28
Examination of witnesses
Professor Ben Bridgewater and Dr Pritesh Mistry.
Q193 The Chair: Welcome to this second session this morning of our inquiry on NHS innovations, personalised medicine and AI. We are pleased to welcome Professor Ben Bridgewater, executive chair of the Health Innovation Network and chief executive officer of Health Innovation Manchester, and also Dr Pritesh Mistry, who is a fellow in digital technologies at the King’s Fund.
I am sure you are both aware that our inquiry is interested in the perennial question of why so many proven innovations in healthcare take so long to be adopted in the NHS and sometimes falter in their adoption. By way of introduction, could you each give us some background on how you approach this problem professionally? What are the major barriers to adopting more innovations within the NHS? What do you see in practice with the Health Innovation Network and when analysing the system at the King’s Fund?
Professor Ben Bridgewater: Thank you for asking me to come and give evidence today. I was a cardiac surgeon in the NHS for 25 years. I left and joined a big global digital business and now I have come into the Health Innovation Network at this stage in my career. It always feels to me as though the problem here is not that we need more invention—there are lots of good ideas. We need to have the best ideas and deploy them at pace and scale. That was my perspective going back to when I was a cardiac surgeon and it is my perspective now.
We know that the opportunity, if we get this right, is absolutely enormous. We commissioned a piece of work with Frontier Economics that showed the opportunity from better health innovation was £278 billion per annum. We know that the addressable opportunity if we take some big-ticket items and deliver those at scale is enormous.
We have some good examples of where this has worked well. That is when there is absolute alignment of priorities between the Government, commissioners, providers and actors such as the Health Innovation Network. When that alignment of priority happens, we know we can go a long way and we can go fast. Without alignment of priorities, we know that it can become challenging because different actors are pulling in different directions. I have a couple of good examples, if you like, that I can call up where that has worked well. I have an example that we are taking forward that builds on those lessons. Would that be useful for now?
The Chair: Yes, please, give those examples now.
Professor Ben Bridgewater: We had one particular programme that was about preventing cerebral palsy in preterm births. If you can give magnesium sulphate at an early stage before the baby is born, it decreases the risk. That went from being a good idea that was proven through research studies to being implemented pretty much all the way across the NHS. That has had enormous benefit. As with many of these things, that is not about a particularly clever innovation in what we are doing. It is not a complicated molecule or technology—it is magnesium sulphate. The challenge is the change management and getting everybody to do it, recognising that it is a problem and recognising that solution and scaling it up. The Health Innovation Network put its shoulder behind making that happen. That is one example.
Another example is a cholesterol-lowering medication called Inclisiran. This is a drug that is given if you cannot get your lipids down to safe levels using conventional therapies of statins and is given by depot injection every six months. It is a clever new molecule. That was a deal done between Government and Novartis as the opportunity there. However, priorities were not aligned. The Health Innovation Network was asked to scale it. It was not really on the agenda for providers, for primary care or for ICBs. We went through a phase of trying to get it on the agenda for everybody, and changed the pathways and incentives. We have found by doing that, four years later, that we are hitting the trajectories that the company was looking for, with accelerated access to population health benefit from those medications. We are leading in Europe now in the deployment of that medication. The importance of that story is that you have to do the learning about what you need to do before you get on and do it but, if you get that learning right, you can go quite far, quite fast.
Dr Pritesh Mistry: Thank you. I am delighted to be here today. I am a policy fellow at the King’s Fund, a healthcare think tank. My work looks at the implementation of technology and the implications of technology use within the health and social care system.
I largely agree with Ben. We do not have an innovation problem in the NHS. We have an implementation and an impact problem. The NHS has a proliferation of technologies and innovations. I am sure we will talk about pilots. There is no end to the pilots in the NHS. However, we do not see longitudinal impact that is the same on a national footprint.
There are examples of technology that have scaled across the NHS. There is blood glucose monitoring. You may be aware of the direct-to-public communications in primary care, Accurx. There are virtual wards and online consultation forms, which I am sure many of us have experienced. These technologies scale by setting, not necessarily across the whole NHS. They are setting dependent. We tend to find, for example, with virtual wards that one organisation will be able to use that technology and transform, and make the change happen and realise the benefits. Another organisation will simply take the technology but not do the change that is needed, and that does not release the impact and the benefits. There is a huge challenge in taking not just the innovation and measuring how many licences we have and how much tech we have out there but the impact, outcomes and value that we are getting from these innovations.
Q194 Baroness Jones of Whitchurch: I want to follow up on this whole problem of pilotisation. Far too many creative people have proven examples of innovation in the NHS but they are never shared or scaled up. That is happening time and again, despite a lot of talk about it. You have started to identify some of the problems with addressing this, but what is at the heart of the problem? You have identified some of the things, but what is the solution? If one trust has a good innovation, why does the next trust not look over the border and think, “They have done it, so maybe we should do it too”? That seems like fundamental common sense to me. I wonder why that sharing and escalation does not happen. It is common sense that you would share better practice and want to follow it.
Dr Pritesh Mistry: I will answer this in several different sections. “Pilotitis” is a big problem within the NHS. We tend to find pet projects and pilots just happen because people are interested in them, and that creates a workforce that has change fatigue, and we do not see that effort going into actual impact.
In one of our publications around medtech and economic growth, we share one example where an organisation has taken a much more strategic approach. This is working for it. It is doing fewer pilots, but its pilots are having more successful implementation. Its approach is to take a group of people from across the organisation, identify their problems and prioritise by organisational need and clinical risk. They source solutions based on those problems and then they take them through. Before they even start the pilot, they use their data to assess the pilots. They also make sure there is funding available for implementation. They agree the measures and the thresholds for success. None of these things usually happens when we have pilots. Often with pilots we have some money and give it a go.
When you have these things in place, you can start doing your pilot. You measure what needs to be measured. You know the threshold for success. You can access funding if that threshold of success has been met. When you do the pilot, you do the testing of the changes that are needed for the workforce and the processes, as well as the tech that you need to link into. Again, one of the problems we find is that the technology is there but does not link to other stuff and so you have islands of technology. Maybe we will come on to that later. That can be a successful pilot and it leads to implementation. That is where we are seeing pilots actually lead to implementation. A lot of the time we find opportunistic pilots as opposed to strategic pilots.
