Paul Mears, CEO of Cwm Taf Morgannwg Health Board, Wales, UK
Paul Mears leads an integrated health board across the pond in the country of Wales, part of the United Kingdom. These traditional old mining communities have–as many post industrial communities here in the States–experienced challenges as the dominant industry exited, leaving many behind and created deep social and health needs. Paul’s vision of health includes one where a collaborative, reactive, digitally-enhanced care system can rise to meet these difficult challenges.
Paul Mears has been Chief Executive of Cwm Taf Morgannwg Health Board in Wales, UK since September 2020. The Health Board is an integrated population health organisation delivering and commissioning healthcare services for a population of 450,000 in the Welsh Valleys. This includes three general hospitals, mental health services, community care, primary care services and public health. Paul is the national CEO lead in the Welsh NHS for innovation and also leads the delivery of value based healthcare across the country.
Prior to this role Paul spent two years as independent management consultant advising a number of clients in both the public and private healthcare sector as well as digital healthcare businesses. This included is working as a Senior Advisor to McKinsey & Company. Paul was previously Chief Executive of Yeovil District Hospital in Somerset where he established the Symphony Programme designed to integrate care across primary care, the acute hospital and community services. Paul started his NHS career in Torbay where he was instrumental in setting up Torbay Care Trust and leading the operational business of one of the first integrated community health and social care organisations in England as well as working as Chief Operating Officer at Torbay Hospital.
Paul has an interest in integrated care, digital healthcare and innovation which has led him to speak at a range of national and international events on these topics. His development of integrated care models has been featured in the Financial Times, The Economist and Health Service Journal. Paul is a strong believer that the future of healthcare is a pivot away from a focus on hospital based care to upstream engagement and involvement of communities in improving health outcomes as well as using digital technologies to drive a more citizen-centred healthcare system.
Show Notes
Paul Mears shares his background as CEO of a health board in Wales, UK and the population it serves. [03:04]
How will the roles in healthcare and hospitals evolve in the future? [05:01]
How will technology change medical specialist training? [13:05]
How can we encourage a mindset shift from treating to preventing disease? [16:45]
Will more online information create greater inefficiencies in the system? [22:45]
What changes will medical providers need to make to remain relevant? [25:28]
What are the ethical challenges with digital healthcare? [28:32]
What are the determinants of good health? [31:42]
Transcript
Jason Helgerson 00:00
Hi. I'm Jason Helgerson, and you're listening to Health2049.
Paul Mears 00:08
You've got a generation of people coming through now in their 20s and 30s, who are used to accessing services at the click of a mouse and that population of people, whilst they might not yet be high users of services in health care, as they become older, they are going to expect more and more of those services that are available to them in the same way that they access everything else in their life. So I think we need to be thinking in health care, how we turn that into a positive for us, because ultimately, in terms of delivering services, getting patients to look after themselves is the most cost effective way of delivering health care and the most empowering way for a patient to be in control of their health care. So I really think there's going to be a huge shift to that relationship with patients becoming much more one where the patient's in control of their own information in control of their condition, and becoming much more discerning about how they want their care to be delivered, which is absolutely the right thing.
Jason Helgerson 02:08
On the western coast of the United Kingdom sits the country of Wales, a beautiful coastal region with some of the most inspiring natural landscapes in Europe. Today's guest is the CEO of a health board in Wales, providing and coordinating health and social care services to nearly half a million residents in order to advance population health. He has worked across many sectors of the healthcare system, including managing hospitals, establishing primary care networks and setting up care trusts. He is a passionate thinker and creator of integrated care models, who is willing and able to implement digital health innovations. And I couldn't be more pleased to have him here today. It's my pleasure to welcome Paul Mears to our program.
Paul Mears 02:56
Hi. Thanks, Jason. It's great to be here.
Jason Helgerson 02:58
Great. Well, first off, Paul, maybe tell our audience a little bit more about your interesting background?
Paul Mears 03:04
Sure. So currently, I'm Chief Executive, as you said, of a health board in Wales. My health board is Cwm Taf Morgannwg Health Board. We serve, as you say, a population of nearly half a million people in the Welsh Valleys. And for those colleagues who don't know the geography of Wales, we support communities in the traditional old mining communities. So it's very much the Welsh Valleys mining communities with a prominent industry for many, many years. But in common with many post industrial communities, we have some particular challenges to support our local communities now with some of the issues that come with an ex-industrial area such as deprivation issues that play through into poor health outcomes.
