Uday Bose: Medicine is important, but the ecosystem around patients needs to be addressed

Matthew Taylor

Hello. Today, a first for Health on the Line. I'm going outside the NHS, indeed outside the public sector, to speak to a leading figure in the pharmaceutical sector. Right now, as we face the Omicron variant of COVID-19, our collective safety largely relies on the efficacy of vaccines developed by pharma companies. And our future safety may rely on those companies staying ahead of the virus.

More broadly, a crucial factor determining the future of healthcare is innovation in digital, in the use of data, and in biotech. Healthcare is also one of the fastest growing global marketplaces. But if the health service is to work effectively with pharma, it means partnership based on respect, understanding, and trust. And for business, that means reconciling commercial imperatives with the principals at the very heart of the NHS.

I'm delighted to be joined by Uday Bose, who is country managing director, and head of human pharma at Boehringer Ingelheim UK and Ireland. And also in November this year, Uday was elected chair of the European Medicines Group, which is a voice for UK operations of continental, European headquartered research-based pharmaceutical companies.

So Uday thanks for joining us.

Uday Bose

Thank you, lovely to be here.

Matthew Taylor

So Uday, as someone outside the sector, I'm going to ask some quite basic questions if that's okay, because it's kind of fascinating and other people may share my ignorance. So, tell me, how do you develop your research priorities?

Uday Bose

So, I think most organisations take a similar approach. So, we call ours a disease map. So, we look to the future and we're typically looking at all diseases or disease areas, and we're trying to identify those areas where there isn't a genuine unmet need. So, over the years, for example, diseases like diabetes, COPD, obviously there's still things that we can do, but it's more incremental improvements.

These are becoming diseases, somewhat chronic conditions. So, the opportunity to have a step change innovation is what we're really looking for. So that's typically the way that we define our research priorities. So, opportunities to make a step change in terms of innovation, and really bring value to the healthcare systems that we’re partnering with.

Matthew Taylor

But it must be quite a complex process because I would imagine that you’ve got a number of different issues. First of all, there’s the supply, that is to say, where does it look as though innovation is possible? Where is the science taking? What are the areas where there may be a breakthrough? Then you've got this question of, well, where is there a market? Because in the end, you have to make money and you have to justify your investment in research and development. And then thirdly, there's this question of where is it that you could most add value to people's lives by improving their health outcomes? And all of those factors, I guess, bringing those factors together, getting them to balance, is that part of the art of what you do?

Uday Bose

Absolutely. It's incredibly complex. It takes on average about ten years to go from concept, so preclinical concept, before you enter the lab, to bringing a medicine to a patient. So that's about a ten-year process. You have to screen thousands of molecules and often make minute iterations to that molecule to get it to the point where it's ready to be trialed.

Of course, safety is incredibly important in our sector. So, before we do trials in larger populations, obviously there's a lot of work that needs to be done. And typically, after screening thousands of molecules, you get to one. As I said, it takes about ten years and the average cost, I think at the moment, most recent estimates, it's about 1.2 to 1.4 billion.

It's pretty much the same for whichever drug you're developing because the rigor you take is very similar. So, you're right, Matthew, it's many different aspects. Increasingly we are, early on, talking to governments, to healthcare providers and especially to patients because if we're going to embark on a path like this, it's incredibly important that this is genuinely something that society needs, that patients can give us their insights in terms of what it really is like living with a disease like this so we can produce that molecule, avoid those certain side effects and things to bring something of value to them as well.

Matthew Taylor

There's been a lot of talk, Uday, during the last two years about the scope to accelerate the innovation cycle, particularly in relation to pharma in the way that we've had to do with the vaccine.

Do you think, and we all pray that this won't be too long, that when covid has passed, we'll return to those quite long lead in times, or is there a real momentum, do you think, about saying, well actually we need to recalibrate the risks and the risk of waiting a decade for an innovation has to be set against the risk that we might get things wrong.

Do you think that debate will have changed as a consequence of covid or will we just return to the way things were before?