Scale and adoption have many challenges, with a lot of variation in the technical capabilities, the workforce skills and the data that is available. We have seen it work well in one of our publications around AI scale and implementation in the NHS. We are seeing self-forming collaboratives, where organisations want to work together and are doing just what you said, but it is not well formed across the NHS. Spots of organisations have leaders that are collaborative and are saying, “We are willing to work together. We will chip in some money to be able to do a joint project, solve a problem and share from each other”, but that is rare as opposed to the status quo.
Baroness Jones of Whitchurch: When you have a successful pilot that is proven and done all that testing that you described, why does the rest of the NHS not look at that and say, “They have done all the hard work, they have proven it, so let us now roll it out”?
Dr Pritesh Mistry: As I mentioned, we have seen that the collaborative way can be successful. What we tend to find is a lot of variation from organisation to organisation. There might be different numbers in the workforce or different training, processes and technologies, which adds more and more complexity. You cannot simply pick up a technology and place it over here. However, one of the examples I mentioned—the blood glucose monitoring—worked really well. There was a technology fund, it was mandated from the centre and we had clinical leadership—from a national, regional and local level—educational material for the workforce, patient engagement and auditing for the data. That in combination means you can see who is deploying the technology, monitor who is doing it, support the workforce to have the training and hold people to account to be able to transfer that technology into use.
Professor Bridgewater: There is nothing there that I would disagree with, but I would focus on three things here. I have written down sensitivity analysis, method and customisation.
I have banned the word “pilot” in my organisation unless you are flying a plane. We talk about proof of value, which is a much better way of looking at it. Going back to my point about alignment of priorities, we need to make sure that where we do the best proof of values we are playing into the biggest problems and the things that everybody in the system will recognise are problems that we want to solve, rather than things that are in the margins. That is the first point.
The second point is around method. We find that lots of pilots or proof of values have not been done to a sufficiently rigorous method. We push the use of logic models. I call this boring but important, the idea that you are clear about the problem you are trying to solve, the activities you undertake, the resources required to undertake those activities and the outputs—the direct consequences of those activities, the outputs, the outcomes and the impacts playing back to solve the problem. If you get that right and it is crisp and the methodology is good, then you do not need to repeat it because it is good enough. So it is about the methodist thing, which has not been good enough in the past and we are trying to drive through the Health Innovation Network to the next level.
The final thing is customisation. There has been a lot of good work on innovation. There are things with innovation where you absolutely need to remain faithful to the thing that has been originally done, which has proven the value, and there are some things that you need to customise to context. That requires the support of experts—some of the thinking done at the King’s Fund and some of the practical stuff that we do on the ground.
I will give you one specific example of that to make it real. We are doing a lot of stuff now in the Health Innovation Network with the NHS App. This is not about making the NHS App different, but about making sure that we take the benefits from the NHS App as it currently exists—benefits realisation from existing functionality within the NHS App. The context of Greater Manchester it is very different from the context of the south-west where there are rural and coastal communities. Ours is an urban community. Some of the things that we need to do are the same to get the benefits, but the way we do them will be different, depending on the context. That needs to play into the way we scale innovation.
Q195 Lord Patel: My question was mostly answered by your blood glucose example. That is one good example and probably the easier one, but what other examples are there of how we get swift introduction of a proven technology or procedure throughout the NHS?
Dr Pritesh Mistry: It depends on what the technology is. Where we have seen the most success, as you alluded to, was with the blood glucose monitoring and the communications in primary care. When technology is scaled rapidly, it tends to be technology that stands by itself, an innovation that does not need to integrate to an electronic health record or need substantial changes within people’s workforces and processes.
The opportunity on the horizon is AI—I am sure we have all been talking about AI recently—with ambient voice technologies and scribes, which we are seeing a massive appetite for within the healthcare system from clinicians. The technology could scale across all settings from primary care to acutes and district hospitals. However, the opportunity here is to buy not the cheapest technology but the most effective technology. We see that procurement tends to go for what is cheap. Our technology is categorised and assumed to be the same, rather than saying, “This is the threshold of acceptance and we need a good level of technology”.
Lord Patel: How often is any kind of technology deployed to spread the good news across the NHS?
Dr Pritesh Mistry: Lots of technologies have been scaled across the NHS. The impact, however, is highly variable. Take virtual wards, for instance. We have virtual wards across our national footprint but the usage and occupancy of virtual wards can change by a factor of two or three from one region to another. That comes down to how much deep-level change is happening and how much that change is being supported as opposed to how much we are just paying for a technology that sits and is not used effectively.
Professor Bridgewater: We have done a lot of thinking in the Health Innovation Network about the most impactful innovations for us to put our shoulder behind. In general, they are not one thing—one widget, one bit of tech or one drug. They are more about playing into some of the big problems in pathways, particularly in chronic kidney disease, where we know there is a big and growing problem that creates inequalities. There are things we can do there, but it is about changing that pathway, which has embedded innovations in it, not just dropping a new innovation in. We have done the modelling around that and it is very compelling. That is one of the things we are putting our shoulder behind and driving through next year.
We have a similar programme around respiratory transformation, which is about getting better early diagnostic for COPD and asthma in the community, and ensuring that people get the right diagnostic, the right treatment and the opportunity of more advanced therapies, such as biological therapies, to make a difference. Again, it is not one thing but a pathway in innovation. We are doing some other things that are a bit more specific around closed-loop diabetic management, ambient voice technology and the NHS App, but it is a mixture of things, bits of technology and pathway transformation with embedded technologies.
Lord Patel: What you are talking about is local at the end of the day; it is Greater Manchester, not NHS wide.
Professor Bridgewater: No. We did a lot of work last year trying to find the big opportunities for innovation with a big return of investment playing into the major problems. These are the things that we are committed to do and scale nationally. The chronic kidney disease example was developed in Leicestershire, but we are looking to scale that up nationally. The respiratory stuff was done in Oxford and we are looking to scale that up nationally. The idea is that we have a horizon scan about the available opportunities and collectively put our shoulder together, through commissioning, the Health Innovation Network and providers, to make these things to deliver the impact.
Lord Patel: How do you influence different ICBs for commissioning?
Professor Bridgewater: That is a good question. We believe that innovation is a collective leadership opportunity and that, therefore, we need to be working in a different way. We need to be more confident about saying to commissioners, “These are the big opportunities and this is the opportunity here”. There is a role for people like me with a national hat on to influence things nationally, and for people like me with a local hat on to influence, in my case, the Greater Manchester ICB. But that also needs to come in a different way down through the commissioning processes—through NHS England, the Department of Health and hopefully recommendations from a committee like this—so you get that alignment of priorities right through the system. No one actor can do it on their own; it is a collective leadership opportunity and responsibility.
