Tuning Healthcare, Episode 19: Impacting change through frugal innovation and community-centric care
This episode of Tuning Healthcare features Dr. Matthew Harris, Clinical Senior Lecturer in Public Health, in the department of Primary Care and Public Health at Imperial College London. Dr. Harris is an honorary consultant in public health medicine for the Imperial College Healthcare NHS Trust. His research spans global health, innovation, diffusion, primary care and health services. Dr. Harris has worked for several years as a primary care physician in Brazil, a WHO polio consultant in Ethiopia, an HIV technical consultant in Mozambique and the global health advisor to the UK Department of Health.
Dr. Harris discusses the benefits, biases and challenges for adopting frugal innovations and community health solutions in leading healthcare markets
“The bigger picture is not how do we treat this person the best way we possibly can, but why is this person even here in the first place? What are the failings in terms of the society at large in terms of the choices they’ve made? In terms of the choice architecture that’s available to them?”
–Dr. Matthew Harris, Clinical Senior Lecturer in Public Health, in the department of Primary Care and Public Health at Imperial College London
In this episode, Dr. Matthew Harris and Lumeris Senior Vice President Nigel Ohrenstein discuss:
- Frugal innovation, reverse innovation and how can we do more with less
- Lessons we can learn from developing countries regarding public and private healthcare partnerships
- The United Kingdom’s adoption of the Brazilian model of care using community healthcare workers
- How COVID response has helped accelerate acceptance of low-cost innovation for public health
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- Read Transcript Below:
Nigel Ohrenstein (47:46): I’m joined today by Dr. Matthew Harris. Matthew is a Clinical Senior Lecturer in Public Health in the department of Primary Care and Public Health at Imperial College London. And is an honorary consultant in public health medicine for the Imperial College Healthcare NHS Trust. His research spans global health, innovation, diffusion, primary care and health services. Prior to joining Imperial College London, Matthew worked for several years as a primary care physician in Brazil, a WHO polio consultant in Ethiopia, an HIV technical consultant in Mozambique and the global health advisor to the UK Department of Health.
Nigel Ohrenstein (48:28): In this episode of Tuning Healthcare, Matthew and I discuss frugal innovation and reverse innovation and how can we do more with less. How we can learn from developing countries about public and private healthcare partnerships. How the UK is adopting a Brazilian model of care using community healthcare workers. And how COVID has driven a greater need for us to focus on these topics. Join Matthew and me as we tune healthcare.
Nigel Ohrenstein (00:40): Matthew, thank you so much for joining us today. This is truly an honor for me. This is a number of firsts. The first time we’re hosting an international guest on the podcast. We are really excited to hear your perspectives about the UK health system and perhaps some of the things that we can learn here in the US from your experience and from your research. Secondly, this is the first time I’m hosting somebody who I went to school with. We were just chatting that it was 41 odd years ago that we first met, which makes both of us feel rather old. But an absolute delight to have you on the podcast and thanks so much for joining us today.
Matthew Harris (01:29): Thank you very much, Nigel. It’s wonderful to see you again. It’s been too long.
Nigel Ohrenstein (01:32): Yes, way too long. You have an amazing story, both as a physician, you’ve worked all over the world, and now you are having a significant impact through research being the primary method that you’re utilizing to try and impact change in the US healthcare system. Tell us a little bit about your background and your career and why you made the choices that you have.
Matthew Harris (02:00): Thank you, Nigel. The first thing to say is I’d love to make an impact in the US health system, but really it’s the UK health system.
Nigel Ohrenstein (02:07): Did I say the US? Sorry, my apologies. The UK health system. Well, maybe after this podcast, you’ll make an impact in the US as well!
Matthew Harris (02:14): Who knows. Let’s think big. No. I’ve had a bit of, I suppose a circuitous trajectory. I began studying medicine at University College London back in the ’90s. I therefore qualified in medicine, became a doctor. I worked in the UK for a little bit doing junior house officer jobs. I think you might call them residencies in the US. Before then, for one reason or another, moving to Brazil and retraining in medicine there. I took all my medical school exams in Portuguese and requalified as a doctor in order to work as a general practitioner in their primary care system. I found myself, I ended up in Recife, which is in the Northeast of Brazil in a state called Pernambuco. I was a single-handed general practitioner in a tiny little clinic in a rural area very impoverished looking after around 5,000 people in a community there.
Matthew Harris (03:14): I was there for about four years. Before then coming back to the UK and doing my master’s in public health at London School of Hygiene. Then working for the WHO on polio eradication programs in Northern Ethiopia. I spent a little bit of time there doing a lot of outreach work on cold chain supports and outreach and training healthcare workers on immunization campaigns such as for measles and polio and other things like that. Then I moved to Mozambique and I worked in Central Mozambique, a town called Chimoio, where I was running an HIV hospital there for a little under a year. Before then coming back to the UK. Doing my doctorate in public health, Oxford University. Then training to become a consultant in public health medicine in our NHS, our health system here in the UK.
