:47:02] because they're stored in different formats,

[00:47:05] in different systems.

[00:47:05] And dealing with that is interconnecting systems

[00:47:09] and doing interoperability is a problem,

[00:47:12] still a problem.

[00:47:12] So we still exchange information,

[00:47:14] but really that's the tip of the iceberg, right?

[00:47:17] And going into advanced technologies

[00:47:19] based on a data quality that is not great,

[00:47:23] doesn't sound like a good idea from the outset.

[00:47:26] And so instead of really focusing on the main problem

[00:47:28] and doing some homework,

[00:47:30] which is really hard,

[00:47:32] it's the emerged part of the iceberg,

[00:47:33] nobody sees it.

[00:47:34] We're still seeing a lot of trends

[00:47:37] in adopting technologies.

[00:47:39] We've implemented this system.

[00:47:41] We've implemented this system.

[00:47:42] We have these applications.

[00:47:44] We have these frameworks

[00:47:45] and portals for patients, et cetera.

[00:47:48] Without a real measurement of the impact that does

[00:47:51] on your bottom line,

[00:47:52] healthy life years,

[00:47:54] has it reduced,

[00:47:55] has it impacted your healthy life years?

[00:47:57] It's a long-term thing.

[00:47:58] Has it reduced your suicide rates?

[00:48:01] Has it reduced your percentage of overweight population?

[00:48:05] That's almost never measured.

[00:48:07] And so technology is a problem

[00:48:10] at the same time as it is a solution.

[00:48:13] And mature governments

[00:48:14] are those who know how to walk that thin line

[00:48:19] in balancing adoption of technologies

[00:48:22] against what they want to do

[00:48:24] with the healthcare systems in the long term.

[00:48:26] What do you usually advise governments

[00:48:30] or decision makers

[00:48:31] around discussions with vendors?

[00:48:34] So because there's an unequal knowledge

[00:48:38] about technology usually,

[00:48:40] vendors will usually know more about the technology

[00:48:43] than the decision makers.

[00:48:44] So how can the decision makers really know

[00:48:48] if what the vendor is saying

[00:48:50] is not exactly true or not true,

[00:48:54] but overhyped,

[00:48:55] not overhyped.

[00:48:56] Because I think the vendors

[00:48:58] will never really tell you the full story.

[00:49:01] They're going to tell you

[00:49:02] like the best case scenario

[00:49:04] of what the technology can do.

[00:49:06] But then when you get into the implementation phase

[00:49:09] and the real world data,

[00:49:11] the same as the challenge that pharma has,

[00:49:13] it's one thing to create data in the clinical trial.

[00:49:16] When you come into the real world,

[00:49:18] a plethora of new challenges might arise.

[00:49:21] So I can understand the challenge

[00:49:24] the decision makers might have

[00:49:26] with not being very trustful towards vendors.

[00:49:29] So how do you bridge that

[00:49:31] when it comes to new technologies?

[00:49:33] We stick to evidence.

[00:49:34] So medicine,

[00:49:35] the practice of medicine and healthcare

[00:49:36] is always anchored in evidence

[00:49:38] or will ever be anchored in evidence.

[00:49:40] So what we try to do is

[00:49:41] vendor claims are vendor claims.

[00:49:43] They're marketing messages

[00:49:44] and anybody,

[00:49:46] talking is cheap,

[00:49:47] anybody can say anything about anything,

[00:49:49] any system.

[00:49:50] And things that have been achieved

[00:49:52] with a specific system

[00:49:53] or a specific system

[00:49:54] that has supported specific outcomes.

[00:49:56] So technology is a means to an end, right?

[00:49:59] Really.

[00:50:00] Should be seen,

[00:50:01] should stay like that.

[00:50:02] We'll not guarantee

[00:50:03] that the same outcomes

[00:50:04] will be achieved somewhere.

[00:50:05] So what we try to do

[00:50:06] is there are two things that we look at.

[00:50:07] We look at NICE,

[00:50:08] the National Institute for Clinical Excellence

[00:50:10] in the UK

[00:50:14] comparative effectiveness research.

[00:50:16] So basically,

[00:50:17] the take-two solutions

[00:50:18] or the now venturing into technology.

[00:50:20] So they say,

[00:50:21] this technology achieves better results

[00:50:24] at lower costs than this technology.

[00:50:26] So we look at that

[00:50:27] if there is an evidence there.

[00:50:28] And number two,

[00:50:29] we look at other areas

[00:50:32] of scientific evidence

[00:50:33] that will allow the client

[00:50:35] to make an informed decision

[00:50:37] about their newly acquired technologies

[00:50:40] to be acquired technology.