My health board is an integrated health board. As you say, we are responsible for our population, we have a budget annually of 1.1 billion pounds sterling. And we are responsible for both delivering services, as well as commissioning services from primary care colleagues in our community. So we provide the full range of health care services through three large district general hospitals providing acute services. We provide care in people's homes in our community services. We provide mental health care through to very high end secure mental health services. And we also have public health set within the health board, so the opportunity we have is to have a capitated budget for our population, and to decide how we best deploy those resources to improve the health outcomes for our community.
Jason Helgerson 04:38
Excellent. So I think your background and the fact that you're already in essence managing so many different services for the population gives you a really great seat to look into the future and this show is all about the future and what health and social care will look like in the year 2049. And I'm really eager to hear your vision for this future state.
Paul Mears 05:01
I think it's really exciting. I know speaking to you at the moment where we are still, certainly in my part of the world, dealing with some really significant challenges, from the pandemic with ongoing COVID pressures, high levels of demand coming into all of our services, it can be quite difficult to look forward 25 years or 28 years or so to think about what are things going to look like that far ahead. But in some ways, I think there's already some markers that are very clear to us about where things are going in the next few years and where health care is going to be in 2049.
If I start by thinking about what our patients are going to want, if we look forward 25 years or so you think about the advances that have happened in health care in the previous 20 years. We've seen huge advancements in healthcare services here in the UK, but around the world and rolling forward 28 years, I think we're only going to see a greater degree of change. If you think about the way patients now are becoming much more discerning about the way they can access health care. You've got a generation of people coming through now in their 20s and 30s, who are used to accessing services at the click of a mouse or a tap on their smartphone. And that population of people, whilst they might not yet be high users of services in health care, as they become older, they are going to expect more and more of those services to be available to them in the same way that they access everything else in their lives.
I think we need to be thinking in health care, how we turn that into a positive for us, because ultimately, in terms of delivering services, getting patients to look after themselves is the most cost effective way of delivering health care and the most empowering way for a patient to be in control of their health care. So I really think there's going to be a huge shift to that relationship with patients becoming much more one where the patient's in control of their own information, in control of their condition, and becoming much more discerning about how they want their care to be delivered, which is absolutely the right thing.
But if you play that through what that's going to mean for professionals, and our workforce in health care, that's going to be quite a shift from an environment where probably for many years, the view and the perspective was that professionals would sit with a patient would impart their knowledge and advice and tell the patient what they should be doing. I very much see the role of the professional moving forward being one where they will bring their clinical knowledge and expertise to the table for a conversation with the patient as almost a partner in their care and advising and supporting the patient in making the decisions. But that's going to mean quite a considerable shift in mindset for our professionals, and the way they're trained and the way they're skilled to really stop and think about how we work with patients as partners.
So a whole area there is around patient empowerment and professional collaboration. I think also for me, rolling forward 28 years, the concept of where we access health care is going to change as digital models advance. People are more in control of their health care digitally remotely. So the need to have health care facilities and buildings as the prime place where health is delivered will shift considerably following the pandemic. We know much of what we do in my organization shifted in the past 18 months to online visits, consultations with professionals via online consultations. Many of our patients have really appreciated that and valued the ability that that brings to be flexible in how they access their health care. But it also means that we started to question what we want our hospitals to look like.
Hospitals historically have been effectively the place where everything takes place, whether it's people having their babies delivered, going for a scan, receiving an operation, being an inpatient, and general hospitals are just that, they are general facilities that provide a bit of everything. I think moving forward over the next 28 years, we're going to see a much greater degree of variation in the way hospitals deliver care here in the UK. I think we will still have very specialist hospitals that will focus on high-end services and treating very acute episodes of care such as stroke, cardiac disease, trauma, with much of that developed already in the UK and certainly in Wales, where we have a well-established trauma network now. But I also think the whole model of long term care will change considerably. People with chronic disease who currently are going in and out of hospital for care will probably see that delivered much more outside of a hospital setting, remotely in collaboration with their primary care physician. So the way in which hospitals are designed and deliver care in the future will change a lot.
