Caroline Clarke, Regional Director for the NHS in London

How can cutting-edge technologies shape the future of healthcare by 2049? Join us as Caroline Clarke. Regional Director for the NHS in London, envisions a landscape where AI, genomics and 3D printing lead to personalized medicine. In this episode, explore the transformative possibilities and challenges in financing, restructuring health systems and achieving a balance between standardization and individualized care. Don't miss this glimpse into a healthcare future personalized for every individual.

Caroline Clarke is the Regional Director for the NHS (National Health Service) in London, which leads the NHS’ work in the capital and has an ambitious transformation agenda.

Caroline was previously Group Chief Executive (2019 – 2023) and Deputy Chief Executive (2012 – 2019) at the Royal Free London NHS Foundation Trust since 2019, leading one of the largest teaching trusts in the country.

Prior to this, Caroline held senior positions including as Finance Director at multiple NHS Trusts and as Associate Partner in KPMG’s health strategy team.

Caroline is a trustee of the Healthcare Financial Management Association (HFMA), the representative body for finance staff in healthcare.

Passionate about both the NHS and London, Caroline started her NHS career as a finance trainee in 1991 and has lived in London for 35 years.

Show Notes

• Caroline Clarke shares her background that led to her current position as Regional Director for the National Health Service (NHS) in Greater London.  [03:30]

• What are the two ways that healthcare can transform by 2049? [05:54]

• What needs to happen for new technologies to be productive? [10:23]

• How can we counter the conservative forces that are slow to adopt the use of technology in healthcare? [16:27]

• How will healthcare services be structured in 2049? [18:34]

• How can we achieve the right balance between standardized approaches and individualized care? [22:23]

• How will we finance the healthcare system, especially personalized medicine in the future? [25:59]

•  What role will the hospital play in 2049? [31:20]

• An optimistic view of our healthcare future. [37:10]

Transcript

Jason Helgerson  00:04

I'm Jason Helgerson, and you're listening to Health2049.

Caroline Clarke  00:07

In my idealized 2049 system, actually, a lot of these budgets have come together. Because the more we look at things in silos, the more we have imperfect solutions. So in my mind, we've brought some budgets together, we've started behaving much more rationally about how you apportion resources. And actually, we're starting to tackle some of the big determinants of inequality and ill health by giving people decent accommodation, giving them good education, giving them good food and if there is any dividend from closing those hospitals, that's where it's going.

Jason Helgerson  01:51

Today's guest is an experienced healthcare leader and transformation champion who is now embarking on one of the toughest jobs in global healthcare. Caroline Clark was recently appointed the Regional Director for the National Health Service in Greater London, which means she has been tasked with improving the health and wellbeing of millions in one of the world's most important cities. Prior to taking on all of London, England, Caroline served as the Chief Executive at the Royal Free London NHS Foundation Trust, one of the largest teaching hospitals in the country. Before her tenure at Royal Free, Caroline held senior positions as a Finance Director at multiple NHS Trusts, bringing her financial expertise to the forefront of healthcare management. She also served as an Associate Partner in KPMG's Health Strategy Team, where her strategic insights made a lasting impact. Join us as we hear from a visionary leader, who is now tasked with transforming the healthcare system in the great city of London. I can't imagine a better guest for our show. And I can't wait to hear her vision for health and healthcare in the year 2049. I'm Jason Helgerson, and you're listening to Health2049. And it's my pleasure to welcome Caroline Clark to the program. Caroline, welcome. 

Caroline Clarke  03:11

Hi Jason, it's lovely to see you. 

Jason Helgerson  03:13

Good to see you. You've got a very interesting and varied background, many stops along the way that have gotten you to your very important position today. But maybe tell our audience a little bit more about your very interesting background.