[00:50:41] For example,

[00:50:43] you know that

[00:50:44] a lot of patents in AI

[00:50:46] have been submitted

[00:50:47] in the US,

[00:50:48] at least the USPTO.

[00:50:50] Maybe 80% of them

[00:50:52] are related to radiology solutions.

[00:50:54] Basically,

[00:50:54] trying to help modalities,

[00:50:57] help radiologists

[00:50:58] reduce the rates

[00:50:59] of misdiagnosis.

[00:51:02] Mainly,

[00:51:03] breast cancer.

[00:51:04] So we know that,

[00:51:06] for example,

[00:51:07] that the technology

[00:51:08] has been trained

[00:51:09] on breast cancer patients

[00:51:13] and image studies

[00:51:14] in the US,

[00:51:15] we know it will not work

[00:51:17] in the Middle East.

[00:51:18] It's a very simple reason for that.

[00:51:20] The breast density

[00:51:21] of Middle Eastern women

[00:51:22] is higher than the breast density

[00:51:24] of North American women.

[00:51:26] So the data model

[00:51:28] is already different.

[00:51:30] So you can't take

[00:51:31] the same algorithm

[00:51:32] that has been trained

[00:51:33] on a specific density

[00:51:36] to extrapolate it

[00:51:37] to another population

[00:51:38] with a very different

[00:51:40] morphotype

[00:51:40] and a very different

[00:51:41] set of data

[00:51:42] and expect the algorithm

[00:51:44] to give you

[00:51:44] the same result.

[00:51:45] We save this all the time.

[00:51:47] Yet,

[00:51:47] yet,

[00:51:49] there's still no puppets.

[00:51:50] But that's fine

[00:51:52] because it never goes

[00:51:53] beyond the pilot

[00:51:54] because they will see

[00:51:55] the results.

[00:51:55] It doesn't deliver the...

[00:51:57] So you have to train,

[00:51:58] retrain your algorithm

[00:51:58] on the new

[00:51:59] set of data,

[00:52:01] which is,

[00:52:01] in this case,

[00:52:02] breast densities,

[00:52:03] and then hone the algorithm

[00:52:04] and work it

[00:52:05] toward being

[00:52:06] more reliable

[00:52:07] and give you

[00:52:08] more reliable outputs

[00:52:09] accordingly.

[00:52:10] So really,

[00:52:11] the answer is

[00:52:11] really stick to evidence.

[00:52:13] One last question.

[00:52:15] So I'm starting to think

[00:52:18] there's a lot of technology

[00:52:19] that's coming in.

[00:52:20] We've got increasing

[00:52:22] challenges in healthcare

[00:52:23] with sustainability.

[00:52:24] And you mentioned

[00:52:26] that there's not enough

[00:52:27] focus on prevention

[00:52:28] in the right sense

[00:52:30] of the word.

[00:52:31] So how do you see

[00:52:32] that governments

[00:52:33] should move forward

[00:52:35] so that the

[00:52:39] users,

[00:52:40] the patients,

[00:52:41] don't lose access

[00:52:43] to care?

[00:52:44] Because sometimes

[00:52:45] if a consultancy

[00:52:46] comes in,

[00:52:47] they can achieve

[00:52:47] exactly the results

[00:52:48] that they claim

[00:52:50] they will achieve,

[00:52:51] but it's not going

[00:52:52] to be for the good

[00:52:53] of the patients.

[00:52:54] And what I mean

[00:52:55] with that is

[00:52:56] that you can...

[00:52:57] Statistics

[00:52:57] is a matter of

[00:52:58] interpretation.

[00:52:59] And if you,

[00:53:00] say,

[00:53:01] reduce the

[00:53:02] readmission rates,

[00:53:03] that can also mean

[00:53:04] that maybe the access

[00:53:05] was hindered

[00:53:05] for the patient.

[00:53:06] And I keep thinking

[00:53:08] about the case

[00:53:09] when McKinsey

[00:53:10] was advising Providence

[00:53:12] Health in the US,

[00:53:13] a non-profit organization,

[00:53:15] how to charge patients

[00:53:16] even when they were

[00:53:17] eligible for free care.

[00:53:18] That's just...

[00:53:20] Basically,

[00:53:20] they did their job.

[00:53:21] They increased

[00:53:22] the financial stability

[00:53:23] or profit

[00:53:24] of the institution

[00:53:27] or the client

[00:53:28] that they worked for.

