AI: the future of radiology?

MATTHEW: Hello and welcome to Health on the Line from the NHS Confederation, the organisation that represents members from across the health and care sector in England, Northern Ireland and Wales. On this edition, I'll be speaking to Dr Katharine Halliday. She's president of the Royal College of Radiologists.

Radiology is a vital clinical function in our health system, but one that, like many other clinical professions, has seen serious shortfalls as experienced clinicians have left. So Katharine and I will be talking about why that's happened, about what could be done about it, but we'll be focusing in particular on the role of technology and AI in supporting the work of radiology.

And before the end of the show, we'll have another Leader in Six, this time with Stacey Hunter, group chief executive officer for North Tees Hartlepool NHS Foundation Trust and South Tees Hospitals NHS Foundation Trust. But first, I'm delighted to be joined by Nick Triggle, a well-known health correspondent at the BBC who's reported extensively on health and social care over a number of years.

Welcome to Health on the Line, Nick. I'd like to start just by helping our listeners, who are mainly leaders, managers, in the health service, just to understand how the kind of BBC's approach to health coverage is structured. We’ve obviously worked with you and know about you, people are used to seeing Hugh Pym on the TV.

Is it a single kind of health team that works through multiple programmes or do you have different approaches depending on which part of the BBC you work in? 

NICK: Well, the BBC is a complex organisation, but I guess the best way is to think of, there's two sides to it, simply put. You've got the programmes, breakfast television, the Today programme, and then you've got the news gathering, the reporters. So myself, Hugh, Sophie Hutchinson, Dominic Hughes, and we will often suggest stories or flag stories that are coming up to the breakfast programme, Today programme, the 1, 6, 10 o'clock news.

It's then up to them to decide whether they want to run them, how they want to run them. They will come to us with ideas and they will also approach people to come on as guests. So, in the health service, you may get calls from the breakfast programme; certainly from the Today programme to appear, but it's really the health team, the team based in London, and we've got a small team based in the north of England as well that produce the stories, write the stories for the website, do the TV coverage and the radio programmes. 

I suppose in terms of deciding when we do stories, often we're looking for a peg, and the monthly statistics that come out from NHS England often give us that peg to devote quite a lot of coverage to the NHS on the second Thursday of every month, isn't it? And of course, in winter, we get weekly figures. So there's often a lot of appetite during winter to see what's happening in the NHS, as you all well know. 

MATTHEW: Yeah. And Nick, in terms of the balance of your coverage, a couple of kind of questions there. 

One is the balance between the kind of positive and the negative.

We work with you sometimes to share examples of really great practice that we think people might be interested in. But as many people have commented over the years, news tends to be about things going wrong rather than things going right. 

How do you approach trying to get the right balance of the fact that the health service has got enormous problems, but yet, day in, day out, it's continuing to provide highly rated care to millions of people.

NICK: I think that is a challenge. It's not just something we hear from the health service. I think the public too. And if you have too much negativity, it can turn people off. People want to know whether there's solutions out there, how things could be improved, or actually how in some areas – and I think we find this, don't we Matthew, in the health service  –  there's often pockets, there's often areas where there's some really good work going on. And highlighting those I think is important, and we're often keen to try and find those, and I know NHS England do try to promote them, but I think we'd want to hear from hospitals and other NHS trusts themselves about some of the work they're doing.

I think one of the challenges when it comes to daily news, it's not your big set piece reports. You know, like when we had the Darzi report or in the spring, we're going to have the ten-year plan, those are kind of locked in, but often events may overtake plans. So for example, during the first week of the new year, we were getting reports of lots of hospitals declaring critical incidents, and that kind of became the story.

And then in the second week of January, the Royal College of Nursing produced a report on corridor code, very strong report, evidence for more than 5,000 nurses. Some of the tales, really harrowing stories about how they were struggling to provide care. And so sometimes events overtake kind of what may be planned.

But I would say to listeners that we are always keen to hear what is working well and trying to put that into some of our stories and some of our programmes. 