Lord Patel: Most clinical practice these days is driven by protocols. Most clinicians follow protocols. The protocols or guidelines are written by NICE, but they are intermittent and never regularly updated. It reviews them two or three years later. So is there a process that we can recommend or suggest whereby, if it was done, any technology or innovations that occur would be swiftly put in place?
Professor Bridgewater: I will stick with the chronic kidney disease example. We know that there are innovations that you can make that will make a big difference to chronic kidney disease. We have done the modelling; the impact is very big. It is about finding the people at risk, diagnosing them earlier, getting them into the best treatment through multidisciplinary diseases and managing them in right place, be that the community or wherever else. That is not actually following existing guidelines; that is about doing things differently. However, everything we are doing is compatible with the guidance and we do not need any updated guidance from NICE to make that work.
Lord Patel: That is not my question. I accept that there are chronic disease innovations that would make a difference to people with chronic disease, like kidney disease. How do we get there? What process can one put in place to make things happen swiftly across the NHS?
Professor Bridgewater: That is about being clear that it is an innovation priority and holding everybody to account for delivering it, from commissioning at the top to commissioning at ICBs, providers delivering that and the Health Innovation Network playing its role and being transparent about whether people are doing it. The point I tried to make—I am sorry if it did not answer your question—is that that does not require NICE to do anything differently; it requires everybody else to do things differently.
Dr Pritesh Mistry: I would lean back on blood glucose monitoring as an example, which is massively transformational for patients and driven from a national mandate. It does take time, I am sorry, but unfortunately scaling within the healthcare system is very different from scaling consumer tech. Where we have seen it work is with that clinical leadership at the centre; the funding alongside it; the clinical leadership at a local level; the education, training and support for the workforce; patient engagement; and, as I mentioned, the audit data to say, “It is working here. It is not working here. We need to provide more support”, and holding them to account. But it takes time.
The Chair: Professor Bridgewater, when you said calling the ICBs to account, what does that mean in practice?
Professor Bridgewater: Did I say holding the ICBs to account? If I did, that was not quite what I meant. I think there is something here about advocacy, raising the opportunities from innovation and making people understand that there are things out there that they could do today and that will make a difference tomorrow. It is not all about research and things for the future. That requires compelling arguments to be put forward in the right way. It requires people to maybe change some of their priorities, moving away from some of the things they might want to do to things that have probably got a bigger, quicker return on investment. There is advocacy for the innovation agenda and there is influencing around that stuff.
Where I would like us to get to is that, if there are things that are commissioned on a national level which we all agree are the most impactful things, people are held to account for delivering them, using mixed methods—incentives, consequences and transparency—so that innovation happens in the way that it should happen all across the system. That should be supported by the Health Innovation Network, but the Health Innovation Network does not deliver care; it is the people who deliver care who need to implement the innovation.
The Chair: What kind of incentives do you envisage?
Professor Bridgewater: Take the Inclisiran example. We had to do a lot of stuff to get that going—changing the pathways, getting it on the drug formulary, educating people, building tools for finding the patients, all those types of things that are first base in terms of innovation. We found that was not kicking up in the way that we wanted it, because there are issues with the way GPs were remunerated for giving the drug. This was about changing the nature of the structure of the financial flows to support the innovation. When we did that learning in the first phase and then put that in, we found—certainly in Greater Manchester—a massive acceleration. There will need to be a mixture of incentives, consequences and transparency to get innovation taken up at scale.
Lord Willis of Knaresborough: I was thinking that at one point you would be saying that AI is forming a crucial element in addressing the question that Lord Patel made about communicating these things effectively to other parts of the NHS system. Why are you not saying that?
Professor Bridgewater: In my organisation we do not do anything without the use of AI. It is completely transforming how everybody is thinking about innovation.
Lord Willis of Knaresborough: But does it answer Lord Patel’s question?
Professor Bridgewater: I do not think it does. I do not think AI answers that question on its own, if I have understood the question properly. I think AI will be a contributor, but actually it is about people, priorities and change, which can be influenced by AI but cannot be done by it.
Q196 Lord Drayson: I want to bring you on to questions of funding, but before doing so I have to push you a little further on the points you are making about the problems that the NHS has in adopting proven innovation. I declare an interest in that I previously built a vaccine company in the United Kingdom and a clinical AI company in the United Kingdom. I am no longer involved in either of them. My experience was that, whereas it is fair to point out the differences in the patient populations across the country, to a large degree the problems that the UK has with the failure to adopt innovation is through lack of consistency in management.
You mentioned blood glucose monitoring. I was responsible for bringing a gestational diabetes blood glucose monitoring product into the NHS. It had very clear clinical evidence of benefit to mothers and babies, yet here we are 10 years after that product was invented and only half of NHS patients with gestational diabetes can access it. Our experience was that each trust went through its own procurement process. The procurement officers and clinical directors in each of those trusts redid the whole process. Therefore, I would push back on you in that it is not really about the difference in the patient population across the United Kingdom; it is the difference in how the NHS is managed across the United Kingdom that is the problem.
Professor Bridgewater: I am sorry if I implied that the difference in the patient population was the problem. I think that is not what I said and certainly not what I intended. My point on the difference in patient populations is that they are different and sometimes that makes a difference for how you do things. Understanding that is key to getting innovation to people. That does not negate your point, which I completely agree with. The reason why we do not get that innovation at scale and pace—particularly for the example you have given—is not down to the patient population. It is about the way trusts do their business and the procurement structures that exist to support that. I agree 100% with your point.
Dr Pritesh Mistry: It also obviously depends on what the innovation is. Some innovations will depend on patient populations, for example digital exclusion demographics, but for your example, I think you are correct. There is a lot of variation in organisational decision-making and workforce, so there will be different priorities and different abilities to be able to take on technology and make change happen. It depends on how services are configured, what service is provided, what that priority is, how they rate that priority and—as you mentioned—the procurement mechanisms as well. Different organisations take different approaches to this, which leads to a lot of the fragmentation that you have already shared with us.