[00:53:29] It just wasn't really

[00:53:30] for the best

[00:53:31] of the patients.

[00:53:32] So how do you see...

[00:53:34] Yeah, basically,

[00:53:35] where we could actually

[00:53:37] go in the future

[00:53:38] for better outcomes?

[00:53:43] It's a true

[00:53:44] two-pronged problem.

[00:53:46] Problem number one

[00:53:47] is we talk a lot

[00:53:49] about accountability

[00:53:50] and then we almost

[00:53:52] always forget

[00:53:53] the patient

[00:53:53] or the citizen

[00:53:54] in the equation

[00:53:55] of prevention.

[00:53:57] And I think

[00:53:58] prevention starts

[00:53:59] with the individual

[00:54:00] healthcare

[00:54:01] or lifestyle choices

[00:54:05] first.

[00:54:05] It starts with people.

[00:54:07] It starts with communities.

[00:54:08] And I think

[00:54:09] that is really...

[00:54:11] That will never

[00:54:12] be emphasized enough.

[00:54:13] Singapore did

[00:54:14] a very good job.

[00:54:15] They have parks.

[00:54:17] They have...

[00:54:17] It's hot and humid,

[00:54:19] but people get used

[00:54:20] to the climate anyway.

[00:54:23] And people do...

[00:54:24] Still do a lot

[00:54:25] of outdoor activities

[00:54:26] despite the weather.

[00:54:27] And so it's almost

[00:54:29] that the government

[00:54:30] encourages people

[00:54:31] to adopt a healthy lifestyle

[00:54:32] by providing them

[00:54:33] with the means

[00:54:34] and spaces to do so.

[00:54:35] When they started

[00:54:36] the health promotion

[00:54:37] board's campaign,

[00:54:39] the war on diabetes

[00:54:41] in 2010,

[00:54:42] they went to agree

[00:54:43] with some specific

[00:54:44] shopping malls

[00:54:45] to open their doors

[00:54:47] and turn on the aircons

[00:54:48] at 8 in the morning

[00:54:49] because shopping malls

[00:54:50] typically open

[00:54:51] a little bit later

[00:54:52] around 10 a.m.

[00:54:53] to allow for people

[00:54:55] to come and walk

[00:54:55] in a cool area

[00:54:57] for...

[00:54:57] And there are big spaces

[00:54:58] for two hours

[00:54:59] before the shops open.

[00:55:01] So they called them

[00:55:02] health promoting malls.

[00:55:04] And that's great

[00:55:05] because they get subsidies

[00:55:06] for the electricity

[00:55:07] they used to turn on

[00:55:08] the aircons before.

[00:55:09] People come and walk

[00:55:10] and it was really

[00:55:11] well-received

[00:55:11] and well-perceived

[00:55:12] by people.

[00:55:12] So there are a lot

[00:55:14] of actions

[00:55:14] that we can learn

[00:55:16] from how other governments

[00:55:17] promoted healthy lifestyles

[00:55:19] and we can learn

[00:55:21] from that and extra...

[00:55:22] These are very easy

[00:55:23] things to do

[00:55:24] in similar countries

[00:55:27] where hot weather

[00:55:28] is a thing

[00:55:28] for people to exercise

[00:55:29] outside, etc.

[00:55:31] That kind of reminds me

[00:55:34] of that video

[00:55:35] that was viral

[00:55:36] when on the subway

[00:55:38] they put keys

[00:55:39] of a piano

[00:55:40] on the stairs

[00:55:41] so people would rather

[00:55:42] walk the stairs

[00:55:43] because the stairs

[00:55:45] produced music

[00:55:46] instead of taking

[00:55:47] the escalator.

[00:55:49] So yeah,

[00:55:50] creative gas

[00:55:50] is one thing

[00:55:51] that comes

[00:55:52] very handy

[00:55:53] in these situations.

[00:55:56] Yes,

[00:55:57] and I think

[00:55:57] on the other side

[00:55:58] if you see

[00:55:58] the cost of healthcare

[00:55:59] is also a big problem

[00:56:00] because it's exploding

[00:56:02] and so

[00:56:03] one way to look at it

[00:56:04] is to look at

[00:56:06] changing the laws

[00:56:08] and the legal

[00:56:09] and policy framework

[00:56:10] to make healthcare

[00:56:11] organisations

[00:56:11] a lot more accountable.