Uday Bose

That's a great question, Matthew. I think what we've seen with the vaccine development is what's possible. And I think for many of us in the industry, the regulators, governments, I think all of us, just assumed and accepted these things take a very long time.

I know, I've got friends where vaccine hesitancy is an important topic and I think it's important to listen and understand. And one of the common criticisms has been how quickly this has happened, how on earth could this have been done so quickly? You must have missed steps. You must have taken shortcuts. That really wasn't the case. Of course, longer-term data is helpful to have, but the rigor can be done quicker. That's what we've seen with the pandemic, because what uniquely happened is everybody came together with that same priority and that same focus. So, we certainly, as a sector and MHRA here in the UK have been incredible. They've done some outstanding work and they've been very encouraging to industry to say let's engage early.

And together they've got something called ILAP, the innovative licensing access pathway, which really encourages us to accelerate innovation.

Matthew Taylor

So, I hosted an event for the Confed around virtual care. And what was interesting to me is it's not just in the area of the vaccine of pharma that we have seen this acceleration.

So, we were hearing examples from India, from Liverpool, of incredibly fast implementation of forms of kind of telemedicine, virtual care, which was necessary because of infection control. And in all cases, the clinicians that were speaking to us at this event had to recognise that they hadn't had time to evaluate this and they were going to have to evaluate it post-hoc.

So, across the waterfront it seems to me there's a kind of sense of how do we accelerate things safely? And I guess one of the issues there is about transparency, which is that one of the ways you can accelerate innovation, one of the ways in which you can say, well, let's try things out and see whether they work is to have a very open way of being able to see whether or not any problems are occurring and a very open way of looking at if something does go wrong of learning from that in a way that people often talk about the airline industry and the black box and the way in which that has been so powerful for airline safety.

But then you've got commercial imperatives, which is, it's hard for a company competing in a marketplace to be entirely open about what they're doing and about what they're learning about their product. So how do we square that circle, Uday?

Uday Bose

So, you touched on digital earlier and this is one of the most exciting areas, I think in terms of drug development, which is the use of artificial intelligence to almost institutionalise that learning. Because you're absolutely right, I think we're all guilty sometimes of reinventing things or not looking back to make sure we take those learnings. And in the area of drug development, whereas I said, it does take quite some time, the opportunity to use data and machine learning to really predict potential pathways, predict the outcomes, means that I think we are getting much better in terms of using technology and science to accelerate innovation.

So, I think that rigor must be maintained. And we were talking earlier about the safety of medicine. So, we have the yellow card that the MHRA runs. Any side effect that you experienced on a product, has to be reported. We should report it as a society. We should report these things because this database is live and it's actively accessing information. And any signals that are picked up by the regulator, by the independent regulator, are incredibly important and action is taken upon that.

So, there are safety rails in place to protect patients, to protect society. But as you say, I think using data to learn and to make sure we learned those lessons from the past is incredibly important and we're seeing more and more of that happening now, which is exciting.

Matthew Taylor

So, one of the things I've learned from conversations with you and with other people in the sector, which I didn't kind of grasp before I think was, I had a kind of view that pharma companies developed drugs and then the health system bought the drugs and that was the kind of interface. And what I've realised is that pharma companies are actually much more engaged in the kind of wider question of the treatment pathway, the health system, so the context in which the drugs or the devices or whatever are being applied, and that's kind of very much your approach, isn't it? That it isn't just about flogging a drug.

Uday Bose

Absolutely. Yeah. We realised quite some time ago now, and again, I think our ownership structure helps us because it's in our actual corporate ethos to serve the communities within which we exist. So as a company that exists here in the UK and in Ireland, it's not just about getting the product over from Germany and then selling it. We have to literally physically improve the environment within which we work. We need to partner with communities at all levels, and what we've recognised, and when you say it doesn't sound surprising at all, is that the medicine and the patient are incredibly important, but it's the ecosystem around that patient that you need to address. Because pretty much all the time, the patient wants access to effective and safe treatments. The clinician wants to give it, so you have to understand actually what's preventing that? And typically, it's things around the pathway, it's things around identifying those patients in a timely manner and bringing them in or treating them remotely. It's insights around that medicine prescription, which is actually critically important, and often more important. I mean, it's more important for a patient to get diagnosed than it is to make sure the medicines waiting for them at the end. You need to manage the whole system, and that’s certainly our approach.