Lord Drayson: The King’s Fund does terrific work and I have read some of your stuff, Dr Mistry. To try to get to the bottom of this, building on what Lord Patel has said, you can look at other industries and organisations, such as how we ensure that flying is safe. As Lord Patel has said, medical practice relies on agreement around protocols and those protocols being adhered to and being kept up to date with developments in technology. Is this not where we are failing—we are just not being consistent and modern in medical practice?
Dr Pritesh Mistry: The challenge is that there are a number of different tools that the NHS can use, and it is not necessarily that it needs to use just one tool to be able to provide services to a group of individuals. Let me reposition this a little bit. Where we have seen this potentially work well is when you have an ICB saying, “We want to deploy this type of technology. Come to us as a group of suppliers and we will allow our set of organisations to choose from a group of commercial suppliers”. That has enabled local choice and autonomy, while still moving towards the deployment of technology and still being wrapped around service transformation and change.
Lord Drayson: But why is local choice a good thing?
Dr Pritesh Mistry: It comes down to the variations in the services, quite honestly. We have mentioned patient population; workforce can also be quite different from organisation to organisation. A lot of my work sits in technology, but it depends on what that innovation sits on in terms of the technology stack and the capabilities. Some things will fit into anything. Others will only plug into other bits of technology. Some bits need different workforce that is not available and then it depends on your patient population and what they need as well.
Q197 Lord Drayson: Thank you. Turning to funding, in your written evidence the Health Innovation Network has called for extra funding towards implementation for those innovations that have already been proven to work, as you have discussed. How is the money being directed? Are you seeing a change in how funding within the NHS is being directed towards promoting the adoption of those innovations?
Professor Bridgewater: Significant amounts of public money go into research, development and innovation across that spectrum. Some of that comes through the NIHR, some through business support and some through the Health Innovation Network. Some goes into the NHS for various different transformation activities. The point that we made in our submission is that the thing that actually gives you the impact and the big near-term return on investment is implementation of proven innovation at scale. Therefore, we suggest that there should be a review of the way that funding is allocated across that pathway to make smart decisions so that you are getting the maximal return on investment for the things that you want as the Government in that particular point of time. I do not think we are suggesting it should be different, but we are suggesting it should be looked at so that those decisions are smart in terms of getting people what they want in the timescale.
Lord Drayson: When you say “smart” could you be more specific about what change you think should be made? Are you asking for centralised funding?
Professor Bridgewater: Look at the size of the allocations that support the Health Innovation Network. We are grateful for the increase. It is about £70 million this year and it gets allocated to the 15 health innovation organisations. We are looking to do our very best with that to get the impact that we want. However, I think coming through for me in some of the questions is the suggestion that we are not good enough collectively at choosing the right innovations, and delivering them at scale requires a step change in that activity and that needs to be supported in the appropriate way. If people want impact from innovation in a three-year cycle, that will lead to different choices about how you would spend that money across the research and innovation spectrum.
Dr Pritesh Mistry: I largely agree. There is funding available for technology and innovation within the healthcare system, but there are a lot of priorities as well so we find that budgets tend to be spread very thinly. Often technology is not a priority at the local level within the NHS, unfortunately, and we find that tech budgets can get raided. I am sure you have all seen articles about that. What this tends to mean, with the restricted amount of funding and the huge number of priorities, is that you pay for the technology or the innovation, and not for the change.
As a kind of wet finger in the air figure, what we and several colleagues have estimated is that one-third of your budget should be for your innovation and two-thirds for the change. By change, I mean upskilling your workforce, changing your processes, changing your governance and integrating into your technology stack—everything that needs to happen to realise the benefit. If you pay for just the technology you get the technology, not the impact, and that—as I mentioned—is a big challenge.
We are seeing things starting to shift a little bit. There are interesting bright sparks and people are innovating in financial mechanisms. They are using risk-sharing models, which is basically where the NHS agrees to try a technology and the company agrees to support the implementation of that technology, but it does not get paid unless there is an agreed benefit that is realised. That helps to align incentives and brings in a bit more capacity, resource and expertise from the tech company into the NHS. That enables change to happen but it means having the right procurement and finance expertise within the NHS to be able to do it.
Lord Drayson: Are you seeing clear funding shifts towards AI innovations and genomics medicine innovations as the result of a policy decision to do so?
Dr Pritesh Mistry: In the most recent spending review there was an allocation of a tech budget. The details are not quite clear yet. Within the medium-term planning framework there are some commitments and some priorities but we are yet to see more detail on what are the particular technologies, the size of the budgets and the timeframes for the allocation of funding.
Lord Drayson: Do you think the NHS is effective in specifying what it wishes to procure? We heard a little earlier about the problem of technology companies providing something that is not necessarily what the NHS wants. I am quite interested in your view. How does the NHS procurement process actually support what the NHS wants? I am quite interested also in how it supports UK-based companies. I read some of your stuff, Dr Mistry, where you have highlighted your concern over the shrinking number of large technology companies that the NHS depends upon.
Dr Pritesh Mistry: There is a lot in that question and thank you for reading my work. We find that UKRI funding tends to come in to support companies on research that does not necessarily get taken up into the NHS. So there is something there about how that works in sequence that is not quite working in the flywheel effect that we would like to see.
As I have mentioned, funding has been allocated from a government perspective but the amount available is still only small. We would say that the UK market is small on a global footprint and, quite honestly, scaling across the NHS as a market is not necessarily the most attractive thing to start-ups. We need a different proposition for start-ups.
We find that technology tends to take a long time to be deployed. VCs do not want to fund start-ups that are prioritising the NHS. Companies are choosing to reallocate elsewhere, taking growth, jobs, et cetera. But where we have seen it working potentially really well is Meridian Health Ventures out in London and Our Health Partnership in Birmingham. These two initiatives are basically setting up an NHS environment, working with venture capitalists. They are sourcing the money from the VCs, they are bringing the start-ups in and they are working with the start-ups to say, “These are our problems, can you help to solve them?” You provide NHS expertise from a clinical and operational perspective and they help to develop the technology. In return, the NHS gets something—a discount or equity. It is early days yet, but we are seeing the growth of these companies, money coming back into the NHS and a real change and flywheel effect coming in as people have more technology that works for them in growing their capability elsewhere.
Lord Drayson: That is really helpful. How do you think things will be affected by the decision last week of the American Government to unilaterally withdraw Anthropic’s two leading AI models?