Matthew Harris (04:10): I’m currently what we call a Clinical Senior Lecturer in Public Health Medicine at Imperial College. I’m essentially a clinical academic in public health. That means, what do I do? I’m a director of the master’s in public health program. I do research into innovation diffusion in healthcare. I have a particular interest in looking at frugal innovations from low-income countries and how we might adopt them in the UK and some of the barriers and challenges to doing so. My work really tries to bridge that, I suppose divide between research and practice by looking for solutions that clinicians can be thinking about adopting and studying those processes of adoption as well. That’s in a nutshell.
Nigel Ohrenstein (04:59): A little bit more than a nutshell. It’s really an incredible journey and experiences that obviously are truly amazing. The breadth I’d imagine you bring to your work is obviously as a result of a lot of the things that you’ve experienced. One of the things that has struck me from reading the content you have written, I haven’t read all of the 100 plus things that you’ve had published, but I’ve read a few. But one of the things that did strike me is that you seem to approach everything from a very practical perspective. Rather than just living in academia, and you went to Oxford, but I went to Cambridge. The people I interacted there lived in academia. It was an academic exercise rather than a practical exercise.
Nigel Ohrenstein (05:52): But one of the things that really struck me about your work is that you’re really trying to drive practical implications and what are the consequences and what can people do as a result of the work you’ve done. As we go through this, it’s going to be fascinating, I think, to learn about how you’ve looked and hope that UK would apply them and maybe some of the lessons that we can learn in the US. Going back to the time when we were in school together, a school called Haberdashers’, did you know then you wanted to be a doctor?
Matthew Harris (06:27): I did, actually. The problem is I didn’t know what it meant to be a doctor. I had a sense of it -it sounded good. I was definitely interested in sciences, biology and human body. I remember at a very early age, it’s embarrassing to say it, but I was reading Grey’s Anatomy from the age of 10. Don’t ask me why. I just, maybe I liked the pictures. It was something and I just got into it. I was always really interested in the body and how it worked. I think we were probably at the school, I don’t know if you’ve had this experience yourself, but we were at the school that really funneled you, I think. If you were reasonably academic, then you would go into medicine. It was as simple as that.
Matthew Harris (07:13): There was a little bit of fumbling there. I won’t lie. But I was still nonetheless very interested in medicine and the caring profession and everything else that came along with it. I was very happy to study medicine. The problem really began when I realized that meant you have to also be a doctor. I actually struggled -I’m not going to lie. I struggled when I qualified as an actual clinician. It hadn’t really dawned on me just how… Well, I suppose the stresses and strains of clinical practice and death and dying, and all those things were really… Took a bit of a toll and they don’t teach you that at medical school. They certainly didn’t signal it at school that these were the things you’d have to really be grappling with.
Matthew Harris (08:02): When I entered the NHS as a junior doctor with for the first time real responsibility for looking after patients and everything that comes along with it, I actually found that I didn’t cope particularly well with that. I didn’t have a particularly supportive team around me, so that also was a bit of an exacerbating factor perhaps. But one of the things that I grappled with most in addition to the struggles of working in a healthcare system was that I was continuously thinking about the big picture. The bigger picture. Not how do we treat this person the best way we possibly can, but why is this person even here in the first place? What are the failings in terms of the society at large in terms of the choices they’ve made? In terms of the choice architecture that’s available to them? If they smoke, why are they smoking? Rather than how do we treat this lung cancer?
Matthew Harris (08:49): I was always from an early age more along the lines of thinking about the bigger picture and I certainly found grappling with those questions as a clinician. Which isn’t particularly helpful when you’re dealing with the day-to-day issues around patient care because of course, those bigger questions, those are questions of public health. Social determinants of health, we call it, of course, and the things that lead people to require care in the first place. I found myself grappling a lot with the inefficiencies in the system. The craziness of the fact that we’ve got, in the NHS, no less than 100,000 different IT systems operating. Sometimes wards within the same hospital will have different IT systems. These things, inefficiencies that just annoyed me, to put it pretty frankly.
Matthew Harris (09:43): I found myself therefore just going more in the direction of these bigger questions. How do we improve the system that the clinicians are working in? How do we improve society at large or identify the issues in society at large to ensure that people don’t need care in the first place? How do we reorganize care in such a way that it costs less? That it does a better service than the one which we are providing? In a way, while I trained as a doctor and I’m always very grateful to have had that experience, one of the driving underpinning drivers for me has always been about addressing the bigger picture.