[00:56:14] If your car

[00:56:14] breaks down

[00:56:15] you go to the

[00:56:15] I know it's a weird

[00:56:17] example

[00:56:17] but healthcare

[00:56:18] doesn't work

[00:56:18] like that today

[00:56:19] it's just to give you

[00:56:20] a similarity

[00:56:20] car breaks down

[00:56:21] you go to the workshop

[00:56:23] get it repaired

[00:56:24] pay 900 euros

[00:56:25] go back to your place

[00:56:27] car breaks down again

[00:56:28] with the same problem.

[00:56:30] Would you claim

[00:56:31] the money back

[00:56:32] from your workshop

[00:56:33] or would you ask

[00:56:34] them to repair it again

[00:56:35] at their own cost?

[00:56:36] Healthcare

[00:56:37] doesn't work like that.

[00:56:39] If you get sick

[00:56:40] you go

[00:56:40] and you get care

[00:56:41] and you get 12

[00:56:43] you don't get 12

[00:56:43] you don't get 12

[00:56:44] now what

[00:56:44] what

[00:56:45] what Sweden has done

[00:56:47] in one instance

[00:56:48] is promoting this

[00:56:49] accountability

[00:56:49] by putting the

[00:56:51] there is a program

[00:56:52] that they did

[00:56:53] 10 years ago

[00:56:54] called

[00:56:54] ortho something

[00:56:55] so basically

[00:56:57] knee and

[00:56:57] hip replacement

[00:56:59] at a fixed rate

[00:57:00] you get 5800 euros

[00:57:03] to get your MRI

[00:57:05] your operation

[00:57:06] your physio

[00:57:07] your treatment

[00:57:08] etc

[00:57:09] and hospitals

[00:57:10] don't get more

[00:57:11] than that money

[00:57:11] 8500 euros

[00:57:13] that's it

[00:57:13] that's all you get

[00:57:14] and guess what

[00:57:16] because hospitals

[00:57:17] understood that

[00:57:18] if they don't deliver

[00:57:19] the outputs

[00:57:20] and outcomes

[00:57:21] that the patient

[00:57:21] will get back

[00:57:22] to work early

[00:57:23] that he's released

[00:57:24] and discharged

[00:57:24] from the hospital

[00:57:25] early etc

[00:57:26] they're not getting

[00:57:27] paid for that

[00:57:27] so made sure

[00:57:29] they made sure

[00:57:30] that everything

[00:57:30] is put in place

[00:57:32] to get the patients

[00:57:34] out of the hospital

[00:57:35] earlier

[00:57:35] 16%

[00:57:37] less length of stay

[00:57:38] lower

[00:57:39] return to work

[00:57:41] return to activities

[00:57:42] was shorter

[00:57:43] than the normal

[00:57:45] hip and knee

[00:57:46] replacements

[00:57:47] and

[00:57:48] 25%

[00:57:49] of more satisfied

[00:57:50] no

[00:57:50] actually more

[00:57:51] I said 98%

[00:57:53] satisfied patients

[00:57:54] about the outcomes

[00:57:55] it's great

[00:57:56] because you make

[00:57:57] organizations accountable

[00:57:58] we'd like to see

[00:57:58] more of that in Europe

[00:57:59] for more diseases

[00:58:00] that's like

[00:58:01] akin to the example

[00:58:02] I gave you

[00:58:03] about the workshop

[00:58:04] but then

[00:58:05] it's a specific

[00:58:06] elective procedure

[00:58:07] we're not talking

[00:58:08] about making

[00:58:09] diabetes disappear

[00:58:11] but we're talking

[00:58:12] about elective

[00:58:13] processes that

[00:58:14] typically take

[00:58:15] a lot of money

[00:58:15] and effort

[00:58:16] and get the patient

[00:58:17] to a path

[00:58:17] where people

[00:58:18] can get depressed

[00:58:19] because they're

[00:58:19] not mobile

[00:58:20] etc

[00:58:22] and there are

[00:58:23] examples to do

[00:58:24] so it's almost

[00:58:24] as if we don't

[00:58:26] have to reinvent

[00:58:26] the wheel

[00:58:27] there are examples

[00:58:28] there that we can

[00:58:29] take and start

[00:58:30] counting from

[00:58:30] 8 instead of

[00:58:31] counting from

[00:58:32] 0

[00:58:32] so these are

[00:58:33] the things

[00:58:34] that I really

[00:58:34] wish to see

[00:58:35] more in healthcare

[00:58:36] more accountable

[00:58:37] focus on prevention

[00:58:38] and encourage

[00:58:41] healthy lifestyles

[00:58:42] by putting

[00:58:43] means

[00:58:45] on the ground

[00:58:46] for people

[00:58:46] to make

[00:58:47] the right choices

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