Matthew Taylor

And do you find when you want to have those conversations with health service partners around the whole kind of clinical pathway and that wider ecosystem, do you find suspicion? Do you find the health service managers and leaders say, well hold on, how can we have that conversation with you? You just have a narrow commercial interest. How do you kind of build trust to be involved in those wider conversations, which see you as having a role that goes beyond simply producing and selling a drug?

Uday Bose

Yeah, it's a great question. And I think, again, there are lots of measures in place. We have a code of practice, the Association of British Pharmaceutical Industry, we're a self-regulated industry, so we have the MHRA. But we put a lot of time and effort in terms of ensuring there's trust there.

We're focused on system change rather than prescription at the end, and again, from a compliance perspective, from an ethics perspective, this isn't about let's get into a partnership to prescribe more drug. The system doesn't need that. As I said earlier, the system needs to be able to better understand, for example, how to identify those patients. Where are those patients? How can we get insights in terms of how the health care system is working? So significant transparency on those agreements helps with trust. And we've seen this over the years, the more you do, the more you demonstrate, the more you build trust. And we're certainly seeing an acceleration in terms of our partnering because of some of the earlier programs we did.

And I think just last year we won or just earlier this year, we won an award with the HSJ for a partnership product with Oxfordshire, which was very much around what was the problem in Oxfordshire? And their feedback was, and what we were observing, was a significant number of A&E admissions for poorly controlled patients with COPD and asthma, significant overuse to the national average of inhaled corticosteroids, and they needed to understand why this is happening and how can they identify those patients. And the project was literally about setting up an MDT, setting up company advice, company support, financial support, explicitly transparent in the agreement. But it was literally helping them to mobilise, get access to that data and do something meaningful. And it's led to improved outcomes, it's led to fewer admissions, it's improved patient outcomes and it's something we're incredibly proud of with Oxfordshire on that one.

Matthew Taylor

This is all very positive, but yet still from time to time, there are things which give the pharmaceutical industry a bad name and possibly one of the most high profile has been the kind of opiate scandal in America.

You’re someone who has a leading voice in the sector and talks about corporate citizenship. What is the message that you give to your colleagues and to other pharma leaders about the principles that need to underlie the industries approach?

Uday Bose

So, what I say for our organisation, and every single new employee that comes in, I have an opportunity to meet with them on day one. And our simple approach, Matthew, is literally to imagine there's a patient. So, any conversation I'm having, like this interview with you, for example, I imagine there's a patient listening to us. The healthcare profession of course, is listening to us. And I want what they hear for them to feel very comfortable that they genuinely are thinking about me and what's good for society and they're doing the right thing. So that's kind of our benchmarks. Just imagine the patient was there and is what you're saying balanced? Is what you're saying appropriate? And in their interests? And if we do that, then I'm very confident that, you know, our intent is good. And we'll end up in the right place. So that's, that's kind of the barometer we use.

Matthew Taylor

Great. And I want to ask you about the future. What we should probably see and hope to see over the next few years is an acceleration in preventative medicine, also in personalised medicine. So, people having more capacity to monitor their health and to have treatments which are particularly based around their own personal kind of genetic profile or own personal needs or whatever.

Now this is a future that we should all want. But one of the challenges of that future is how do you avoid it being a future where inequality grows even further? Because people who've got the kind of confidence, the skills, the resources to take advantage of these new possibilities, push ahead and leave behind those who don't.

So how do you think, Uday, we get the very best of what the future offers us in terms of more preventative, more personalised healthcare, but how do we do that without exacerbating what are already pretty terrible health inequalities?