Caroline Clarke  03:30

Well, when you introduced me, I started to feel slightly sick in the pit of my stomach, so what have I done? But thank you it's a very, very generous introduction. I'm from Wales, I'm not English. I'm from Wales, which is really important, just so people know that. And that means that I like rugby and I grew up in Wales. Wales is tiny. It's only like three and a half million people there. Whereas the population of Britain, in the UK it's like 65 million. Anyway, I came to London back in the 80s. I read economics and I didn't know what to do with it, but I knew that I had to get a job, I didn't have any money. I joined the NHS because it had a fantastic graduate finance training scheme. And so my background has been financial, but not because I'm a finance whiz or particularly good. I'm okay with numbers. But I see finance and economics as tools to help us make better decisions to run organizations better. And my journey really has been all about trying to do those things, but using finance, and lately I've been in general management, which has been a blast actually, I've really enjoyed it. I've really enjoyed the leadership challenge that being a CEO gives you. I was a CEO during COVID of one of the biggest COVID treatment centers in our country. And that as a non clinician was hugely humbling, very, very difficult in lots of ways. But also, I got to work with some of the most amazing people and I will never ever forget that stuff. So think that those are the big things that kind of really change you as a human aren't they, and probably give you a slightly different insight into what could be possible or what needs to change. So this new job that I'm in NHS London, I've been doing for about five or six months now. And I've gone from worrying about the health of a population of about 2 million to worrying about the health of a population of about 10 million. So London's a tiny bit bigger than New York, but pretty much the same size, and lots and lots of very similar issues. 

Jason Helgerson  05:33

Well great, so you are clearly very qualified for the job you now hold and a job of tremendous importance. And, as we always like to do with our guests, is to give you the opportunity to talk about what you think health and healthcare should look like in the year 2049.

Caroline Clarke  05:54

Okay, so first thing, I'm going to be over 80 and assuming that I'm still here, I'm gonna need it to be like this thing. Because I was interviewed for this job relatively recently and I remember saying, I think one of the biggest challenges we have in the UK and particularly in London is actually it's just quite hard to get healthcare. It's quite hard to access it. It's just not digital, it's really differential, there's tons of variation. So in 2049, I think there will be much less variation or variation that we see will be warranted and it will be there because healthcare will be very, very personalized. I think that whilst we are all living longer and have more morbidity, because we collect conditions along the way, as we get older, we will have done more preventative meds, more preventative action over the next 30 years. So that people like me, will be living longer, but not with three or four competing long term conditions, but maybe just the one. And I will have a really, really good drug regime, which will be personalized, or AI will have got to the drugs that I need much more quickly, because it will have been sequencing and finding the best drugs, so drug discovery will be super quick. If I needed a new organ, it would have been 3D printed. Hopefully, I won't, but it might. I probably won't need much gene editing, but that will be a feature of some conditions. And I suppose the other thing for me is, so I've got two parts to my answer, Jason, one is that I see medicines and life sciences really, really picking up strength and pace on these amazing technologies. So using AI, but also nanotechnology and genomic editing and all that stuff. And then I also see the health systems working quite differently. So in the UK, right now we have general practice, which is often owned by small businesses, it's not particularly well collectivized or capitalized. We find it difficult to put technology into, it's quite small. I think in 2049 general practice, it will be like the kind of primary care that I think you're more used to in the States. The sort of big resource center that you go into that has multidisciplinary teams, you get pulled in if the conditions are worried about you and those systems will just work better. So I suppose I've got the two streams of thought running side by side, and one will influence the other. What I haven't thought about that we might want to talk about is how we pay for all that because of course, by 2049, in my country, we've got loads and loads of old people living longer. And we haven't necessarily got enough young people to pay for their health costs, because the fertility rates have been much, much lower since the 70s. So we've got an economic problem building and haven't figured that out yet. But you told me that I could be optimistic. I'm optimistic that we will figure it out.

Jason Helgerson  09:13

Yes, you are right, the demographic wave that I think at least from my perspective is already starting to come ashore. Here in New York, we're certainly seeing increasing costs in what we refer to as long term care, you refer to as social care are rising just because there's more people who need those services and that isn't ending. As we extend life, those costs will also rise because people will need that kind of assistance and help and we'll need more health care services. But if we could tap in before we go to how we're going to pay, you're very optimistic about some of the new technologies that are really the hot button topics at the moment globally. Things like artificial intelligence and the role that they could play. But it sounds like you're very much the optimist, that it's going to give us the ability to personalize care, transform care, to move upstream and to real prevention and things. Maybe talk a little bit more about why you're so optimistic about these new technologies and what they'll mean for healthcare.