Nigel Ohrenstein (10:22): That’s great. Obviously, it helps explain the transition from clinical practice to clinical research. In 2018, you wrote an article that I thought was really interesting. The one from Malawi to Middlesex: the case of the Arbutus Drill Cover System. What’s fascinating to me is that’s the drill system itself. Because that obviously was, the gist of the article I think was MSK is a huge burden, not just on the NHS, but in the US health system as well. A lot of interesting companies that are trying to address that from an overall care perspective. But you are focusing here on just a particular piece of surgery and how this particular Arbutus Drill Cover System was 94%, I think, cheaper it was than the standard surgical drill available in the UK.
Nigel Ohrenstein (11:23): To me at least, what was fascinating about that article and a number of other articles you wrote about and you’ve written about is this whole concept of frugal innovation. First of all, define for us what that means because I really do believe in the US health system, it’s a term that we don’t hear often, but I actually think is a term that might be surprising to many people that live and breathe in the US health system, which is a costly health system and a lot of expenses is placed and little is spared.
Matthew Harris (12:04): Thanks, Nigel. It’s a really good question and there’s, I suppose, quite a lot in that. Part of the perhaps reason why you haven’t heard a lot about frugal innovation in the US is the term frugal innovation itself. The very connotation that frugality might give to people is not entirely a positive one. It often evokes what? An image of being cheaper and therefore [crosstalk 00:12:31]-
Nigel Ohrenstein (12:31): And missing out.
Matthew Harris (12:32): Exactly. Less effective. Maybe lower quality and so forth. It actually couldn’t be further from the truth. The frugal innovation is one that is as good as the existing innovation if you’re comparing technologies, for example. Sometimes even better at delivering the outcomes that you expect it to deliver. That it intends to deliver. But just at a far, far lower cost.
Matthew Harris (12:57): It achieves that through a number of mechanisms. Through simplification of the technology. Through repurposing technology from one domain into another. The technology already exists, you’re just using it for a different reason through ensuring that the materials used are sourced sustainably or locally through making the innovation perhaps more lightweight or more rugged. Removing some of the complicated features that might make it more sophisticated, but aren’t necessarily needed in order to deliver its function.
Matthew Harris (13:33): One of the things we often see in healthcare innovation is something that’s called sustaining innovation. It’s in little improvements on the technology that aren’t actually necessary, but make it more attractive to the market and also increase the cost. Frugal innovation does the opposite. It removes the things that aren’t really necessary. They’re a bit superfluous and strips the innovation back down to its barest bones without scrimping on the function that it requires.
Matthew Harris (13:59): The case of the Arbutus Drill is a really interesting one. Just to put some flesh on the bones, the drills that we use in orthopedic surgery, at least here in the UK are fantastically expensive. They’re about 30,000 pounds each. They’re expensive because they’re encased in a sophisticated stainless-steel encasing that allows them to be autoclaved and therefore made sterile for use within the operating theater. But in Malawi and in Uganda and Kenya and other places where the drills aren’t procurable because of the resource restrictions and limitations, they innovated in a different way which was frugally. Which was to take a regular hardware drill, the kind that you would use to put up your shelves at home or something similar. Which on its own wouldn’t be suitable for an orthopedic operation, obviously. But put the drill, the hardware drill inside a sterile bag.
Matthew Harris (14:57): The concept is therefore using an ordinary hardware drill inside a sterile bag, making therefore the drill system suitable for an operation. It’s so simple and so much cheaper that it actually becomes really an interesting and viable alternative. That particular technology has been used hundreds of thousands of times in Sub-Saharan Africa with absolutely no demonstrable increase in postoperative infections. Which should be your main concern, of course, in using a hardware drill.
Matthew Harris (15:29): The issue there, which leads to the second interesting point is yes, in and of itself it’s a really interesting alternative to the sophisticated technologies, but can it be used in the UK and elsewhere, in fact, in high-income settings. It has in fact been used as a bit of a world first, if you like, in a hospital in Baltimore. In a trauma hospital called Shock Trauma Hospital. It’s been used for spinal traction and we’ve not noticed as part of the evaluation that we did with colleagues there, any increase at all in postoperative infection rates. Which goes to show that this technology that it could be used in even in a high-income setting as well. Which of course, why wouldn’t it be able to be used in a high-income country setting? There’s no intrinsic difference between the patients there and the patients in Malawi.