Uday Bose

I think it's been said before, the pandemic really accentuated and magnified inequalities. My wife's family are Bangladeshi, came over from Bangladesh. Bangladeshis are twice as likely to die from covid than white people. The statistics are real. We are seeing this exacerbation of the inequalities up and down the country. And I think what we've done is, as I said before, we connect, we speak to the patients, we really take a lot of time to understand the patient perspective. And we actually partnered with the patient association last year, because we were really keen to understand what's the patient perspective on exactly the question you just asked in terms of this digital transformation and this excitement and this opportunity.

And what patients told us through that survey was yes, they are absolutely excited. But they want to be involved. They feel things are happening to them, not with them and then not having the opportunity to shape things. And there are many examples of digital technologies, and there was a recent, I think, early this year about the oximeters that measure oxygen in the blood. Now we realise it's not as sensitive to different skin tones. That's such a profound insight. And then if you look back into the trials, ethnic minorities tend to be underrepresented in trials. So, they're overly impacted but underrepresented.

So, we have to get to the root, and for us as a sector and certainly for us at BI, it's about connecting with the patient very, very early on, getting them to help create those solutions rather than presenting them something at the end. And I think that would be the key to helping patients become more comfortable. And we're patients, you and I. We all often forget that we're also patients. And I think we all agree that if I was involved in something earlier, my level of engagement would be higher. And I think that's what we have to do more of, definitely.

Matthew Taylor

Yeah. And indeed, it was the Confed's own Race and Health Observatory which raised some of those questions around oximetry and its differential kind of efficacy for different groups. So really, really important.

We've been talking a lot about the kind of pharma industry here. But what about messages coming the other way? In the sense of, as someone who's been working with the health service, someone committed to innovation, someone committed to doing things in ways which aligned with the NHS' values. What do you think are the ways that the NHS needs to change? If it's going to become better at innovation?

Uday Bose

As I said, so I've been born and raised here in the UK. And I'm so proud. There's so much pressure, especially right now. I mean, the incredible pressure the NHS is under, and I think they do an incredible job.

And I certainly have that comfort that the NHS is there for me. And it's something that I think we as a society hold very, very precious. But I think it's equally true the opportunities to be more efficient need to be taken up. I'm a patient, my mum's a patient. Calling up to get an appointment, appointments being cancelled. There is work to be done. And I think you touched on it right at the beginning of this conversation, Matthew, about collaboration and partnership, because these are areas where we need to work together to help each other.

And I think digital and data, there's so much excitement around this. And again, we did some work with innovators a while ago. So, innovators on the frontline of the NHS and through a partnership project we're doing with Orca. And we did a survey with them to understand how are you finding getting innovation into the frontline? And this was the biggest topic that they had. We did a digital pioneers fellowship program with Digital Health London. We published the report, which is available, which basically said innovators did not know how to navigate the NHS with their good ideas. How on earth do you get a good idea to the patient? So, it's a complex system. So, the guide that we produced in collaboration with the AHSN's, and at that time NHSX, really helps provide support for that navigation piece.

And then once you're there, and it touches on the earlier topic around co-creation, innovators are mindful that there are inequalities and they see they have a role. I think it was about 97 per cent or 100 per cent of the innovators felt that they have a role to address inequalities, which is great. But again, how do they do that? How do you engage patients? So again, that's where the patient association or the fellowship and this digital health academy that we've been working on as well. There are, there are lots of opportunities now I think for collaboration and to really help and support the navigation of the system to get innovation to the frontline.

Because, I think if you ask me, that's probably the biggest challenge that we're facing. Time to realise these innovations takes too long and by its very nature, innovation has to move quickly. It has to get to the frontline as soon as we can get it there.

Matthew Taylor

And is scale part of this, Uday? In the sense that, for two or three fascinating years, I was on the ethical board for DeepMind Health before it was taken back into Google Health. And DeepMind was able to go to other parts of the world, to HMOs in India or America and sign huge contracts, which really justified a lot of expenditure in Research and Development and a lot of commitment to collaboration. Whereas in England, they would have to try and win contracts with individual foundation trusts where the economies are very, very different. Moving now to ICSs, and I've talked to many system leaders and they see Research and Development in digital as one of those things, which the system can add value in coordinating.