Dr Pritesh Mistry: It is a substantial challenge. Even if AI development stops today, the power of the technology that we have today is amazingly capable and will have transformative effects, irrespective of what that capability will look like in the next five to 10 years. Not being able to access that technology obviously puts us on the back foot. It has implications for how we work through public services and how our sectors are able to modernise, grow and continue to enable economic growth, jobs and the development of prosperity for individuals and people. It is a matter of concern.
We are seeing a lot of different types of models being developed now. There are options and opportunities for the UK, especially around sovereign tech and sovereign AI, but it does mean plugging in some of the stuff that I have already mentioned—what is a concept and a tool that is being developed that has implementation and uptake within the healthcare system or the appropriate sectors. We tend to find that there will be a scramble for procurement, as opposed to asking how we cultivate and grow capabilities on a longer-term mechanism.
Professor Bridgewater: I completely agree that, with the AI tools available today, it will take us a long time to get to the limit of sweating their capabilities, but that is something we must do. We need to think pretty clearly about how we use AI to transform our business processes and data landscape, and how we play that out into care pathways. However, related to my previous point about where you put the investment, at the moment I do not think there are such compelling innovations in AI and genomics as there are in some of the other areas. I think the key is in proportionally growing the value propositions in those things so they are really compelling for the future, while making sure that we do not stop taking opportunities for the present.
Q198 Lord Stern of Brentford: Thank you both very much. I want to go a little further into the question that Lord Drayson asked, which I think you had begun to answer. We heard earlier that UK life science companies are very cautious about investing where their sole customer is likely to be the NHS, and that is linked to the behaviour of the NHS as customer and partner. Am I right in understanding that you are describing changes in behaviour in the NHS which makes it a more attractive and more reliable partner, so that companies that are selling primarily or only to the NHS could now be investable where they were not before? Is that a change that you want to underline or is that still a big problem?
Dr Pritesh Mistry: There are a couple of ways in which you can skin this cat. There is the risk-share mechanism, where organisations like the NHS can work with companies and have shared incentives and shared benefits. We are seeing that that has potential, but it needs procurement and financial expertise, which is not widespread in the NHS. Then there is the venture side of things, which I mentioned, with Meridian Health Ventures and Our Health Partnership that are working with Harbour Health. That is quite different. That is a mechanism for bringing in funding and developing start-ups that solve the NHS’s problems from a very early perspective. Again, I think there are opportunities to do that. The NHS is often criticised for not being a good partner or purchaser. We often see the opposite being true as well, where suppliers are not being good partners to the NHS. It is about validating on both sides.
Lord Stern of Brentford: Do you think the statement that life science companies creating things that are primarily or wholly for the NHS are uninvestable is becoming less true than it was in the past?
Dr Pritesh Mistry: It remains a challenge to get venture funding if you are focusing on the NHS. We have seen opportunities for that to change, as I have outlined, but not at a national scale yet.
Lord Stern of Brentford: Could you offer recommendations of how that could change, building on the experience you have described?
Dr Pritesh Mistry: Yes. I am happy to do that now, but I could point you to our documents as well.
Lord Stern of Brentford: It would be very helpful if you could give your view. Professor Bridgewater, did you want to come in as well?
Professor Bridgewater: Yes. If you are looking at global life sciences companies, I think the argument would be slightly different. There has been a position where it has been a popular place for global life sciences to invest. I think that has gone backwards a little bit. Some of that is related to trials performance. I know there is a lot of activity trying to increase trials performance, and that is important, but it is also about making ourselves a great place to go, from positive trials to things that can be deployed at scale.
The Inclisiran example I gave you was a significant investment from Novartis into that particular opportunity. We have done a lot of work in Greater Manchester with Eli Lilly around Mounjaro and obesity medications. The respiratory transformation programme that I described before is a consortium of four different global pharma companies coming together. So I do think we have all the ingredients here to make us really successful in harnessing that energy from the global life sciences companies, if we can decide the things that we want to do and do those at scale. I think the opportunities are really clear, but it does require different prioritisations. One of the things we should be doing is encouraging the life sciences companies to collaborate, not compete for market access, working together to try to transform care pathways. We have a huge opportunity in that space, but it does require some priority decisions to be made.
Lord Stern of Brentford: The Inclisiran example is an important one. You said that the difficulties between Novartis and the NHS were resolved by changing the incentive structures to GPs. Can you say what you meant?
Professor Bridgewater: The Inclisiran example is an important example that we all need to learn from. To be honest with you, when we embarked upon that opportunity collectively, we had not thought through every step in the dance to get maximal innovation done at pace and scale. I think it is one of the points of committees like this to learn the lessons from that. Sometimes you try to design a perfect programme, but you do not always get it right, and you find resistance or things that you were not expecting. You then need to respond and do things differently. I can send a written submission that details all of that with respect to Inclisiran. I think there was a first phase that was an implementation phase where we did a bunch of learning. There was then a “Why are we not getting to where we want to get to?” phase. I have to say, Novartis was not entirely pleased with where it went in the first phase of things. We then made those changes collectively and I believe Novartis is very happy with where that is now. Having some agility in terms of how you roll out those programmes is key.
Lord Stern of Brentford: The incentive structures for GPs were changed, is that what you are saying?
Professor Bridgewater: The incentive structures for GPs were changed. How that happened is quite complicated but I can put written evidence in to give you that information if it would be useful.
Lord Patel: Following on from Lord Drayson’s question, you introduced the subject, so I ask the question: do you think the NHS should have its own sovereign AI and Cloud?
Professor Bridgewater: No, I do not think it should.
Lord Patel: Why not?
Professor Bridgewater: I worked in a global tech company. These numbers will be old, but they are relevant. When I was working around the world selling global tech, we used to say that when you migrated your applications to Azure—Microsoft’s cloud project—you were benefiting from a £1 billion a month investment into Azure in terms of developing all those capabilities. Why would you not want to do that and make that work well for you? The idea that the NHS develops its own sovereign AI thing does not make sense. To have the right partnership with the right partners to have something that works for the NHS may make sense. However, you would have to make sure that you did that in a way that you did not fall behind, because you can fall behind very rapidly.
Dr Pritesh Mistry: There are applications where the UK may want to have sovereign capabilities. For example, Oculomics says there is already work happening in Moorfields to create an image of the eye, an AI-based tool that is sovereign to the UK. I would say that what is important is options and leverage. By that, I mean not having a lock-in to one AI capability, whether that means building our own or working within a collection of countries to have AI tools which are accessible and usable and fit the values and priorities of the UK.
Lord Patel: So you mean sectoral sovereign AI in the NHS?