Matthew Harris (16:22): The question is, I suppose around how do we reframe what’s palatable as well in terms of what we use clinically. It might not look sophisticated. It might not cost a lot, but it does what it says on the tin and doesn’t scrimp and doesn’t compromise patient safety. The savings that you could anticipate from using innovation like that in the high-income setting is really, really interesting. We calculated in the UK that if we swapped out all of the existing drills with that technology in the UK overnight, which of course, it’s a hypothetical scenario. But we’d save something like a £100 million just by swapping out the technology.
Nigel Ohrenstein (17:03): It’s crazy.
Matthew Harris (17:04): It’s a really an interesting policy alternative.
Nigel Ohrenstein (17:07): Is the largest barrier that you’ve come across to frugal innovation in the UK the physician community or the executives of healthcare trusts who are resistant to doing anything that might upset their physicians?
Matthew Harris (17:27): It’s a really good question. Look, we already know from the literature that adopting a new innovation is one of the hardest things you can do in healthcare -because it requires a change in behavior. You need to stop doing what you’re currently doing, which you’re doing for all sorts of reasons and relearn your practice and use something else. It’s very, very difficult. There’s lots of inertia with any innovation.
Matthew Harris (17:48): But when with an innovation like a frugal innovation, which on its own confers all sorts of different constraints because people don’t immediately like the idea of it for all sorts of reasons. Plus coupled with the fact that they tend to be coming from contexts, shall we say, that we don’t typically associate with innovative practice, such as Sub-Saharan Africa and other low-income countries. That’s where frugal innovations are most often found. Born out of necessity most often. But for both of those reasons, it makes it really challenging. In addition to the inertia you’d expect anyway with innovation adoption, it makes it really challenging to adopt these innovations because you’ve got battles on all sorts of different fronts. Your perception of the country where the innovation came from. The perception of the innovation itself being frugal and not quite so sexy as the ones you’re already using. And the idea of course, of actually having to change your practice. Clinicians obviously are going to be central to that.
Nigel Ohrenstein (18:52): No tickets to a football match from the manufacturer.
Matthew Harris (18:59): Yeah, it tends not to come with those perks. You’re absolutely right. Those mechanisms to get these innovations into practice are really… That’s not going to happen on these things. The work we do is to serve as intermediaries to really be persuasive around the business case, if you like, for using these innovations and we’ll work with clinicians closely to try and, if you like, change hearts and minds around their use.
Matthew Harris (19:28): There’s another obviously very difficult issue, which is around the regulatory barriers. These technologies are very rarely patented. They’re very rarely have any commercial backing or an enterprise behind them that can promote them and enter into new markets. We have to do all of that work for them, if you like. That’s a very practical barrier that’s a difficult one to overcome.
Nigel Ohrenstein (19:49): Another reason I find this topic fascinating is because, all the merits. And in fact, we are also a part of what we do in the business of physician behavior change. Trying to get physicians to change the way they behave from a fee-for-service system to managing populations and even little things like outreach to patients to bring them in proactively rather than cafeteria style, seeing who comes in is sometimes for some price is a monumental change. Getting them just to do that is sometimes takes an enormous amount of time and effort.
Nigel Ohrenstein (20:31): What your research illustrates is that there’s so much room for realistic cost savings that don’t impact quality and obviously, going beyond that, there’s, as you delve into some of the other innovation, there’s the opportunities to improve quality. That ties into the second topic of your research that I find fascinating. It’s obviously really tightly linked to frugal innovation is reverse innovation.
Nigel Ohrenstein (21:01): I must admit, I’m not entirely sure of the difference. My assumption of the difference is reverse could be, it doesn’t necessarily be frugal. It’s just innovation that comes from a less developed country as opposed into the more developed country where historically most innovation has come from developed countries and then applied to less developed countries. Is that the distinction between frugal and reverse? But tell us a little bit about some of the research you’ve done into reverse innovation and again, a little bit the bias you’ve come across as you’ve tried to do that.
Matthew Harris (21:45): You’re absolutely right in terms of the difference between reverse and frugal. Although reverse innovations tend to be frugal because they’re coming from low-income countries. But they don’t have to be. A frugal innovation doesn’t have to be a reverse innovation because unless it’s adopted into a high-income setting, it wouldn’t be called a reverse innovation. [crosstalk 00:22:04]-
Nigel Ohrenstein (22:04): That means I could have done the academic path at Habs after all. They pushed you to medicine. They pushed me to sport.
Matthew Harris (22:09): It’s a really interesting area. The first thing to say is I don’t like the term reverse innovation. It has all sorts of connotations as well because it really reinforces this idea that innovation flows in one direction. That’s from high to low-income countries. Expertise, technical know-how, everything else goes from rich to poor. When that happens in the other direction, then that’s in reverse. In some senses, it’s an unfortunate terminology because it reinforces the very thing it’s trying to solve.
Nigel Ohrenstein (22:48): It’s degrading from the very beginning.
