Inclusion in Health Tech- an interview with Dr Arup Paul 7 January 2019 stc

15 February 2019

Why we need to think about inclusion in health technology more than ever- and some top tips for the future.  An interview with Dr Arup Paul, Deputy Chief Medical Director, AXA PPP healthcare

Interview conducted by Tina Woods, Founder & CEO, Collider Health

I caught up with Arup Paul to explore new thinking in diversity, equity and inclusion in health technology. Arup is a trained doctor and has experience in management consultancy, but now spends a lot of time with innovators and entrepreneurs to come up with new ways to incentivise people to keep healthy in his role as Deputy Chief Medical Director at AXA PPP healthcare.

The meaning of inclusion in the context of health

Inclusion in health is a hot area, especially with concerns over creating a digital divide between ‘haves’ and ‘have nots’ regarding access to technology.  In Arup’s view, inclusion is more to do with a mindset of stakeholders across the value chain of care: ‘we need stakeholders who understand the ‘unintended consequences’, recognising benefits in whole populations and making sure resources are not taken away from others in the course of adopting a new technology’.  Robotics is a clear example of this, where significant investment in new technology has not resulted in the expected cost benefits, and has actually diverted funding away from other critical services.

More broadly outside health, it is well known that social media has had significant unintended consequences (one of the main 2018 technology failures cited in a recent MIT technology review).  Arup says, ‘One needs to think about the unintended consequences of any single technology- and if the only objective is creating a unicorn that may not happen. Look what is happening in social media which has in some cases compounded exclusivity, not enhanced inclusivity, for example, in online bullying.’

The current state of inclusion in health

Arup argues that entrepreneurs in health need to be very focussed on benefit versus harm their technology will bring: ‘we need to ask, is the service meant to disrupt or augment health?  You can’t do healthcare like a Silicon Valley start-up disrupting the status quo, when there are lives at stake’.

Arup adds, ‘there needs to be a clear definition of a problem to be solved. But will there be benefits for caregivers as well?  We need to think about that too- to improve accessibility’.

There are some real issues with bias entering AI, and there are some useful lessons from the past to be applied here.  Arup believes the four principles of Beauchamp-Childress medical ethics he learned at medical school are as relevant now as it was then but ‘need to be  translated for modern times’. These principles are:

  1. Autonomy – The right for an individual to make his or her own choice.
  2. Beneficence – The principle of acting with the best interest of the other in mind.
  3. Non-maleficence – The principle that “above all, do no harm,” as stated in the Hippocratic Oath.
  4. Justice – A concept that emphasises fairness and equality among individuals.

A conversation with citizens is also needed for a modern-day consensus on which values are important in maintaining good health and intervening in bad health.  Arup adds, ‘a longer-term approach is needed to protect equity- as being better at consuming is often at the expense of those who are less good at consuming’.

Decisions on reaching excluded groups (those ‘less good at consuming’) need to involve users in these groups- to get their voice heard. Arup says it is helpful to refer to NHS Digital statistics, to understand where digitally excluded people are:  

  • 51% are people over 65
  • 45% earn less than £11.5K a year
  • 19% are unemployed
  • 37% are social housing tenants
  • 56% have a disability or long-term condition (27% have never been online)
  • 78% left school before 16

What does good inclusion look like? Some examples…

With the concept of inclusivity poorly defined and nebulous, the first question to ask is whether we are referring to an app or a broader technology? The best examples are in the latter category in Arup’s view, with DeepMind Moorfields retinal scanning and Kheiron breast imaging as two stand-out examples since ‘they enhance accessibility, quality and equity across the entire value chain: they address resource scarcity (eg lack of radiologists), fix the problem (eg improve throughput) and increase outcomes (eg more people get reviewed, more quickly and more accurately).’

Arup adds that ‘simpler delivery models are needed, like Physitrack that helps people with their physiotherapy and exercise programmes, and but also provides data for compliance.  A more text - based relationship makes it less formal and improves engagement too’.

Increasingly, behavioural economics will drive thinking in Arup’s view, but so will ‘doing the right thing’ for society, taking a steer from the ‘conscious capitalism’ movement which will be pushed by the new generations coming into power.  Shareholder value as the single measure of ROI and corporate success is ‘going out’ and the ‘shape of big companies to come, especially in a data- and tech driven world, will be different’.

The future of inclusion: what will it look like?

Arup believes that companies will need to evolve to meet the needs of customers wanting truly personalised care, and says, ‘ to be credible, they will need to nail their culture and values first and foremost. At AXA, we are looking to approve and apply certain technologies in context, to address specific areas of need such as access to GPs with our dr@hand service, a streamlined prostate pathway including the use of the newest scanning modalities to reduce unnecessary surgical intervention and we’re trying to integrate care-provision with specific platforms and providers. ’

The regulators need to become more inclusive too- and collaborate with all relevant stakeholders to get the fundamentals right for sustained continuous improvement in a wider environment context.

Top tips to guide entrepreneurs on inclusion

Arup offers the following tips:

  1. Get your culture and values right around ‘purpose’: this involves understanding the issues and making credible plans to address different components
  2. Ensure you have an ethical framework to guide your decisions: this will help you deal with externalities and understand how what you do might impact others.  It may make sense to engage with the ethics departments of the Royal College of Physicians or the new Centre for Data Ethics and Innovation chaired by Roger Taylor
  3. Make sure you engage appropriately with all relevant stakeholders to understand their needs (and gaps in services)
  4. Understand the regulatory framework, and where relevant engage with it as a stakeholder: refer to the recently published NHS Digital Code of Conduct as a starting point.

Dr Arup Paul, Deputy Chief Medical Director, AXA PPP Healthcare

Arup is a London born and trained doctor passionate about achieving excellence through analysis, understanding, design and implementation. He is Deputy Chief Medical Officer at AXA PPP Healthcare and has had several roles in both public and private spheres.  He has a Master’s degree in healthcare commissioning and enjoys the study of politics, policy, behavioural economics and change management. He is a member of the AXA Health Tech & You Expert Group.