Caroline Clarke  10:23

Yeah, it's a good challenge. So in order to do these kinds of jobs, I'm sure it's the same in the States and globally, healthcare leaders generally have to be quite optimistic. You have to think you can change things otherwise, what's the point? So that's the first thing. I saw Bob the other day, he's back in the UK doing a bit more work. He advised our government in I think 2016 and he talked a bit about electronic patient record adoption in the US and how quickly that had gone, because I guess it was Obamacare that heavily incentivized people to do that. And I thought it was quite interesting and we were having this conversation about whether there's a parallel between AI and EMR implementation. And have we reached a kind of tipping point for AI yet. And then he was very careful to remind us that actually all these new technologies come with problems. So he pointed to the problem of the EMR inbox that currently happened in the States where, as soon as a patient gets their results, there's a little button that says, if you're not sure about your results, go and have a chat with your clinician. You get your result, and it says you've got raise magnesium. And it's like, what does that mean? So hospital physicians now have a massive, massive inboxes full of probably very, very low risk patient questions. And so all these implementations of new systems have to come with thoughts about what they mean and the potential consequences of introducing new bits of policy, like, presumably some very consumerist going on in the States where patients are given their results. It sounds like a good thing, but you need to give them some tools to deal with their results, not just expect it to go back to the poor old doctor. So that was quite interesting. And then he said there was an advertisement for a doctor in an Arizona medical sector center and it had all kinds of terms and conditions and everything of the job and then it says at the bottom as a selling point, no EPR. So there's this real thing about how good is new tech and why is it that new tech doesn't bring productivity, and there's a productivity paradox that we were talking about. And you never see the productivity gains that you expect. The reason why I'm optimistic is because he's got a notion that there are probably two conditions that need to happen to get technology to be pretty productive, and to get better adopted. One is that it just improves over time. I've used Cerner a lot in most of the hospitals that I've worked in, but colleagues that use Epic tell me that the technology now is so much better than it was even a couple of years ago. And these things just do get better once people use them. Those companies are all quite clunky and in the UK we complain about American companies because we have to go through coding changes across the Atlantic and the timezone. But I think there is something about the fast cycle of technological change that happens the more and more people adopt it. And then the second thing, of course, is that you can't just use technology, you need to reimagine the work that goes with it. And if you think about AI and particularly large language models, like ChatGPT, to that point about how quickly is technology changing? ChatGPT is changing so quickly. Bob was giving us some examples, he put a few patient case studies into the AI just to try and get a decent treatment plan for these patients and to test it. And you could see, even in a couple of months, that the AI was getting better and better and more and more trustable as a clinician. I thought that was quite interesting. So there's something about these things moving quickly. And then of course, large language models, things like ChatGPT and stuff are just much easier to bake into existing technology. It's something that's in our everyday life now. So I use ChatGPT a lot, actually. And I've got clinical colleagues that use it a lot, even in conversations with patients, just to make sure that they've covered all bases and so my optimism is that, some people say it's like the printing press. I don't know, that sounds a bit grand doesn't it, being that the printing press totally revolutionized literacy and everything. But there's something going on with these large language models that potentially revolutionizes the way our industry is and it's happening everywhere else in other parts of our life. So my optimism, I think, is founded on that. And whilst I don't fully understand it, and I can see some very big downsides with it, I think it has the power to change things so much that it will just happen. I really do. And what I'm struggling with slightly is I can see how that will happen in the next five to 10 years. My mind is just slightly blown if you want the honest truth for what it will be like in 2049, or whether I'll still even be able to use my smartphone. In fact, we won't have smartphones in 2049, Jason will have something else, we'll just be talking, we're just going to have ambient voice technology. And the clinicians will never have to enter another note into Epic or Cerner again, because it'll all be hoovered up by ambient voice technology and structured into case notes. And the world would be a lovely place.