Dr Pritesh Mistry: Cloud is very important. Being able to store the data within the UK is very important.
Lord Patel: Would that be sovereign Cloud for the whole of the NHS?
Dr Pritesh Mistry: It depends on what the tools are. We would not be able to clinically validate our foundation models, so you would need clinical AI tools for the NHS. Potentially, you could develop an AI sovereign tool for the NHS that is clinical.
Professor Bridgewater: You would have to be clear about what problems you are trying to solve with that sort of solution. The one thing that I think is important to think about is that we are in a global world and it is a global market. Some of the things that you would want to develop we are not competitive on, not because of our intellect but because of our numbers.
A pragmatic example is AI working on top of ECGs. If you were to do that in India, you would get millions of ECGs very quickly. Here it would take us a long time. In China, they are doing stuff on image recognition. You would have to be very thoughtful that what you wanted to do with that approach was to leverage the capabilities and the value propositions that were generated globally and make them applicable to the NHS, not cut yourself off from the learning that is happening. AI is driven by scale and data scale, which is a place where we are not competitive.
Q199 Lord Winston: You have been hugely helpful, and we are very grateful, but I would like to focus specifically on the issue that we are facing. We are looking at personalised medicine and AI together as an issue. Can we try to concentrate our answers on that, because we still have a number of issues that we really need to try to get into this report? Innovation is being discussed all over the place in Parliament, but this specific issue really is not. I would just like to remind ourselves of the need. It is not your fault. You have been answering the questions brilliantly.
Dr Mistry, could I ask for your assessment of the current appraisal and regulatory processes for the MHRI and NICE, and whether or not these are adequate for this area of medicine? Where are the approaches possibly falling short, if they are?
Dr Pritesh Mistry: We are not regulatory experts, so I will hand over to Ben in a minute. The regulatory bodies in the UK are well respected and globally renowned, and that is a massive opportunity. Unfortunately, they are not set up for the pace or the sheer amount of innovation that comes through. There are opportunities for us to think about data-informed approaches to regulation. We have talked about the number of pilots. How do those pilots get regulatory approval? What happens to that data? There is a need to close the loop on the pilot—how it builds a regulatory evidence base and helps to inform regulation. That does not happen yet. Our regulatory bodies are not yet able to keep up to pace with the sheer breadth of the novel innovations that are coming through right now.
Lord Winston: Is there an existing structure where the data can actually be collated?
Dr Pritesh Mistry: Not yet. As far as we are aware, there is no use of what we would consider real-world data to inform regulation and evidence building. Ben may have additional information.
Professor Bridgewater: I would agree with my colleague. I am not a regulation or guidance expert. What I would say—I think I said it before—is that I am not sure that the regulation and guidance is holding us back from some of the opportunities that are out there. I have said before that I do not think the earliest-win, big, addressable opportunities are in that personalised medicine and AI space. We need to consider that as an area where there are going to be opportunities in the future, but we need to build the innovation pipeline and supply chain in a way that is compelling. There is a requirement to do that and to ensure that the regulation and the guidance catch up with the speed of technology.
What we really want is to have that working so that in, say, two years—it may be sooner than that, it may be longer—we have a portfolio of things in this particular space that are compelling and impactful and have been demonstrated to give a return on investment and make a difference to population health, NHS performance and economic development.
Lord Winston: Perhaps I am wrong here, but would we not agree that the sorts of technologies we are looking at are particularly uncertain still?
Dr Pritesh Mistry: There are some personalised technologies—stem cell-based technologies, CAR-T therapies—that are still very novel, and we are not sure what kind of processes need to sit alongside them as a supply chain. When it comes to regulation, breakthrough implantable devices are pushing against what our regulatory frameworks are set up to be able to do. What we are seeing potentially work well in AI is a sandbox environment: taking a category of innovation, using that as a case study, taking it through regulation, and making sure the funding is there as well as the upskilling and the capabilities to be able to do that at pace with one category of innovation. We feel that could work within the life sciences sectors as well as AI.
Lord Winston: Professor Bridgewater, are there other ways we could ensure the safety of patients and the efficacy of the treatment?
Professor Bridgewater: There is an opportunity to be much smarter at post-market surveillance. When I was a cardiac surgeon, I did a piece of work looking post hoc at all the valves that had been put into people over the previous 20 years, to see whether there were any early signals we could have picked up from those valves before they were found to be suboptimal through the reporting systems.
That needs to be the place where we get to, using the developments that are happening with the single patient record, with the HDRS and so on, where routine data collection and effective post-market surveillance is used to detect patient safety signals in a different way. I do think that has implications for NICE because there is something here where your guidance would change in terms of its certainty, but on the basis of ongoing post-market regulatory surveillance.
Of course, we then need to design all the data structures that we have in terms of the single patient record, in terms of the HDRS plans and in terms of the federated data platforms, et cetera, so they have a whole bunch of functions, some of which are direct care, some of which are commissioning processes, some of which are research and some of which are post-market surveillance, which supports the regulatory process.
Q200 Lord Winston: That brings me neatly to my next question. Could you both tell us what you feel is going on with regard to collaboration or information from other countries and their interest? Clearly, these are going to be very hot topics elsewhere. What are we doing to look at other countries processing this?
Dr Pritesh Mistry: I am afraid I am not aware of what is happening in this space for international comparisons.
Professor Bridgewater: I am speaking now with a Greater Manchester hat on, rather than the national hat, if that is okay. We have a global partnership strategy at Health Innovation Manchester. Our vision is to be world class in improving the lives of local people, transforming care and boosting the economy through innovation. We have deliberately targeted three places to form that partnership with, after having conversations with a lot of places.
The first of those three places is in Telangana state, in Hyderabad, which is a compelling centre for life sciences and vaccine manufacturing but also for entrepreneurial tech, to try to create a bridge between Indian entrepreneurial tech and the NHS. The second is the University Health Network in Toronto, which has a very strong academic health system but is not playing into the population health ambitions where we have innovation in that space. We have a lot to learn from them and we have something to share, particularly on how you use primary care data and transform care, and move to left shift. The third is Kaiser Permanente.
What we are trying to do with those places is learn from the way they do things. This is not directly related to your question, but I am not seeing from this experience with three top-tier health systems a whole bunch of learning out there that is going to help us—that is, menus that we can copy and bring here. Otherwise, I would have brought them. It is more that we are in a reasonable place and we have some opportunities, but we need to create things differently to take the opportunity in front of us.