MATTHEW: And in terms of directly engaging the NHS, obviously we advise trusts, and often we will talk to them about coverage they're getting. And we often encourage trusts, because everywhere I visit there's great practice, to want to share that with you and sometimes share the challenges they've got, for example, around crumbling buildings.

But there's a sense often in the NHS that you have to be very, very careful that you have to get approval from NHS England, etc. How do you find engaging bits of the health service? Is it a kind of rather bureaucratic risk averse process? Or do you find people are kind of open to talking to you? 

NICK: I think some are open and certainly we visit regularly a number of hospitals and speak regularly to some of the chief executives. Some of the chief executives, who've been there quite a while, are probably more comfortable about talking to us.

I do get the sense, I mean I've covered health nearly 20 years, and I think when I started out it seemed, and I don't know if your experience reflects this. But it seemed people were more open to talking. There was less control from, say, NHS England about media relations. And it seemed easier. I think now it seems more difficult to get to talk to people.

Maybe they are more risk averse. Is that your experience? 

MATTHEW: I think so. I mean, obviously, people are happier talking about positive stuff than challenging stuff. But, we worked recently with a hospital, there was a great piece in the Financial Times about corridor care. And it was about the challenges of corridor care, but it was also about what the hospital did to try to keep people safe given that they had to undertake this. So I think giving leaders the confidence to feel that they can talk to journalists and that the journalists will cover the story in the round, not just the kind of more, not exactly sensational, but the kind of the more difficult bits.

That's a confidence that we have to grow. But it's also, to be honest, about individual journalists that we know, like you, and people we trust will present the whole picture. 

Can I challenge you in another way, which is that one of the things we always say, and this is an issue of our health service reform, is that it is the acute sector, it is hospitals that get the attention, partly because people know what hospital is, and most haven’t the faintest idea what an integrated care system, or even a community trust is. 

But also as, as Malcolm X said, it's the hinge that squeaks that gets the grease. And it's accident emergency departments and waiting lists that kind of draw public attention. And what that means is that other parts of the service, like community services, mental health trusts, sometimes primary care, don't get the same coverage. And many people have argued that that actually leads to an impact on health policy. It means that health policy tends to follow those things which the media finds the easiest to talk about, and that the public cares most about. Although if you spend more time with the public, they kind of get to recognise the importance of other bits of the system. Is that a challenge that you get people to know the whole health service, not just what goes on in A& E departments? 

NICK: It is really difficult. I think it's something like nine in ten patient contacts are with primary care and yet probably 90 per cent of our coverage is hospitals. 

I think one of the things with the hospital sector is there's very good data, isn't there? There’s very good figures about waiting times. A lot of the targets are focused on that part of the NHS, and that naturally draws the attention of the media towards that. 

I think there's growing interest, though, in GP services, and we're beginning to, I think, probably devote more coverage to GP care than perhaps we did previously. I suppose this is also related to the challenge of governments facing; the Darzi report talked about moving care from hospital to community. And it's not the first time we've heard that. And in his report, he pointed out that actually the proportion of the NHS budget being spent on hospitals had actually increased over the past decade or so, despite trying to move that.

So I would throw that back and say, is it the media or is it just a nature of the NHS and hospitals swallow up more of the money, more of the attention? 

MATTHEW: And all these things are, they're always kind of dynamic, aren't they? Between what the media reports, how the public feels, what's going on in general.

And I would say it's the responsibility of an organisation like ours to work with you to, to help people to understand all the parts of the health system. 

That brings me to final question, Nick, which is, you know, the ten-year plan published, I think June, probably, maybe May. But what will you be looking for in that plan and how will you be seeking to engage the public in understanding the significance of what is going to be a major document? 

NICK: It will. I mean, it's going to be a major moment for the NHS. I think, though, often these big policy announcements, it's not always easy to engage the audience in that, when we're talking about what's happening in the here and now, what's happening, we're waiting times that grabs a public attention. It’s more of a challenge when you're covering a kind of big policy announcement.

And I think the big thing translates into this: What does this mean for patient? How might the patient experience change rather than thinking about the structures of the NHS or how NHS organisations may have to adapt. For us, it will be about what does this mean for the patient? Is the patient going to get more care? Out of hospital – what extra services are going to be available in the community? Because of course, one of the themes set out in the Darzi report, which I'm sure will feature heavily in the ten-year plan, is as we've just been speaking about that move from hospital to community. 