I'm also really interested in the whole concept of what diagnostics will look like because at the moment, certainly in the UK, if you want a CT or an MRI scan, your primary care doctor refers you for that. You go to the general hospital which is where all the scanning equipment is. We are just starting on the cusp now in the UK of thinking about how we might develop diagnostics centers to provide that outside of a hospital setting, much more in a community. But I think we need to take that even further beyond that and think about how technology will enable some of that diagnostic to be done remotely at home. How will we use genomics to really focus on precision medicine for individuals? I think the whole arena of hospital care will change significantly, but then as we do that, the model of care in the community and at home will significantly shift. How we get a much more integrated model of care outside of the hospital, around the patient, bring it together: GPs, a primary care doctors, primary care nurses, therapists, social care staff, all of that for us here in the UK, it's been something we've been trying to change for many years indeed.
One of the first things I ever did in my career in the NHS was to bring health and social care teams together in a place called Torbay in Devon. I strongly believe that patients don't recognize the interface of health and social care between doctor, nurse, physio, therapist. They want to receive the care from the right person at the right time. So our job is to connect all of those pieces in the community to enable the patient to be able to get the care they need, when they need it, from the right type of person, regardless of whatever professional background they come from. So that development of a multidisciplinary team working in collaboration with other partners such as social care and housing, is going to be another key part of the infrastructure that's going to be really important to develop proactively over the next 28 years or so. So that's just a bit of scatter through the key bits of where I see the core architecture, if you like, that will need to change and shift over the next few years.
Jason Helgerson 11:48
So that's great, I think you give us a very clear picture of not only the future state, but also the transition. And I'm struck by the change in power that your vision involves where power is shifting from clinicians, to the patient, and making the system much more patient-centered, and also the shift in terms of the focus, the central point of the system, moving from hospitals, into the home, into providing services to individuals in the most convenient way possible through technology and new models of care.
One of the big things that your vision makes me think about is the workforce challenge. You mentioned briefly that the role of physician, the role of the nurse is going to change pretty fundamentally under your future states. And one of the challenges I think we all have in countries around the world is that the physicians of 2049, those who are a couple of years away from graduating, will be at the height of their professional medical careers. Do you see that as a major challenge, because to a great extent, they're not necessarily being trained with the skills that match the system that you describe?
Paul Mears 13:05
Yeah, it's a really valid point that you raise. And I think we have this tension, because we are, if you think about medicine, and physicians, we are always going to need specialists. So we're going to need orthopedic surgeons, we're going to need renal physicians, we're going to need stroke physicians to deal with very clearly defined, acute problems that people are presenting with. But if I think about the way in which in the UK, our training for doctors has gone down a very specialty-driven route. Yet, if you think about the biggest challenges in health care over the next 25 to 28 years, we're seeing this already, it is the rise of frailty and age and multiple comorbidity that is driving utilization of services and indeed cost of healthcare delivery.
Our model of physician training has shifted, over the years, away from the general medical sort of specialty. And it used to be the days when people would have the general physician who was able, in the hospital, to deal with the multiple comorbid patients. And I guess today certainly in our part of the world, we have a challenge where we've got people coming out of medical school and medical training, who are very specialist in certain areas, but perhaps don't have the overall general medical or general physician type of background that we are going to need in the future. So there's definitely a need for us to think about how we shift that balance within medical training here in the UK.
I think also the point about technology is huge. We need to be training clinicians now in all areas to really understand how technology will be a key part of their role in the future. So, think about the way in which radiologists are now training. Many radiologists are having to get to grips with how AI is going to be used or is already being used to interpret scans, which is only going to grow exponentially over the next few years. People coming into pathology careers, where digital pathology is now being more and more used, and the potential for AI to start interpreting pathology results is going to become ever more apparent.
The clinicians coming out of medical school now are going to need to understand how those sorts of technologies are going to shift and improve in some ways, their work, but they're also going to need to understand what's that going to mean for them as the clinician who is responsible for the patient where actually some of the diagnostic tests in those cases may have been read by machine. So what does that mean for a physician, in terms of their accountability, in terms of governance, in terms of legal responsibilities. I think that's a really interesting dynamic that's gonna play through into many specialties now moving forward as technology comes into play, and physicians and nurses and other professionals will be needing to understand not just how the technology works, but also how the technology is interpreting and making decisions on the data as the basis for those decisions.