Do you think ICSs are going to be a good kind of scale for companies like yours to work out? Or are they still too small for some of the bigger innovations?

Uday Bose

No, I think for us, the closer we can get to the communities the better. And I think the promise and from what I've seen in the health and social care bill, I think the opportunity is absolutely there.

We do a lot of work, for example, with health innovation in Manchester up in the north, which as you know, Manchester is a devolved healthcare system and it's certainly more joined up. And it's a great place to innovate, to test innovation, because I think we need that. And it's again, one of your earlier questions in terms of trust and how do you build that trust? I think it's by working in a pilot situation to be able to test ideas. And honestly, I'm quite excited about the ICSs and think partnering is going to be a good opportunity.

The challenge, if I'm honest, from my perspective, and I think from a sector perspective is inconsistency. If every single ICS takes a different approach to simple, what should be simple things like contracting, for example, that's going to be really difficult because the contracting can take up to a year, which as I said earlier, innovation won't last that long. The idea isn't relevant in a year. So, I would just hope with the ICS is that if they're open for collaboration, which I know they are. I've heard that from Amanda Pritchard and others that collaboration and partnership is key.

We just got to make that efficient. We've got to make sure that that process is quick, it's efficient, it's of course rigorous and robust. But that certainly for me would be a KPI I would apply. Partnership's great to say it but to realise it, you've got to have the right mindset and the right approach to accelerate innovation.

Matthew Taylor

And then finally, Uday. It's one of the cliches, isn't it, about technology and innovation that we tend to overestimate the change that'll happen in the next year and underestimate the change that will happen over the next ten years. So, look into your crystal ball, Uday. Tell me what you think is going to be different about the health service in 2031. And is it what people think is going to be different or do you have your own distinctive view of how things are going to be?

Uday Bose

Yes, it's a difficult one! And we do this a lot. We are always trying to look ahead and trying to make sure that we're future-proofing, future ready. I think how society, how the world's reacted to covid, is going to leave a lasting impression on all of us . And you see this playing out in terms of the vaccination campaign and the kind of faith people are putting in the vaccination campaign. And we all are hopeful, but we're also getting to a point where we're realising we have to live with this pandemic. And I think this experience will last for people. And I think taking more ownership of their healthcare is definitely going to be a big feature of the future. I think it's going to be less of being told, this is what you need. And more of this is what I believe I need. I've done the research. I've got access to my own data. I think there's going to be a lot more patient ownership of the situation which I personally, I think is only a good thing. It's incredibly important that each of us take accountability. And I think our reliance on the healthcare service needs to be more responsible.

And as I said earlier, I'm a big fan of the NHS, but I do think we as a society often need to be more empathetic to the healthcare system. And so, I would hope greater empathy, greater ownership of our health and of course, greater transparency so that patients and physicians and all of us can make more informed decisions.

Matthew Taylor

I agree. And I think that the immediate challenge, Uday, is that we have seen this acceleration in the application of new vaccines. We've seen the acceleration in virtual care. We've seen an acceleration in telemedicine, hospital at home. A whole variety of ways we've moved more quickly, but yet we have a service that is completely exhausted and going through the toughest winter, and somehow, we've got to not lose the momentum that we've built up in terms of innovation and change.

But be realistic about the fact that when we come out of this virus, as all hope we will, all come out of the kind of worst stages of it, people are going to be very battered and bruised. And I think that trying to sustain optimism is really important in the period that we're coming into.

Well Uday, it's been really fantastic talking to you. Thank you so much for joining me.

Uday Bose

Thank you, take care.

Outro

You've been listening to Health on the Line from the NHS Confederation. Visit nhsconfed.org for more information about us and to register for events and webinars that delve deeper into the issues explored in this podcast. And save the date for NHS Confed Expo, the premier event in the health and care calendar, taking place on the 15th and 16th of June 2022 in Liverpool.