Matthew Harris (22:51): Exactly! You might say it’s a bit like, it’s an oxymoron perhaps. It’s a patient-centered care, is a bit like that. Because if it really was patient-centered, then you’d be calling it person-centered care. Patient-centered care is really doctor-centered because you’re calling the patients.
Nigel Ohrenstein (23:06): With that, we can spend a long time there. You’re hitting a topic that I’m passionate about. We have physician-centric care in the US and it’s about time we had truly, as you say, person-centric care. But anyway, we can come back to that if we have time.
Matthew Harris (23:24): Oh, well, that will be fascinating I’m sure. Again, it touches a lot on how the health systems are structured, of course. It’s difficult to compare between the UK and US because our systems are really so different. But in the US of course, you have a market-based system where costs are really someone’s income, actually. It’s very difficult to think about reducing costs to some extent in the US when that is in some senses, so closely linked to the income of a clinician. But that’s related to this idea of frugal innovation, of course, because in whose interests is it to actually adopt a technology that actually saves money. It might not be at all in the interest of a clinician to do that. In the US at least. Whereas in the UK, because we have a single-payer system, any efforts to reduce overall costs in terms of procuring technology is going to be a reason, at least from the first principle, it’s a good idea.
Matthew Harris (24:24): But the reverse innovation piece is interesting because it really taps into this sort of legacy effect that we might say this historical effect of development assistance and almost colonialism actually, as well. That has really what’s been the signature, if you like, and the defining characteristic of much of the overseas development and aid policies. It’s difficult to separate the history of post-colonialism from the work that governments do overseas through either directly through bilateral assistance or indirectly through supporting international non-governmental development organizations. There’s been a sea-change shift in some of those approaches being more participatory and so forth and the way aid is delivered is certainly improving much more recognition of the importance of mutual benefits in the delivery of international health partnerships and reciprocity.
Matthew Harris (25:22): But reverse innovation takes much more of a direct approach. It’s about specifically looking for innovations from low-income countries that do more with less without scrimping on quality and seeing how we can directly implement them into the UK.
Matthew Harris (25:40): You touched on one of the research papers we’ve written about, which I think was the one you were referring to was one around cognitive biases. Essentially what that did was to essentially look at, well, what is one of the main challenges around reverse innovation? Do we treat innovations from low-income countries palpably different to innovations from high-income countries? What might be some of the reasons why?
Matthew Harris (26:04): What we did was a research study that essentially randomized research abstracts to English clinicians and asked them to rate those abstracts against a couple of criteria. What was the strength of the evidence in the abstract? How relevant was it to their clinical practice and would they recommend the abstract to appear? But when we asked them to rate it a second time a month later, changing the source from a rich country to a poor country under these controlled conditions, we found that actually their views of the research just radically changed. They’re just much, much worse. They rated on all measures much, much worse. Which we think is a real challenge when it comes to reverse innovation because whilst we were looking at research abstracts in this instance, you could swap that out for an innovation, a healthcare technology of any sorts, and you’d probably get exactly the same effect.
Matthew Harris (26:53): When you think of an innovation coming from, and no disrespect to these countries. But when you think of innovation coming from Malawi, Burundi, Rwanda, Uganda, when you’re sitting in the UK and you’re thinking of innovations coming from those settings, you’re immediately, and it’s unfortunate, but you’re immediately going to view those in a certain way. Whereas when you think of an innovation from the US or from Canada, from Germany or Switzerland, you’ll have the opposite effect. That’s really because of the legacy effect that we have. The way those countries are stereotyped or represented in the media, it filters through into our unconscious and we reach snap judgements about those innovations very, very quickly.
Matthew Harris (27:34): When it comes to reverse innovation, when we’re talking about adopting innovations, frugal innovations from those settings that are perceived rightly or wrongly to be very different to our settings here in the UK or in the US, that becomes a real issue. It’s how do you then address those cognitive biases head-on by neutralizing the effect of what we call the country-of-origin effect so that those cognitive biases are minimized as much as possible. Then you’re just looking at the innovation itself and reach a judgment based on its merits alone.
Nigel Ohrenstein (28:07): So fascinating because obviously bias exists in every sphere of life. The whole concept, if you like, of innovation, even if you take it out of reverse innovation, it’s often a smaller, cheaper, skunkworks company who eventually grows to unseat a giant. Because innovation happens often in a very low-income way. That’s how a lot of innovation happens.
Nigel Ohrenstein (28:46): The concept should really apply equally. Just because it was born in a cheap garage, everyone loves the garage story in Silicon Valley. It’s not someone spending, at least initially spending millions and millions of dollars on that innovation. Everyone loves the garage story in Silicon Valley. But the garage story, as you say in Mozambique, doesn’t… Has the UK adopted any of the suggestions that you’ve put out to try and remove some of this bias and to advance some of these, for want of a better term, a reverse innovation?