Jason Helgerson 13:05
Yeah. You raise a very good point. In fact, we had a previous guest on the show, Monica Lypson, who's a senior person in one of the United States biggest medical schools who basically said, we're training people in specialties in medical school today that will not exist or nearly not exist by the year 2049 because technology will replace it. The machines ultimately will be better than human beings when it comes to certain types of medical services. But you paint a very optimistic vision, and on this show we're all about optimists. How confident are you that your positive vision will actually be achieved roughly 30 years in the future?
Paul Mears 16:45
So yeah, I'm by nature optimistic and looking for the positives, but I'm also a realist and recognize that if I think about the healthcare system and the journey it's got to go on it, there are some huge challenges that we have to make to get us there. And I think that could be broken down into a couple of areas.
First of all, as we've just talked about the culture within the physician and nursing professionals and others is going to have to shift and there's a mindset shift that's going to need to happen. And that's going to need to be paid through, not just in terms of the physicians and the training models, but it's going to need to be paid through in the professional bodies. In the UK, all the colleges that support the professions, they're going to need to get their head around all of that and be supportive of that.
I think we're in a transition period with a wider workforce. We're going to see some people retiring and coming to the end of their careers who are going to be feeling that they don't necessarily see the need to invest their energies in getting underneath some of these other new technologies or new devices because they're not going to be there. So we're going to have to think about how we bring those people along with us to bring about change, particularly at a time where demand pressure is so high.
One of the biggest challenges I find in my day job is how do we give staff the headroom to even stop and think about some of this stuff, because they're also busy dealing with today's pressures and the realities of the work we're currently facing. So there's a big piece of work there about how we bring the workforce with us and change the culture of our workforce. But I also think there's a big change to make in how patients are going to expect to interact with the health service.
We talked earlier about how I think we will probably have a patient and population who are more exacting and demanding of the health services in terms of access, and be able to get information quickly about that. But also, I think we need to shift patient's understanding of what different professions do. So part of the challenge I found over my career in the health service is when you shift models of care, and you change things from say, a doctor doing something to a nurse, to a pharmacist to a healthcare support worker, often part of the challenge is the patient’s expectation is that the doctor is the person who knows most. So actually, they see a service provided by a nurse or a pharmacist or another professional as almost a second rate service. And they get frustrated by that and say no, I need to see a doctor. So we have to shift the conversation with our population to appreciate that actually health care in the future is going to be much more about a multiprofessional team supporting a group of patients or patients with particular chronic diseases, rather than always being seen as the doctor is the only person who can deliver the care to that population. So there's going to be a bit of education to do with population expectations around health care.
I also think about my particular part of the world where we have some significant challenges in our population's health around some of the determinants of ill health that are driven by lifestyle. We have high rates of obesity in my part of the world. 67% of our population are overweight or obese. We still have had some high rates of smoking in particular age groups, high levels of alcohol abuse, drug abuse, all of those sorts of behaviors which are driving poor outcomes. So we need to be also thinking about how we're going to change and have the conversation we have with our populations and encourage more accountability and responsibility for our own health. And that's a big, big challenge for us in our part of the world because if you're in an environment where things that government and public sector organizations have done over the years have been about taking things away, or instructing people how to live their lives, culturally, it's then quite difficult to sit down with people and say, well, you need to stop smoking, or you need to lose weight.
What we're trying to think about is, how do we use people who are effectively agents of our organization? So community groups who are well-trusted and well-regarded, local, elected politicians, or voluntary sector groups or sports groups. How do we tap into some of the natural networks that are out there to convey the messaging of why changing lifestyle behaviors is so important to helping improve the health outcomes for the population? So I think for us, and I guess this would be the same in any population health driven environment, shifting cultural norms in communities, is potentially also one of the biggest barriers we're gonna have to make if we're going to really try and shift our focus away from constantly treating disease to trying to prevent disease occurring in the first place.