The work on prevention, this is a really interesting one, that I think can resonate with people because it's often about the lives that they lead diet, nutrition, physical activity, smoking, drinking, and I always think there's more we could do, more we could cover in that area. And I think sometimes, and I think the government would do this, is unpick parts of it, preview parts of it, and maybe give space on different days to different areas of the plan, because it will be so all encompassing.

And then finally, the analogue to digital. This is one thing, this feedback we get from the audience is, obviously they're used to the way they shop, the way they watch television now has completely changed over the last ten years, and they're always asking, why can't the NHS change? Or why hasn't it changed as quickly in terms of embracing digital technology?

So I think there'll be great interest in that area. And I think what would be good to hear from NHS trust now is kind of how things have changed and things we may not know about and that patients may not know about in terms of how they access the NHS. I think telling good, clear stories about that would be really, really interesting. 

MATTHEW: And that technology piece is really interesting. The public perception reinforced by Wes Streating that there's a big gap between the potential and the reality. But a colleague of mine was at a conference a few days ago, an international conference, and came back saying that probably the UK is one of the leading countries in the world in in the way in which we're trying to use AI in the system.

So there's always, isn't there, that kind of challenge, that gap between perception and reality. Well, Nick, we enjoy working with you and the trust leaders that I know work with you also. We look forward to working with you over what will be a really important few months for the health service. Thanks so much for joining us.

NICK: Thank you for having me.

MATTHEW: I'm now delighted to be joined by Dr Katharine Halliday, President of the Royal College of Radiologists. Katharine, welcome to Health on the Line. 

KATHARINE: Thank you, Matthew. And thank you so much for inviting me on the show. 

MATTHEW: So I should tell you that one of the reasons that we wanted to get you on is that somebody said to me that of the Royal Colleges, yours is perhaps one that is particularly kind of positive about technology and the role that technology can play, where other colleges might be slightly more kind of sceptical or defensive.

But anyway, we're going to get into that. I just wanted to explain to you why it was we particularly wanted to talk to you. So just let's start. For those people who don't really understand what radiology is or whatever, just give us a kind of two minute overview of the role that your members play in the health service.

KATHARINE: The Royal College of Radiologists represents radiologists and oncologists. So the link there, which may not be immediately obvious is radiation. So radiologists use radiation to take x-rays and to guide image guided procedures. So there are diagnostic radiologists who look at imaging studies like scans and x rays and interpret those, and there are also interventional radiologists who use imaging to guide them to, for instance, take biopsies in a particular place or do things that involve some sort of invasive. It's sort of keyhole type procedures. So that's the radiology side of it. 

We also look after clinical oncologists who use both radiotherapy and drugs to treat cancer. And so, as I say, the link is that we all use radiation. So there's quite a lot of physics involved in both. 

And radiologists are the people who will look at your requests for imaging, decide on which is the best imaging to use, sometimes scan patients themselves, sometimes just interpret the images and then put it all together and spend quite a lot of time in clinical consultations with the other clinicians talking to them about how to get the most out of the imaging and what it means for their patients.

MATTHEW: Great. And obviously a critical part of diagnostic services in particular. And we're in the mid to what some people kind of call the diagnostic revolution. We'll come back to that, but more kind of immediately it's the kind of workforce issues that you're facing. 

The college has talked about the current shortage in radiologists is 30 per cent will rise to 40 per cent which is you say would have a huge impact on the system. Quite a lot of consultants have left the workforce a pretty young age, under 45. So why is this workforce gap occurred and why is it that so many of your members are choosing to leave the workforce relatively young. 

KATHARINE: The first thing is that the demand for both imaging and cancer treatments is increasing very, very rapidly. So we are increasing the workforce actually, but we just can't keep up. 

So for imaging, there's a lot more we can do. When I started radiology, we did some ultrasound and some x-rays and a bit of CT, but now there are so many more techniques, MRI techniques. We can do loads more with. And there are also much, many more treatments going on in hospitals and each of those needs to be monitored with imaging. 