Lord Winston: What can we do to ensure post-treatment monitoring, for example? How would that look?
Professor Bridgewater: I have not had a conversation with the leaders of the HDRS about their view on post-market surveillance. I will pick that up when I next speak to them. I guess the point is to raise that as an opportunity that can potentially accelerate the process and make things safer, because you have a forward look about what you think may be a problem and a backwards look to check it is not a problem. In my opinion, baking that into the priorities of the HDRS data structure would be a sensible thing to do.
Dr Pritesh Mistry: I think the data exists in various different forms and pots. The problem within the NHS is that a lot of the data is fragmented and in silos. Something like the Health Data Research Service—the single patient record—provides an opportunity for the data to flow and be able to do some of that monitoring post deployment.
Lord Winston: You have not mentioned your own area. What about RCTs? Should we or could we do more controlled trials in the National Health Service to try to sort some of the issues we need to understand the data we are getting?
Dr Pritesh Mistry: There are huge opportunities to do more RCTs, and different designs of trials to gather the evidence. As I mentioned earlier, we do not use much real-world evidence. The data exists, but it is not necessarily plugged together, and we do not necessarily use the right methodologies, as Ben has already mentioned. There is an opportunity to use RCTs to be able to help inform and accelerate regulation and evidence generation.
To your point on global exemplars and what is happening internationally, from one of the reports we published and the round table we convened, we heard from the start-ups that generally what happens is that every nation has a very different regulatory appetite and requirement. That is not reciprocated, unfortunately. Start-ups sometimes feel that the UK is more onerous and so they will go to other countries first and may avoid the UK altogether. That does happen. I do not have an idea of the frequency of that at all.
Professor Bridgewater: Clinical trials are a globally competitive landscape, and we should try to win our fair share and make up some of the ground we may have lost in that. The place of using real-world evidence for different sorts of pragmatic real-world trials is something where we have a structural advantage because of the nature of the NHS and its data structure. We have been successful in Manchester at winning a big trial for obesity with Eli Lilly, which is exactly that: a pragmatic real-world evidence trial utilising existing data. Getting into that space is something where we have a competitive advantage, which potentially gives us many opportunities, because we can trial the things here first that we think are going to make the biggest difference to population health. Therefore, we actually leverage that innovation supply chain from global pharma. That is certainly an area that I think we should be going after.
Lord Winston: Do you agree that ultimately the RCT is the gold standard?
Professor Bridgewater: I agree that the RCT has always been the gold standard. That is probably starting to change a little bit now, and it depends exactly what you mean by an RCT. I think that, with different data and different AI techniques, there are probably faster, cheaper ways of getting to the same certainty of conclusion.
Q201 Lord Verjee: My question is about workforce, skills and training. The NHS faces many workforce challenges and a workforce under pressure, and without adequate training is less able to implement healthcare innovation. What recommendations do you have to ensure that the NHS workforce and the broader culture in the NHS is enabled and empowered to support innovation? We have heard a lot of evidence that investment can only come if it is supported by cuts. How can we change this culture? It seems to me one has to invest before we can get the benefits from extra skills.
Dr Pritesh Mistry: The workforce is our greatest asset within the NHS. It is absolutely essential to be able to realise the benefits of the innovation and the technologies. Where we see it work best is when you have that actual funding, not just for the innovation but for the change itself. We have seen organisations in the NHS being able to collaborate, being able to support their workforce to upskill and having the right knowledge, confidence and training to be able to use technology and innovations.
However, we would also say that, as per the health Select Committee report—I believe from 2023—digital skills within the healthcare system and digital confidence remain below what they should be. What we would like to see, and what we would recommend, is an ongoing programme of support for our workforce to be able to have the basic knowledge and skills for digital tools and innovation methodologies, as Ben has mentioned, but also looking at the new world of AI and how we start learning faster to be able to train up and support our workforce to have the right skills.
Professor Bridgewater: The official definition of innovation for the NHS is the introduction of something new that adds value with some degree of disruption to the existing operating model. That is a really important definition because, by definition, you are disrupting the existing operating model. That means this is going to make a difference to people. Some people will embrace it, and some people will resist that.
When I was working in industry, it was an industry standard that we used to think about three to one in tech and change management, with the three being the change management and the one being the tech. We do not think about it in that way. If you do not think about it in that way, you introduce technology but you do not make the change. Therefore, you do not take the benefits and you cannot transform the system.
Certainly, with current issues, we need to try to make smart decisions about things that will give us in-year return on investment, certainly within two years, as best we can, execute those and be thinking about the whole change management process. That needs to be supported by expertise such as some of the thinking from the King’s Fund and some of the practical things that the Health Innovation Network does.
It also needs to be owned at the top of the shop. It needs to be owned by boards and chief executives making this stuff happen. It needs to be very sophisticated and supported by people who understand some of the cultural challenges of doing things differently with NHS organisations, which often have not changed that much over a long period.
Q202 Lord Patel: My question is in three parts, so I will ask it in three parts. The first part is about your view of the NHS track record in digital transformation.
Dr Pritesh Mistry: The NHS is very good at buying technology, but not necessarily at getting the impact and benefits from technology. We have seen a lot of technology being rolled out. We have an NHS App, which has continued to improve. However, generally in virtual wards and blood glucose—all the examples I have given—there is a lot of technology but we are not seeing the benefits and the impact on a national footprint. Yes, we will see it in patches, but not necessarily everywhere.
Lord Patel: So that is the answer. How is it going to play out with the new technologies, like AI and other stuff that we are trying to introduce?
Dr Pritesh Mistry: That is an opportunity to learn from the past. Rather than buying technology and assuming that it is going to have an impact—as we have been talking about—we need to structure the change. We need to integrate the technology. We need to decommission old technology. We need to design our service pathways and support our staff to be able to use the technology. With that, taking the learning from the past, we should be able to unlock the benefits of this technology as long as we are not trying to spread it too thinly as well. If we try to do everything all at once, we are more likely to fail.
Professor Bridgewater: The track record of digital transformation in the NHS is not strong. I think we would all agree with that. When you look at it from the perspective of clinicians, there have been a lot of false dawns around technology and things that have been promised going back for quite a long time, so I think there is a degree of scepticism in the clinical workforce about the opportunities from digital. The level of user-centric design in some of these things has not really been where it needs to be: the idea that something helps you—as a doctor, as a nurse or as a manager—to do a day’s work in a day, rather than putting the burden of administration on top of your already busy job. Ensuring that user-centric design is baked in all the way through those processes is absolutely key.