Jason Helgerson  15:52

I share your optimism, in the sense that, although I am sobered by the hit recent history, or not even recent, but even farther back that healthcare as a sector tends to be much later adopters of newest technology. I mean, healthcare is still the last bastion of the fax machine. The rest of the economy globally has left the fax machine behind, but healthcare and in fact, I think NHS England is the largest purchaser if I'm not mistaken. This was not that long ago as fax machines in the world.

Caroline Clarke  16:27

Yeah, I think we're not now, but I think it took a supreme effort to get rid of them. And we still use pages, I agree. So how do you counter the conservative forces of healthcare? And I think there are a few things, these large language models and other forms of AI and natural language processing stuff are already there and they are being used. I mean, look, even the British government has got into the thing now. So we're recording this in the week where the Prime Minister of England has convened a bunch of people internationally to talk about AI safety. I think that's probably a political move more than a thing that is much more meaningful. And your president has pronounced on safety this week, and the Chinese are doing stuff and Europeans doing stuff. So I think it's there, and it's there in most walks of life. And I do think that healthcare is slower, but I don't know if it's going to be exponential, but it's gonna be pretty quick. We've got to kind of get with it, I guess.

Jason Helgerson  17:29

So one of the questions, just before we get into how we pay for this question, because that's a big one. But I want to talk a little bit about the structure of the health system in 2049, your vision for it, as you mentioned, you have in most developed countries around the world, you would look and the health system, its structures, its locations for where care is provided that they don't differ that much in the sense that you have primary care providers, GPs who are in clinical settings, sometimes those settings are larger, sometimes they're smaller, and then you obviously have as sort of the backbone of the acute care system, the hospital. And I'm just wondering what your thought is, I mean, there's been a lot of focus on trying to move care into the home. A lot of these technologies allow individuals to receive services in the home, the concept which is being implemented as a hospital at home, in the UK, and still early days. But just your thoughts on what you think about how healthcare services are actually going to be structured in 2049.

Caroline Clarke  18:34

Yeah, so a couple of things to say. So just in terms of, organizationally, I am a very, very big supporter of group models. So primary care at scale, hospitals at scale, not necessarily in their structure, but in what they share. So if I think about my most recent experience in North London at the Royal Free Group, we were a collection of three large hospitals where we shared all our non clinical services, we shared an EMR Cerner, we worked very, very hard on the digitization of care pathways in order to reduce unwarranted variation. So that was the thing clinically that held the three hospitals together. And so wherever you got your care, you should have had the same set of pathways, assuming you fit that particular profile. And if you got care delivered at home, it would have been the same as well. So you've got a quality premium there. So I think in 2049, in my mind, there will be more collectivization or services to get those scale benefits. And of course, we're not gonna have enough staff, so therefore, we're gonna need to do these things in order to share our talents more effectively. And to digitize more effectively so that we can take some of the more arduous tasks out of the care system, and I hope I will be looked after at home. I hope that my Apple Watch, which had so much potential until I put it in the washing up and it wasn't waterproof, but it's a bit like the thing I say about AI, the wearable technology is increasing, improving all the time. And you can see that with all sorts of diagnostic monitoring. And through COVID, we did lots more work with nursing homes to make sure that they could really look after patients there rather than having to bring them into hospital. And you talked about hospital at home. So virtual wards for us are a really big deal. With this winter coming now in the UK, I think we won't get through winter nicely unless we have a very, very big virtual ward, home bed capacity which relies significantly on technology. But that will be run out of hospitals, pretty much all out of big community organizations. So again, I'm thinking about my 2049 structure. I don't know if it's the same in the States, but I worry quite a lot about small providers who are on their own who are quite fragile, who could fall over. And so grouping people together and making sure that people get to work across a great set of providers is really a thing.

Jason Helgerson  21:21

The other thing is what I wanted to get at, and get your perspective on is that as you describe the delivery system of the future, you talk about clinical pathways, eliminating what I would call bad variation in how people are treated and trying to achieve levels of aggregation of providers that allow for some economies of scale, so to speak, and some resiliency perhaps, and some redundancy. And so I see all the values of that. But at the same time, I also see this trend with some of the other technologies that I'd like to talk about, personalized medicine and the idea that not all of us are the same, the needs, the right treatments, how we are cared for. What will be the right balance between standardized approaches and individualized care? How do we achieve the right balance between those two and 2049?