There's an older population who are sicker, who need more imaging. And I think there's something very fundamental about everybody's attitude towards risk. We all like to get a diagnosis straight away, particularly in places which is everywhere where there's huge pressure on beds. So you, you want to get a diagnosis quickly so as you can decide whether, patients need to be imaged or not. So for all those reasons, we're doing much more imaging. 

And the same is true of cancer for the oncologists. There's loads more treatments. It used to be that you had a choice of one or two treatments, but now there's lots of new drugs and lots of different surgical techniques. So each of those means that you do more imaging. That puts huge pressure on both workforces, oncology and radiology. 

And the second thing is that people are, you're absolutely right, leaving earlier. And again, the reasons for this are quite complex. One is we didn't really train enough to keep up with the demand. So the number of radiologists we're training was never going to be enough. And because of that, we're recruiting a lot of doctors from overseas, which is. marvellous. We're very lucky because actually, radiology is such a popular specialty that we get for a training scheme, we get at least ten applicants for every place. So we attract a lot of doctors from all over the world who want to learn that interesting subject and also learn in the UK. So that's amazing. And we also get a lot of consultants from abroad. 

But for one reason or another, international medical graduates don't tend to stay as long in the workforce. And if you look at the differentiation between the ages of people who leave, you find that the international medical graduates, their average age of leaving was about 46 compared to 59 - this is in radiology for UK consultants. So that, that's one thing. 

The second thing is that 59 is still younger than it used to be for UK graduates and people are finding the pressure they're really feeling it I think, and, I mean everybody goes into healthcare to provide a good service, don't they? And when you can't it's very difficult. And the pressures on call are a great deal. 

We expect everything very much more quickly than we used to. So I think people are really feeling that pressure and they're also feeling that they're not able to provide a good service for patients and this actually drives them away. So I think there's a few things we need to work on there.

There's one final point, and that is that because capacity is so limited in imaging at the moment, one of the things that has proliferated is outsourcing companies. So these are companies, private companies, where if you've got a backlog of reporting, you can send those images out to the company and pay per scan to get them reported.

And nearly every radiology department in the country is using some form of outsourcing at the moment. So they pay in addition to paying their consultant staff and their trainees. And actually, the pool of radiologists is still the same size and those companies are employing people who previously were working in the NHS.

And a lot of people are doing a bit of that and a bit of NHS working. And so actually now there is an alternative. So as you get to a certain age, you might think, well, I don't want to do on call, and I'd like to have a flexible job. And actually the outsourcing companies offer that. So there is all of those factors plus the fact that there's a viable alternative now.

MATTHEW: That's absolutely fascinating and in a way it kind of leads into the questions about technology and AI that I wanted to ask because of course the private sector is generally better than the public sector in the pace with which it applies technological innovation. 

So yours is obviously a specialism that has been impacted by technology. No one's suggesting that it's going to replace the need for experienced professionals. How is technology, and particularly how is AI, starting to impact the way we go about the work that your clinicians undertake?

KATHARINE: Well, we're definitely on the brink of something very big, and that's pretty exciting. And I honestly think that's one of the reasons why so many people want to come into radiology, because it's really exciting. It's at the forefront of everything. a technological revolution, and that's very attractive. So on the whole, everybody feels quite positive about it. 

Radiology is completely digitised. So all our images are viewed on a computer and those computers are all connected up to all the machines that take the images. So that's one reason why over 80 per cent, I think of all the AI products on the market in the UK are for radiology. So that's where the biggest number of technologies are. And so that's why we at the college need to be right on the front foot with working out how we deploy them and what's the best way. 

So we have a census every year at the college, which actually gets 100 per cent response rate. And so we asked everybody who was using AI products, and just over half said they were using AI in their clinical workflow at the moment. But in fact, some of the AI is actually used outside radiology departments to look at radiology images. So for instance, stroke is a common place where we use AI and that's not used by radiologists. It's mainly used by stroke physicians. So I think probably it's even more than half. 