Matthew Harris (29:26): We’re beginning to see some shifts in narrative and we’re beginning to see some shifts in practice as well. With COVID obviously, we can’t have this conversation without mentioning COVID once at least. Has been a real, I think, disruptor to a large extent, because what we’ve done, we’ve published on this as well. We had a piece out in Nature Medicine last year talking about frugal innovation responses in the context of COVID.
Nigel Ohrenstein (29:50): Yeah. I read it. It was quite good.
Matthew Harris (29:51): About the frugal ventilator machines using the parts off the shelf rather and parts from other technologies. Or proning patients rather than using ventilation so you don’t have to rely on technology. Simple checks in clinical practice at low cost. I’m not sure these ideas actually came from low-income countries and so it’s not… COVID has been a real, if you like, disruption in terms of us beginning to realize in the UK at least, that we should be looking to some of those settings. We continue to bang that drum.
Matthew Harris (30:25): That being said, at some policy level, we would only hear of the US and Germany and France. You’d never really hear in the press about what was going on in other parts of the world. There’s still a lot of work to be done about homogenizing the influences that we have within our societies, at least. I think what it’s also done is shown that we have a pressing need here in the UK, at least now, that we never really fully appreciated before. The COVID has cost us a lot of money. We’ve been borrowing ridiculous amounts. Our health system has exhibited all sorts of fragilities that we’ve never really fully appreciated before. The public health response was slow and left wanting to a large extent.
Matthew Harris (31:13): Whilst there’s been some hubris to some extent and some British, good old British exceptionalism, I also find that there’s been a little bit of a shift in narrative. A good example of that is the frugal innovation that I’ve been talking about for many, many years, because I had personal experience of it. Not least, but it was the Brazilian primary care system.
Matthew Harris (31:38): As mentioned at the beginning, I worked there for several years. What makes that a very interesting system is that they use community health workers to reach out into every household that they’re responsible for irrespective of need or express demand. These are monthly visits, at least as a minimum to at least 150 to 200 households per community health worker. And the community health workers integrated into primary care as well so they’re part of the team. By doing that, the outreach work on a proactive basis, they can identify all health and social care needs before they become major issues and before they require health care. It’s that proactive approach, that universal approach across the life course that has shown some extraordinary outcomes in Brazil in recent years. Pre-COVID, at least. Where they’ve seen a decrease in 30% of mortality for cardiovascular disease. Mortality in areas where this primary care system has had a high penetrance.
Matthew Harris (32:41): This month, in fact, whilst it’s taken many, many years to get it off the ground, we’re piloting the same approach. We’re using community health workers in a local authority in a bower in London called Westminster. In order to see whether or not this proactive universal outreach approach using lay community health workers is going to be as effective as we see in Brazil. We’re already seeing good signs that it’s scaling into other regions around the country. It’s a really exciting moment for people interested in reverse innovation to see a primary care system from a low middle-income country in the case of Brazil being explicitly drawn upon to draw some learnings from there and actually changed practice here in the UK as well.
Nigel Ohrenstein (33:23): That’s fascinating. I’d love to delve a little bit more into some of these concept that I saw, I think you wrote the article. At least the one I read was back in 2011 about your experience in Brazil and the integration of public health and primary care. Which as you have correctly articulated, the pandemic has illustrated we need that more than ever. The public health, clearly in many countries around the world was left wanting and primary care runs in a completely siloed fashion to anything that was done from a public health perspective. And so community health workers, let’s delve into that into a little bit more detail.
Nigel Ohrenstein (34:14): Tell us a little bit, what does the profile look like of a community health worker and how many, based on your research of again, I know you’ve put some numbers out there in your research. But share for us, how many would you need? Do you think about it per practice? Do you think about it per number of patients? What is the geographical area? How often do they visit? Put on a little bit of meat on the bones for us. What is a community health worker, as you think about it?
Matthew Harris (34:46): Well, we try to adhere very closely to the model that was used in Brazil because there it’s been in place now for 30 years. It’s been scaled throughout the entire country. This model serves 70% of the population across 95% of its territory. Imagine a country the size of Brazil. It’s actually the largest primary care system on the planet. It’s all government funded. All free at point of use. Taxpayer funded and very much centered on the core principles of primary care around universality and comprehensiveness.