Jason Helgerson 21:24
Sure, yes, behavior change, and trying to encourage the population individuals to begin to live, act differently is going to be crucial if we want to ensure sustainability, at least from a cost standpoint. And so I couldn't agree with you more. I think one of the more profound aspects of your vision is the change in power dynamic between a world of today or maybe even more pronounced way, in the not too distant past of the physician being the omniscient individual, and individuals going to the doctor expecting answers, and you almost see it today in the US, we call it Dr. Google, where people go to Google to find information and then take that information to doctors offices. But I think we're starting to see an increasing number of patients who are questioning what medical experts say. You see this within the anti vax movement and other things, as more information, more technology and empowerment, which I think all is a good thing overall for patients, are you at all worried about getting to a point where individuals are relying on really bad information or limited information, that may lead to worse outcomes and a less efficient system and as a result, the population health suffers?
Paul Mears 22:45
Yeah, you're right to highlight it. It's interesting, because there's an advantage to the doctor being the source of all knowledge, because that gives you at least confidence that the information is coming from a trusted source. But the reality as you just said is that we're in a world now where information is accessible to everybody at their fingertips. And there's no way of containing that. And I know in the UK, we have some really good national information websites for people through the NHS. They can go on and read about symptoms and understand how to get help if they've got particular concerns. But of course, as we all know, and I've been there myself with family members, who as soon as they are told something, or they've got a symptom, they Google it and think they've got some terrible disease.
So you're right to highlight it, because this is a risk that as this information is out there, it's uncontrolled. It creates anxiety, it creates fear, and it leads to utilization and cost. If you look at what's going on, for example, at the moment in our country, we're talking about the RSV, the respiratory virus that's coming out with being seen quite prevalent within children. And I was talking to some general practitioners the other day in primary care, and they were saying, we're now getting every parent who has a kid with a cold thinks it's this virus, so they're all phoning up the primary care practice and want to see a physician to get reassurance. And I suppose that's a good example of how as people become more aware of all these health care issues, there is a danger that we are going to overload the system with people with anxiety and worry.
I suppose part of that solution is how, going back to the technology answer, how can we use advanced digital technologies, AI bots, and all sorts of decision support tools to help perhaps stream some of that anxiety and worry out when it isn't a genuine issue. But also to highlight when there are people with symptoms that do genuinely need to be looked at and should be seen by a professional. So I think you're right to highlight the risks of it. But the answer has to be how well we can try and turn the technology to the advantage to enable us to get the people in touch with the right professionals when they do need support.
Jason Helgerson 22:58
So in terms of your vision, and any vision, any set of changes that happens, a system as big and complex as health care invariably creates winners and losers. And I'm just wondering as you think about 2049, who are the big winners in the future state? And who are perhaps some of the losers, those who would maybe see their relative position change and be forced to adapt the most by the year 2049?
Paul Mears 25:28
Yeah, I think there's some interesting ones. So winners, where are things going to be really growing and developing? Clearly, the whole space around digital healthcare is going to be a huge growth area over the next 28 years or so. And therefore, clinicians, professionals who are really involved in that, and take that on board and utilize that opportunity to really drive their services forward. I think there'll be definite winners in this. I think people who are focusing on out of hospital care, so community-based care, I think there's a lot of opportunity here for us. And I'm really keen in my part of the world to focus on how we develop primary care and grow the primary care and associated team to support people in their own homes. I think anybody working in that space in community primary care care at home is going to be a massive growth area, and it's going to need to be developed and supported.
Losers, I don't know if it's a losing team, but I guess there's going to need to be a complete rethink about hospitals, and what they do. I think that particularly hospital doctors focusing on chronic illness and disease, I think there's going to be a different need for those professionals to be working more in a community-based setting alongside primary care physicians to work differently with patients with long term care. And I think also there will be bits of different specialties that will probably become automated and process driven. The whole back office and support infrastructure that supports health care is, certainly in the UK, still a very bureaucratic admin lead, admin heavy structure and I would hope will disappear. And it's not about saying we don't need those people, because health care is a big challenge. We don't have enough healthcare workers. But it's going to be about reskilling and reshaping some of those people who are currently working into more administrative back office roles, to perhaps be more patient support roles, patient care, navigators, digital health care champions, whatever it may be. But I think there's definitely going to be a reduction in some of that behind the scenes bureaucracy, which can often stifle and slow down the progress of advancement in health care, and certainly in our part of the world.