So it's coming now, but I think what's really important is that we work with the companies and with the government to make sure that it's actually affecting us in the way we need it to. It's really being useful. Because one of the things about the increasing digitization of the health service, and this won't be news to you, I don't think, is that actually it can really slow us down.

So, if you take clinics, which oncologists do, for instance, in the old days, when I, because I'm at the end of my career, as it were, if we take the time, when I started, a consultant would take their secretary to clinic, who would do all the admin, type the letters, all of that sort of thing. Now, what's happened, is the consultants actually do the typing themselves, and they may not be very good at that.

And there are multiple different systems and they have to put in different passwords and a few times they get it wrong. And so they open up all these different systems and have to type in various different things so as we can collect good data. And actually that tends to slow people down and people report being able to see half the number of patients that they could in clinic.

So, we talk about digitisation and we kind of assume that it's going to make us more efficient and more productive, but actually it doesn't. And if we use it in the wrong way, it could actually slow us down and make things worse. So we need to be really proactive in working out how we can free up clinicians to spend more time with patients and doing the things that only humans can do.

MATTHEW: That's fascinating. And one of the kind of best use cases I've seen is voice recognition AI, which can enable GPs to record consultations and therefore they don't have to spend time off for every consultation doing all the notes. So I guess it's about kind of how do we join up these bits of technology so they genuinely make people's life easier.

How profound is this though in terms of the kind of core technology? So you, you're absolutely, I mean it doesn't surprise me in some ways that private sector investment the AI offer is so concentrated on radiology because it's the area where people come to say things like, it's more accurate than the clinicians and it's, you know, it can do it in almost real time. It's unbelievably fast. 

Is some of that stuff exaggerated or what are the kind of barriers to being able to use AI to take quite a lot of that kind of diagnostic, to do quite a lot of that area which previously relied on diagnostic judgment? 

KATHARINE: There is huge potential, but again, it needs to be used in the right way. So for instance, let's give you some examples – one of the things that we do quite a lot is CT of the chest for people who've smoked or their job has put them at risk of having lung disease. And quite a lot of those people will have small nodules in their chest. Now you don't know whether that nodule is just something that's just going to stay there and not be of any concern or whether that small nodule is going to grow into a cancer.

So, what we tend to do is then repeat the CT scan a few months later and measure the nodule and have a look at it and see whether it's looking any different or grown in size. Now that actually is something that a computer is much better at doing than a human. The measurements are more accurate, they can rapidly look at several slices, they can characterise the nodule. And that is much more of a science, if you like, than an art. And so that sort of thing is absolutely great. The other thing that AI is really good at is bringing together very large amounts of information and analysing that. And I'll come back to that in a minute, but at the moment, we're really concentrating the AI on the diagnostic side of things.

So actually interpreting the scans. And actually that's probably not the most productive area for us; that's probably not the biggest problem. The biggest problem is probably actually selecting the right patients for imaging and making sure that those people who are really going to benefit most from the tests are getting them. And I think that's where we probably ought to be concentrating our efforts. 

MATTHEW: So what do we need to do about that problem that you've described? 

KATHARINE: There's a great deal of a structure, essentially, that needs to be built around this. When you get a product, you can't just buy it off the shelf and hope that it'll work in your environment. It depends very much who it's been trained on or what data has been trained on. 

So if for instance, you take an algorithm has been trained on mammograms of Swedish women, it may have worked very well in that environment. But it may not work in our population, or it may not work in Manchester, as well as it works in the South End.

There are different things about different populations, so whenever you get an algorithm, or plug it in, as it were, you have to first of all test it very extensively on your own population, and make sure that it does what it says on the tin. And actually AI algorithms are just like people. You can test them against a load of different mammograms, and you find that if you test people against mammograms, you'll find that some people have areas that they're particularly good at and areas that they persistently don't see very well. And the same is true of AI – they're not perfect. 

The other thing is that when you're using them they can then drift. So you might test them when you're starting off and think, oh yeah, that's great. Ninety-five per cent of the time they're right and this is the same as the radiologist, so that's great. 

But then, sometimes, something can happen in their digital environment. One example is that for mammograms, somebody changed something on one of the machines when they had an AI algorithm working. Just a little tweak to make the images look a bit different, and the radiologist couldn't even tell the difference between the images. But actually, the algorithm then suddenly started recalling or bringing back twice as many women for additional scans.