Caroline Clarke  22:23

It's a brilliant question because we're struggling with that right now. So I think about the work we did at Royal Free, we were digitizing, I don't know, a fractured neck of femur pathway on the Cerner System, we would specify pretty much exactly what was going to happen to that patient at every point in their treatment from coming to the pre surgery joint school where you learn how to be a good patient, how to rehab well, through to how much anesthetic you're going to get, through to what your recovery was gonna look like and when you'd see a physio. Actually that does sound very, very standard, doesn't it? And for lots and lots of patients, that probably still will be the case. But if you are six foot nine and 85 years old, and you have a very low BMI, then actually that might not be right. And so you have to be able to opt out of those standardizations. This is for those of your colleagues that know Intermountain, this is pure Intermountain. My journey into all this started with a trip to Utah, where we were having a look at their Cerner implementation, and they very generously shared their methodology with us. And then we worked with the IHI on, how do you use QI to improve all this? But you're right, there's always this tension between how much of that is, for me? Most of the personalization I've been thinking about actually is around drug regimes and potentially therapy regimes. So some of that does have a bearing on the process. And I remember we talked to the guys at Intermountain about this way back in I don't know 2017-2018 and they described the tensions then and they saying, Well, they iterate these pathways. And, of course, I  imagined that if you've got a digital pathway on your system, you should be 100% compliant, and they were like, oh, no, no, you don't want anything like 100% because that will just imply people aren't really thinking about their patients and the personalization of the patient needs. So there's a tension that individual clinicians have to live through. And I don't have a great answer, except to say that there will be some patients, the majority who will fit a demographic, which will be the standard pathway, I'm sure. And then there'll be some who won't and that dynamic is going to change over the next 20 years to 30 years. It's really going to change, isn't it? But I don't know how to predict it. And I don't think I should. I haven't got a great answer for you. Actually. I think it's really hard.

Jason Helgerson  24:50

I agree. I think it's hard but I also think it's a huge question to where I want to go next which is cost and how we pay for it because I was thinking about this, individualized medicines, for instance, there's a lot of people with, say, heart disease or chronic lung disease or things like hypertension, where their disease today is managed with very low cost generic medications. And if personalized medicine means that we replace those generics with highly personalized branded, potentially vastly more expensive drug treatments, that only have say, a 5% improvement in outcomes, but it's 50% more expensive, that's the concern I have is that the same time that technology could be our friend in the sense allow us to individualize personalized in ways that lead to better outcomes and ultimately lower costs, or it could just heap tremendous costs onto the systems.

Caroline Clarke  25:59

Yeah. So of course, in the UK, we have the National Institute for Clinical Excellence, NICE, which will need to adapt to take into account the increasing personalization of drugs and therapeutics. So I don't know what the equivalent is in other countries. But this is exactly what NICE is thinking about. And I thought you were gonna say, so what if there's a really, really expensive drug or therapeutic that actually means that you don't have to have I don't know, a heart transplant. So the savings are made somewhere completely different. And therefore the holistic cost. And the whole life cost, actually, probably is, it's better just to have the drug rather than the surgery. So therefore, but actually, you gave a different example, which I think NICE will help us manage in the UK, and I think NICE needs to get into that space. I know they're thinking about it. But the other thing that we have in the UK, which I definitely don't think you have in the States, is the Pharmaceutical Pricing Regulatory Scheme. I think that's PPRS, where they were, effectively, the UK government agrees with the pharmacy industry, a set of prices, which will allow a certain amount of research and development and pipeline to exist, as well as pay for all the drugs that are around at the moment. And that clearly won't work for what I think 2049 is going to look like. So I don't know what you have. Do you have anything like that in the States?