Matthew Harris (35:25): In terms of what they do and who they are, the community health workers essentially, there’s usually between four and six per GP practice. Each community health worker will have between 150 to 200 households of their own. They will be in a defined geographical area with no overlaps or gaps between their territory, if you like, and the other community health worker’s territory that’s affiliated to the same practice. It’s fully universal and it’s fully comprehensive. Essentially what that means is the community health worker visiting at least once a month all of the households in their territory. But they’ll be trained to deliver at a very low technical level, but nonetheless to be useful, if you like, across a wide array of different clinical areas from infancy all the way through to care of the elderly.
Matthew Harris (36:15): They would be as interested and concerned with whether or not a child under five has had all their immunizations. Whether the mother has had her cervical smear. Whether the father is exhibiting symptoms and signs of hypertension or diabetes. Whether someone smokes or doesn’t. Whether an adolescent might have concerns around sexual health or drug use. All the way through to social isolation and loneliness. All of those things can be happening all the time in their patch of 150 to 200 households. By not being constrained clinically or in a typical vertical way that we often have in the UK and the US, I’m sure as well, where you’re focused on specific clinical areas like improving diabetes care exclusively or something. It’s the opposite. The community health workers are fully comprehensive. They look at the household as a whole and everything in it. Then they also look at the community as a whole and how the household fits in within the community and what can they be doing to leverage assets within the community to improve health and social care in that geography?
Matthew Harris (37:23): Essentially, the model what that does, it merges what is otherwise a pretty arbitrary distinction between primary care and public health. Primary care is public health in Brazil. They have as much responsibility for individual clinical care ambulatory care, just as you might see in the US or UK, as they do for looking out for the needs for the entire population that they’re responsible for and identifying the opportunities to improve healthcare at a community level. Not just waiting for people to come through the door. It’s population health. But it’s the responsibility of the community health workers.
Nigel Ohrenstein (38:07): As the community health worker then identifies an area of concern. We can pick anyone. Let’s say they visit and they realize that the grandfather recently fell and they’re concerned about that he hasn’t been fully checked out. As we know, fall in the elderly is often the precipice for many complications. The community health worker thankfully visits and it’s two days after grandpa fell. They haven’t done anything about it. They just, as far as they can tell us, it’s just a bruise and they’re treating it at home. Does the community health worker then contact the primary care physician? Does the community health worker encourage the patient to go be seen? What are the responsibilities at that point of the community health worker and how does that then tie into that continuation of care?
Matthew Harris (39:08): It’s a really good question and it’s a good example, actually. Because I would say that they would probably have identified the full risk in the first place to avoid the grandfather actually falling over in the first place.
Nigel Ohrenstein (39:21): Even better.
Matthew Harris (39:22): Even better. But you’re right. If that fall had happened, the other important thing to mention is they’re not clinicians. They can’t diagnose in that sense. That’s way outside of their remit. But what they are able to do is, because they would intimately know the family through building up that trust and that relationship, getting to know them over the many, many visits, over many months and years, they know when something’s wrong. They know when that person’s behavior is slightly off. They’ll know if someone’s not quite telling the truth or whatever. They’re hiding something. They just know them intimately. They just know the families intimately because they’ve built that trust. They’ve built that relationship. Even though they might not be able to clinically diagnose, they’ll have a high degree of suspicion when something’s wrong. Not quite right.
Matthew Harris (40:10): We talk a lot about artificial intelligence. But really what the community health workers are about is emotional intelligence. It’s that idea that they just can pick up on things through a trusting, and quite frankly loving relationship with the households that they’re responsible for. When there’s a need therefore, they’ll absolutely signpost it to the primary care physician who would be in a position to be able to affect any clinical care as needed. Essentially what they are is they’re the ears and eyes of the primary care team in the community. Where GPs no longer have time to be going on home visits and dealing with things in the community and they therefore don’t know the community or their households that they’re responsible for very well because health worker does that job for them. It’s their early warning system.
Nigel Ohrenstein (40:53): And as we know in the follow-up aftercare, the situation that you have at home significantly impacts how you deal with aftercare in terms of even just taking medication, which is low-hanging fruit. Then is the concept that the community health worker, is it best to think of that as a social worker being the best quantification for that? What’s your thoughts on, or what does the person who does that role look like?
Matthew Harris (41:27): They can definitely come from a social work background. They can come from, in the UK the ones that we’ve recruited in this pilot, they’re what’s called Community Champions. These are people who are passionate about the community. Have been working as volunteers, perhaps in a particular area, but want to take it to the next level. Because this is a paid role. Full-time. 40 hours a week and a professional role, quite frankly. But they’re not healthcare professionals. They wear, if you like, two hats. They’re part of the team, but they’re also a part of the community and they have to navigate that duo dynamic quite carefully.