What we call that is drift. And so you have to keep checking them to make sure they're working as you thought they were. And at the moment, we don't really have the systems in place for that. 

And finally, what we don't really know is whether overall patients do better when we use AI. There are very complex interactions between people and the AI. So will I become too dependent on the AI? How dependent I am on it, is that different if I'm a resident doctor or an experienced consultant? Does it make residents better and experienced consultants worse? Do you see what I mean? There's so many complexities and we don't actually have the whole system set up which we need to monitor this at the moment.

MATTHEW: Now that's fascinating, Katharine. Thank you. And I think this combination of a positive attitude, but also one that is kind of pragmatic and recognises that each technology has got its kind of pros and cons is what we need. We're nearly running out of time and I've got two more questions. 

I see that you're hosting a global AI health conference in February. Just in a couple of ways, tell us how the UK compares with the rest of the world, where would you say was leading practice and how is it better than us? 

KATHARINE: Well, actually, we are pretty much up there. We really punch above our weight in terms of research. I mean, the Americans have a lot more money to spend, and often very big health systems, which is good. So, there's a lot that we can learn from there. Korea is obviously a place that does a lot of technology. 

But at the AI conference, we're bringing together people from around the world, not just in radiology, we're also bringing together Royal colleges from the UK. You mentioned dermatology, ophthalmology, lots of AI and those things.

And we're bringing together all those people to look at the whole pathway, you know, what products are available, what needs to happen in terms of regulation, all the things I've been talking about. And we need it. We need it to help us. We do, as you pointed out, have a workforce problem. And so we've got to think of something different. We can't keep working in the same way. 

MATTHEW: And then finally, obviously, the government is in the midst of consulting around its ten-year plan. Thinking on the one hand of radiology and technology and the potential there, but also of Wes Streeting's three shifts, just tell us a couple of things that you think are possible that you would like to be happening if we look forward five or ten years.

How could things be different? 

KATHARINE: Well, the big one of the three shifts is of course the analogue to digital in this one. And we have a great opportunity in the NHS because we're one system and the Federated Data Platform, that's one example of that, of where we can start to get all our data together and look across the whole system.

And we have common language so we can look at all our data together. So we have a big opportunity, but some things need to happen. We need to work on standardising the way we collect data. We need to look at interoperability between all these different systems. And basically a lot of our IT hardware is very out of date.

If we could do that, then a lot starts to become possible for us. And I think also there needs to be a big conversation with everyone about privacy and sharing of data. Though the Sudlow report suggests that actually patients are keen on having their data shared if it improves their care, which it would.

MATTHEW: That's fantastic, Katharine, to hear the kind of positive attitude that you're taking to the potential here, but also to be reminded of some of the challenges. Thanks so much for joining us on Health on the Line. 

KATHARINE: Thank you for having me, Matthew. 

MATTHEW: And now to wrap things up, it's time for another Leader in Six, our series of quickfire questions with NHS leaders. Stepping up to the plate this time is Stacey Hunter. 

And just a quick note to say we, I do these interviews whenever I go out on visits, we kind of store them up. So just so you know, this one was recorded before the US election and that helps to explain one of Stacey's answers.

STACEY: Hi, I'm Stacey. I'm the chief executive of University Hospital Tees Group up in the north east of England. 

MATTHEW: Thanks Stacey. So question number one, what's the most pressing issue for you right now? 

STACEY: I think the most pressing issue for us is still how we support our people. So you will know there's huge pressure in all parts of our system, whether that's our community services, hospital, etc, and people are feeling it.

So what I kind of, I guess, worry the most about is how do we do the things we can do to keep them going? Because we know they're out there delivering these frontline services and we're coming up to winter. So that's always going to be kind of first and foremost in my mind. 

MATTHEW: Thank you. Second question, give me an example of an innovation in your trust that you're particularly excited about or particularly proud of.

STACEY: Oh gosh, that's a hard one, Matthew. I think we've got, I say we, the royal we, this has nothing to do with any of us actually, the exec team, but our team at Knotties and Hartlepool did a piece of work with NHS England. 