Jason Helgerson  27:30

No, I mean, in fact to great extent, the prices for pharmaceuticals in the United States are much higher than they are anywhere else in the world, which too has a benefit to the rest of the world, in the sense that the US market opportunity for manufacturers is lucrative enough that it basically I think, encourages them to take the risks. So a lot of the drug development cost, it's a high risk business, most drugs that start the development process don't ever get to market, as we know the failure rates are very, very high, 80 plus percent. So as a result, due to the lucrative nature of the US market, it helps to basically fund a lot of that R&D. But I think that, perhaps, back to the new technologies, for instance, if we could create machines, computers that could replace the need for human drug trials, or allow for much quicker drug development or modification, then a lot of that cost could be cut out, the risk could be cut out. And then with that you could bring drugs to market and hopefully at lower prices than what we're paying today. So I don't want to paint a doom and gloom. But I think there's just going to be this tension between individualization and the path we've been on for a long time in healthcare, globally, which is standardization to root out bad outcomes, to root out examples of things being missed, or inappropriate care. I think that's just going to be a tension we're gonna have to grapple with. 

Caroline Clarke  27:30

Yeah, I mean, the other thing I thought we were gonna talk about was digital twins. And I haven't really thought enough about those. But presumably, again, if you can create digital twins for patients, to test stuff out, how do you pay for that? Sorry, I thought some of this stuff through but it turns out, it's quite hard.

Jason Helgerson  29:23

It is hard. But I think what also makes it super interesting and one of the reasons we started his podcast is about trying to inspire people to design a better healthcare system and think about what the needs are in the future. But I want to get to this question around cost and the cost of healthcare and how we're going to pay for this and just what your thoughts are in terms of what you're thinking, or what you think would be an ideal system. And if you have any thoughts on this vexing challenge.

Caroline Clarke  29:59

Okay, so we'll come back to the vaccine thing, but just in terms of how we finance the system, so in my world, I'm gonna need a lot of capital to start everything off. And at the moment in the UK, we just do not have enough capital, it's in the wrong place. And we don't have enough incentives for the big tech companies to load up stuff at the beginning. So we really need to think about that. So in my ideal world in 2049, I would have resolved some of that. And we will have long term partnerships, in my world, Jason, the NHS still exists, right? And we still have socialized medicine, but it'll be organized slightly differently, I'm sure. I mean that's a detail that I haven't gotten to, but we'll have a better way of contracting long term with organizations who are heavily capitalized, who will then want to make the necessary investments into my health system. So that's part of the problem, I think. So I mean, we talked about the drug thing before, that's going to need an awful lot more investment. And the PPRS is going to have to look quite different in the UK to deal with the personalization elements we were talking about before. I think I'm really torn about whether we'll need more estate or less estate, I don't know, do you have a view on that? So, if everyone's being looked after at home?

Jason Helgerson  31:20

Yeah, so it's an interesting question. I personally think that in the year 2049, that the role of the hospital will have been so significantly modified that its scope and its role will have shrunk so much that we won't even call them hospitals, we'll call them something else. And that much of the service, and the people who receive services in that setting will be there for shorter periods of time. And it will be high acuity, and that far more things will be in the home. And so as a result, I mean, that's my hope. And I think the virtual wards, as we call them today, which is really kind of like almost like a version of remote patient monitoring, and staff and resources coming into the home, I think will be a far more common way of delivery. And what does that mean? And it could mean that we are in the business of repurposing hospitals, and other things, maybe it's affordable housing, maybe it's something else that people need more of. 

Caroline Clarke  31:21

Yeah, I was smiling to myself, because of the irony, so the UK Government has launched this new hospital program to build 30-40 new hospitals. And I wonder if that will be finished by 2049? Note to self, check. So I think you're right, so the capital, the financing that we need then will all need to be in technology, and in the training and development of our staff to use it and to keep pace with the changing technology. Because I'm guessing at this point, things will be moving quite quickly, won't they, and I can't really predict, it does blow your mind, doesn't it.