We need to segment the thinking a little bit. The opportunities that can come from enterprise-wide deployment of AI tools, such as Copilot, are significant in terms of helping everybody be more effective and efficient in their day jobs, which ought to be possible with existing infrastructure. If it is not possible with existing infrastructure, that needs to be rapidly supported. Putting AI into that space is one bit of the jigsaw. There is a more fundamental transformation bit of the jigsaw as well, which is how you have the right electronic patient records, supported by the right ambient voice technology with the right embedded AI tools for bringing in clinical decision support.
Lord Patel: That was the second part of my question. To drive the innovations, particularly in AI, we need more faith in data and IT infrastructure. Do we have the right technology for data and IT infrastructure to drive innovations related to AI?
Dr Pritesh Mistry: The IT infrastructure and the data infrastructure within the NHS is highly fragmented. Technology tends to be purchased piecemeal. There are a lot of challenges with basic infrastructure within the NHS. Shared devices are still a thing within the NHS. Connectivity is not particularly great. Permissions are limiting the capability of technology.
Lord Patel: So nothing is right?
Dr Pritesh Mistry: The base level is not good enough. We have district nurses having to juggle three electronic health records. They have to do manual work, typing into this record, copying and pasting it into this one and then copying and pasting it into this other one. They have mobile phones, but they cannot use the cameras to take images of wounds because of the permissions for the technology. Where the technology is there, they do not have the right permissions. The baseline of the technology is not good enough, so there needs to be investment to improve the digital capabilities of the NHS.
The data itself is fragmented. I believe you have heard from the chief executive of the HDRS and that you are familiar with the health data environment, which is fragmented. We do not have a mechanism to continually improve our data quality and data consistency. There are opportunities to create a virtual loop through the HDRS. We need to go much further if we want to realise the benefits of AI to the fullest extent.
Professor Bridgewater: I have a slightly less bleak assessment of it. There are places where this is working well. There are a few hospitals that are very mature with their deployment of EPR systems, with AI working at scale through them in various different bits of the jigsaw. There are places that have a single patient record that is working and giving benefits to patients, clinicians and health services in general, with a compelling return on investment. It is not like these things do not exist, but I think there is the same issue here as in the questions before. If it is working well somewhere, why is it not working well everywhere?
When it comes to the technology part of the jigsaw, we could do more to learn from the experience of places where things are working well, which are clearly blueprinted and where we understand the tech, the change management process that has gone on and the return on investment. We should be using that to inform the rollout rather than a new process which is redesigned.
Lord Patel: The third part of my question is the short part. In his report, Lord Darzi commented on the fact that the people who work in the NHS see AI and other technology related to digital transformation as a burden and, therefore, they do not engage. I know the King’s Fund has produced reports related to how staff have perceived this.
Dr Pritesh Mistry: Our work was prior to AI development. We see a very strong interest and positive attitudes towards ambient voice technology specifically but, yes, there is what we would refer to as a cultural deficit when it comes to technology and innovation in the healthcare system. As I mentioned, a lot of the technology is purchased piecemeal. It is duplicative. It relies on staff doing the manual things that I have mentioned that technology should be doing a lot of.
The technology often has crashes and failures. When I last spoke to a doctor, they mentioned they have to juggle 60-plus log-ins every day. There are some real baseline challenges within the IT infrastructure of the NHS. However, as Ben mentioned, we have globally renowned capabilities within some of our organisations as well, but that baseline and high-level capability is too wide and we need to have that baseline much higher.
Professor Bridgewater: I know a lot of clinical people who use AI every day at home and in the workplace, so I do not think it is as bleak as has been described. I will tell you a brief story. I was involved in a Shelford Group piece of work on the future of the workforce, and we had a very clever final year medical student there. I asked her: what is your view of AI? Is it something that scares you or excites you for the future? The answer she gave me was that it scares her, because she spent the last five years of medical school worrying she was going to fall foul of the algorithms that look for the use of AI to write your essays. We have a situation where, right from the start, we have not necessarily stimulated everybody’s use of AI and their optimism for the future of it. Changing that whole culture right through from medical students up through the workforce is something that we need to do collectively.
Q203 Baroness Willis of Summertown: We have heard throughout your whole session some of the answers to this question, but our report will ultimately make conclusions and recommendations to the Government, the Department of Health and Social Care, the National Health Service and the regulators. What would be your top three recommendations to enable the National Health Service to adopt the sorts of innovations we have been talking about more effectively in supporting the UK life sciences industry and patient care?
Dr Pritesh Mistry: My first recommendation would be around accelerating the health innovation zones. This is a unique opportunity to create a zone per region to enable a different way of innovation. The collaborative way that I spoke about previously is starting to work in some areas. The health innovation zone could really create a local economy that has start-ups and has the NHS working in collaboration with a lead organisation for innovation that supports the scaling and adoption across that region.
Baroness Willis of Summertown: When you talk about a zone, is that a physical zone or a virtual zone?
Dr Pritesh Mistry: I would say a physical zone, so a geographical one. My second recommendation is around finance innovations. I mentioned the concept of bringing venture funding into the NHS environment, with the start-ups creating a positive flywheel of technology change and development, as well as the risk sharing that we spoke about. Financial innovation is particularly powerful, but that is not being used effectively right now. Third would be the basics. We need to measure, monitor and hold to account in improving reliability, data flows and technology capability in the NHS environment.
Professor Bridgewater: I agree with those three things. They are things for the near-term future rather than for today. My three are more for today. The first is getting alignment of priorities for the most impactful innovations right down through commissioning, through providers, using all the incentive structures that we have—performance management structures and transparency—and holding everybody to account for their part of the jigsaw in terms of that.
Recommendation number two is something that could happen quite quickly, which is reviewing and considering rebalancing the spend across the spectrum in a way where, if you want impacts in a year or in two years, you ensure that that is the way you have set up the financial support for those structures.
Recommendation number three is what I call boring but important. That is about making sure that we absolutely move and hold everybody to account through using rigorous methods in terms of the pilots or proof of value, so that when things are done, the evidence is there to be able to scale those things if they are sufficiently positive. Those are my three recommendations.
The Chair: Professor Bridgewater and Dr Mistry, thank you both very much for answering our many questions. We very much appreciate it.