And I won't bore you with the details. It takes too long, but it's a piece of software called Optica, if people want to know about it, that brings all of the kind of what I describe as subterranean information about somebody's discharge. You get a live feed and it comes from social care, health, etc. And the team that use it absolutely love it because it stops all that toing and froing, loads of legwork, loads of time and effort all day every day, because it's there and it's rag rated.

So they work on all the ambers to try and get those people out of hospital that day. And it's massively improved length of stay, documented evidence, but as importantly, it's one of those transformations that the team genuinely own and genuinely can see the benefits, not just to patients, but to a huge sector of colleagues and they are like red coats, the host visits all the time. So if anyone's interested, please feel free to get in touch. 

MATTHEW: Fantastic. We must feature that in some of our best practice work. So Stacey, questions three, tell us something about yourself, which is interesting and which has nothing to do with your job. 

STACEY: Oh, gosh, Matthew. Interesting. Well, that's always a question of his personal life, isn't it?

What one person says is interesting, but nothing to do with my job. I am an enthusiastic, but still fairly incompetent, sailor. And so, I've been, my partner and I have been learning how to sail over the past few years. I was previously working down in Salisbury and we were lucky enough to get to do a lot of sailing there.

Now I'm up in the north east, that's slightly harder, but I'm braving the waters near Hartlepool, which let me tell you are colder and more choppy than they are in the south west. 

MATTHEW: That's fantastic, must give you lots of scope for metaphors when you're talking to your team. Question four, if you were king of the NHS for a day, what's the one thing you'd do?

STACEY: That is really hard, Matthew. I would bite the bullet on having a proper conversation with the public about what can we really expect from our health and social care services. 

MATTHEW: Well, that's certainly going to be happening over the next few months, I think with the ten-year strategy plan. So an opportunity to fulfil that, that hope, Stacey.

Question five. Which leader in the health service or anywhere else do you most admire? 

STACEY: I mean, there's many leaders in the NHS I've admired genuinely. I've been lucky and worked for some great people. And I guess rather than name one, and that's not to duck it, I admire people who are curious and open and don't think we've got all the answers.

So that's what I'm kind of draw to. I did work for a chief executive quite a long time ago called Bridget, who was fundamental in helping me look up and out. So she was passionate. This is kind of back in 2012, long time pre kind of where we are now, but passionate about all of our executives being outward facing and getting to know their communities and understanding the power of connection and networks.

I learned a lot from her, but I felt really lucky because as an exec in that organisation, I wasn't expected just to stay in the organisation, and as a chief operating officer, we were often stuck under a pile of work, as you know. But she made us go out and do that type of work and I learned a huge amount because of that. 

MATTHEW: That's lovely Stacey.

And then final question between Running the trust and out there sailing in the wild seas, you must occasionally get time to watch TV or listen to podcasts or read books. Give us a recommendation for something that we should be watching, listening to, or reading. And it can be as random as you like. It can be Rivals if you want it to be.

STACEY: God, no. Actually, I put rivals on my thing and I turned it off after four minutes. Because I've got a massive capacity for rubbish TV, but even I couldn't cope with that. 

What I would say to people at the moment, without wanting to be too heavy, we are 36 hours away from a significant election in the United States of America.

So I have been avidly listening to the podcasts that are done by Cathy Kay and Anthony Scaramucci about actually what's going on, sometimes in a very depressing and despairing way, but actually also just hoping that we get to a place where we can all feel quite optimistic about what happens over in the US.

MATTHEW: Well, Stacey, thank you. Scaramucci today tweeted, Harris is going to win. By the time people listen to this conversation, they'll know whether he was right, whether you're right, whether I'm right, whether the world is safer or more dangerous. Stacey, thanks so much for talking to me. 

STACEY: Thank you very much. Cheers. 

MATTHEW: Well, sadly, I'm afraid that's all we've got time for on this edition of Health on the Line. We'll be back with our next episode very soon, but in the meantime, please do follow us and leave us a rating or review wherever you get your podcasts. It really does make a difference. Thank you.