Matthew Harris (42:04): Definitely there’s a lot of social work involved in the role, but there’s also a lot of community engagement. There’s a lot of participatory methods. There’s a lot of clinical care to some extent. A very low technical level around giving advice on health care issues, screening, immunizations, and health promotion and lifestyle advice. It’s actually an intervention that’s quite difficult to pigeonhole. Something that we struggled with in the UK getting this off the ground is, well, who owns it? Is it a primary care service? Is it a public health service? Is it a social care service? Is it a community action service? What is it? Who owns it? Where’s the funding going to come from? Because the truth is, it’s the intervention that will impact on all of those domains across the ecosystem. It impacts on primary care. It impacts on public health. It impacts on social care to greater or lesser degrees. One of the ways to get it off the ground is to have a… If you like a convening of representation of all of the different elements of the ecosystem to get involved, to get skin in the game and to understand how it will benefit everything that they do as well.
Nigel Ohrenstein (43:08): That’s fascinating. I’m going to watch with great interest to see how the pilot goes. I hope you’ll send me results because I think it’s definitely something that we could integrate into our health system here and it’s something that’s clearly needed. Interesting enough, and we don’t have time to delve into more detail, there are some ethnic communities in the US that don’t have exactly the same, but have these intermediaries that help them because they, either language barrier or cultural barrier makes it hard for them to seek care and access care. Some communities have built these intermediaries that help them find the right doctor. Find a specialist. Some communities have built, by necessity again. We’re back to necessity driving innovation. They have built something that’s a little bit similar, but not exactly the same. But as I said, I’m going to keep an eye on your pilots and maybe we can bring something similar to the UK.
Nigel Ohrenstein (44:15): Matthew, I could keep chatting to you for hours about lots of different topics. As we said, your background’s fascinating. Your experiences is really intriguing. But we’d like to end with what we call the quick fire round. These are four quick questions that we ask every guest we have and I think people find it interesting to hear what different people say. [inaudible 00:44:43], what’s the best piece of advice you were ever given?
Matthew Harris (44:49): That’s a really, really good one. I would say that pretty much anything that my wife says to me on any given day, it probably will be the best advice I’m given. But more specifically, I think it was probably when I was deciding to go to Brazil back at the end of medical school and I was actually going to quit medicine and not finish my medical training. The best piece of advice I was given at that point was to continue. It was hard, but I got through it. But had I not continued, then I wouldn’t actually be able to do what I’m doing today. That was actually a good piece of advice.
Nigel Ohrenstein (45:26): So persevere. What do you do to relax, have fun when you’re not trying to fix the UK health system?
Matthew Harris (45:36): Not much time left over, but look. I’ve got two kids and so that takes up a lot of time. But I’ve recently taken up the drums and I have really been enjoying just banging and crushing on the drums. [crosstalk 00:45:52]-
Nigel Ohrenstein (45:53): Hopefully you’ve got a soundproof room to avoid the rest of the family suffering. What advice would you give to your younger self?
Matthew Harris (46:03): That was an intriguing question. I think what I would say is take more photos of everything that you’re doing because I never did and it’s getting harder and harder to remember all the good times. I probably would take more photos.
Nigel Ohrenstein (46:21): If you had married an American like I did, we take photos all the time. Then finally, if you could change one thing about health care, what would it be?
Matthew Harris (46:33): Well, it’s a difficult question. Of course, healthcare is different everywhere. But I think one thing I’d probably change is how we train doctors that go into healthcare. Because I think it drives a lot of the fundamental problems that we have around the world. I would work on fixing this idea that we should all become specialists in something. We first should be generalists and then develop specialisms thereafter. It feels that the rush to become specialists is unhelpful.
Nigel Ohrenstein (47:05): Man, that’s very interesting. Then I’m sure we could talk for a lot longer on just that topic alone. Matthew, thank you so much for joining us today. Really appreciate it. As I said in the outset, it’s an honor for me to have you. The longest person I’ve known ever on a podcast. Thank you so much for joining us today and sharing all your insights.
Matthew Harris (47:28): It’s been an absolute pleasure. Let’s not wait another 41 years to see each other again. Thank you for the invite. It’s been really fun!
Nigel Ohrenstein (49:03): Thank you for joining us today. Please follow us on your favorite streamer and don’t forget to rate us, as it helps others find our podcast. Please join us again next time as we tune healthcare. This is Nigel Ohrenstein in New York.
The opinions of the podcast guests do not necessarily reflect those of Lumeris.
- Text Message Alert 1 Sound. Available at http://soundbible.com/2154-Text-Message-Alert-1.html.
- ECG Sound. Available at http://soundbible.com/1730-ECG.html.
- AM Radio Tuning Sound. Available at http://soundbible.com/2099-AM-Radio-Tuning.html.
- Intro music. Gordon Household. August 2019. WAV File.