Jason Helgerson  33:10

Think of healthcare now as a very bricks and mortar business, where we go to it, it never comes to us. And I think the future is going to be much more like healthcare comes to us. And hopefully that means it's more personalized in ways that matter. It's more efficient, it's more convenient, it's easier to access. We had a previous speaker on who is the Dean of the School of Social Work at New York University, whose view is on technology was that the gaps particularly for people of color in the United States for access to mental health services is so great, that unless we offer them, in essence, AI-enabled solutions, non human to human, but human and machine type services, we're never going to close the gap. So if we can harness the full power of this technology and we can bring it into the home and we do it in ways that people like and want, we move the system away from a real estate bricks and mortar service too much more of a flexible, dynamic, individualized in the home type of service. 

Caroline Clarke  34:23

But your repurposing point is really important because actually the one thing whenever I talk about technology, there are always people that say, oh, Caroline, but what about digital exclusion? What about people that can't use it? What about people who don't have the language? And then to this point about looking after people in their homes, of course, what if they don't have a decent home? I live in a part of London where Michael Marmot comes from and most health is defined by social determinants rather than by what we do in the health service. And so, therefore, decent housing is really important. So I wonder if in 2049, that will be one of the things that we spend more time talking about.

Jason Helgerson  34:57

Yes, we had an example in some of the delivery system reform efforts in New York where a hospital in the Bronx closed an entire tower and converted it into affordable, what we've referred to as supportive housing, which means you have people who have mental health substance use or physical health issues and services are brought into that housing, but it basically converted into housing for vulnerable people.

Caroline Clarke  35:24

Yeah, I mean all of these budgets have come together because the more we look at things in silos, the more we have imperfect solutions. So particularly in the UK, social care and healthcare are still a bit separate and people like me are trying to bring these things together. The politicians don't want to do it for lots and lots of very good reasons, particularly the kind of demographic time bomb that probably makes nobody want to go near social care for a long time. But I think starting to behave as if we have one budget for in the way that, was that the Montefiore health system you were just describing?

Jason Helgerson  36:06

It wasn't Montefiore, but it was another one in the Bronx that's very similar.

Caroline Clarke  36:10

So we look at that and think, yes, that's exactly what we need to do. So in my mind,  we've brought some budgets together. We've started behaving much more rationally about how you apportion resources and actually, we're starting to tackle some of the big determinants of inequality and health by giving people decent accommodation, giving them good education, giving them good food. And if there is any dividend from closing those hospitals. That's where it's going. 

Jason Helgerson  36:11

Great. So we are coming close to the end of our time. But there's one final question I wanted to ask you, which is, how optimistic are you when we talk about your vision for the future? How optimistic are you that we achieve your vision in the sense that, a lot of challenges in health and healthcare, a lot of challenges from government finance standpoint, a lot of challenges from a geopolitical standpoint, that we will collectively have to overcome, but how optimistic are you that your vision for health and healthcare and 2049 will in fact be achieved?

Caroline Clarke  37:10

Well, I think there's stuff in the Life Science sector, the stuff I started off with really around genomics and 3D printing, faster drug discovery and all that stuff. I think that stuff will happen. I think there's just such a push globally, and there is money behind it. There is a danger, I guess that the regulation slows it down, or there are issues around data, privacy, all that stuff that could slow it down a bit. But I feel pretty optimistic about that stuff. And I have enough colleagues, clinical colleagues that are working on this, I absolutely see that. What is harder, of course, is how we organize it. I mean, I spent my career thinking about how you organize health services and systems. And in my country, the way we organize it is very politically dependent. So I worry that we will go through another few cycles of political administrations in the UK, and we'll never quite get to the right answer. And I say that, I'm very cognizant of it at the moment because it's the pre-election year so you can feel the thing kind of hotting up. But I think we could get close to utilizing all these amazing new, technologically enabled discoveries. We could get close to it. I think it's the system side of it that I'm less clear about. And I think that's because of politics really, rather than from one's who try.

Jason Helgerson  38:38

Well, on that note, we'll leave it there for this great conversation. And that was Caroline Clark's vision for health and healthcare in the year 2049. As always, thank you for listening to Health2049. If you enjoyed what you just heard, please subscribe to us on Apple Music and Spotify and share this podcast with a friend. Thank you and see you next time.