Jason Helgerson 27:52
So technology, the role of technology in the future state, you certainly highlighted whether digital health or artificial intelligence, genomics which leads to precision medicine, a lot of excitement, some might say, hype around the potential role of that, but also concern around the role that technology will play roughly 30 years in the future. Do you see the technology as a positive force or are you at all concerned about what it could mean from a cost standpoint, or some of the ethical challenges that various observers have raised about how that technology is used relative to patient care?
Paul Mears 28:32
Yeah, so I think, rightly, people are very concerned about how data collected, using technology, is then used and security of data is really relevant. And as we all know, in every part of our lives, nowadays, it seems that there's news about various data breaches in different sectors. So, yeah, absolutely, we have to be very cautious with technology in terms of how data is going to be shared and used. I think also, we need to be careful about seeing this as an incremental growth journey. I think bit by bit as people become more confident and used to using technology in different parts of their health care experience, I think so their confidence begins to grow, and some of the anxiety about digital solutions begins to wane. You start with some of the more administrative sides of health care, such as booking appointments, and getting test results and things like that. It gets people confident, being able to use it, interacting with a physician over a video consultation gives people confidence that it's okay. So that makes them feel more able to adapt to future things that might be coming down the line.
I think the other thing I'm very alert to, and again, this is partly driven by the fact that I work in quite a community with high levels of deprivation, we can't assume the digital skills are there in all of our community to be able to use some of this technology. So we just have to be mindful of potential groups who are at risk of exclusion if we switch everything into a digital environment. Part of what we need to be thinking about is how do we, as healthcare providers, support other bits of the public sector, and other indie business or private business to grow and develop the digital skills of some of our more deprived communities, or some of them were excluded communities, so that actually digital technology doesn't become the next divide for our population.
I think there are some things we need to be mindful of. We're on this journey and we're never going to be able to go back now, the digital solutions that are emerging are going to continue to emerge. But what we have to do is try to think, how do we learn? How do we adapt? How do we gradually move ourselves down that road? In a healthcare setting like ours, we're never going to be perhaps the people who are right at the forefront of most digital things that are the highest risk because of the nature of the work we do. But I think there's lots of great opportunities for us to use some of these solutions to really improve the outcomes for our population, but also to streamline and automate and improve the lives of our staff working in our services as well.
Jason Helgerson 31:16
Excellent. So we always like to end on a question that asks you to take a few steps back and envision the world that you've been discussing today actually being accomplished, a very positive, very optimistic view of the future, which we always appreciate, if that is achieved, and that's where we are in the year 2049, how will the world actually be a better place?
Paul Mears 31:42
The world in my part of Wales will be a better place because we will have tackled some of the really intransigent problems that we've currently got in our communities with poor health outcomes. So I would be really pleased to see some of the outcomes for things like cancer and stroke prevalence and cardiac disease, but they will have shifted significantly because of the work we've done outside of hospitals to improve the determinants of ill health in some of our most deprived communities. So people will feel happier, they'll feel healthier, they will feel more empowered, in terms of their engagement with their health services.
Health will be part of a wider sense of well-being because we know that health is just one part of people's lives, the things that affect people's lives, and not just things that we as a healthcare provider deliver. They're about their employment, their education, their housing, so we will have worked together to improve the lives of our population. And I know it sounds a very altruistic ambition, but I want to feel that in 2049, people in my part of Wales will be living happier and healthier lives, and that they will feel more positive about things. They will feel that their healthcare services are enabling them to do the things they want to do that are important to them and giving them satisfaction in their daily lives. That's a really strong ambition that I hold for our communities. I constantly say to my team and my organization, we have to be ambitious for our communities because if we're not ambitious for them, we're missing an opportunity. So it sounds like a big, bold aim, but it goes back to my optimistic ambition. If you can't be bold and ambitious in these things, then I don't think perhaps you should be doing some of these leadership roles.
Jason Helgerson 33:23
I couldn't agree with you more, and we'll leave it there on that uplifting and positive note. And that was Paul Mears vision for health care in the year 2049. As always, thank you for listening to Health2049. If you enjoyed what you just heard, subscribe to us on Apple Music and Spotify, and share this podcast with a friend. Thank you and see you next time.
